Passion For Paediatrics

Passion For Paediatrics

Key contacts

Priyen Shah – Paediatric Trainee

Su Laurent – Paediatric Consultant

Introduction

Rota gaps, service cuts and record patient numbers have made working in the NHS more stressful than ever.  As doctors we train for years to treat our patients, yet we are surprisingly bad at looking after ourselves and our colleagues. Paediatric services are being affected more than most, with a drastic decline in doctors applying to paediatric training and an increasing number of unfilled posts.

With this in mind, we organised Passion for Paediatrics with one simple aim – to support the mental and emotional wellbeing of paediatric trainees and help them manage the strain associated with working for the NHS in the current climate.

First, we highlighted the services available to trainees finding it difficult to cope such as the Practitioner Health Programme and the Tea and Empathy movement that was formed in the wake of the suicide of a doctor during the implementation of the new junior doctors’ contract. Professor Clare Gerada, medical director of the Practitioner Health Programme and former chair of the Royal College of General Practitioners, shared some of her experiences in identifying and supporting doctors in difficulty.

We then focused on examples of morale-boosting projects from across the NHS, such as ‘Barnet Bopping‘, a project utilising dance lessons to improve the working relationship between doctors, nurses and patients, was demonstrated by Dr Guddi Singh and Karelle Evans. ‘Balint Groups’ led by Dr Lucy Fullerton and Dr Susannah Pye showed how peer-based discussions can help doctors work through difficult and emotional cases in a supportive and confidential environment.

Finally, we heard about ‘Learning from Excellence’, a project by Dr Adrian Plunkett at Birmingham Children’s Hospital, which has been introduced at Barnet General Hospital by Dr Dominic Fenn and Dr Patricia Lutalo in an effort to highlight and share examples of excellence in healthcare practice. The hope is that others will be inspired to initiate similar projects in their own departments.To finish, we highlighted ways that doctors can protect themselves. Dr Michael Farquhar outlined the importance of sleep hygiene, especially on night shifts while Dr Caroline Fertleman, Dr Serena Haywood and Dr Reina Popat Shah showed the benefits of cultivating mindfulness and creativity in everyday life.

The feedback was incredibly positive and we had a number of requests to make this an annual event.

SMART objectives

Specific: To support the mental and emotional wellbeing of paediatric trainees and help them manage the strain associated with working for the NHS in the current climate.

Measurable: Feedback during and after the event.

Achievable: The project requires collaboration with paediatric trainees and consultants, speakers, caterers, venue managers and sponsors. It also needs to attract sufficient attendees to make it financially viable.

Relevant: In the current climate, it is more important than ever that doctors have the tools and support they require to manage the physical, emotional and psychological burden associated with working in the NHS. If we can master this, trainees will not only manage, but will thrive.

Time: In line with sponsorship requirements, the event had to be held before the end of the tax year.

 

Progress made: What have you learned from doing this?

Event management – the importance of setting a realistic budget and timescale. Early liaison with venue managers and caters. Effective advertisement of the event and the power of word-of-mouth recommendation,.

Leadership – The importance of early delegation with clear, well defined roles and an effective way to keep up to date with the progress of the team.

What’s your take home message?

If we can look after and support ourselves and our colleagues, we will have more capacity to care for our patients and improve their care.

Resources?

https://www.huffingtonpost.co.uk/priyen-shah/healing-from-within-impro_b_18039656.html?ncid=engmodushpmg00000006

Parkview Olympics

Parkview Olympics

Key contacts

Beatrice Liddell

Dr Sarah Blackstock

Introduction

Parkview Olympics was a six-week pilot health and wellbeing programme in White City, London. Parkview Olympics is a community-based initiative designed and delivered by Practice Champions who are volunteers at their local GP Practice, supported by Imperial College Healthcare Trust’s Connecting Care for Children (CC4C) team.  This grass-roots approach is targeted at children from low socio-economic groups aged 8-12 years within the White City Estate, an area of deprivation. The pilot was available for up to 30 participants.

