Paediatric Unscheduled Care Critical Decision Support Pilot

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Bertha Fisher
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1 Meeting: NOSPG Date: 17 th December 2014 Item: 67/14 (iii) Paediatric Unscheduled Care Critical Decision Support Pilot NoSPG is asked to: Note the Paediatric Unscheduled Care Pilot Evaluation Executive Summary Synopsis: At the last NoSPG Executive meeting in September it was noted that the final report of the Paediatric Unscheduled Care pilot would be brought to this meeting. The report is attached. Boards representation / contact: Name Role NHS Grampian Cameron Matthew Service Manager, Child Health NHS Highland Dr Deborah Shanks Consultant Paediatrician NHS Orkney Dr Malik Woranski Consultant Anaesthetist NHS Shetland Dr Roger Diggle Medical Director NHS Western Isles Dr Angus McKellar Medical Director NHS Tayside Dr Donald McGregor Consultant Paediatrician NoSPG Jim Cannon Anne-Marie Pitt Regional Director Child Health Network Manager

PAEDIATRIC UNSHCEDULED CARE (PuC) PILOT Evaluation Executive Summary FORWARD Remote decision support in paediatrics was agreed as a key element towards sustainable services at the Remote and Rural

2 PAEDIATRIC UNSHCEDULED CARE (PuC) PILOT Evaluation Executive Summary FORWARD Remote decision support in paediatrics was agreed as a key element towards sustainable services at the Remote and Rural Implementation Group s final event in July At this event it was recognised that there was a requirement to develop safe systems of emergency care, particularly for children. The Director of Regional Planning in the north, at that time (Dr Annie Ingram), consequently chaired the first Project Board meeting of the Paediatric Unscheduled Care / Decision Support in November The Consultation Review carried out with staff in six Rural General Hospitals later in 2010 reported that staff were keen to have a single point of contact for paediatric emergencies where they could seek advice from a senior paediatric clinician, using video conferencing. Regional collaborations are seldom quick or easy solutions to negotiate and notwithstanding the inevitable challenges, the evaluation has shown that there were tangible benefits for children, young people and their families to have this type of service in place. A number of stakeholders made significant investments to design and deliver this year long pilot. There has been close joint working between the North of Scotland Planning Group team, the Scottish Centre for Telehealth and Telecare, NHS 24, the Centre for Rural Health, the pilot s clinical lead, the consultants who took part in the on-call rota, staff at the referring hospitals and lastly the families who were willing to take part. We would like to express our appreciation to those who have seen the potential for clinical decision support to reduce risk and increase quality, and for their willingness to participate and test the concept, in many cases giving their time beyond normal expectations. Given the levels of investment described above, and the alignment with national strategic direction, we believe it is incumbent on organisations and individuals responsible for the care of children to ensure learning from this pilot is implemented in individual systems. You will read in the various evaluation documents about how care can be improved and services made more robust and sustainable from adopting the principle elements of the pilot. In addition there are implications for wider decision support models. The recommendations listed at the end of the Evaluation Executive Summary are primarily meant for the North of Scotland NHS Boards. However there are relevant points for NHS Education for Scotland, the Royal College of Nursing and the National Planning Forum. I am assured that the NHS Boards within the north will continue to develop their service models, taking into account the learning from the pilot and look forward to working with the National Planning Forum on future clinical decision support work, which will further sustain other services, particularly in remote and rural settings. We commend this report to you and hope it will be useful in implementing future clinical decision support models as the body of evidence in this field grows. Jim Cannon, Director of Regional Planning, North of Scotland Planning Group Dr George Crooks Medical Director NHS24 2

