Paediatric Unscheduled Care Project

1. Paediatric Unscheduled Care Project North of Scotland Planning Group SCTT/NHS24 NHS Highland, NHS Grampian, NHS Western Isles, NHS Orkney, (NHS Shetland).

2. Background • The project led by the Scottish Centre of Telehealth and Telecare (SCTT) and funded by National Development Plan, began in 2010, intending to provide Video Conferencing (VC) to reinforce existing paediatric decision pathways between 6 Rural General Hospitals (RGH), community hospitals (CH)and their Receiving Centres. • The original project identified that it is not always likely that Paediatric skill sets are available in the RGH’s and most likely that paediatric patients will be considered for Transfer to a specialist centre. • There was a positive feeling among project stakeholders that if effective support was easy to access and on-going, then it could lead to an increased level of confidence at the local RGH and possibly a reduction in the number of transfers of children to Receiving Centres. • The proposal to provide 24 hour access to a remote Paediatric Consultant via a Single Point of Contact (SPoC) using VC was proposed to participating members of the project board. The idea was well met and it was agreed in July 2011.

3. Is this a new idea?? The Jetsons 1962!

4. Dr. Zoe Dunhill Report 2011 • NoSPG commissioned a report to look at paediatric services in the NoS. Titled NoS Paediatric Sustainability review • The reviewer was asked to review paediatric services across the five North of Scotland health boards and to report on the current picture of Paediatric Secondary care in the NOS. She was to identify where regional collaboration might strengthen future sustainability of services in the NOS • 1. An obligate network for Child Health is resourced and put in place with the utmost urgency in the NOS area • 2. The unscheduled care initiative (single point of contact) pilot is afforded prime importance by all NOS paediatric units and RGH partners

5. Also....... • Anecdotally, 50% of transferred children are discharged within 24hrs • Transfers have a significant impact on rural based children/families • Access to OCC could be quicker via VC • Gather robust transfer data • Contribute to critical care work • Transfer learning • Identify barriers • Increase use of VC for all situations • Wider applicability?

6. The Healthcare Quality Strategy for Scotland:Effective The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated

7. Agreement • Through general support for trialling a new model, it was decided that........ • Provide paediatric critical decision support to Remote General Hospitals and Community Hospitals from an on call consultant via Video Conferencing.

8. The Model • 12 month trial of concept – commenced July 2013. • Ongoing Evaluation by external evaluator - CRH • 24/7 dedicated OCC available • Patient pathways mapped • Close working with PICU’s and SAS • Extensive training and support to HB’s • Clinical lead for the project • Data collection • Learning

9. RGH/CH RGH/CH RGH/CH RGH/CH RGH/CH RGH/CH 1 2 Call Handler (NHS24) 6 3 4 OCC 8 5 Receiving Centre Receiving Centre Receiving Centre Receiving Centre 7 1 RGH/CH rings Single Point of Contact and speaks to a Call Handler Call Handler, captures essential information. 2 Call Handler, hands over to the OCC and facilitates the VC between them and the RGH/CH. 3 VC to RGH/CH takes place with RGH/Patient/parent and OCC 4 If transfer is required, on call consultant contacts receiving centre 5 If transport is required, on call consultant contacts transport option 6 Transport unit, transports patient to receiving centre 7 OCC completes patient notes - SBAR, saves record to system, further follow up calls take place as agreed between RGH and OCC via VC if needed. 8

10. Anticipated Benefits • A single number to call • A dedicated OCC to support RGH/CH staff triage, care and support the decisions which may lead to transfer • The dedicated OCC will provide on going support for patients who are not transferred, but cared for locally. • The local clinicians dedicate their time to their patient while the OCC facilitates transport arrangements • An additional set of qualified eyes will be virtually in the room with the staff and patient providing clinical advice and support • Patient will be ‘seen’ by a paediatric Consultant sooner than current models, therefore reducing any risk from delay in appropriate care. • There is potential for paediatric skills transfer to local staff in the RGH’s • The collection of data which will inform the Project Board of numbers of transfers, VC calls and outcomes. • More patients may stay locally reducing their inconvenience and stress and aligning with the strategic objectives outlines in the NHS Scotland 20:20 Vision. • The dedicated resources will initially have enough flexibility to manage significant increase in calls, so RGH/CH’s may place multiple calls per patient.

11. Evaluation CRH provided a mixed method approach of: • Literature scoping review by NHS Healthcare Improvement Scotland (HIS) and the Scottish Health Technologies Group • Site visits to 6 hospitals and qualitative interviews with 10 OCCs and 17 key stakeholders • Cost consequence analysis by HIS • Activity data analysis

12. What Did we find.....

13. Key Findings Activity • 98 calls from August 2013 until Jan 2014 approx 4 per week • Most (60/98) were by VC • Small majority (53%) met the KPI of VC set up with all attendees within 10 mins • 9 emergency retrievals and 21 transfers included • 27 closed calls and follow up in 34 cases (with further 9 transfers)

14. Key Findings (cont.) Qualitative Positive • VC support from the OCCs improved the confidence of staff • OCCs thought calls were appropriate • Consultant led VC enabled more consistent pattern of support than previously, particularly to junior staff • Likely that VC support improved quality of local care • VC useful for aiding decisions on, and support whist waiting for, discharge/transfer • Parents were reassured by the availability of the expert

15. Key Findings (cont) Qualitative – negative • VC not always appropriate, technically or logistically and telephone used as an alternative. • Clinical responsibility for the child caused tension in some cases. • Some referrers thought PuC jeopardised some pre-established clinical relationships. • Some referrers and OCCs thought lack of local knowledge of geography etc hindered good decision making. • PuC was bypassed where consultation time thought to be quicker, problems with VC or appropriateness of VC was questioned.

16. Technical Challenges??

17. Current Position – as at May 2014. • Pilot running for almost 12 months • External evaluation received • Roadmap of engagement post evaluation ongoing • Lessons learnt logged • Future planning in place. • Discussions about future models and geography. • Further trialling. • Widespread buy-in.

18. Thank you for listening Lynn.garrett@nhs24.scot.nhs.uk