Responding to Non COVID-19: Identification of deterioration in children

1. Andrew Cooper Clinical Director, Innovation Agency 18th October 2021 Paediatric Managing Deterioration Network Introduction

2. We are catalysts for innovation, helping facilitate change across whole health and social care economies – to improve health, drive down the cost of care, and stimulate economic growth. Drive down the cost of care Stimulate economic growth Improve health @InnovationNWC

3. Public Sector and Local Authority Public Third sector We connect regional networks of NHS and academic organisations, local authorities, the third sector, businesses and the public - responding to the diverse needs of our patients and populations through partnership and collaboration Business Academia Health and care @InnovationNWC

4. England’s 15 AHSNs were set up by NHS England in 2013 and were relicensed from April 2018 to operate as the key innovation arm of the NHS. @InnovationNWC

5. @InnovationNWC England’s 15 Patient Safety Collaboratives (PSCs) play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the system. The PSCs are funded and nationally coordinated by NHS England and NHS Improvement, with the regional PSCs organised and delivered locally.

6. SOUTH CUMBRIA LANCASHIRE MERSEYSIDE CHESHIRE LIVERPOOL DARESBURY PRESTON LANCASTER CHESTER NORTH EAST NORTH CUMBRIA AHSN HEALTH INNOVATION MANCHESTER YORKSHIRE AND HUMBER AHSN @InnovationNWC

7. National Patient Safety Improvement Programmes Managing Deterioration Delivered by: Led by: NHS England NHS Improvement @NatPatSIP / @MatNeoSIP www.improvement.nhs.uk National Patient Safety Improvement Priorities (NatPatSIPs) Katie Whittle Head of Programmes – Patient Safety– Patient Safety and Care Improvement Innovation Agency North West Coast Patient Safety Collaborative

8. The NHS Patient Safety Strategy

9. National Patient Safety Improvement Programmes Five national programmes: >Maternity and Neonatal >Managing Deterioration >Medicines >Adoption and Spread >Mental Health | National Patient Safety Improvement Programmes 9

10. NatPatSIPs national driver diagram

11. All NatPatSIPs: Key enablers for system safety | National Patient Safety Improvement Programmes 11 Key enablers Addressing inequalities Patient and carer co-design Safety culture Patient safety networks Improvement leadership Building capacity and capability Measurement for improvement Improvement and innovation pipeline

12. National Patient Safety Improvement Programmes Managing Deterioration Delivered by: Led by: NHS England NHS Improvement @NatPatSIP / @MatNeoSIP www.improvement.nhs.uk Managing Deterioration Katie Whittle Head of Programmes – Patient Safety– Patient Safety and Care Improvement Innovation Agency North West Coast Patient Safety Collaborative

13. | National Patient Safety Improvement Programmes 13

14. | National Patient Safety Improvement Programmes 14 ManDetSIP Programme Ambitions • Support the adoption and spread of the COVID Oximetry@home remote monitoring model across England by March 2021 - COMPLETE • Support the spread and adoption of the acute Paediatric Early Warning Score (PEWS) and a primary care system-wide paediatric observations tracker for children across all appropriate care settings in England by March 2024. • Increase the adoption and spread of deterioration management tools (e.g. NEWS2, RESTORE2, RESTORE2 mini, SBARD etc.), reliable personalised care and support planning (PCSP), and approaches encompassing end of life care principles, to support Learning Disabilities, Mental Health and Dementia care management in relation to deterioration in at least 80% of all appropriate non- acute settings across health and social care by March 2024. • Setup and co-ordinate two Patient Safety Networks – the Managing Deterioration Networks and Care Homes Patient Safety Networks (jointly with MedSIP) by March 2021 and develop and establish these by March 2022.

15. PIER Plan/Prepare Interventions reducing the risk of deterioration-associated harm prior to deterioration occurring. These include developing awareness of and taking actions to mitigate risk at individual and system levels through: • Building safe and reliable care pathways, with co-ordinated system-level working across providers and professions • Baseline assessment and sharing of individual risk factors and choices • Reducing the potential for inappropriate transfer and treatment • Integration of safety culture into daily processes • Strengthening the voices of patients and their families • Building improvement, measurement and human factors capability | National Patient Safety Improvement Programmes 15

16. PIER Identification | National Patient Safety Improvement Programmes 16 The expedient recognition of physical deterioration through the reliable monitoring, identification and assessment of all patients’ conditions in all environments.