3 PAEDIATRIC UNSHCEDULED CARE (PuC) PILOT Evaluation Executive Summary 1. Context Equitable delivery of high quality paediatric unscheduled care across Scotland has proven challenging due to a variety of factors; geography, workforce issues and organisational aspects of existing healthcare services etc. Despite significant investment, current provision of service is suboptimal and based on an historical model, which has little objective evidence of effectiveness. Despite no evidence of increasing prevalence of illness/injury in the paediatric population, there is an alarming increase in emergency department attendances and hospital admissions of children (ISD). Investment has been made in measures to reverse the increasing demand for paediatric unscheduled care in secondary care settings (e.g. provision of videoconferencing facilities in rural general hospitals and remote GP practices, additional training of community practitioners etc.). However, there has been no demonstrable impact on secondary care attendances. Existing practice is reliant on the community practitioners perception of risk in their treating the child locally. Unsurprisingly, when doubt exists, transfer for assessment is the default,. Videoconferencing facilities are rarely used as secondary services are not configured, or willing, to supply support via this medium. A review of secondary care paediatric services was commissioned by North of Scotland Planning Group (NoSPG) 1. A key recommendation was the redesign of delivery of paediatric services, with the PuC pilot being specifically recommended as a potential tool for delivering support to community services. Currently, an opportunity exists to implement widespread re-design of delivery of paediatric unscheduled care services to ensure maximum return from investment by: 1. Improving quality of paediatric care; 2. Improving access to paediatric services; 3. Reducing harmful and wasteful variation in paediatric care; and 4. Improved patient, parent and staff satisfaction. 2. PuC Pilot The Paediatric Unscheduled Care pilot was a joint venture between the NoSPG and NHS24, with funding from NoSPG of 350,000. The pilot implemented and evaluated the clinical, and logistical, impact of a 24/7 consultant paediatrician delivered decision support service across the north of Scotland to a limited number of referral sites. This was primarily via videoconferencing (VC) for paediatric emergencies in rural general hospitals and selected community hospitals, directed through a call handling process provided by NHS 24. The pilot ran from 31 July 2013 to 31 July 2014 and is the first study of its kind. There were a total of 230 referral calls made to the service from 14 referral hospitals with 66% of children maintained locally at the rural hospital. At 6 months into the pilot 61% of referral calls were made by VC of which 53% were progressed within 10 minutes. 1 Dunhill Z North of Scotland Paediatric Sustainability Review, NOSPG 3

4 3. Evaluation The evaluation of the pilot has taken part in four stages: 1. An external evaluation at 6 months carried out by the University of Aberdeen Centre for Rural Health (CRH). This included a literature review prepared by NHS Healthcare Improvement Scotland who looked for evidence of the clinical effectiveness and cost-effectiveness of telemedicine in the context of paediatric unscheduled care (excluding neonates) in rural areas. It also included a small survey of parents whose children received care via the service; 2. A further evaluation by CRH of referrers views; 3. A report by the PuC Clinical Lead at the end of the pilot; and 4. An Expert Peer Review of 30 PuC referrals by an independent panel of Consultants. (included in the Clinical lead report). The main findings of the evaluations were: 1. CRH report There is very little research on the utilisation of decision support in paediatric unscheduled care. The limited literature suggests potential benefits but has not been quantified. VC is not always appropriate, technically or logistically, and the telephone was used as an alternative. VC support from the On-Call Consultants (OCCs) improved the confidence of rural staff. OCCs thought calls were appropriate. Consultant led VC enabled more consistent pattern of support than previously, particularly to junior staff. Likely that VC support improved quality of local care. VC useful for aiding decisions on, and support whist waiting for, discharge/transfer. Parents were reassured by the availability of the expert. Clinical responsibility for the child caused tension in some cases. Some referrers thought PuC jeopardised some pre-established clinical relationships. Some referrers and OCCs thought lack of local knowledge of geography etc hindered good decision making. PuC was bypassed where consultation time thought to be quicker, problems with VC or appropriateness of VC was questioned. The process of NHS 24 call handling was highlighted as an area for improvement. The pilot showed it can be difficult to observe children for lengthy periods of time in remote hospitals due to variation in facilities, resources, access to VC, capacity and competence/confidence of staff. It is not clear if PuC had any net impact on transfers for self-limiting conditions. 2. CRH Referrers Views The majority of remote referrers were positive, with 76% indicating they strongly agreed with the clinical outcome of the PuC case they were referring. VC was used in 64% of the cases with technical challenges noted by a small proportion. Referrers perception of parental satisfaction was high with 82% agreeing or strongly agreeing that they perceived parents to be satisfied. Paediatric training needs of doctors working in remote and rural A&E departments should be reviewed, with a number of junior doctors highlighting the need for PILS, APLS and EPLS training as standard. Positive comments were made describing PuC as reassuring and a useful resource with advantages over the traditional model. 8 out of 9 referrers making additional comments said they hoped the service would continue. 3. PuC Clinical Lead Report VC enhances clinical assessment & decision support of children in remote locations*. Rapid access to SENIOR advice is valuable in this setting*. 4

