PPT presentation supporting education for the NHS SEC SCN Acute Care Pathways: Fever, Bronchiolitis, Diarrhoea and Vomiting, Head Injury and Acute Asthma

1. Children &
Young People
Acute Care
Pathways
Dr Tim Fooks, GP and Clinical Lead
SEC SCN Children and Young People

2. UK Mortality Rate
If the UK health system performed as well as
that of Sweden, as many as 1500 children
might not die each year.

3. Children & Young
People Strategic
Clinical Network

4. CYP Work Programme

5. Children and young people emergency and urgent care pathway
Parents/Carers
Self Help
Internet
Digital TV
Pharmacist
NHS Direct
Professionals
Health Visitors
Community
Children’s Nurses
Social Services
Children’s Centres
A&E
Children’s A&E
Urgent Care Centre
Ambulance
GP Practice
Out of Hours Service
MIMI Unit*
Walk in Centre
Children’s
Assessment
Unit
Ward
Children’s
Critical
Care
Community
Care
Home
CAMHS**
Dedicated children’s environment and play facilities
Children and young people’s trained workforce
Child protection systems
System wide information
CYP and Family Involvement
* Minor illness, Minor InjuryUnit
** Child and AdolescentMental Health Service
Self Referral
Referralfrom
the community
Open Access
Self referral
Children, Young People and Families
Commissioners
This Whole
System
approach
applies across
all CYP areas
with
collaboration
key
5

6. Right place, right time ....?

7. High Volume
Conditions
Admission Data

8. CWS
B&H
Crawley
0
500
1000
1500
2000
2500
Fever
D&V
Bron'litis
Head
Injury
CWS
B&H
Crawley
Admissions with No LOS for children <5yr
2013/4

9. In most CCGs, up
to 50% are the
target group

11. Keeping Sick
Kids Safe
Role of the Clinician

12. Role of the Clinician for parents
• Recognition of serious
illness
• Reassurance
• Resilience promotion

13. • Factors affecting parents seeking help
from medical services:
• Sense of responsibility + fear of failure
• Felt or enacted criticism by professional
• Failure to be reassured:
• “Viral” explanation seen as sign of medical
uncertainty
• Inconsistent approach by Clinicians
Accessing Care - Parents with
Sick Children

14. The Goldilocks Zone

15. Acute Care
Pathways

16. 60 Second Practice Survey
• >80% response
• 91% aware of pathways
• Usage – sometimes
• Advice sheets – sometimes
• 82% Pulse sat monitor suitable for children
<5yr
16

17. GP Quotes
• “Personally I found them very useful
providing a clear concise and reassuring
checklist”
• “I feel much safer handling bronchiolitis
patients than I have done in the last 25
years”
17

18. • Fever, D&V and Bronchiolitis
• Dr Nelly Ninis, Consultant Paediatrician,
St Mary’s, Paddington.
• Expert in diagnosis of septicaemia
• Member of NICE guideline panel
• Available NOW at e-LfH
e-learning module (HEKSS)

19. Fever
Acute Care Pathways

20. • normal part of childhood illness,
• ~ 70% of preschool children yearly.
• ~ ½ taken to health professional
• Probably important component of immune response
• Use of antipyretics is widespread.
• reasons for treating fever are contested and not
necessarily evidence based but include minimising
discomfort, controlling the fever, and preventing
febrile convulsions.
• May be a component of early serious disease
Fever

21. • Definition of threshold for fever
• 81% <38.0°C, (100.5°F)
• 0% between 38.0°C and 38.3°C,
• 19% >38.3°C. (101°F)
• 20% children brought to clinic for a chief complaint of fever were
never truly febrile.
• 93% participants believed that high fever can cause brain damage.
• For a comfortable-appearing child with fever,
• 89% of caregivers would give antipyretics
• 86% would schedule a clinic visit.
Fever Literacy and Phobia

22. • Consideration of sepsis associated with
faster onset of treatment
• Delay in antimicrobial Rx associated with
hour by hour worsening of outcome
• Only 50% of neonatal cases of meningitis
(<3m) present with fever, but do have
other features of serious illness
(poor feeding, lethargy and poor overall state)
Pre-hospital Recognition of Serious Illness

23. • 448 children and young people ,16yr
• 103 fatal, 345 non-fatal
• Micro confirmation 373 cases
Recognition of Meningococcal Disease

24. • 4-6hr - non-specific symptoms
• 8hr (median time) – 72% signs of early sepsis
(leg pains, cold hands and feet, abnormal skin colour)
• 24hr – most close to death
• 50% admitted after first consultation
• 19hr – median time to hospital admission
• 13-22hr – median onset of classic features
(haemorrhagic rash, meninigism, impaired consciousness)
Recognition of Meningococcal Disease

