Context The Paediatric Assessment Unit (PAU) in our District General Hospital arose out of necessity and occupies a small space with limited privacy. Acute attendances continue to rise and demand for PAU increases.
Problem Some children wait an unacceptable time for senior paediatric review and flow through the unit is poor. Longer stays (>4–6 h) are inappropriate. Consultant input is variable and junior rotas are understaffed. Parental questionnaires stated dissatisfaction with waiting times and facilities.
Assessment of problem and analysis of its causes A working group (consultant and trainee Paediatricians, senior nurses) aimed to standardise and improve quality of care, specifically, improving waiting times and patient flow. To assess the scale of the problem we:
Formally audited current practice against national standards from RCPCH’s Back to Facing the Future (2013).
Held consultation sessions with multidisciplinary PAU team. An assessment proforma including timings, observations, history, examination and predicted outcome was designed to aid data collection.
Areas identified for improvement included:
Consultant cover at peak times
Facilities and space
Waiting times to see a decision maker
Early discharge/admission planning
Intervention Some improvements were more challenging to tackle than others. We are exploring relocation of PAU to a more fit for purpose area. Consultants are reviewing working patterns to provide cover during peak activity. In the meantime we carried out simpler interventions:
Following feedback we developed the integrated assessment proforma improving assessment efficiency and focussing professionals towards planning for likely outcome. Prescription boxes and prompts will encourage early interventions (such as antipyretics, dioralyte).
A junior doctor dedicated to PAU should meet nursing team at shift start ensuring names +/- photos are on the PAU board. A full time trust doctor employed for consistent middle grade PAU cover (although sometimes fills rota gaps).
Consultants to attend PAU after morning ward rounds and evening handover to discuss +/- review patients.
Expected waited times standardised o Seen by doctor within 1 h o Seen by senior within 4 h
Patient/parent information leaflet distributed, outlining what to expect from a visit to PAU.
Study design Not applicable
Strategy for change We produced Standard Operating Procedures outlining the above expectations. This was presented and e-mailed to all staff. Three months were allowed for changes to be embedded before re-audit.
Measurement of improvement The results of our original and re-audit are summarised in the following Table1:
There was an 18% increase in patients seen within 1 h and a 14% increase in patients seen by a senior within 4 h, bringing us closer to national levels. Although consultant input doubled with our initial interventions, it is clear that planned review of consultant working patterns is necessary for us to achieve national standards.
Effects of changes These improvements led to reduced waiting times and earlier decision making and discharge from PAU. There is a tangible sense of improved parental satisfaction, although this is to be formally assessed.
Lessons learnt/Message for others To produce adequate, consistent improvement requires a longer process of workforce planning and service relocation/development. However, we have shown that significant improvements can be made by going ‘back to basics’. Formalising and communicating expected standards, more efficient paperwork and maximising medical staffing, has been the mainstay to achieving improvement within our service. It can be difficult to obtain agreement for service developments from all involved, but we found involving all parties early in the process was beneficial.
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We have no conflicts of interest to declare.
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