Paediatric Ambulatory Paediatric Ambulatory CareCare

- A Model of Care -- A Model of Care -

Dr. Jackie Bucknall Dr. Jackie Bucknall

Homerton Hospital LondonHomerton Hospital London

Objectives TodayObjectives Today

BackgroundBackground DemographyDemography Our Service aimsOur Service aims Stand Alone Ambulatory UnitStand Alone Ambulatory Unit ActivityActivity Lessons we LearntLessons we Learnt

Reprovision of East Reprovision of East London Children’s ServicesLondon Children’s Services

1998 1998

East London & City HAEast London & City HA 5 Acute Hospitals inc. 4 A&E Depts, 5 Acute Hospitals inc. 4 A&E Depts,

Children’s Hospital & No acute paeds.Children’s Hospital & No acute paeds. Mix of Management models in districtMix of Management models in district

QEH acute children’s service providerQEH acute children’s service provider Secondary general care to Homerton Secondary general care to Homerton Tertiary/specialist/inpatient care to RLH Tertiary/specialist/inpatient care to RLH

Hackney - DemographyHackney - Demography

Population of under 16 years Population of under 16 years >54,000>54,000

Area high deprivation & needArea high deprivation & need Multicultural & ethnic mix - 47%Multicultural & ethnic mix - 47% High refugee & migrant communityHigh refugee & migrant community Significant percent Significant percent notnot registered registered

PHCTPHCT

Aims of Homerton Acute Aims of Homerton Acute Paediatric ServicePaediatric Service

High quality care led by senior cliniciansHigh quality care led by senior clinicians Care accessible to all local populationCare accessible to all local population Avoid unnecessary admission to hospital & Avoid unnecessary admission to hospital &

facilitate early dischargefacilitate early discharge Family Centred individualised careFamily Centred individualised care Offer partnership in care, empower families Offer partnership in care, empower families

& primary care & primary care Develop integrated Children’s service with Develop integrated Children’s service with

RLH on “hub/spoke model”RLH on “hub/spoke model”

Key Service ElementsKey Service Elements

Children’s Emergency Assessment Children’s Emergency Assessment (A&E)(A&E)

Stand Alone Ambulatory Care UnitStand Alone Ambulatory Care Unit Hospital at Home ServiceHospital at Home Service Primary Care HotlinePrimary Care Hotline GP Rapid Referral ServiceGP Rapid Referral Service OutpatientsOutpatients Transfer ServiceTransfer Service

A Stand Alone Ambulatory A Stand Alone Ambulatory Care Unit - What is it?Care Unit - What is it?

Acute Assessment & Observation UnitAcute Assessment & Observation Unit 24 hour admission remit24 hour admission remit Establish AND Maintain PhilosophyEstablish AND Maintain Philosophy Review & Reassessment criticalReview & Reassessment critical No long term care /inpatient unit on siteNo long term care /inpatient unit on site Supports A&E / Emergency careSupports A&E / Emergency care Acute medical /Elective surgical serviceAcute medical /Elective surgical service

A Stand Alone Ambulatory A Stand Alone Ambulatory Care Unit - How does it Care Unit - How does it

work ?work ?

Tailored to local need & demandTailored to local need & demand Robust inpatient provider locallyRobust inpatient provider locally Senior assessment / MultidisciplinarySenior assessment / Multidisciplinary Proactive decision makingProactive decision making Observation facilityObservation facility To support A&E - need 24 hour To support A&E - need 24 hour

assessment & on site paediatric teamassessment & on site paediatric team Good gatekeepingGood gatekeeping

Why 24 Hours ?Why 24 Hours ?

Emergency Care SupportEmergency Care Support Different models of Ambulatory care in Different models of Ambulatory care in

same population during reconfigurationsame population during reconfiguration With 24 hour Ambulatory support With 24 hour Ambulatory support

A&E transfers fell (8.4% to 3.5%) Despite A&E transfers fell (8.4% to 3.5%) Despite change casemix & increased activity change casemix & increased activity

Statistically significant changesStatistically significant changes(p<0.001) (p<0.001)

Supporting 24 HOUR ModelSupporting 24 HOUR Model

Service Activity (00/01)Service Activity (00/01)

A&E attendances - 18,700A&E attendances - 18,700 Outpatients - 7,900 + 1,500 GPRROutpatients - 7,900 + 1,500 GPRR Inpatient Equivalent - 3,400 (18%)Inpatient Equivalent - 3,400 (18%) Hospital at Home - 450 childrenHospital at Home - 450 children

Total Transfers - 5.1% (954 children)Total Transfers - 5.1% (954 children)94.9% CHILDREN ARE TOTALLY CARE 94.9% CHILDREN ARE TOTALLY CARE

MANAGED IN AMBULATORY SERVICEMANAGED IN AMBULATORY SERVICE

TransfersTransfers

3.5 % Total A&E attendances3.5 % Total A&E attendances 9% of ACU admissions9% of ACU admissions 80% Received Nominated IP receiving 80% Received Nominated IP receiving

Unit - Royal London Children’s ServiceUnit - Royal London Children’s Service

59% Emerg. Surgical 59% Emerg. Surgical 11% PICU11% PICU 27% Medical27% Medical

Lessons we LearntLessons we Learnt

Locally AppropriateLocally Appropriate Robust Inpatient CentreRobust Inpatient Centre 24 hour Paediatric support to A&E 24 hour Paediatric support to A&E Consider Casemix AND ActivityConsider Casemix AND Activity Good GatekeepingGood Gatekeeping Training/Retention Nurse PractitionersTraining/Retention Nurse Practitioners Creative/Flexible Medical StaffingCreative/Flexible Medical Staffing