Safety recommendation
It is recommended that the Association of Ambulance Chief Executives agrees guidance that can inform its members on the competency and authority for staff to convey, refer and discharge children under five years who are subject to 999 calls.
Response:
The recommendation was reviewed by the National Ambulance Services Medical Directors group (NASMeD) on the 4th July 2019 and subsequently a working group was established to explore the recommendation and agree on specific actions.
It was felt by the working group that any actions we agree for ambulance services on have implications to the rest of the system, for example to be able to refer children under five years that are not conveyed into primary care. Therefore, the working group lead has been in contact with the Royal College of Emergency Medicine (RCEM), the Royal College of Paediatrics and Child Health (RCPCH), and the College of Paramedics to consider a joint response to the recommendation and to discuss each organisations proposed actions. We are continuing to liaise with them.
We are aware that the RCEM will be helping the RCPCH to develop a Key Practice Point (KPP) within their online decision support tool Paediatric Care Online (PCO UK). We will continue to liaise with them to establish if paramedics will be able to access this on-line tool and how this may guide decisions around the conveyance, referral and discharge decisions of children under five.
We are also awaiting the report of an audit of children under the age of two being undertaken by the RCPCH. This audit was already underway when we received the safety recommendation from yourselves and stems from a letter that all ambulance services received in February 2009 from the RCPCH recommending that all children under the age of 2 are not discharged on scene and are conveyed to hospital. The audit was proposed after discussions at NASMeD around the current variation in conveyance and referral guidance of under 2’s and we have assisted by enabling ambulance care records to be submitted for this audit. We await the report of this audit as we will use it to inform our considerations around your safety recommendation. We anticipate that this audit will help inform future guidance on the conveyance, referral and discharge on scene of children under 2.
We have been in discussion with MPDS and NHS Pathways which are the two systems in use across the English ambulance services to assess 999 calls. We are aware that NHS pathways have now included a question on if a child might have ingested a button battery.
The working group presented three proposed actions to NASMeD on the 4th September. The actions were agreed, and these will be now taken forward.
Action 1
All ambulance Trusts to agree the age at which a child should either be conveyed to an appropriate healthcare facility or referred to a health care professional with more expertise in paediatric assessment and/or at what age a child can be discharged from ambulance service care, with no further follow up arranged by the ambulance service clinicians on scene.
This will be discussed at the NASMeD meeting on the 7th November, and by this time we hope to be able to include the results of the audit of under 2’s.
Action 2
To define the processes and age ranges for referring children that are not conveyed to other Health Care Professionals (HCP) - to include:
Arrange an agreed timeframe for follow up with the accepting HCP and documented by the ambulance health care professional. If discharge on scene is advised, the health care professional to whom the referral is made (with higher urgent and emergency care paediatric expertise than the referring paramedic), has responsibility for that decision.
The point of handover of clinical responsibility, will be when a health care professional to health care professional referral decision has been made and the accepting health care professional in primary care/GPOOH [GP out of hours service]/ED [emergency department]/Paediatric unit have agreed the time and date that they will see the patient or call the parent/guardian to arrange this, or have agreed to discharge on scene.
This will be discussed at the NASMeD meeting on the 7th November
Action 3
To agree a proposal for discussion at Joint Royal Colleges Ambulance Liaison Committee (JRCALC) if a child (agree age) has seen another HCP or other ambulance clinician for the same or a similar presentation/condition in the previous 72 hours they should be conveyed to an emergency department or referred by the assessing ambulance clinician directly to another appropriate HCP.
To be discussed at the next JRCALC meeting on 19th September 2019.
Response received on 18 September 2019.
Update
As previously stated, the recommendation was reviewed by the National Ambulance Services Medical Directors group (NASMeD) on the 4th July 2019 and subsequently a working group was established to explore the recommendation and agree on specific actions. The actions we agreed were detailed to you in our previous letter.
At the November NASMeD meeting we reviewed the actions and the findings from an audit of patient report forms of children under the age of 2. We had anticipated that the audit would help inform future guidance on the conveyance, referral and discharge on scene of children under 2 but unfortunately this was not the case. The clinical outcome was not explored, and we didn’t think there was sufficient power or granularity in the study to draw any firm conclusions. NASMeD concluded that there is very little evidence available currently to inform us towards agreeing guidance for under 5’s. We are now considering how to gather further evidence and informed opinion to help further discussions on formulation of guidance. We have asked the NHSE/I safety team if they could provide a thematic analysis of SI’s involving children and are awaiting to hear back from them. We are also gathering trust current policies and procedures relating to conveyance, referral and discharge of children.
We are now planning to hold a workshop in the New Year. The workshop will bring together partners to review the available evidence, undertake case review and the objective will be to try and agree guidance as per your recommendation. We have requested that the RCPCH will provide support and expertise at this workshop.
Updated response received on 24 December 2019.