26. Parent Advice Sheets

27. NICE CG 160 Fever – key messages
A. Thermometers and the detection of fever
In children aged 4 weeks to 5 years, measure body temperature by one
of the following methods:
1. electronic thermometer in the axilla
2. chemical dot thermometer in the axilla
3. infra-red tympanic thermometer. [2007]
B. Reported parental perception of a fever should be considered valid
and taken seriously by healthcare professionals. [2007]

28. NICE CG 160 Fever – key messages
C. Clinical assessment of the child with fever
Assess children with feverish illness for the presence or absence of
symptoms and signs that can be used to predict the risk of serious
illness using the traffic light system [2013]
Measure and record temperature, heart rate, respiratory rate and
capillary refill time as part of the routine assessment of a child with
fever. [2007]

29. NICE CG 160 Fever – key messages
D. Recognise that children with tachycardia are in at least an
intermediate-risk group for serious illness. Use the Advanced Paediatric
Life Support (APLS)[1] criteria below to define tachycardia: [new 2013]
Age Heart rate (bpm)
<12 months >160
12–24 months >150
2–5 years >140
E. Management by remote assessment
Children with any 'red' features but who are not considered to have an
immediately life-threatening illness should be urgently assessed by a
healthcare professional in a face-to-face setting within 2 hours. [2007]

30. NICE CG 160 Fever – key messages
E. Management by the non-paediatric practitioner
If any 'amber' features are present and no diagnosis has been reached,
provide parents or carers with a 'safety net' or refer to specialist
paediatric care for further assessment. The safety net should be 1 or
more of the following:
1. providing the parent or carer with verbal and/or written
information on warning symptoms and how further healthcare can be
accessed (see section 1.7.2)
2. arranging further follow-up at a specified time and place
3. liaising with other healthcare professionals, including out-of-
hours providers, to ensure direct access for the child if further
assessment is required. [2007] 013]

31. NICE CG 160 Fever – key messages
F. Management by the paediatric specialist
Perform the following investigations in infants younger than 3 months with
fever:
full blood count
blood culture
C-reactive protein
urine testing for urinary tract infection[2]
chest X-ray only if respiratory signs are present
stool culture, if diarrhoea is present. [2013]

32. NICE CG 160 Fever – key messages
G. Antipyretic interventions
• Antipyretic agents do not prevent febrile convulsions
and should not be used specifically for this purpose.
[2007]
• No place for tepid sponging
• Do not underdress or overwrap
H. When using paracetamol or ibuprofen in children with fever;
• continue only as long as the child appears distressed
• consider changing to the other agent if the child's distress is not alleviated
• only consider alternating these agents if the distress persists or recurs
before the next dose is due. [new 2013]
• do not give both agents simultaneously

33. Paracetamol or Ibuprofen or Both

34. 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Ibuprofen Paracetamol Both I+P
Reporting Odds Ratio - Acute Kidney Injury risk in <12yr
Yue Z1, et al 2014
ROR
Paracetamol or Ibuprofen or both?

35. • Safety profiles when used alone similar but underlying health
issues need to be considered
• Ibuprofen is more effective than paracetamol
• has faster onset of action & lasts longer
• relieving fever-associated discomfort,
• providing symptom relief
• improving general behaviour
• Selecting the most suitable antipyretic for the individual child
may help to optimize the chance of treatment success first
time, thereby limiting the need to administer further treatment
• Drugs R D. Jun 2014; 14(2): 45–55. Published online Jun 12, 2014. doi: 10.1007/s40268-014-0052-x PMCID: PMC4070461 A Practical
Approach to the Treatment of Low-Risk Childhood Fever Dipak Kanabar
Paracetamol or Ibuprofen or both?

36. • Children under 3 months
• Varicella zoster infection
• (NSAIDs linked to increased risk of severe cutaneous complications in VZV infection)
• Known aspirin sensitivity
• (2% asthmatic prone to exacerbation with ibuprofen, + another 2% have drop
in spirometry), but in those who are not NSAID sensitive, ibuprofen reduces
risk of asthma exacerbation more than paracetamol)
• Pre-existing renal failure ie marked dehydration
• Multi-organ failure
• Risk of GI bleed
When to use Paracetamol

37. • 30mg/kg in 24 hours in divided doses
• 3-6 months: 50 mg (2.5 ml) 3 times daily.
• 6-12 months: 50 mg (2.5 ml) 3 or 4 times daily.
• 1-4 years: 100 mg (5 ml) 3 times daily.
• 4-7 years: 150 mg (7.5 ml) 3 times daily.
• 7-10 years: 200 mg (10 ml) 3 times daily.
• 10-12 years: 300 mg (15ml) 3 times daily.
Ibuprofen dose?