17. PIER Escalation The reliable communication of deterioration using a ‘common language’ recognised across the NHS with high quality, structured communication. | National Patient Safety Improvement Programmes 17

18. PIER Response Timely actions taken to respond, including review by appropriately senior clinicians and reliable activation of clinical interventions including acute or end of life treatment appropriate to the patient and setting. | National Patient Safety Improvement Programmes 18

19. Challenges

20. What is a patient safety network? | National Patient Safety Improvement Programmes 20

21. How the Patient Safety Network can help deliver the programme • Key to delivering safety improvement at a sub-regional level by aligning local systems more closely within an improvement framework • Promote sharing, cross-working and increase the speed of uptake of innovation and successful change ideas • Organisations within the system remain autonomous but receive support from within the network to deliver locally responsive safety improvement work • Formed through groups of individuals, organisations and agencies – organised on a non-hierarchical basis around common issues or concerns, which are pursued proactively and systematically • Developed on the foundations of commitment and trust | National Patient Safety Improvement Programmes 21

22. Verity Mather- Project Manager Patient Safety & Care Improvement Team

23. Improvement in Systems Training Offer | National Patient Safety Improvement Programmes 23 Supporting the Improvement:  Quality improvement tools  Human factors  Coaching methodologies The goal:  Understanding their current systems  How best to implement the new PEWS charts  Offer guidance in trusts local measures of improvement.  Assist in the evaluation of the chart implementation.

24. Next Steps Deterioration pathways Site Assessment Survey: Training needs Patient and family involvement Communication and escalation Training prior to implementation testing Utilise the QI knowledge: Influence Culture Mindsets | National Patient Safety Improvement Programme 24

25. Children and Young People Transformation Programme System-wide Paediatric Observations Tracking (SPOT) Programme Paediatric ManDet Patient Safety Network October 2021

26. 26 www.england.nhs.uk Towards a national Paediatric Early Warning Score for England…. The lack of a single, nationally validated system to recognise and respond to acutely unwell children in England presents a risk to patient safety. It is also a challenge for staff who work across sites where different scoring systems are used. Many children are appropriately managed, but sadly local and national case reviews have shown that this is not always the case. Scotland, Northern Ireland and the Republic of Ireland have rolled out national Paediatric Early Warning Score (PEWS) charts across all inpatient settings and there has been call to do the same for children in England. The English PEWS programme board, which came together in June 2018 with representation from NHSE/I RCPCH and RCN. The use of a national early warning score in adults, NEWS2, has standardised the approach to acute deterioration. Developing a parallel system for children is hoped to realise the benefits seen with NEWS2.

27. 27 www.england.nhs.uk How did we develop a standardised chart… As part of the PEWS Programme Board’s work, a number of working groups were held via teleconference between August 2018 and August 2019. These working groups collectively established the scope and principles of a universal PEW System. 1.2018/19 a UK-wide PEWSystem survey • This was conducted to ask NHS organisations with paediatric in-patient settings to assess their current PEW System for the early identification of potentially critically unwell children. • A similar survey, conducted in 2011, showed that the implementation of a PEW System in the UK had increased from 21% in 2005 to 85% in 2011. 1.A review of PEWS charts: a selection of PEWS charts from around the UK were analysed to identify similarities and differences. The main findings demonstrated: • a variety of age brackets used; • variation in how scores are calculated; • variation in whether higher or lower scores represent increasing severity/concern; • similarity in most types of physiological observations measured; • that many incorporated additional tools (e.g. for sepsis screening); • that most had hospital specific information such as contact details for response teams; • that most showed similarity in the overall format and visuals. On 24th September 2019, the Board brought the working groups together. The primary aim was to identity areas of clear consensus and those areas where it was likely further discussion would be needed. Following this, a consensus was reached with the working group and a trial ready version created.

