Trust along with CCG aims to change the care pathway to prevent children and young people attend hospital for any longer than required, resulting in excellent patient satisfaction

As part of the closure of Ealing Children’s ward under the shaping a healthier future programme West Middlesex paediatric unit in partnership with Hounslow CCG reviewed and redesigned its model of care. High proportion of NEL patients attend the site seen through UCC and ED, if admitted over 40% had a LoS of 1 day.

PAU changed the process to enable 24 hour discharge, reduction in inpatient bed base (from 20 to 16 beds) and shortened the LoS. Patient and parent satisfaction was excellent.

Challenges

Increased front door attendances through UCC & ED (14% increase)

Lack of ability to increase paediatric ward capacity leading to increasing treat and transfers

Large volume of children admitted for just over 24 hours for observation changes in service provision across NW London

Irritation from parents who stay longer than they required

Actions

 In collaboration with Hounslow CCG changed the front door pathway to include referral from GP and community services directly to Paediatric Assessment Unit (PAU)

Patients can stay for up to 24 hours for assessment, observation and treatment

Ability to be discharged 24 hours a day and safety netting with a rapid assessment clinic

Senior decision maker as gatekeeper to PAU admission, with prompt nursing and medical review on admission

Results

Closure of 4 inpateint beds with the movement out of previous activity

Demonstrate discharge from area throughout 24 hour period

Value

The project was designed to be cost neutral except for the quality investments of additional consultants to meet the London quality standards. The PAU sees an average of 30 patients a day which would have been in the UCC and ED setting.

The quality implications are that those children on the PAU pathway have an early treatment plan by a senior decision maker and are discharged at the time of day or night which is appropriate for their condition. The unit has continued to respond well to increasing front door attendances by offering the PAU pathway The PAU at West Mid was the first in NW London.

As a pilot site SaHF have adopted this change in model of care and rolled this out now through the sector. The learning has been taken into the NW London specification, influenced the PAU standards developed by Healthy London Partnership and fed into the national standards developed by the RCPCH

In detail

Ambition

WMUH and Hounslow CCG aimed to change the care pathway to prevent children and young people attending hospital for any longer than required (NSF 2003). It is recognized once a child or young person is admitted to an inpatient bed the process of ward round and review can lead to delays in discharge. The PAU model of delivery was developed to provide access to community GP, nurses and midwives to a senior clinical decision maker who could make a plan of care and discharge with safety netting as appropriate. The PAU aimed to remove sufficient activity for the pediatric ward that inpatient beds could be closed and resources used to staff the PAU.

The model of care was trialed and assessed if it could impact more widely across NW London as part of the shaping healthier future programme (SaHF). SaHF saw the closure of the paediatric inpatient ward and ED at Ealing hospital with the activity flows being dispersed across NW London acute Trusts.

Outcome

The PAU opened on 21st September 2015 and on average sees 30 patients a day. The ward has been able to close 4 inpatient beds and the resources that would have staffed this now operate the PAU.

The unit is open 24 hours a day and has led to an increase in through the 24 hour period discharges. Children and young people stay for up to 24 hours and do not breach this; the unit is not used as an ED breach avoidance measure, with only suitable patient cohorts admitted. Spread 4 out of 5 acute trusts in NW London have adopted the model of care. The change in practice has been instrumental in the service redesign in the sector and has ensured the ability of all trusts to continue to deliver care to children and young people despite increasing demand. The feedback has been positive form patients and their families with them now only staying in hospital for a short period of time.

Value

The project was cost neutral but at the point of roll out there was a quality investment to ensure adequate consultant cover on site in line with the London Quality standards. Involvement Feedback form children and young people has really helped to design the service and saw the department move to a new location after an initial trail, getting better facilities and more privacy. The Team as a whole were involved with junior medical and nursing staff assisting in pathway design and the scope of the service.

The collaboration with the CCG and the Trust was essential to delivering a service fit for purpose and which met the needs of both the CCG and the Trust More broadly working with SaHF and using this model to roll out more widely across NW London was essential to the capacity issues raised by the transition Spread and learning The PAU model is the first in NW London and as a pilot site it has been rolled out as a change in model of care under the Shaping a Healthier future programme. The model has helped develop the NW London specification which in turn has fed into the Healthy London Partnership PASSU standards. We have worked with the RCPCH to develop national standards. The change in model of care is art of our STP for NW London to cope with increasing demand of children and young people attendances.