The programme was not funded and did not plan to create any new activities within the area. This bottom up approach aimed to bring organisations together, support capacity building and empower and mobilize community members to create behaviour change across sectors. The programme is a collaboration between Queens Park Rangers (QPR) football club, London Sports Trust, Access Sport, Better Gym, My Time Active (the local authority obesity service, who provide nutrition and behaviour change support) and the Hammersmith Community Gardens (who support food education, growing and production of food locally).

SMART objectives

The initiative was developed following the desire of Practice Champions (volunteers from local GP Hubs) to do something to tackle obesity within their community. They were frustrated that children in the community were being sent letters from school saying that they were overweight and they perceived that there was not enough provision of interventions to prevent or tackle this issue locally that parents were aware of.

The Practice Champions were aware that local organisations delivered activities for children and families but they didn’t know how to access them. Furthermore, it wasn’t clear if the stakeholders were already collaborating. Parkview Olympics was not just about improving health and well being for children and families but developing a collaborative relationship, improving promotion and access of all the local services.

It was really important that the Practice Champions developed a programme that could be sustained, therefore they didn’t ask stakeholders to develop new activities that would need a lot of funding but promote existing services.

Anthropometric measurements were completed on 17 participants. Four (24%) were obese (>95th centile), 3 (18%) were overweight (85th-94th centile) and 10 (58%) were healthy weight (5th-85th centile). This is higher than the local average population statistics; the National child measurement estimated in 2015/16 that 34.6% were overweight and 21.0% were obese within this area.

All participants who recorded their postcode were from the target population, the majority living within the White City Estate. Based on 2011 census data this area is predominantly purpose-built flats with a higher than average level of social housing 76%, (compared to national average of 18%.) 41% of the population in this area as from social grade DE classed as semiskilled or unskilled workers. It is also a diverse area.

Parkview Olympics ran from January to March 2017, the six week programme was agreed by all stakeholders and seen to be an achievable commitment for parents and children. However, due to the time it took to design and develop (factoring in the Christmas period), there were fewer activities available in winter. As we were working with QPR Football club we had to work at a time that suited everyone.

Progress made: What have you learned from doing this?

Parkview Olympics highlighted the importance of listening to patients and really understanding what matters to them. It is crucial that professionals don’t act on behalf of a patient before knowing how they feel about their healthcare. But the real learning was that we can not only listen to patients but work with them and encourage them to make changes for themselves and others. Here is some of the feedback from Practice Champions, parents and participants:

Wow! What a journey! I wanted to help and make a difference and now that it’s come to reality I am speechless. How can we thank the stakeholders enough for helping us to make a difference. Thank you, thank you! I have learnt during this journey that you don’t have to be a Doctor or have a degree or PHD all I needed was to care! I am so grateful’

Myself and Sade would like to thank you for a day at the closing ceremony’

‘Thank you so much for a wonderful programme, Aya and myself had a fantastic time today and during the 6 weeks. I look forward to carrying it on with her and the rest of my children’ 

‘Thank you for a wonderful day’ – ‘Thank you to everyone for the Parkview Olympics, we had a lot of fun’ 

‘Thank you to everyone at Parkview for the 6 week Olympics programme, my daughters really enjoyed it’

Evaluation highlighted that this intervention was acceptable and feasible could be a useful strategy to improve Physical Activity, Nutrition and Self Esteem of children within the White City Estate. Longer term follow-up is required to see if self-reported behaviours are sustained.

What’s your take home message?

Qualitative and quantitative data was used to evaluate this 6-week health and well being programme. Data suggests that this intervention is acceptable and feasible. The programme reached the appropriate target audience and recruitment was successful, achieving 26 participants for 30 places. Qualitative data was very positive, highlighting that participants and parents felt that the programme was enjoyable and had physical, mental and social benefits. Stakeholders also highlighted positive benefits to the intervention emphasising improved organisational relationships.

Resources?