28. 28 www.england.nhs.uk Prototype chart and escalation guidance….

29. 29 www.england.nhs.uk

30. 30 www.england.nhs.uk Case for standardisation and de-implementation evaluation….

31. 31 www.england.nhs.uk SPOT – System-wide Paediatric Observations Tracking ambitions… To create a platform that facilitates a standardised and interoperable method of tracking and detecting the deteriorating child. This PEW system will adapt and expand the inpatient PEWS into ED, community, ambulance and primary care, creating aligned tools, training in communication and evaluation to deliver a cross-system approach to acute deterioration in paediatrics. The basic levels should be achievable by all providers of acute services, if not already in place. The higher levels will require a system-wide approach and incorporate a more systematic action to identify acute serious illness in children. The highest level will also enable a systematic approach to data collection, audit and quality improvement in the field of acute deterioration.

32. 32 www.england.nhs.uk The Governance during in-patient testing…. NHS England and NHS Improvement Executive Boards Children and Young People Programme Board Chair: Sarah-Jane Marsh Vice Chair: Russell Viner SPOT Delivery Board Children and Young People Stakeholder Council Chair: Russell Viner Reporting from other national programmes SPOT Testing Collaborative (Inpatient PEWS) SPOT Testing Steering Group SPOT Clinical Advisory Group Training and education elements Implementation and clinical evaluation elements SPOT Testing Oversight Team

33. 33 www.england.nhs.uk Oversight Team membership…. Named Attendee Organisation Role Damian Roland NHSEI University of Leicester NHS Trust Chair – Clinical Lead for SPOT Consultant and Honorary Associate Professor in Paediatric Emergency Medicine John Alexander University Hospitals of North Midlands RCPCH, SPOT Delivery Board member, Paediatrician - Childrens Intensive Care Gerri Sefton Institute of Child Health Alder Hey NHS Foundation Trust Co-CI for the DETECT study, ANP PICU, Rachael Bolland St George's Healthcare NHS Trust RCN, Delivery Board Member, Nurse Consultant Acute Paediatrics at Peter Davies Bristol Royal Hospital for Children Chair of Paediatric Critical Care Clinical Reference Group Clinical Director South West Paediatric Critical Care Operational Delivery Network Consultant Paediatric Intensivist Peter Marc Fortune NHSX Royal Manchester Children’s Hospital Clinical SRO | Digital Child Health & Maternity | Consultant Paediatric Intensivist | CCIO Caroline Haines Bristol Royal Hospital for Children Consultant Nurse - Paediatric Critical Care Heather Duncan Birmingham Children's Hospital Intensive care consultant Karl Emms Birmingham Children's Hospital Lead Nurse for Patient Safety

34. 34 www.england.nhs.uk Jan-Feb 2021 Spring 2022 May 2022 Summer 2022 Winter 2021 Autumn 2022 Publish Programme Overview + Case For Change documents Chart design with human factors input Trialling paper and digital SPOT in local sites Develop SPOT + ESPOT guidance documents National roll out paper and ESPOT into inpatient settings Engagement and adaption for non- inpatient settings Development of digital standards Publish inpatient SPOT guidance documents Development of ESPOT in non- inpatient settings Piloting ESPOT in non- inpatient settings, with development of guidance Publish (non- inpatient setting) guidance document National roll out of ESPOT into non-inpatient settings e.g. primary care and NHS111 October 2021 Late 2021 TBC SCOPING OUT OF HOSPITAL WORK INCLUDING CASCADING PULSE OXIMETRY We are developing and progressing work to spot deterioration in children, broadening the scope from in-patients…

35. 35 www.england.nhs.uk For more information… You can register for more information on the FUTURENHS Platform at: www.future.nhs.uk You can also contact the National SPOT team at: england.pews@nhs.net

36. National Patient Safety Improvement Programmes Adopt and Spread Delivered by: Led by: NHS England NHS Improvement @NatPatSIP / @MatNeoSIP www.improvement.nhs.uk North West Coast Patient Safety Collaborative Health Inequalities & Health Equity Assessment Tool (HEAT) Anika Neill Programme Manager, System Partnerships Verity Mather Project Manager, Patient Safety & Care Improvement

