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Modelling the potential impact of new out-of-hospital models of care on paediatric emergency department presentations Russell Viner, Professor of Adolescent Health, UCL
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Authors Russell Viner Francesca Blackburn Francesca White Randy Mannie Tracy Parr Clare Lemer Anna Riddel Mando Watson Francesca Cleugh Michelle Heys Dougal Hargreaves
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Background to the data collection
A major component of better integrated care is improving urgent care for children and young people (CYP). Few data are available to guide commissioners/providers in planning OOH models to reduce ED presentations.
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Methods Prospective data collection on sequential CYP <18 years presenting to 6 busy EDs across London 10am-10pm over 14 days (Feb-March 2016). Supernumerary clinician collected data on diagnosis, severity and clinical need for investigations and management. Algorithms based upon clinical need used to assign patients as being appropriately managed in a range of new OOH models. Models were identified from literature and service review.
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Description of models Model Descriptor Site Segments Investigations
Management Clinician expertise Obs facility? Health education A. Current primary care Community pharmacy Community pharmacy with pharmacists providing walk in care for basic illness and minor injuries Illness + Injury Nil Reassurance Health Education Oral rehydration Antipyretic Analgesia Bronchodilator Pharmacist No Yes Standard GP practice GP practice offering appointments during standard working hours GP practice illness Basic Ix Basic lab Ix 48h Micro 48h All excluding: Minor injury NG or IV fluids Inpatient Rx Resuscitation GPs Practice nurse
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Description of models Model Descriptor Site Investigations Management
Clinician expertise Obs facility? Health education B. Enhanced primary care Enhanced GP practice GP practice with extended hours, walk-in opportunities; regular visits/contact with Paediatrician GP practice illness Basic Ix Basic lab Ix 48h Micro 48h All excluding: Minor injury NG or IV fluids Inpatient Rx Resuscitation GPs Practice nurse Paediatrician 48H No Yes GP confederation CYP service APNPs and GPs working within GP confederation with extended hours: coverage includes minor injuries plus illness; regular visits/contact with Paediatrician Illness + Injury APNPs
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Description of models C. Enhanced illness assessment and management models Nurse-led Acute Illness Team for CYP APNP appointment-only service, using strict algorithms to manage a very limited set of common illnesses GP practice 1. Transiently unwell child 2. Exac of LTC 3. Complex LTC / Disability Basic Ix Basic lab Ix 48h Micro 48h Reassurance Orals Bronchodilator inhaler APNP No Limited Walk-in Nurse-led Centre for Illness in CYP Walk-in centre with APNPs using algorithms to manage a limited set of common illnesses Community centre Yes <6hrs Multi-speciality Community Provider for CYP MCP providing appointment-only service focused on illness, including nurses, GPs and daily Paediatrician input. Broad range of illnesses treated. Basic lab IX 48h XR & US 48h GP Nurses Pharmacist Paediatrician 12H
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PACS (Primary & Acute Care System) Acute Health Centre for CYP
Description of models D. Comprehensive assessment and management models Walk-in Centre for Illness & Injury in CYP APNPs in walk-in centre using algorithms to manage a limited set of illnesses and common injuries. Paediatrician input available within 48 hours. Community Centre 1. Transiently unwell child 2. Exac of LTC 3. Complex LTC / Disability 4. Injury Basic Ix Basic XR Basic lab IX 48h Micro 48h Reassurance Orals Bronchodilator inhaler Oral rehydration Basic resusitation GP Nurses Pharmacist Radiographer Paediatrician 48H Yes <6hrs Limited PACS (Primary & Acute Care System) Acute Health Centre for CYP GPs, APNPs providing a walk-in service for CYP on hospital site with rapid access (<4 hours) to paediatric and other specialists, thus able to manage a very broad range of illnesses and injuries GP practice on Hospital site Lab IX 12h Micro 12h XR & US 12h All management excluding IV fluids or IV treatments. Paediatrician 4H Other disciplines or specialists 4H Yes
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Patients 3020 children – Median age 6.2 years , 53% <5 years
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42.2% judged to have been totally avoidable if the family had had better health education.
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% potentially manageable % <5yrs potentially manageable
Model % potentially manageable % <5yrs potentially manageable Current primary care Community pharmacy Community pharmacy with pharmacists providing walk in care for basic illness and minor injuries 9.5% 10% Standard GP practice GP practice offering appointments during standard working hours 22.3% 28.5% Enhanced primary care Enhanced GP practice GP practice with extended hours, walk-in opportunities; regular visits/contact with Paediatrician 28.4% 37.4% GP confederation CYP service APNPs and GPs working within GP confederation with extended hours: coverage includes minor injuries plus illness; regular visits/contact with Paediatrician 44.6% 51.8%
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Model % potentially manageable % <5yrs potentially manageable Enhanced illness assessment and management models Nurse-led Acute Illness Team for CYP APNP appointment-only service, using strict algorithms to manage a very limited set of common illnesses 14.1% 19.2% Walk-in Nurse-led Centre for Illness in CYP Walk-in centre with APNPs using algorithms to manage a limited set of common illnesses 28.4% 39.7% Multi-speciality Community Provider (MCP) for CYP MCP providing appointment-only service focused on illness, including nurses, GPs and daily Paediatrician input. Broad range of illnesses treated. 25.7% 33.4% Comprehensive assessment and management models Walk-in Centre for Illness & Injury in CYP APNPs in walk-in centre using algorithms to manage a limited set of illnesses and common injuries. Paediatrician input available within 48 hours. 64.3% 65.6% PACS (Primary & Acute Care System) Acute Health Centre for CYP GPs, APNPs providing a walk-in service for CYP on hospital site with rapid access (<4 hours) to paediatric and other specialists, thus able to manage a very broad range of illnesses and injuries 75.5% 76.4%
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Summary High proportions of ED presentations by CYP could potentially be managed in current or new OOH models Primary care 26% appropriate for current primary care offer (GP and Community Pharmacy) Extended to 32% with simple enhancements to primary care Improved access paediatrician advice Further enhancement across GP Federation could manage up to 45% Nurse-led community models Useful if range of conditions is not too narrow – up to 28% managed Comprehensive models Potentially manage up to 75% of ED presentations
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Next steps? What should be the next steps for the Alternative Models of Care data? Discussion and answers on a flip chart please!
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