38. • Single dose 10–15 mg/kg
• 4 times daily regimen - max 60mg/kg/24hrs
• Suspension (120mg/5ml) daily dose
• No. of 5ml tspns in 24 hour period =
wt(kg) x 0.5
Paracetamol dose?

39. Paracetamol or Ibuprofen or Both
The PITCH Study Conclusion
“Parents, nurses, pharmacists, and doctors
wanting to use medicines to supplement
physical measures to maximise the time that
children spend without fever should use
ibuprofen first and consider the relative
benefits and risks of using paracetamol plus
ibuprofen over 24 hours.”
BMJ 2008;337:a1302

40. Role of the Clinician
• Recognition of serious
illness
• Reassurance and
Resilience promotion of
parents and carers
• Respond in timely
fashion
• Record clinical findings

41. Diarrhoea &
Vomiting
Acute Care Pathways

43. Diagnosis
Perform stool microbiological investigations if:
• you suspect septicaemia or
• there is blood and/or mucus in the stool or
• the child is immunocompromised.
NICE CG 84 D&V – key messages

44. Fluid management
In children with gastroenteritis but without clinical
dehydration:
• continue breastfeeding and other milk feeds
• encourage fluid intake
• discourage the drinking of fruit juices and carbonated
drinks, especially in those at increased risk of
dehydration (see 1.2.1.2)
• offer oral rehydration salt (ORS) solution as
supplemental fluid to those at increased risk of
dehydration (see 1.2.1.2).
NICE CG 84 D&V – key messages

45. Nutritional management
After rehydration:
• give full-strength milk straight away
• reintroduce the child's usual solid food
• avoid giving fruit juices and carbonated
drinks until the diarrhoea has stopped.
NICE CG 84 D&V – key messages

46. Information and advice for parents and carers
Advise parents, carers and children that[4]:
• washing hands with soap (liquid if possible) in
warm running water and careful drying is the most
important factor in preventing the spread of
gastroenteritis
• hands should be washed after going to the toilet
(children) or changing nappies (parents/carers)
and before preparing, serving or eating food
• towels used by infected children should not be
shared
NICE CG 84 D&V – key messages

47. Information and advice for parents and carers
• children should not attend any school or other
childcare facility while they have diarrhoea or
vomiting caused by gastroenteritis
• children should not go back to their school or
other childcare facility until at least 48 hours after
the last episode of diarrhoea or vomiting
• children should not swim in swimming pools for 2
weeks after the last episode of diarrhoea.
NICE CG 84 D&V – key messages

48. Bronchiolitis
Acute Care Pathways

50. Consider in an infant with
• nasal discharge
• wheezy cough
• fine inspiratory crackles and/or
• high pitched expiratory wheeze
• apnoea may be a presenting feature
SIGN 91 - Diagnosis of Bronchiolitis

51. Seasonality

52. • Prematurity (<35 weeks)
• Congenital Heart Disease
• Chronic Lung Disease of Prematurity
• Parental Smoking
• (Social Deprivation)
• Protective factor – Breast feeding
Significant Co-Morbidities

53. • Antivirals – not recommended
• Antibiotics – not recommended
• Beta-2 agonists – not recommended
• Anti-cholingerics – not recommended
• Nebulised ephedrine – not recommended
• Inhaled corticosteroids – not recommended
• Oral corticosteroids – not recommended
• LTRA - not recommended
• Chest physio – not recommended (unless on PICU)
• NG suction, Oxygen therapy, Ventilation – should be
considered
Treatment options

54. Head Injury
Acute Care Pathways

55. Take head injuries seriously, says NICE
• 1.4 million people attend A&E in England and Wales
each year with a recent head injury. Up to 700,000 of
them will be children under the age of 15.
• Head injury is the most common cause of death and
disability in people up to the age of 40.
• Early detection and prompt treatment is vital to save
lives and minimise risk of disability, says updated
guidance from the National Institute for Health and
Care Excellence (NICE).
NICE CG 16 Head Injury

58. PAEDIATRIC HEAD INJURIES
Dr Helen Milne
Emergency Medicine Consultant
Worthing Hospital

59. Head injury data 2011
Head Injury
Presentations
Total Paeds
Attendances
% Total ED
Attendances
% Paeds
ED Attendances
Worthing 2157
<16 years
16,033
<19 years
23% 10-15%
SRH 1703 ~14,930 ~25% ~11-12%

