CLINICAL GUIDELINE FOR THE ADMISSION OF PATIENTS TO PAEDIATRIC HIGH DEPENDANCY UNIT V4.0

CLINICAL GUIDELINE FOR THE ADMISSION OF PATIENTS TO PAEDIATRIC HIGH DEPENDANCY UNIT V4.0 Page 1 of 13

Abbreviation (P/A)HDU (P/A)ICU GCS IPPV CPAP BiPAP DKA Reg Meaning (Paediatric/Adult) High Dependency Unit (Paediatric/Adult) Intensive Care Unit Glasgow Coma Score Invasive Positive Pressure Ventilation Continuous Positive Airway Pressure Biphasic Positive Airway Pressure Diabetic Keto-Acidosis Any medical staff member deemed capable of fulfilling the role of senior paediatric resident on call Page 2 of 13

Summary. Medical or nursing concern that patient may require PHDU admission Decision undertaken by paediatric senior staff (nursing or medical) Yes Does patient meet PHDU admission criteria? (See section 2.2 of guideline) No Patient remains in place with current care or is transferred as appropriate for assessed need Senior paediatric medical discussion with parents (& documentation) Assigned PHDU Nurse retrieves patient from clinical area where assessment took place, with full nursing handover prior to transfer Ward clerk to tracer all relevant notes/paperwork Senior paediatric medical review within 1 hour of arrival unless reviewed during transfer or immediately prior Page 3 of 13

1. Aim/Purpose of this Guideline 1.1. To provide guidance for those concerned about the level of care required for a paediatric patient, with criteria for escalation from normal level of care. 2. The Guidance 2.1. Critically ill children may need one or more of three levels of intensive care. This guideline deals with the first stage of escalation normal ward care to level I care (PHDU) & covers details for assisting with transfer to & from level II care (AICU at RCH) within the same hospital setting. It does not cover transfer to other hospitals. 2.1.1. PHDU care is generally for a child who requires closer observation and monitoring than is usually available on a general children s ward. High dependency may also be provided as a step down from intensive care. 2.2. Categories of children who may require High Dependency Care 2.2.2. Requirement for closer observation and monitoring than is available at standard ward level: Examples: Invasive monitoring Unstable or deteriorating GCS Status epilepticus Unstable insulin dependent diabetes mellitus Potential cardio-respiratory instability due to medication Bacterial meningitis (Unstable cases may require level II or III care) Meningococcal septicaemia (Unstable cases may require level II or III care) Acute renal failure or uncontrolled hypertension Cardiac arrhythmia for monitoring and intervention 2.2.3. Single organ support, excluding invasive respiratory support (ie IPPV): Examples: Dopamine infusions Fluid boluses Non-invasive positive pressure ventilation eg CPAP, BiPAP 2.2.4. Step down from AICU (Level 2 care at RCH) 2.2.5. Following major surgery Examples: Cardiac Neurological Spinal 2.2.6. Advanced analgesic techniques: Page 4 of 13

Examples: Problematic pain control requiring increasing rates of continuous infusion of opiates, possibly with bolus top-ups Rectus sheath catheters 2.2.7. Non-intubated children with moderately severe respiratory issues Examples: Patients requiring aminophylline or salbutamol infusions. Patients requiring increasing amounts of oxygen who are not stabilising Patients requiring frequent nebulizers who are not stabilising 2.2.8. The recently extubated child 2.2.9. Treatment of complicated metabolic and/or severe electrolyte issues: Examples: DKA MCAD patients who are vomiting Severe hypernatraemic dehydration 2.3. Admission Pathway to PHDU See also flow chart page 3 2.3.1. Child considered by medical and/or nursing staff to meet criteria for admission to PHDU (see section 2.2). 2.3.2. If medical and/or nursing assessment confirms that child meets guideline criteria, liaise with senior nurse on paediatric ward and HDU nurse. 2.3.3. If it is agreed that the child is to be transferred to PHDU, Paediatric Reg or Consultant explains to the parents reason(s) for move (and documents this discussion in paediatric medical notes). 2.3.4. PHDU nurse goes to retrieve child from clinical assessment area, introducing themselves to child and parents (if necessary, Polkerris coordinator provides relief to existing PHDU patients during retrieval of new patient to PHDU). 2.3.5. Transferring nurse provides full handover to PHDU nurse in transferring area prior to transfer. 2.3.6. Transfer child with all relevant paperwork to PHDU (ward clerk for transferring area tracers all relevant documents to PHDU). 2.3.7. Following transfer to PHDU, patient should be reviewed by Paediatric Reg or Consultant within the hour, unless has been reviewed just prior to or during transfer. Review care plan including registration details and explain plan of care to parents. Page 5 of 13

2.3.8. Complete audit form. 2.4. Discharge Pathway from PHDU 2.4.1. If likelihood of transfer out anticipated, book bed on receiving ward (if no bed available, discuss with paediatric nurse bleep holder). 2.4.2. Medical decision that child fit for transfer out from PHDU. This decision communicated to family by member of medical team. 2.4.3. PHDU nurse confirms child ready for discharge to receiving ward and explains plan to child and parents. 2.4.4. PHDU nurse hands over to receiving nurse. 2.4.5. PHDU nurse transfers child & all relevant documentation back to receiving ward. 2.4.6. Polkerris ward clerk tracers documentation to receiving ward. 2.4.7. PHDU nurse ensures audit form completed and filed in PHDU audit file. 2.5. Medical Supervision for all PHDU Patients (including Peripatetic) 2.5.1. There will be a daily consultant ward round on any PHDU patient (wherever located), after which liaison with the patients responsible consultant may be undertaken, as appropriate. 2.5.2. Paediatric handover at 1700 hours must include Reg or Consultant visit to and review of all high dependency patients wherever located. 2.5.3. For any urgent clinical queries arising between ward rounds, high dependency nursing staff will bleep Paediatric Reg on-call for the wards. 2.5.4. Paediatric surgery patients admitted to any paediatric high dependency beds (including peripatetic) will come under paediatric medical shared care. They will come under the supervision of the Paediatrician ontake on the day that they are admitted to a high dependency bed unless already under the supervision of another Paediatric Consultant. 2.6. Transfer of Children from Level I (PHDU) to Level II (Paediatric Bed on AICU) 2.6.1. When joint medical and nursing assessment indicates that a child s condition has deteriorated to require move from Level I to Level II, or Page 6 of 13