Teen Health Talk

Teen Health Talk

Key contacts

Dr. Stephanie Lamb  stephanielamb@nhs.net

Susan Malkin  susan.malkin@gstt.nhs.uk

Elanor Williams elanor.williams@gstt.nhs.uk

Introduction

Health inequalities impact heavily on adolescents; this and many more aspects of adolescent health are often neglected. We know that adolescent health is important, not least because 70% of preventable deaths among adults are the result of behaviours initiated or reinforced in adolescence. Healthcare for adolescents is not adequately responsive to adolescents health needs, and communication between healthcare professionals and teens is often poor. Adolescents tell us that they want better healthcare that is more responsive to their needs and lifestyles. Timely healthcare interventions at this developmental stage can have long term benefits.

  • Healthy behaviours can be established
  • Long term mental health problems can be prevented
  • Appropriate use of health services can be encouraged

The Teen Health Talk (THT) is a resource that has been developed to support a structured and meaningful consultation with young people, for early identification of vulnerable teenagers with physical and mental health issues so that they can be supported to make healthy lifestyle choices which can potentially last the life course. 

It has been designed by a GP expert in adolescent health, Dr Stephanie Lamb, clinical lead for primary care within the Children & Young People’s Health Partnership (CYPHP). This resource was developed in close consultation with the many young people who have been helped by her and the team’s service at The Well Centre.

CYPHP is exploring how the Teen Health Talk can be used more widely, both by GPs and other professionals such as youth workers.

SMART objectives

To improve young people’s experience of primary care consultations.

To identify unmet areas of need and signpost young people to appropriate support.

To engage young people in hospital to talk about their physical and emotional well-being and to signpost them to services and encourage them to remain engaged with health services. 

Progress made:

The Teen Health Talk is available as an EMIS (GP data system) template as a structured set of questions and ‘conversation starters’ alerting the GP to current medical problems, lifestyle, risk factors, and safety. It provides prompts, helping the GP conduct an effective consultation, and provides links to available resources.

CYPHP are training Redthread and the London Gang Exit youth workers in the use of a modified version of the THT called ‘You and Your Health’ to support them in engaging hard to reach groups

A youth worker, funded by CYPHP, as part of the King’s Adolescent Outreach Service (KAOS) is using the resource tool to support young people aged 16 to 19 years old who are being treated on adult wards across King’s College Hospital. Using the tool the youth worker is able to engage the young person in talking about their physical and emotional well-being and to signpost them to services and encourage them to remain engaged with health services.

 

What have you learned from doing this?

Early pilot testing has shown us that to support wider role out across primary care we need to provide more input and training to raise awareness of why teen health is relevant and important. We are developing materials that are readily accessible within primary care, for example a training/awareness video to help support primary care in the use of the THT.

We will be evaluating the youth worker training to assess improvements in knowledge and skills and impact, by convening focus groups to follow up with the youth workers experience of working with young people.

We are working with King’s Health Partners to scope the potential for developing an electronic version of the THT so that it can be accessed via tablet or phone in the hospital and information will be readily accessible through the electronic patient record (EPR).

 

What’s your take home message?

70% of adult preventable deaths are the result of behaviors initiated or reinforced in adolescence. Timely interventions at this developmental stage can have long term benefits in all aspects of life. However healthcare for adolescents is often poor, due in part to lack of support and training for workforce. The Teen Health Talk supports general practitioners and other people working with young people to have structured conversations about physical and mental health care to enable healthy behaviors to be established, prevent long term mental health problems and encourage appropriate use of health services.

Resources?

If you are interested in using the Teen Health Check in your practice, please contact Ellie Williams at elanor.williams@gstt.nhs.uk for further information.

For informaton about the CYPHP visit  http://www.cyphp.org/

The Well Centre https://www.thewellcentre.org

About Kings Adolesecnt Outreach Service    https://cyphp.org/whats-new/134-kaos-king-s-hospital-s-new-project-to-improve-care-for-adolescents

Stop the Seizure

Stop the Seizure

Key contact: Dr Audrey Soo (Paediatric registrar) audrey.soo@nhs.net


Introduction

What is Epilepsy? Epilepsy is the most common significant neurological disorder in children and young people, leading to a tendency to have epileptic seizure.1 More than one in 220 children under the age of 19 years old (approximately 63,400) in the UK have epilepsy.1

What is a seizure? Normally there is electrical activity happening in the brain all the time, sending messages to various parts of the body in a coordinated manner. When a seizure happens, there is a sudden burst of intense activity, causing a temporary disruption to the way the brain normally works.