37. Wider Determinants of Health | National Patient Safety Improvement Programmes 37 www.gov.uk/government/publications/health-profile-for-england-2018/chapter-6-wider-determinants-of-health

38. Health equality vs health equity | National Patient Safety Improvement Programmes 38 Equality… • “Treat everyone the same” …which could cause inequalities • Avoidable • Unfair • Systematic differences Health Equity • Fair opportunity for all • Level playing field

39. Who experiences health inequalities? | National Patient Safety Improvement Programmes 39

40. AHSN Network Involvement & Co-production strategy: May 2021 | National Patient Safety Improvement Programmes 40

41. PHE: Health Equity Assessment Tool (HEAT) Tool for professionals across public health and healthcare landscape to: systematically address health inequalities and equity-related to a programme of work or service identify what action can be taken to reduce health inequalities and promote equality and inclusion HEAT is best used by a group that includes professionals who can speak to their own communities about the equity issues or in a dialogue with wider stakeholders and service providers | National Patient Safety Improvement Programmes 41

42. Why use HEAT to ensure health equity in our work? | National Patient Safety Improvement Programmes 42 Tools, training module, case studies and worked examples •Clear & straightforward framework – 4 stages •Supports to identify concrete actions & prioritise effort •Can be used across a range of work programmes & services / embedded •Measurable service & programme improvements

43. Applying the Tool Identification of Deterioration in Children: Reduce deterioration-associated harm by improving the prevention, identification, escalation and response to physical deterioration, through better system co-ordination and as part of safe and reliable pathways of care. NW Coast: PHE Local Authority Health Profiles Joint Strategic Needs Assessment Different aspects of health inequalities in different environments: Acute In-patient settings Emergency departments Primary care | National Patient Safety Improvement Programmes 43

44. Taking Action | National Patient Safety Improvement Programmes 44 Innovation Agency  Share and collaborate across the region.  Paediatric clinical lead  Work alongside PPI leads  Advocate use of QI tools  HES data review  Join regional C&YP forums Acute Trusts  Support baseline evaluation of patient, family & carer engagement.  Patient safety reviews.  Advocate an awareness of health inequalities. System Approach  Stakeholder engagement.  Explore social media/ digital options.  Influence improvement of access to services.  Support adaptation of health information.

45. Thank you Any Questions? | National Patient Safety Improvement Programmes 45

46. Planning for Paediatric Respiratory Viral Infections Vicky Webster Clinical Nursing Lead Dr Vanessa Holme Dr Santhosh Davis Kirsty Hamer – Pennine Lancs CCG

47. Background information In last 12 months we saw a dramatic reduction in the prevalence of common paediatric respiratory viruses This was a significant factor in the 40% reduction in paediatric emergency admissions in winter 2020-21 An increasing cohort of pregnant women, young infants and children have never been exposed to these viruses. Risk identified that this could lead to a surge in infection when face and space and other infection prevention measures were relaxed Publication of a national letter advising systems for plan for this surge Modelling undertaken based on Australia and NZ suggested a 20-50% increase in RSV infection

48. Potential Scenarios

49. What did we do –we knew we had to work as a system • Each Region was asked to submit an RSV surge plan to detail how they would respond to the increase in demand – including critical care capacity in the tertiary centres • PHE released a toolkit for communication messaging which has been widely circulated • We started to monitor all our hospital activity daily and started a daily sitrep call to manage demand across our hospital sites • We provide updates to Gold Command, the Hospital Cell, Regional Critical Care Cells and the L&SC Adult Critical Care Cell – ensuring a ‘joined up approach’

50. Processes / guidance – ensuring a safe approach • Mutual aid and transfer policy agreed at the Hospital Cell for L&SC ( with access to additional transfer vehicle – non NWTS) • Respiratory syncytial virus 2021 preparedness Children’s safer nurse staffing framework for inpatient care in acute hospitals • Staffing frameworks in place for both tertiary centres • Escalation process commenced

