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CHAPTER TEN: EMERGENCY CARE

The Action Framework identified 2 targets and 5 milestones for measuring performance in emergency care and listed 6 associated actions.

10.1 TARGETS AND MILESTONES

Existing targets

Consultees were asked whether they agreed that existing targets for emergency care remain relevant for children and young people in a 21 ^st Century Scotland. As shown in table 10.1, over four-fifths (83%) agreed.

Table 10.1
5: Whether existing targets for emergency care remain relevant for 21 ^st Century Scotland

Base: All those responding in each category

Maximum 4 hour waiting time from arrival to discharge or treatment

Consultees were given the opportunity to comment on the targets and 4 consultees included comments on the 4 hour target time, with three suggesting that this time should be shorter. One Voluntary/ Charity Body felt "it would be beneficial for children and young people with PMLD who find it difficult to wait or had challenging behaviour to be fast tracked through A&E". However an NHS Management & Strategy consultee suggested that completing treatment within a casualty department, even if this takes over 4 hours, is preferable to admitting a child. In addition, 2 consultees highlighted concerns over accessibility and treatment in remote and rural areas. One Individual (Professional) expressed concern that this target time would "encourage presentation to A&E of families with conditions that may be better addressed by primary care or other community providers."

75% of emergency calls responded to within 8 minutes

Four consultees commented on the second target. One gave a general welcome to the target while two favoured increasing the percentage of calls. One NHS Service Provider felt "Emergency response needs to reflect rural locations, poor weather conditions and remoteness."

In addition, one Individual (Professional) wondered whether the targets should include dealing with bereaved families in A&E while an NHS Service Provider suggested that Minor Injury Sites also be included in the targets.

Milestones

Consultees were then asked whether they agreed with the 5 milestones listed in the Action Framework. In each case a large majority of those responding at each question expressed agreement.

Care pathways for the 10 commonest conditions

Table 10.2
6: Care pathways in place for 10 commonest conditions developed and implemented by 2008

Base: All those responding in each category

Twelve consultees took the opportunity to comment on care pathways for the 10 commonest conditions. Four consultees requested clarification on what the conditions are, or how they would be determined, while 2 felt that this should instead refer to high-risk conditions, identified via risk assessments. One NHS Board felt the pathways should be drawn up nationally while a Royal College felt "explicit identification to 10 commonest conditions will be important".

Concerns were expressed, by 2 consultees, that the care pathways may be difficult to develop, implement or utilise. One consultee queried whether there would be AHP involvement in the care pathways. One Professional Body stated that "We are concerned about the potential for overly rigid service delivery which can result from a 'one size fits all' approach to care pathways".

Explicit arrangements within each region regarding role of emergency care sites

Comments on emergency care sites included the need for good communication between stakeholders (mentioned by 2 consultees), while an NHS Board felt " links with regional emergency care sites are improving, however more clarity is required for admission/transfers")

One Local Authority felt that the setting for treatment may depend on the "the clinical nature and their psychological development" and therefore an adult specialist may be a better option in some cases, and a Voluntary/ Charity Body felt that flexibility is required within adult services. A Royal College also felt that it was important to consider the emotional and psychological needs of Children and Young People ahead of facilities.

Table 10.3
7: Explicit arrangements within each region regarding role of every emergency care sites for the provision of paediatric services by 2007

Base: All those responding in each category

Local NHS systems reviewed on progress against delivery of the ECF by 2007

Again, the majority of those responding at this question expressed agreement and there were no specific comments on this milestone.

Table 10.4
8: Local NHS systems reviewed on progress against delivery of the ECF by 2007

Base: All those responding in each category

Availability of a module of core skills and competencies for staff proving emergency care by 2007

One Professional Body felt that this milestone is "essential, as in many places the children's nurse may be a lone worker and there is no 24/7 provision by children's nurses."

Table 10.5
9: Availability of a module of core skills and competencies for staff providing emergency care to children and young people by 2007

Base: All those responding in each category

Other comments on this milestone, each from one consultee, included:

• a suggestion of separate core competencies for a variety of emergency care needs;
• the need to give thought to accessibility of the module for remote and rural staff;
• careful planning to ensure training is relevant and appropriate;
• the need to include disability awareness training, including methods of communication.

Staff providing emergency care have achieved core skills and competencies by 2008

Three consultees highlighted the resource and time implications while a Professional Body felt that the target may be ambitious due to the number of staff involved. One NHS Management & Strategy consultee recommended that a "scoping exercise is carried out to establish robust workforce figures in order to inform educational planning."

Accessibility issues for remote or rural staff were raised by 2 consultees and this included a suggestion that tele-health decision support should be included.

The lack of child nursing training among staff in district general hospitals and a shortage of GP paediatricians were raised, each by 1 consultee.

Two consultees mentioned other staff who should also achieve the core skills and this included multi-agency staff, for example a school first-aider, and community staff who may provide support or treatment after discharge.

One NHS Board felt that the core competencies should be defined by NES and monitored locally.

Table 10.6
10: Staff providing emergency care to children and young people have achieved core skills and competencies by 2008

Base: All those responding in each category

Other comments on milestones

Of the other, more general comments on the milestones for emergency care, the need for NHS 24 to be included in targets, training and pathways featured in 2 responses.

