Implementation of recommendations for the care of children in UK emergency departments: national postal questionnaire survey

Introduction

In June 1999 an intercollegiate working party of Royal College of Paediatrics and Child Health, British Association of Accident and Emergency Medicine (BAEM), British Association of Paediatric Surgeons, Faculty of Accident and Emergency Medicine, Royal College of Nursing (RCN), and Royal College of General Practitioners was established. Terms of reference were to review emergency services for children and to make recommendations for future provision of these services. The subsequent report—Accident and Emergency Services for Children (AESC)—made 32 recommendations (representing minimum levels of care), to be implemented by 2004.1

Participants, methods, and results

We sent questionnaires to lead emergency doctors (listed in the BAEM's directory of 2001-2) between Oct 2003 and Jan 2004 about the recommendations. Nonresponders were re-sent the questionnaire.

Of 219 departments with inpatient paediatric facilities,2 139 (63%) replied (table). In all, 47 (34%) of replying hospitals saw more than 18 000 children annually; 41 (87%) were district general hospitals. Only 64 (29%) departments with separate paediatric emergency facilities responded; the 71% that did not respond accounted for 47% of nonresponders, many seeing more than 18 000 children annually.

Although currently 41 departments have separate paediatric emergency departments, 92% of children attend general departments; these show the largest differences from recommendations of the AESC report. In 1997, 10% of hospitals did not have inpatient services onsite3 now only 1.9% do not (minor injury units excluded).

Wards are safe for only the initial reception of emergency admissions if appropriately equipped and staffed for reception, triage, and resuscitation1; these criteria are often not met.

Assessing the severity of illness is essential, but a quarter of departments seeing more than 18 000 children a year do not have separate triage facilities, and 23% do not triage children with an appropriately trained nurse. Although the pain assessment tool and the national triage score are used widely, their effectiveness must be questioned where non-trained staff are triaging. Level 2 care, while awaiting a paediatric retrieval team (children's mobile intensive care unit), is delivered in 85% of departments, often at cost to emergency, paediatric, and intensive care services. The current trend of centralisation means that emergency staff must deliver this care, so there must be the appropriate mix of skills on duty.

In 1996, 30% of hospitals did not cater for children within major incident plans (required by the National Service Framework for children and young people)4 5; fewer now have children in their plans.

The National Service Framework expects emergency professionals to do courses in paediatric life support and to regularly update; currently, 47% of nurses do not attend such courses.

Comment

One in four patients presenting at emergency departments is a child. Child centred good quality care which is accessible at the right time is required, however there is considerable room for improvement in the care of children in emergency departments. This government has recognised unacceptable variations nationwide in the quality of care for children and wants to eliminate these differences (the National Service Framework).4 5 The framework allows adult nurses to care for children only within the limits of their knowledge and should be under direct supervision of a children's trained nurse. Recruitment and retention of nursing staff is a problem in emergency departments. The Royal College of Nursing recommends rotational posts with community nursing and paediatric wards. The number of applicants for training in children's nursing exceeds the number available, so structured investment in nurse training may provide the necessary skilled nurses.

The AESC recommends that hospitals seeing more than 18 000 children should have a consultant in paediatric emergency medicine by 2004 and in all emergency departments by 2010. This, along with many of the other AESC recommendations made five years ago, has not been met and without future investment in staffing and facilities a child centred service will be hard to achieve.

This article was posted on bmj.com on 3 December 2004: http://bmj.com/cgi/doi/10.1136/bmj.38313.580324.F7