51. System wide approach to planning We knew we needed to involve our whole system Patient safety has been at the heart of our planning Consistency of resources and information provided Ensured regular meetings and updates are provided

52. Support underway for Primary Care Aim – consistent assessment approach • Bid finalised for pulse oximeters- to include baby and paediatric probes ( now ordered) • Training videos produced by acute colleagues – basic SAO2 monitoring; how to conduct the complete paediatric assessment; how to apply a saturation probe to a ‘wriggling child’ • Access to hot clinics / urgent advice • Resources to support assessment – including links to Healthier Together Pathways and parental advice leaflets to be circulated

53. Getting the sick children to hospital and support for self care • Successful grant bid to extend education to harder to reach communities via VCFSE – using a Community Champion model • Talks commenced re adopting the Healthier Together app and website • Partnership working commenced with Primary and Secondary care colleagues - to allow pathways to be developed for children falling into the ‘amber ‘ category of assessment (respiratory) • Discussions progressing re ‘respiratory / acute breathing hub’ models and the digital technology that might support this.

54. Pennine Lancashire System Response to ICS Plans

55. Responding to Paediatrics Winter Demand in Pennine Lancashire Working together the process and plan • ICP system wide cell established consisting of: – Secondary Care – Primary Care – NWAS – Out of hours • Meeting weekly • Data analysis of expected pressure across the system • Development of joint pathway based on the national adult pathway model to ensure children and young people seen and treated in the right place at the right time • Development of Pennine Lancashire Plan

56. Data Analysis Average seasonal RSV-attributable burden of general practice episodes Average seasonal RSV-attributable burden of hospitalisations 70.8% Surge Scenarios 70.8% Surge Scenarios Respiratory Outcome Age Average Scale up to 12 months 0% 20% 50% Average Scale up to 12 months 0% 20% 50% Respiratory disease <6 Months 393 555 555 666 833 114 161 161 193 242 6-23 Months 1182 1669 1669 2003 2504 116 164 164 197 246 2-4 years 1535 2167 2167 2600 3251 23 32 32 38 48 5-17 years 1090 1539 1539 1847 2309 0 0 0 0 0 Acute Upper Respiratory disease <6 Months 234 330 330 396 495 0 0 0 0 0 6-23 Months 672 949 949 1139 1424 0 0 0 0 0 2-4 years 750 1059 1059 1271 1589 0 0 0 0 0 5-17 years 480 678 678 814 1017 0 0 0 0 0 Bronchitis/bronchiolitis <6 Months 204 288 288 346 432 102 144 144 173 216 6-23 Months 516 728 728 874 1092 69 97 97 116 146 2-4 years 415 586 586 703 879 12 17 17 20 26 5-17 years 237 335 335 402 503 3 4 4 5 6 Pneumonia and influenza <6 Months 4 6 6 7 9 2 3 3 4 5 6-23 Months 15 21 21 25 32 10 14 14 17 21 2-4 years 21 30 30 36 45 10 14 14 17 21 5-17 years 23 32 32 38 48 4 6 6 7 9 Otitis media <6 Months 13 18 18 22 27 0 0 0 0 0 6-23 Months 212 299 299 359 449 0 0 0 0 0 2-4 years 534 754 754 905 1131 0 0 0 0 0 5-17 years 439 620 620 744 930 0 0 0 0 0 Antibiotic Prescription <6 Months 227 320 320 384 480 0 0 0 0 0 6-23 Months 1089 1537 1537 1844 2306 0 0 0 0 0 2-4 years 1524 2152 2152 2582 3228 0 0 0 0 0 5-17 years 1068 1508 1508 1810 2262 0 0 0 0 0 12877 18180 18180 21817 27275 465 656 656 787 986 0 3637 9095 0 131 330 Modelling estimates of the burden of respiratory syncytial virus infection in children in the UK BMJ June 2016 Surge Modelling on respiratory predicts 9,095 additional appointments in primary care and 330 additional admissions to secondary care in Pennine Lancashire