is likely to do so, the Paediatric Reg or Consultant should discuss the case with the senior staff on-call for AICU. 2.6.2. The PHDU nurse caring for the child liaises with nursing staff on AICU re: bed availability. 2.6.3. Once a decision is made that transfer is needed, paediatric medical and nursing discussion takes place with child and parents. 2.6.4. The child is transferred to AICU with all relevant documentation. 2.6.5. PHDU nurses complete transfer documentation, including audit form. 2.6.6. Polkerris ward clerk tracers all documentation to AICU. 2.6.7. PHDU nurse accompanies child to AICU for full handover to AICU nursing staff. 2.6.8. PHDU nurses liaise daily with AICU re: child s progress. 2.7. Guidelines for transfer of children from AICU (level II) to PHDU (level I) 2.7.1. When joint medical and nursing assessment suggests that a child is fit for discharge from AICU to PHDU, AICU nurses liaise with PHDU nurses re: bed availability. 2.7.2. Once a decision has been made to move the child, medical and nursing discussion re: proposed move with child and parents. 2.7.3. Ensure medical handover at senior level from AICU staff to Reg or Consultant for Paediatrics 2.7.4. PHDU nurse collects child from AICU for full handover from AICU nursing staff. 2.7.5. Child transferred from AICU to PHDU with all relevant documentation. 2.7.6. Documentation tracered from AICU to PHDU. 2.7.7. Documentation including care plan(s) and audit form completed. 2.3.9. Following transfer to PHDU, patient should be reviewed by Paediatric Reg or Consultant within the hour, unless has been reviewed just prior to or during transfer. Review care plan including registration details and explain plan of care to parents. Page 7 of 13

3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Correct level of care in each area. Involved ward managers and departmental audit leads for Paediatrics & ITU Patient admission figures and PHDU critical care audit See appendix 3 Annually or before if required Ward managers meetings Audit and guidelines child health meeting. Dr.S.Goyal Ward managers meetings Audit and guidelines child health meeting. Required changes to practice will be identified and actioned within 3-6 months to allow for reaudit. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders. 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 8 of 13

Appendix 1. Governance Information Document Title Date Issued/Approved: 10 th Nov 2017 CLINICAL GUIDELINE FOR THE ADMISSION OF PATIENTS TO PAEDIATRIC HIGH DEPENDANCY UNIT V4.0 Date Valid From: 10 th Nov 2017 Date Valid To: 10 th Nov 2020 Directorate / Department responsible (author/owner): Dr.S.Goyal paediatric consultant Contact details: 01872252636 Brief summary of contents Clear guidance for medical and nursing staff caring for patients requiring admission to the paediatric high dependency unit. Suggested Keywords: Target Audience Executive Director responsible for Policy: Children Paediatrics High dependency RCHT PCH CFT KCCG Medical Director Date revised: 10 th Nov 2017 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: CLINICAL GUIDELINE FOR THE ADMISSION OF PATIENTS TO PAEDIATRIC HIGH DEPENDANCY UNIT V3.0 Paediatric consultants Child health audit and guidelines meeting Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings David Smith Not Required {Original Copy Signed} Name: Caroline Amukusana Page 9 of 13

Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? {Original Copy Signed} Internet & Intranet Clinical / paediatrics none Intranet Only Paediatric high dependency unit steering group, directorate of child health. No Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) 2003 V1.0 Initial Issue Dr.N.Gilbertson paediatric consultant June 2011 V2.0 Review Dr.N.Gilbertson paediatric consultant January 2014 V3.0 Review and re-format Nov 2017 V4.0 Review & re-format Dr.S.Goyal paediatric consultant Tabitha Fergus deputy ward manager- Re-format Dr K Tomlin (Specialty Doctor in Paediatrics) & Dr S Goyal (Paediatric Consultant) All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 10 of 13

Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed CLINICAL GUIDELINE FOR THE ADMISSION OF PATIENTS TO PAEDIATRIC HIGH DEPENDANCY UNIT V4.0 Directorate and service area: child health Name of individual completing assessment: Shama Goyal Is this a new or existing Policy? existing Telephone: 01872252800 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Clear guidance for medical and nursing staff caring for patients requiring admission to the paediatric high dependency unit. 2. Policy Objectives* Clear guidance for medical and nursing staff caring for patients requiring admission to the paediatric high dependency unit. 3. Policy intended Standardised practice. Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. HDU audit Children and families Workforce Patients Local groups x Please record specific names of groups Clinical Guideline Group Paediatric Directorate External organisations Other Page 11 of 13

What was the outcome of the consultation? Guideline agreed 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development Page 12 of 13

8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No areas indicated Signature of policy developer / lead manager / director Shama Goyal Date of completion and submission 10/11/2017 Names and signatures of members carrying out the Screening Assessment 1. Shama Goyal 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Chris Warren Date 10/11/2017 Page 13 of 13