Master slide deck from the Responding to Non COVID-19: Identification of deterioration in children Patient Safety Network on Monday 18 October 2021..

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
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10. NatPatSIPs national driver diagram

11. All NatPatSIPs: Key enablers for system safety
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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
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14. | National Patient Safety Improvement Programmes
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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
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16. PIER
Identification
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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.
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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.
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19. Challenges

20. What is a patient safety network?
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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
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22. Verity Mather- Project Manager Patient Safety & Care
Improvement Team

23. Improvement in Systems Training Offer
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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
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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
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www.gov.uk/government/publications/health-profile-for-england-2018/chapter-6-wider-determinants-of-health

38. Health equality vs health equity
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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?
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40. AHSN Network Involvement & Co-production strategy: May 2021
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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
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42. Why use HEAT to ensure health equity in our work?
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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
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44. Taking Action
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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?
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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).