1. ACE – a new model for children’s urgent care
Anne Pinches – Staff Grade Paediatrician,
Bradford Teaching Hospitals NHS Trust
Mat Mathai – Consultant Paediatrician,
Bradford Teaching Hospitals NHS Trust

2. Background
Emergency care across the NHS in England is under great pressure
Four-hour ED target not met
CYP are frequent users of emergency care, attending ED more frequently than the adult population
Children are vulnerable and dependent on carers
Emergency care across the NHS is under great pressure. This is especially true at certain times of day and night and certain times of the year
Departments are struggling to meet the 4 hour target
Children and young people are frequent users of emergency care, attending ED more often than the adult population
Children are vulnerable and are dependent on their carers to bring them to hospital or GPs for treatment

3. National trends over the past 10 years
CYP use of ED continues to increase, particularly for infants and year olds
‘Ambulatory care sensitive conditions’ e.g. asthma and acute URTI are common
Average LOS has declined from 1.99 to 1.64 days
Same-day discharges have increased by 20%
Re-admissions to hospital after an emergency admission have risen by 10%-15%
CYP use of ED continues to increase, particularly for infants (a rise of 30%) and for 1 to 4 year olds (a rise of 25%)
‘Ambulatory care sensitive conditions’ e.g. asthma and acute URTI are common reasons for attendance
Average length of stay has declined from 1.99 days to 1.64 days. This is thought to be due in part to short stay units
Same-day discharges have increased by 20% representing 50% of all emergency admissions
Re-admissions to hospital after an emergency admission have risen by 10%-15%
Bradford specific data
Majority of urgent care managed successfully at home
Small number of diagnoses making up majority of presentations
Steady rise in A&E attendances
Children account for around 25% of A&E assessments at BTHFT
50% are ≤4 years
Attendance is highest at weekends
A&E peaks between 5 and 6 pm
Variations seen by Practice
Variations seen by Postcode
Around 17% of children arrive by ambulance
Around 70% of patients are discharged
5% of children seen in secondary care are admitted to a hospital bed

4. Increasing attendances
BTHFT figures for CYP
Increasing attendances
Age categories
Peaks in children and young people attending the ED in the winter. Lowest attendances in August.
Highest attendance is in the 0-1 age group and then gradually decreases with age

5. What is ACE?
An alternative pathway for GPs, ED and the Children’s Decision Area to use for sick children
Within a complex and fragmented healthcare system
Quality
Reduction in hospital admissions
Ambulatory Care Experience
“Step up” model of care. Aiming to keep children out of hospital and in their own homes as their condition allows.
Means that children and their parents won’t have long waits in ED and on children’s assessment units and can be managed at home. This will hopefully mean that they will be more comfortable and will improve quickly.
Offers an alternative referral pathway for GP’s to use instead of referring to ED or the children’s assessment unit at BRI
“The wheezy child” is the first pathway we are going to use (going live on the 4th of December) and the next pathway will be gastroenteritis. This will hopefully be launched in late February/early March

6. Philosophy of the project
‘the key to delivering effective emergency and urgent care is ensuring that the whole system is designed to support self-care and community care at home, thereby reducing avoidable hospital admissions and facilitating timely early discharges’ Institute for Innovation and Improvement

7. Phase 1 Children’s Ambulatory Urgent Care
Carer/ child with symptoms
consults pathway
Self Care
Phase 1 Children’s Ambulatory Urgent Care
Primary care Diagnosis
Step up community
‘virtual ward’
Step down
community
‘virtual ward’
Ambulatory care nurse GP
Consults pathway
Senior medical opinion
Consultant hot line
phase 2?
Clinical Decision Area (including short stay 24hr)
Needs
Emergency Treatment
Emergency Department
Hospital admission
Rapid response clinic
Phase 2?

8. Impact for ED Reducing fragmentation
Reducing referrals and admissions to Trust
Reducing representations to Trust
ED and hospitals caring for the sickest
Right care, in the right place, at the right time
Reducing fragmentation
Reducing referrals and admissions to Trust
Reducing representations to Trust
ED and hospitals caring for the sickest
Right care, in the right place, at the right time

9. Evaluation of the project: working alongside Connected Yorkshire, Connected Health Cities
Map and model the current pathway for urgent asthma care in children across Bradford
Work with local stakeholders to make changes to the pathway for urgent paediatric asthma care
Explore associations between routine data parameters in the community (such as prescription data) and subsequent unplanned hospital admission with asthma
Map and model the current pathway for urgent asthma care in children across Bradford by using routine linked data. This would be in order to help identify potential pathway targets for improvement.
2) Work with local stakeholders using linked, whole pathway data as a measurement for tests of change to the pathway for urgent paediatric asthma care. I.e. working out where the need is and whether our project is helping to reduce admissions/referrals.
3) Explore associations between routine data parameters in the community (such as prescription data) and subsequent unplanned hospital admission with asthma. We plan to use any associations that are identified as the basis for an electronic decision support tool designed to help reduce emergency admissions. And use the information gathered for community involvement and change. Looking at whether children are picking up for example their preventer inhalers

10. The future
Networks - professional, commissioners, providers and users; patients
Shared vision guiding commissioning
Connected health data informing development
Technology - telemedicine
Social media: twitter
Networks - professional, commissioners, providers and users; patients. Working alongside other professionals, comissioners or provision, patients and families
Shared vision between GP’s and secondary care guiding commissioning
Connected health data informing development or project and whether we need to change the pathway at all
Use of technology- telemedicine. Piloting telemedicine project: large screen on the Paediatrics ward and mobile tablets/lap-tops for Children’s community nurses. Use of Cisco/baby view currently in the neonatal unit. Enables parents to see their babies in the NNU
Social media: twitter. For example, sending out a tweet aimed at parents in September when children go back to school after the long summer holidays, to make sure that they are taking their preventer inhaler.

11. Thank you!
Any questions??