What is status epilepticus? A proportion of children who have seizures present with or develop status epilepticus. Status epilepticus is a condition resulting from:

a) the failure of the mechanisms for seizure termination or

b) the initiation of mechanisms which lead to abnormally prolonged seizures2

The prolonged seizure can have long term consequences, including brain cell death, brain cell injury and alteration of brain networks, depending on the type and duration of seizures.2


SMART objectives

To reduce the seizure duration in children/young people presenting to A&E with status epilepticus

To ensure the right medications are given and interventions made at recommended time points during status epilepticus [as per the UK Resuscitation Council’s Advanced Paediatric Life Support (APLS) guidelines or as per the child’s individual epilepsy care plan]


Progress made: What have you learned from doing this?

Results: Data was compared between paediatric status epilepticus episodes at West Middlesex Hospital during time period July2016-June2017 versus July2017-April2018. We were able to achieve a 35 minutes reduction in average seizure duration in children presenting to A&E with status epilepticus (from 108 minutes to 78 minutes). There was also a reduction in time taken from hospital arrival to Step 2 (delivering 2nd benzodiazepine) and Step 3 (administering phenytoin or phenobarbitone) by 2 minutes and 21 minutes respectively. 

There were also other positive consequences which were not anticipated from this project. This include less emergency hospital attendances with status epilepticus, less children needing intubations for status epilepticus and more proportion of children with status epilepticus having had the first benzodiazepine dose administered by parent/carer at home.

Interventions:

  1. Designing and delivering regular multidisciplinary simulation scenarios incorporating status epilepticus into in situ simulation sessions [attended by nursing and medical teams (paediatric, emergency medicine, anaesthetics)]
  2. Ensure copies of latest APLS status epilepticus algorithms are available in paediatric A&E
  3. Working with paediatric secretarial team and neurophysiology teams to identify how they can be better supported in streamlining phone calls, requests and referrals
  4. Presenting data at trust clinical governance meeting and departmental teaching sessions
  5. Improving epilepsy care locally as a whole (as per NICE guidelines and Epilepsy12 Audit standards) through education and other smaller Quality Improvement projects
  6. (In progress) Submission of business case for paediatric epilepsy clinical nurse specialist

Lessions from project: Improvements are rarely the result of a single intervention or person/team. Every intervention has marginal gains leading to overall improvement and effect. Involve every member of the MDT who might be involved in a patient’s journey (remember secretaries, nurses, administrators, managers).


What’s your take home message?

Status epilepticus is a medical emergency that requires the concerted efforts of parents/carer and health professionals to deliver the right intervention at the right time. Multiple small interventions can lead to overall larger sustainable improvements in reducing episodes of prolonged seizure or duration of seizure.


Resources?

  • Epilepsy Action – What is Epilepsy? (link here)
  • Epilepsy Action – Treatment and care for seizures that last longer than 5 minutes (link here)
  • UK Resuscitation Council Advanced Paediatric Life Support algorithm for Status Epilepticus (see page 2 – link here)
  • American guidelines for Treatment of Convulsive Status Epilepticus  (link here)

References

  1. Royal College of Paediatrics and Child Health’s 2017 State of Child Health Report – Epilepsy subsection. Accessible from here 
  2. Trinka E, Cock H, et al. A definition and classification of status epilepticus of the ILAE task force on classification of status epilepticus. 2015. Epilepsiea, 56 (10): 1515-1523

Rabbit Remedy: the impact of having a pet rabbit on a paediatric inpatient unit

Rabbit Remedy: the impact of having a pet rabbit on a paediatric inpatient unit

Key contacts

Tami Benzaken, Rebekah Short, Sarah Crew, Joseph Machta, Kerry Robinson, Caroline Fertleman.