57. NHS 111 Parent calls/presents direct to practice Options available: • Referral to Children’s Community Nursing Service for follow-up/observation/monitoring • Paediatrician HOT Line for urgent advice and guidance • Referral to Paediatric HOT Clinic (via the Paediatrician HOT Line) • Referral to Children’s Observation and Assessment Unit SEVERE MODERATE MILD Community services referral to include social prescribing, community matron, neighbourhood teams Pennine Lancashire Pathway for the Management of Acutely Unwell Respiratory Children in Primary Care NWAS Point of presentation Outcome of Assessment Monitoring Ongoing Assessment Assessment Severity Pathways Self-care, self-escalation and safety netting advice given to patients/carers A single website for all resources Children https://what0-18.nhs.uk/ RED SYMPTOMS AMBER SYMPTOMS GREEN SYMPTOMS Discharge Self-care, self-escalation and safety netting advice given to patients/carers Referral to Children’s Observation and Assessment Unit (COAU) Discharge Primary Care OOHrs CAS Point of Care testing – where available Hospital Assessment: Refer directly to COAU (by phone) or consider 999 if severe illness Clinical judgement is paramount Discharge Triage To ED Triage To ED View links to Management and Treatment guidance PROMPT FIRST ASSESSMENT in Primary Care View link to pathway schematic

58. Strengthen: Pathways and Processes • Acknowledging remote assessment as part of the process in both primary and secondary care – but face to face a key requirement in escalation of cases • Ensure all parts of the system are following the same pathways • Direct referral into our Children’s Observation and Assessment Unit rather than ED • Address acceptance criteria of services to improve flexibility when demand is high

59. Enhance: Additional Capacity into the System • Extension of children’s community nursing service 8am to 10pm, 7 days • Additional HOT Slots for children who need to be seen urgently • Promotion of paediatric hotline • Promotion of the Healthier Together pathways, with local information • Promotion of training packages, pulse oximeters and patient information • Primary Care Launch of enhanced offer and Desktop Icon with all pathways and local information in one place on EMIS

60. Innovate: New hub model? In line with national thinking around community assessment hubs and virtual wards Assessment at Hub (Observations may be completed by CCN) Allocate Green/Amber/Red via clinical pathways AMBER Salbutamol (check inhaler technique) x 10 ‘puffs’ via inhaler and spacer • Oral Prednisolone as per guideline ASTHMA > 1 yr of age • Reassess after 20 – 30 minutes GREEN Home with appropriate safety netting AMBER Transfer to COAU as appropriate CROUP Keep child & family calm Dexamethasone 0.15mg/kg / pred 1mg/kg Reassess after 30 mins BRONCHIOLITIS Consider observing feeding And referral to CCN for virtual follow up FEVER (particularly tachycardia) Consider Anti- pyretics if not been given Reassessment in 30 minutes IMPROVED WITHIN 60 MINS OF ASSESSMENT YES NO

61. Lessons learned • System buy-in – having strong clinical involvement across primary, community and secondary care • Being aware of the pressures across the system – everyone is stretched and tired • Difficulty in recruitment of staff both primary and secondary care to do the work – needs to be working differently

62. Challenges • ED’s and Assessment Units are busy , bed occupancy is rising. • Pressures evident in tertiary critical care beds • The respiratory admissions are not necessarily RSV (getting croup, asthma , viral induced wheeze, rhinovirus etc) • HDU admissions are a mix of conditions – certainly not just respiratory • Increase in CYP admissions for emotional health and well being needs. Update given at Board today • Challenges with complex discharges ie requiring therapeutic placements etc • Staffing challenges especially when considering escalation of bed capacity

63. Key resources • CS52646_NHS_Bronchiolitis_Pathway_Primary_and _Community_Care_April_21v2_2.pdf (what0- 18.nhs.uk) • CS52646_NHS_Croup_Pathway_Primary_and_Com munity_Care_April_21v2.pdf (what0-18.nhs.uk) • Bronchiolitis :: Healthier Together (what0- 18.nhs.uk) • Croup :: Healthier Together (what0-18.nhs.uk) • Reaching the Tipping Point – children and young people’s mental health Aug 2021).

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