Implementation of recommendations for the care of children in UK emergency departments: national postal questionnaire survey

In June 1999 an intercollegiate working party of Royal College of Paediatrics and Child Health, British Association of Accident and Emergency Medicine (BAEM), British Association of Paediatric Surgeons, Faculty of Accident and Emergency Medicine, Royal College of Nursing (RCN), and Royal College of General Practitioners was established. Terms of reference were to review emergency services for children and to make recommendations for future provision of these services. The subsequent report—Accident and Emergency Services for Children (AESC)—made 32 recommendations (representing minimum levels of care), to be implemented by 2004.¹

Participants, methods, and results

We sent questionnaires to lead emergency doctors (listed in the BAEM's directory of 2001-2) between Oct 2003 and Jan 2004 about the recommendations. Nonresponders were re-sent the questionnaire.

Of 219 departments with inpatient paediatric facilities,² 139 (63%) replied (table). In all, 47 (34%) of replying hospitals saw more than 18 000 children annually; 41 (87%) were district general hospitals. Only 64 (29%) departments with separate paediatric emergency facilities responded; the 71% that did not respond accounted for 47% of nonresponders, many seeing more than 18 000 children annually.

Table 1.

Facilities, function, and staffing of 139 UK paediatric emergency departments

	No (%) of responses from the targeted UK emergency departments
Facilities
Trusts where children may be seen first for emergency conditions outside the emergency department	95 (61)
With triage and resuscitation facilities	63 (40)
Function
Separate paediatric triage	56 (35)
Triage by trained nurse	36 (22.9)
Pain score used at triage	143 (90)
National triage scale used	129 (82)
All paediatric surgical cases can be managed on site	113 (70)
Provision for children in major incident plan*	14 (10.1)
Ability to maintain level 2 care†	24 (15)
Adequate audiovisual separation	104 (64)
Play area or separate waiting area	147 (94)
Paediatric resuscitation area screened from adult patients	123 (78)
Patient information	131 (82)
Leaflets available in languages other than English	28 (17.8)
Staffing: nursing
Not having at least one children's trained nurse on duty at all times	107 (68)
Senior nurse coordinating	113 (72)
Nurses attended paediatric advanced life support course	84 (53)
Staffing: medical
No of consultants with recognised training	102(64)
In departments > 18 000 children a year	14 (30)
Designated liaison paediatrician	119 (78)
Interaction with other agencies
Induction programme including child protection	127 (91.7)
Informing primary care about attendances	129 (92.9)
Bereavement policy	120 (87)

^*Nine (7%) did not know if children were included in the major incident plan.

^†Level 2 care is continuous nursing supervision where the patient may be ventilated and needs support of two or more organ systems.

Although currently 41 departments have separate paediatric emergency departments, 92% of children attend general departments; these show the largest differences from recommendations of the AESC report. In 1997, 10% of hospitals did not have inpatient services onsite³ now only 1.9% do not (minor injury units excluded).

Wards are safe for only the initial reception of emergency admissions if appropriately equipped and staffed for reception, triage, and resuscitation¹; these criteria are often not met.

Assessing the severity of illness is essential, but a quarter of departments seeing more than 18 000 children a year do not have separate triage facilities, and 23% do not triage children with an appropriately trained nurse. Although the pain assessment tool and the national triage score are used widely, their effectiveness must be questioned where non-trained staff are triaging. Level 2 care, while awaiting a paediatric retrieval team (children's mobile intensive care unit), is delivered in 85% of departments, often at cost to emergency, paediatric, and intensive care services. The current trend of centralisation means that emergency staff must deliver this care, so there must be the appropriate mix of skills on duty.

In 1996, 30% of hospitals did not cater for children within major incident plans (required by the National Service Framework for children and young people)⁴,⁵; fewer now have children in their plans.

The National Service Framework expects emergency professionals to do courses in paediatric life support and to regularly update; currently, 47% of nurses do not attend such courses.

Comment

One in four patients presenting at emergency departments is a child. Child centred good quality care which is accessible at the right time is required, however there is considerable room for improvement in the care of children in emergency departments. This government has recognised unacceptable variations nationwide in the quality of care for children and wants to eliminate these differences (the National Service Framework).⁴,⁵ The framework allows adult nurses to care for children only within the limits of their knowledge and should be under direct supervision of a children's trained nurse. Recruitment and retention of nursing staff is a problem in emergency departments. The Royal College of Nursing recommends rotational posts with community nursing and paediatric wards. The number of applicants for training in children's nursing exceeds the number available, so structured investment in nurse training may provide the necessary skilled nurses.

What is already known on this topic

Paediatric emergency services were under resourced in the United Kingdom, a report in 1999 found; the report made recommendations for improvement

What this study adds

Current emergency services for children in the United Kingdom still fall short of these essential recommendations

The AESC recommends that hospitals seeing more than 18 000 children should have a consultant in paediatric emergency medicine by 2004 and in all emergency departments by 2010. This, along with many of the other AESC recommendations made five years ago, has not been met and without future investment in staffing and facilities a child centred service will be hard to achieve.