Introduction

An increasing evidence base has shown contact with animals to have positive health impacts on children, both physically and emotionally1-2. In particular, there is increasing research into the use of Animal Assisted Therapy as a therapeutic adjunct in a variety of healthcare settings3.

In October 2017 we introduced a very important new member to the general paediatrics team at the Whittington Hospital, Holly the rabbit. To our knowledge we are the only hospital inpatient department in London with a pet on site.

SMART objectives

  1. Encourage interaction between patients and Holly to help improve their experience in hospital (in both in the inpatient and outpatient setting).
  2. Facilitate staff interaction with Holly and her participation in staff meetings, to help improve inter-team working and boost morale.
  3. Review Holly’s impact on both patients, carers and staff through free text questionnaires and independent feedback.

Progress made: What have you learned from doing this?

Holly has been a wonderful addition to our team and our recent survey results are a testament to that. She lives in the play area of Ifor ward and is often visited by both our inpatients, outpatients, their families and staff.

Out of the total of 37 patients and parents who responded to the survey, the entire cohort responded positively regarding their experience with Holly and her impact on their stay. When exploring the feelings she evoked in patients, happiness (n=15) and calm (n=17) were reported in 86% of respondents. One 10-year-old inpatient reported that, ‘meeting the rabbit made me happy, when I go to hospital I’m always sad’.

A parent of one of our patients seen in the out-patient department describes their first experience of meeting Holly, ‘We were soothed and calmed by sitting outside and running our hands through her soft and fluffy fur as she sat contently on our laps. In a time of advanced medicine and complicated technology, I was moved by such a simple yet insightful way of caring for children (and their parents!).’

As part of our project we aimed to survey staff’s attitudes towards the introduction of a pet into a hospital environment, a novel concept for most of our staff. Out of the 19 staff surveyed, 15 cited a positive therapeutic response on patients. Other reported benefits included her calming effect on patients, her being a great distraction, boosting staff morale and improving team working. One member of staff summarises her experience of Holly, ‘Holly is the best thing that has happened to paediatrics in years. She has a positive effect on enhancing working relationships between nursing and medical staff’.

A few issues raised by staff included concern regarding infection control and caring for Holly. The introduction of Holly to Ifor ward has been approved by our infection control and microbiology team. At times looking after Holly has been challenging, especially during busy periods on the ward when there has been a lack of ownership over her care. We have have addressed these issues by discussing her care as part of our daily safety huddle to ensure she has been fed, watered and cleaned on a daily basis.

Finally, a theme that consistently emerged from both patient and staff questionnaire responses, was the effect Holly has had in improving experience for mental health patients admitted to the ward. Twenty percent of patients who responded identified a mental health complaint as their reason for admission (including depression, self harm and intentional drug overdose). They all cited Holly’s positive impact on their stay. One patient wrote that Holly made her stay, ‘more relaxed and happier to be in hospital’. Another staff member recounts one experience she had with Holly and a patient, ‘One time in particular Holly helped a mental health patient suffering from depression, low self esteem and lack of self-worth. She often said to the nursing staff, ‘why would anyone love me?’. Her mood changed remarkably when in the rabbit’s company… it was almost as if her depression left the room once the rabbit was there’.

What’s your take home message?

Introducing Holly to the ward has been shown to have beneficial effects on both patients and staff, as demonstrated by both our qualitative questionnaire as well as independent feedback. She has made patients’ stay more enjoyable, improved staff morale (especially important in a time of increasing stress levels reported amongst NHS staff4), and in particular has positively impacted the stay of patients admitted with mental health complaints.

We feel this project’s benefits could be replicated in other paediatric units to improve the care we provide and impact positively on patient experience of the healthcare system.

Resources?

