1

Clinical Pathways:

Children’s Services

September 2014

Contents

1a. Child with illness RSH walk-in PAU open

1b. Child with illness RSH walk-in PAU closed (without resident paediatrician)

2. Child with illness – Out of Hours

3a. Child with abdominal pain – RSH PAU open

3b Child with abdominal pain-RSH PAU closed (without resident paediatrician)

4. Child with serious injury–across county (without resident paediatrician)

5a. Child with injury (not life threatening) –RSH PAU open

5b. Child with child protection concern presenting to RSH

6a. Child with a head injury RSH (not life threatening) RSH PAU open

6b. Child with a head injury RSH (not life threatening) RSH PAU closed (without resident paediatrician)

7. Child with an orthopaedic injury (not life threatening)

8. Paediatric Triage and Transport – GP Calls

Walk in to

RSH ED

Triage

Observe

on PAU

Assessment by ED clinician +/-

assessment by or discussion

with ED Middle grade

Discharge

Refer to Paediatric Team

at RSH PAU with

involvement of

MG or above

Refer to

Inpatient unit

PRH

1a. Child with illness RSH walk-in PAU open

RSH

PRH

Tertiary site

Refer to

PICU at tertiary

centre

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Walk in to

RSH ED

Triage

Discuss with

resident

paediatrician at

PRH

Assessment by ED

Clinician

+/or ED Mid grade

DischargeTransfer to

Inpatient Unit

PRH

1b. Child with illness RSH walk-in PAU closed

(without resident paediatrician)

Refer to

PICU at tertiary

centre

RSH Paediatric

Consultant

to attend if needed

RSH

PRH

Tertiary site

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Child arriving by

Ambulance

999 Call

Stable

Take to

PRH A& E

Take to

nearest A&E

Unstable

A&E PRH

A&E RSH

Follow algorithm

for Child with

Ilness RSH

Walk-in

PAU Closed

2. Child with illness – Out of Hours

Tertiary

centre

Discussion with or

assessment by

Mid grade ED Doctor

Refer to

Paediatric Team

In PAU

Observe on PAU

Discharge

Refer to

Inpatient unit

PRH

Refer to

PICU at tertiary

centre

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Triage

>6 months old

Discharge

Newborn = < 6 hrs old

RSH

PRH

Tertiary site

Walk in to

RSH ED

Triage

Tertiary

centre

Assessment

by ED Clinician and/or

Mid grade ED Doctor

Discharge

Refer to PAU

team

Observe in

RSH PAU

Examine,

Investigate,

Treat

Joint assessment by

ED Doctor, PAU Middle-grade

and Surgeon

UnstableStable

Admit inpatient

unit PRH

+/- operate

3a. Child with abdominal pain – RSH PAU open

In extremis patient taken to

theatre at RSH

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Triage

Assessment by

ED clinician Discharge

Joint assessment –

ED mid grade

Surgeon

Non-resident consultant paediatrician

UnstableStable

Admit on to PRH

inpatient ward

Walk in to RSH

ED

Transfer to

tertiary centre

3b. Child with abdominal pain – RSH PAU closed

(without resident paediatrician)

Discussion with

paediatric

mid grade at PRH +

potential discussion

with non-resident

paediatrician Assessed by surgical team

in ED at RSH

In extremis patient

taken to

theatre at RSH

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Trauma Team Assessment

+

Non-Resident Consultant

Paediatric Consultant on-call

Resuscitation

Investigation

Stabilisation

Transfer to

Tertiary

centre

Admit to RSH ED

4. Child with serious injury – across county

(without resident paediatrician)

Transfer to

PRH

children's ward

Life/limb threatening –

Immediate

theatre

+/- other

investigations

/head scan

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Triage

Assessment by ED

Clinician

Discharge

Refer to PAU

Team

RSH

Admit to

inpatient

unit PRH

Walk in to

RSH ED

Clinic

5a. Child with injury (not life threatening) RSH PAU open

Assessment by

ED mid grade

NAI – to be considered for all

injuries/ mechanism of injury

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Triage ED Clinician

? NAI/ social concerns

Consult Safeguarding

Children and Young People

Policy and Procedure

Admit to

Inpatient unit PRH

Admit to RSH ED

5b. Child with child protection concern presenting at RSH

Assessment by

ED midgrade and/

or discussion with

RSH Paediatric Middle Grade

PAU

at RSH

Discuss with RSH On-Call

Consultant Paediatrician

Discharge (this

may be into care of

Social Services)

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

NAI – to be considered for all

injuries/ mechanism of injury

Assess by ED

clinician

+/- scan

Transfer to

tertiary centre

Admit to

children's

ward

at PRH

Patient walk into

RSH ED

Observe PAU

at RSH

6a. Child with a head injury RSH (not life threatening)

RSH PAU open

Assess/ discussion

with ED mid

Grade +/- scan

Paediatrician

assessment

NAI – to be considered for all

injuries/ mechanism of injury

Discharge

Discharge

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Assess by ED

clinician

+/- scan

Transfer to

tertiary centre

Admit to children's

ward

at PRH

Patient walk in

RSH ED

6b. Child with a head injury RSH (not life threatening) RSH

PAU closed (without resident paediatrician)

Assess / discussion

with ED Mid

Grade +/- scan

Discuss with

Resident

Paediatrician

at PRH

NAI – to be considered for all

injuries/ mechanism of injury

Discuss with on-call

non resident

Paediatrician

Discharge

Discharge

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Simple

‘non GA’

intervention

at RSH

Admit to

inpatient

unit PRH

Limb

Threatening

injury?

Discharge

home

Semi-elective

procedure

at PRH

PRH +/- surgical

intervention

(Orthopaedics)

Vascular on-

call as

required

RSH Orthopaedic

intervention

Discharge Theatre

7. Child with an orthopaedic injury (not life threatening) –

RSH

Admit to

RSH ED

no

yes

In hours

PAU

at RSH

Out of hours

Admit

to PRH

Assessment by ED Clinician +

ED Mid Grade

RSH resident T&O

team inform

Mid Grade paediatrics at PRH,

OOH inform on-call

consultant paediatrician

All children under 6 months old

being discharged from A&E must

be discharged by or with the

knowledge of a paediatric mid

grade with level 2 competence or

an ED Consultant if in the

department

Newborn = < 6 hrs old

Triage

Child seen by GP at home

or at surgery/walk-in centre

Discussion with Paediatrician

required

8. Paediatric Triage and Transport – GP Calls

Care Co-ordination Centre facilitates call

Illness severity agreed

Immediate management advice as appropriate

Consultant Paediatrician Mon to Fri 0900 - 2100hrs

Sat to Sun 0900 - 1500 hrs

Middle-tier Paediatrician At all other times

Same-day review required Same-day review NOT required

Transport requirements discussed (family car vs. ambulance)

Overnight

admission

probable

Overnight

admission

unlikely

Observation

& treatment

beyond 8pm

probable

Overnight

admission

unlikely

Observation

& treatment

beyond 8pm

unlikely

Admit to PRH CAU

Admit to nearest open CAU

RSH CAU is only open for assessment

Mon-Fri 9am-8pm & Sat-Sun 12pm-8pm

Urgent

OPA

(within 2 wks)

arranged

Advice

given

pending

appt.

Routine

OPA

arranged

Advice

given

pending

appt.

Next day

review

on CAU

arranged

Advice

given

pending

appt.

Advice

only

CCC = Care Co-ordination Centre

CAU = Children’s Assessment Unit

OPA = Outpatient Appointment