5 Significant variation in competencies and service across the NoS (and probably beyond)*. Parents/Carers find VC useful/helpful (and probably this helps improve further the outcome for children). Even in those requiring transfer, early assessment and management adds value. Data - there is no data on the clinical effectiveness of traditional pathways of care. * These key findings should be considered the main outcomes of the PUC pilot. 4. Expert Peer Review The expert peer reviewers gave very positive feedback on the outcomes of the service. There was agreement by all the reviewers that the pilot had improved clinical outcomes due to the PuC referral although this varied between 15-60% of cases. 4. Next Steps The NoSPG PuC Project Board has noted the main findings and relevant members have agreed to take back to their represented NHS Boards the following action points: Promoting the increased use of videoconference; Reducing response times to calls from remote sites seeking advice and support from paediatric doctors; and Collecting data on paediatric unscheduled care transfers and telephone/videoconference support for use in future planning of services, combined with independent clinical review on a regular basis. These have been endorsed by the NoSPG Executive group. However, it was agreed that further implementation of a PuC decision support service would require wider discussion on learning from the pilot, future models for PuC, and links to national strategic decision support work. Consequently, a PuC workshop was held as a parallel session to the SCTT/JIT Annual International Digital Health and Care conference on the 6 th November Themes from the discussion at the session were: The existence of variation and inequality of existing paediatric emergency services Lack of clarity about accountability when using decision support services The continued need for obligate networks and support to remote care providers There had been some stakeholder engagement issues within the pilot There was support for rolling out a decision support service to remote providers. Standards for paediatric emergency care & training should be revisited. 5. Recommendations The pilot has demonstrated benefits in terms of quality of clinical care and patient and clinical staff experience and support. It confirmed that remote specialist support from other regions in Scotland may add significant value to local management and decision making. Recommendations to NoSPG, individual NoS Health Boards and the wider NHS Scotland are: For Health Boards to implement the actions agreed in paragraph 4 above in terms of use of videoconferencing, rapid response and data gathering; For Health Boards to reduce variation of delivery of care within its boundaries i.e. a review is undertaken of remote healthcare sites to determine the measures required to improve capacity for management of paediatric unscheduled care cases for locally determined, extended periods of time (e.g. education and training, equipment, physical space, access to communications etc); 5

6 For the NoSPG to work with the Scottish Government to clarify accountability when using decision support services; For the NoSPG and Health Boards to consider obligate networking in their service planning; For the NoSPG and Health Boards to consider implementing paediatric decision support across the region and consider options of how this could be delivered; For NES and the RCN to consider training and support available to remote providers of paediatric care and; For the National Planning Forum to consider the learning from the pilot; with regards to the development of wider decision support services, their design and implementation and the national implications and opportunities that may be realised in time. December

Mutual Aid between North Of Scotland Health Boards

Meeting: NoSPG Date: 16 th March 2016 Item: 13/16 NORTH OF SCOTLAND PLANNING GROUP Mutual Aid between North Of Scotland Health Boards NoSPG is asked to: To review and reflect on the content of the enclosed