60. Age of patients
0
50
100
150
200
250
300
350
400
<
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Worthing
SRH

61. Outcome
0
500
1000
1500
2000
2500
discharged admitted didnot wait
Worthing
SRH

62. Data Review
< 5 years Admissions CT Abnormal
CT
Neurosurgical
Worthing 56.5% 4.5% 0.8% 0.2% ?1 patient
SRH 55.7% 8.1% 1.5% 0.2% 1 patient
CHALICE
(22,772)
56% 6.4% 3.3% 1.2% 0.6%

63. Key Points
Most head injuries seen in the ED –
• Could be managed with observation at home
• Few need admitted
• Rare to need a CT scan
• Even more rare to need neurosurgery
Likelihood of brain injury increased by -
• LOC
• Mechanism of injury
• GCS
Children’s brain injuries
• Most non surgical treatment
CT scan radiation
• 100-200 chest x-rays

64. As soon after event as possible [1]
• Unconsciousness or lack of full consciousness, even if
the person has now recovered.
• Any clear fluid running from the ears or nose.
• Bleeding from one or both ears.
• Bruising behind one or both ears.
• Any signs of skull damage or a penetrating head injury.
• The injury was caused by a forceful blow to the head at
speed (for example, a pedestrian hit by a car, a car or
bicycle crash, a diving accident, a fall of 1 metre or
more, or a fall down more than 5 stairs).
NICE CG 176: Head Injury – when to go to hospital

65. As soon after event as possible [2]
• The person has had previous brain surgery.
• The person has had previous problems with
uncontrollable bleeding or a blood clotting disorder, or is
taking a drug that may cause bleeding problems (for
example, warfarin).
• The person is intoxicated by drugs or alcohol.
• There are safeguarding concerns, for example about
possible non-accidental injury or because a vulnerable
person is affected
NICE CG 176: Head Injury – when to go to hospital

66. If any of the following develop subsequently
Problems understanding, speaking, reading or writing.
• Loss of feeling in part of the body or problems with balancing or
walking.
• General weakness.
• Changes in eyesight.
• A seizure (also known as a convulsion or fit).
• Problems with memory of events before or after the injury.
• A headache that won't go away.
• Any vomiting.
• Irritability or altered behaviour such as being easily distracted, not
themselves, no concentration, or no interest in things around them.
This is particularly important in babies and children under 5.
NICE CG 176: Head Injury – When to go to hospital

67. Acute Asthma
Acute Care Pathways

68. National Review of Asthma Deaths
Confidential Enquiry – reported 2014
• Review of all deaths from Feb 2012 to January
2013 where asthma was listed in part 1 or 2 of the
death certificate
• 3544 death certificates reviewed, 2644 excluded as
either over 75 or asthma not thought to be cause of
death
• 900 deaths included
• After data review 195 deaths thought to be from
asthma
• 80 male, 115 female

69. Paediatric data
• 40 (of 195) children identified
– 12 cases no data returned therefore only 28
paediatric deaths reviewed
• 28 under 19 years
– 10 under 10 years
– 18 aged 10 – 19 years
• 12 though to have mild / moderate asthma
• 4 had PAAP (Personal Asthma Action Plan)
• Most died before reaching hospital
• 4 known to social services

70. Key recommendations – all ages
• All patients prescribed more than 12 short acting reliever
inhalers in previous 12 months must be reviewed urgently
• Assessment of inhaler technique should be done at every
asthma review. This should be checked by the pharmacist
for any new device
• Use of combination inhalers is encouraged
• Monitor adherence
• Electronic surveillance of prescribing should be introduced
as a matter or urgency
• Document smoking / smoke exposure, and
• refer current smokers or carers to smoking cessation
service

71. Red flags
• Excessive beta agonist use
• Poor adherence to preventer treatment
• Long acting beta agonist (LABA) as
monotherapy
• Lack of PAAP
• Poor perception of worsening symptoms

72. Key recommendation - children
• Parents and children, and those who care for or
teach them, should be educated about managing
asthma.
• To include
• ‘how’, ‘why’ and ‘when’ to use asthma medications,
• recognising when asthma is not controlled
• knowing when and how to seek emergency advice
• Emphasise minimising exposure to allergens and
second hand smoke, especially in young people
with asthma

74. Personal Asthma Action Plan

75. Other Resources

76. e-LfH Learning Module

77. Spotting the Sick Child

78. Short Film for parents and carers