Paediatric ambulatory service, King’s College Hospital

Staged over several years: Rapid access clinic – 2009, Paediatric phone line – a 2014, Healthcare at Home – 2014, Short Stay Unit (SSU) – 2014
Region: London
Geography: Urban

Background / Motivation

To deliver high quality healthcare for children, streamlining their patient journey and thereby optimise their patient experience.

The service model

Portfolio of clinical services targeted at meeting the needs of children and their families

1. Education – annual paediatric GP conference at King’s College Hospital delivering interactive lectures on clinical topics of importance to GPs. The feedback collated is proactively utilised to refine the programme content, to ensure ongoing relevance to a primary care audience. There is also education provided at CCG-organised annual paediatric educational events – there are 3 dedicated, free events per annum for formal paediatric learning for local GPs from Lambeth and Southward CCGs.
2. Paediatric Phone Line – since June 2014 there has been a phone line for GPs to speak directly to a paediatric consultant between 8am-10pm on weekdays and 8am-5.30pm on weekends. This optimises patient care by enabling timely, reciprocal discussion with the most appropriate hospital-based paediatrician and thereby facilitates streamlining of outpatient referrals, a reduction in numbers of inappropriate paediatric emergency department (PED) attendances and stronger professional relationships between primary and secondary care. The phone line is also used by junior doctors who require senior advice from the duty paediatric consultant in the hospital, and this enables timelier decision-making in PED, improved clinical care and avoidance of unnecessary admissions.
3. Rapid access clinic – this has been running since 2009 and in July 2014 there was expansion to provide a clinic on every weekday. Referrals are accepted from primary care by phone, email or fax and patients are seen within 2 weeks of referral (although this can be expedited if required).
4. Email advice – using the established ‘choose and book’ system, local GPs can email enquiries for clinical advice to a consultant paediatrician. The response time during weekdays is 24 hours.
5. Outreach clinics – a consultant paediatrician delivers a monthly primary care clinic alongside a GP partner. They see patients together, who would otherwise have been referred to a hospital outpatient clinic. Each clinic is preceded by a lunchtime teaching session with the wider primary care team, and there is opportunity for discussion of specific patients’ management following the clinic. The clinics provide reciprocal learning opportunities for both clinicians. Patient feedback is very positive
6. Healthcare at Home (HAH) – a clinical service providing consultant-led, nurse-delivered acute paediatric care and short term conditions in the home (or school). The HAH nurses are integral members of the general paediatrics team and they attend the morning general paediatric handovers 7 days a week (this services to optimise the referral rate). Once the child has been referred they meet with the family whilst they are still inpatients (ensures continuity of care from hospital to home setting). The nurses can visit children up to 4 times/day to administer medication, provide wound care, perform observations and provide clinical reviews. Care episode notes are recorded electronically on tablets in the home and these notes are linked back to the hospital based electronic patient record. All patients are reviewed during a daily consultant-led virtual ward round, which is conducted in person between the HAH nurses and consultant. (The innovative use of IT facilities this and provides an accessible, continuous record of patient care until their discharge date.) The initial goal was to expedite discharge from hospital and this has been achieved. The service has subsequently evolved to facilitate direct admission to HAH from PED following a paediatric consultant review. This new pathway avoids hospital admission for some.  Children are accepted onto the service based on clinical need and capacity.
7. SSU – This 48 hour 6-bedded, Consultant-led unit was opened in June 2014. It is complemented by strong nursing leadership. Paediatric patients with medical and/or surgical health needs are eligible for admission. All patients must be discussed with and/or reviewed by a consultant prior to admission. There are twice daily consultant led ward rounds. There is proactive discharge planning. Since opening the unit, they have found that there has been a significant reduction in elective paediatric surgical cancellations. It has also enabled optimised care for children with mental healthcare needs that are admitted.
8. Hospital at Home– an 18 month pilot program funded by Lambeth, Southwark and Lewisham CCGs. This nurse led service takes primarily referrals from the PED with a view to supporting families at home following their child’s acute attendance. The nurses provide clinical assessment and advice regarding acute illnesses and health promotion advise with a view to positively impacting on modifying the family’s healthcare

Opening times

Paediatric Phone Line –8am-10pm on weekdays and 8am-5.30pm on weekends. Healthcare at Home-7 days a week  8am-10pm. Outreach clinic is monthly.

Staffing

Five Paediatric Consultants

Who can refer

GPs, Community midwives (via PED), PED clinicians.

Who is accountable for patients

The named Consultant Paediatrician

Resources

Staff costs £ 1,838,063;  Ward-related costs: £328,890;Total cost: £2,166,953 Total income from additional elective and outpatient activity: £ 1,619,980 Net cost: £ 546,973

Funding organisation

King’s College Hospital

Level of patient/family involvement

Patient feedback collected for every child and family utilising the service

Evaluation

Hospital at Home service has saved 841 inpatient bed days (£336K cost saving). 121 Paediatric ED attendances and 26 hospital admissions prevented by GP hotline. 466 patients admitted to Paediatric SSU with median length of stay of 18 hours. 33% reduction in PED 4 hr breaches. 37% reduction in paediatric surgery elective cancellations. Patient satisfaction questionnaires reported that 100% of families would recommend the short stay unit to their friends and family.

Challenges, successes, lessons learned and advice

Consultant rota model needed modification to make it a long term sustainable work pattern.

Stakeholder engagement for some professional groups was a challenge but this rapidly improved once the service was in operation and the patient benefits were demonstrated.

Contact for more information

Dr Omowunmi Akindolie, Consultant in Ambulatory Paediatrics

Omowunmi.akindolie@nhs.net

0203 2994697

In: Case studies

Tagged: acutely unwell children and young people: compendium of new care models, children and young people, Out-of-hospital care

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