  1. Vagnoli, L., Caprilli, S., Vernucci, C., Zagni, S., Mugnai, F., & Messeri, A. Can presence of a dog reduce pain and distress in children during venipuncture?. Pain Management Nursing, 16(2), 89-95.
  2. Lima, M., Silva, K., Amaral, I., Magalhães, A., & Sousa, L. 2014. Can you help when it hurts? Dogs as potential pain relief stimuli for children with profound intellectual and multiple disabilities. Pain Medicine, 15(11), 1983- 1986.
  3. Calcaterra et al. 2015. Post-operative benefits of animal-assisted therapy in pediatric surgery: a randomised study. PLoS One. 2015 Jun 3;10(6):e0125813.
  4. Rimmer. 2018. Staff stress levels reflect rising pressure on NHS, says NHS leaders. BMJ2018; 36

 

https://twitter.com/hollywhitrabbit?lang=en 

https://www.instagram.com/hollywhitrabbit/

SOCKS!

SOCKS!

SOCKS

Stamp Out Cyberbullying and Keep Safe!

Dr Hannah Opstad, Paediatric Registrar, St Mary’s Hospital, London.

Introduction:

Adolescents are well recognised as highly vulnerable to online abuse. We sought to target state primary school children, using a novel teaching programme, SOCKS, to foster online safety awareness skills before adolescence. We report on the development of this programme and the pilot results.

Method:

Objective: To improve knowledge about online safety and abuse reporting in primary school children.

This programme was designed following a focus group discussion with adolescents. It comprises a 1-hour long teaching session. This has been trialed on two Year 5 classes with feedback obtained by questionnaire before/ after the session.

Results:

Data: 60 Year 5 children took part in the pilot. Prior to the class being delivered, 18/60 (30%) 9-10 year-olds signalled that they have a social media profile. One 10-year-old boy stated “Snapchat is my life!”

6/60 (10%) children admitted that they have friends online who they do not know offline. The feedback following the teaching showed many children had obtained greater awareness with qualitative analysis demonstrating themes of ‘intent to report harmful content’/ ‘insight into hurt caused by anonymous comments’:

e.g. “I probably would have written “that’s really funny…lol!” but after this session I don’t think I would because that would probably upset her”. Age 10

 Conclusion:

Our pilot programme highlights how common use of social media is, even in this young age group. The SOCKS programme is an engaging teaching programme to develop online safety awareness skills. It was universally well received by staff and students. This programme is due to be taught in a further two schools in the near future, pending wider rollout.

 

Acknowledgements:

Dr Ian Maconochie, Consultant in Paediatric Emergency Medicine

Dr Rebecca Salter, Consultant in Paediatric Emergency Medicine

‘Training doctors to mentor doctors’

Key contacts

Nicola Storring

Introduction

I’m a paediatric trainee from the Kent, Surrey and Sussex deanery in my 7th year of training. 2 years ago I set-up a peer mentoring programme within my deanery. It was always something I had wanted to do after experiencing how much of a positive effect a good mentor can have on your training and also other aspects of your life too. I also wondered if it may help the increasing number of junior doctors suffering from mental health problems and aid retention of trainees which is a very prevalent issue with increasing number of junior doctors leaving training creating even more pressure on an already strained work force.

For the past 2 years every new ST1 has been offered a place within the programme as a mentee with about 90% uptake. At the beginning of each year I arranged a training day for all those who were ST2 and above who wanted to become mentors. I then matched the mentees and mentor based on geography and interests. The mentors and mentees have then met-up at least three times a year. The most inspiring aspect of this project has been how so many trainees are so keen to give up their time to support their fellow trainees. It’s only because of this that projects like this can work.

The next stage is to try and expand the programme to provide mentors for all trainees of all levels who would like one. The limiting factor has been the number of people who can attend a training day to become a mentor due service provision. Hence, we are currently developing an online module on e-learning for health so people can train to be mentors online. This should be available for use before the end of this year and any training school will be able to use it from any deanery.

Please contact me if you are interested in setting up a peer mentoring scheme within your deanery: nicola.storring@doctors.org.uk. I will also be presenting the scheme at the DEMEC in Manchester on 28th November this year and would love to talk to anyone who would be interested in creating their own scheme.

SMART objectives

Progress made: What have you learned from doing this?

What’s your take home message?

Resources?