Two consultees identified stakeholders who, they felt, should be included in development; one mentioned service users and, the other, clinicians. Child Mental Health along with Paediatric Trauma and associated services were identified, by 1 consultee each, for inclusion in emergency care milestones.

Some concerns were raised, each by one consultee, and these included:

• resources and timescales;
• care pathways in transition between children's and adult services;
• how competencies will be maintained.

One NHS Management & Strategy Group felt the milestones should include details of who is responsible for delivery while another felt it "ambitious, possibly unrealistic to have this work completed" and another felt care pathways were overrated.

A Professional Body suggested mandatory rotation programmes to main centres in order to up-date clinical skills while another expected to see "close communication between the acute and community sector pre-discharge and the same level of commitment that is being shown to acute specific children, and young peoples nursing being shown to relevant specialists (public health and community paediatric nurses) in the community."

10.2 ACTIONS

The Action Framework listed 6 actions in relation to emergency care and invited consultees to comment. Responses from 30 consultees were mainly general in nature but some made points in relation to specific actions.

Implementation of the Emergency Care Framework

Two consultees commented on the implementation of the Emergency Care Framework; one Professional Body suggested this should happen before 2009 and a Royal College suggested progress should be measured to ensure implantation was not left until 2009. One NHS Management & Strategy Group felt that there would need to be a Health Department Letter to achieve this action.

Development of a multi-professional emergency care competency system

One NHS Management & Strategy Group agreed that a multi- professional emergency care competency should be implemented by NHS Education for Scotland and added that social work and social care professionals should be included in local multi-professional collaboration.

Another felt that a multi-professional emergency care competency should form part of the training for practitioners in remote and rural secondary care.

A Royal College felt that the competency should include skills to respond effectively the communication support needs of children, their families and carers.

One Individual (Professional) saw the opportunity to establish a core of qualified GPs who could then train others.

Level of care at emergency care sites

There was only one comment on this action, from an NHS Management & Strategy Group who commented " RGHs may be level 1+ or level 2 for child health services and models need to reflect their requirements".

Development of a standard assessment method

A variety of suggestions were put forward for this action including 2 consultees who highlighted the importance of including assessment of communication support needs or including those with complex or social care needs and learning disabilities.

One Education Body commented on the importance of standard assessment in emergency care and asked "How will all staff in E/C settings be regularly updated?"

Other suggestions included:

• the need for this to be multi-professional and not to only include secondary or tertiary specialists;
• the inclusion of clear guidance about child protection;
• for the assessment method to be electronic and to make use of existing data shared through a data store;
• consider linking to the integrated assessment framework;

Development of national guidelines and best practice statements

One consultee felt that these should be developed on a UK wide basis, another stressed that these would need to take into account geographical challenges. One Charity gave details of a guide for Emergency Care developed in their own health area.

Development of expanded roles for emergency care practitioners

Suggestions on this action included:

• that the Royal College of Nursing should be one of the professional bodies involved;
• the need to link emergency care competencies for adults with a similar one for children;
• the need to include social care expertise for children with complex needs in a formal manner, including at local level;
• the inclusion of an action around out of hours services and staff education;
• training on awareness of the needs of young carers.

One Professional Body commented "Expanded roles MUST (not should) consider needs of children and young people".

This was echoed by a general observation from an Individual (Professional) who commented "Change 'should' to 'will'. We have a tendency in Scotland to opt for recommendations rather than requirements so that things tend to drift and there is a lack of consistency on a national basis."

Other General comments on the emergency care actions

There were some other areas which consultees felt should be included in the actions:

• access to advocacy services;
• dual issues (drug or alcohol problems);
• mental health emergencies;
• provision of pharmaceutical care in emergency situations;
• the care environment.

The care environment was also mentioned by one Local Authority who commented "It may not always be possible to ensure appropriate facilities in the case of emergencies but in that instance it is even more appropriate to provide suitably trained staff to reassure and comfort as well as to liaise with parents", and a Professional Body who felt "The differences of children and young people are not reflected in hospital at night". Another Professional Body commented that the document did not address resource sharing where adult and paediatric emergency departments were on the same site.

The need for a consistent system for speedy access to information (health and social work data) was highlighted by 1 consultee while another suggested there should be Special Notes screens within the emergency duty service for all children with complex needs. This information should include resuscitation advice.

Children with complex needs were also the focus of one response, from an NHS Management & Strategy Group who commented on children with complex needs, in remote or rural areas, requiring emergency support;

"There can be a reluctance on behalf of both families and professionals (health) to send a child to a mainland hospital - emergency transport can in itself be difficult - this places pressure on essential community social care respite / support services to meet complex needs beyond their professional and role capacity: for although these social care services staff are expert in caring for children with complex needs they are not medical or nursing trained)."

One NHS Service Provider wondered whether there might be too many action points and suggested combining 30 with 31 and linking 27 and 29.

One consultee commented that plans for the new Children's Hospitals should take the actions on emergency care into account while another felt that planning for any hospital services should take account of mental health problems and liaise with Mental Health Services.

One Charity commented "The proposals for ensuring that staff have the required skills and competencies for providing care to children and young people are welcomed and it is hoped that this will go some way towards addressing the often negative assumptions, perceptions and attitudes of medical staff. A young person in pain and distress may be perceived as aggressive and defensive, and staff must be better trained to respond in an appropriate, non-judgemental, manner."

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