PAGES – PAediatric Guideline Exchange Site

PAGES – PAediatric Guideline Exchange Site

Key contacts

 Jane Simpson, Ronny Cheung, Mark Butler – contact info and full list of participating trusts and individuals on the site 

Introduction

We have brought together clinical guidelines for paediatrics from across London. We hope you find them useful and appreciate the work that has gone into them. We hope this project will help reduce the duplication of effort that currently occurs in guideline development and helps us to ensure we deliver high quality evidence based care for our patients.

This site is intended as a resource to allow paediatricians to access and share guidelines across institutions for guideline development and research purposes. All clinicians are responsible for their use of these resources and should follow the procedures and protocols of their own institution.

SMART objectives

We aim to build up a database of clinical guidelines that are categorized and searchable which will be useful to 

Progress made: What have you learned from doing this?

 The importance of getting engagement from seniors and juniors across institutions, and that there is a huge interest in this as a resource.

What’s your take home message?

 Please get involved, help share this idea across trusts and contribute your own guidelines to our project.

Resources?

 https://paediatricguidelineexchange.wordpress.com/

Improving Initial Health Assessments for Unaccompanied Asylum Seeking Children

Improving Initial Health Assessments for Unaccompanied Asylum Seeking Children

Key contacts

Roshni Mistry: Roshni.Mistry@nhs.net

Fionnuala Ryan: Fionnuala.Ryan@nhs.net

Anna Gerrard Hughes: Anna.GerrardHughes@nhs.net

Introduction

In recent years the UK has experienced an influx of unaccompanied asylum-seeking children (UASC). Home office statistics indicate that in 2016, 3290 unaccompanied children applied for asylum in the UK; all of these children require an initial health assessment (IHA) after arrival in the UK. This population of children have very different health and social care needs to other looked-after children (LAC): in 2015 the largest proportion of asylum seekers originated from Eritrea, Syria, Pakistan, Iran, and Sudan – countries with high prevalence of blood borne viruses (BBV) and tuberculosis (TB) – and had travelled through many countries with widely differing health needs prior to arrival in the UK. Additionally, the higher rates of sexual violence, torture, and physical and mental health problems in this population contribute to growing evidence that their health assessments require a tailored approach.

The IHAs are performed in LAC clinics across the UK, and legal guidelines state that they should be completed within 28 days of being placed in state care. In East London there is no standardised pathway or guidance, and this project aims to assess the need for a tailored local guideline to ensure the health and social care needs of this vulnerable population are not being overlooked.

SMART objectives

Over a 1 year period we aim to assess and reach the following standards (based on national guidelines, including the RCPCH, NICE, the Kent guidelines for UASCs and the Camden Integrated Care Pathway):

  1. In 100% of cases the patient is seen with an interpreter (RCPCH Child Protection companion 14.3.1).
  2. In 100% of cases the legal status of the child is documented (RCPCH Child Protection companion 14.3.1).
  3. In 100% of patients a list of countries travelled through is documented (UASC Health: Clinical guidance for primary care and GPs on the health needs of UASC).
  4. In 100% of patients risk of exposure to TB is assessed (NICE Clinical Guideline NG33).
  5. 100% of new entrants to the UK who are from countries with a high incidence of TB is offered screening for latent TB (NICE Clinical Guideline NG33).
  6. In 100% of patients from a country with HIV prevalence over 1% or at increased risk of HIV, screening is recommended (Public health England: Migrant health guide).
  7. In 100% of patients from a country of medium or high prevalence of hepatitis B or C, screening is recommended (NICE Public health guideline PH43).
  8. 100% of patients are assessed for a risk of haemoglobin disorders and screening recommended if appropriate (Public health England: Migrant health guide).
  9. In 100% of cases the child is screened for having been a victim of torture and referral to organisations is offered (RCPCH Child Protection companion 14.3.1).
  10. In 100% of cases contact with birth family is asked about and advice offered (UASC Health: Clinical guidance for primary care and GPs on the health needs of UASC).
  11. In 100% of cases mental wellbeing is assessed and support offered if indicated (UASC Health: Clinical guidance for primary care and GPs on the health needs of UASC).
  12. In 100% of cases a full immunisation history is taken (RCPCH Child Protection companion 14.3.1).
  13. In 100% of cases children with an unknown or incomplete vaccination schedule are recommended to have a catch-up schedule (Public Health England; Vaccination of individuals with uncertain or incomplete immunisation status).
  14. In 100% of cases a recommendation is made for child to have FBC to screen for eosinophilia and anaemia (Public health England: Migrant health guide).
  15. In 100% of patients symptoms of PTSD are screened for (UASC Health: Clinical guidance for primary care and GPs on the health needs of UASC).
  16. In 100% of cases a history of being trafficked is screened for and advice offered (Department for Education: Care of the unaccompanied and trafficked children).
  17. In 100% of patients the risk of Female Genital Mutilation (FGM) is assessed (RCPCH Child Protection companion 14.3.3).
  18. 100% of patients with a history of FGM are referred to a specialist (RCPCH Child Protection companion 14.3.3 ).

Progress made: What have you learned from doing this?

We have completed the initial audit and presented the findings in the local audit meeting.  

The demographic details of the patients in this study are representative of national statistics, with the majority being from Eritrea or Sudan. Most of the countries listed do not routinely speak English as their first language, and it is encouraging that the majority (80%) were seen with an interpreter. 73% had the countries they visited on their journey documented. Only 73% had a risk assessment for BBV, and 60% of patients had a recommendation for BBV screening sent to their GPs; 33% had their risk of TB documented, and all of these had a recommendation made to their GPs for TB screening. 13% of patients had a recommendation sent to their GP for a full blood count. All the UASCs audited came through countries with a high prevalence of BBV and TB, and are at high risk of sexual violence on their route here, necessitating a blanket approach to screening. All patients had their immunisation status checked with a recommendation to the GP to complete catch-up vaccinations.

Of the two girls included in our patient population, one was asked about FGM and had a positive history. She was referred appropriately. Both were from countries where FGM is practiced. 

From a mental health, social and safeguarding perspective, the numbers asked about whether they had contact with their family, were trafficked, or had experiences of torture were poor (47%, 13%, 20% respectively). However, all children were asked about their mental health in general.

What’s your take home message?

In conclusion, the current IHA for UASC in Tower Hamlets meets some of the national standards for this population, however many specific needs remain unmet. We feel that the current proforma, documentation methods and lack of guidelines in Tower Hamlets are contributing to the substandard quality of care.

Recommendations: 

  1. To develop guideline and an integrated health pathway aiming to support LAC clinicians in making the appropriate referrals and signposting the patient and social worker to other services.
  2. Institution of a tailored proforma for IHA medicals in UASC aiming to aid the clinician in asking the relevant questions and referring to appropriate services.
  3. To improve awareness amongst clinicians completing IHAs at Tower Hamlets of the specific health and social care needs of UASC.
  4. To re-audit IHAs in UASC after completing the above steps.
  5. To gain feedback from service users to inform and improve our service and pathway. 
  6. To use this data to advocate for changes in health policy which protect and safeguard this vulnerable population. 
  7. To contribute data to a London wide project assessing IHAs in different boroughs with the aim of standardising and streamlining care. 

Resources?

  1. Home Office. National Statistic, Asylum. Asylum – GOV.uk. [Online] 27 August 2017. [Cited: 10 Jan 2018.] https://www.gov.uk/government/publications/immigration-statistics-april-to-june-2015/asylum#key-facts.
  2. Refugee Council. Asylum Statistic Annual Trends. London : Refugee Counci Informationl, 2018.
  3. UASC Health. Clinical guideline for primary care and GPs on the health needs of UASC. UASC Health. [Online] 2017. [Cited: 03 October 2017.] http://www.uaschealth.org/resources/paediatrics/#1490284388881-f29da208-8e9d.
  4. —. Clinical Guidance for Primary Care and GPs on the Health Needs of UASC. Kent : UASC Health.
  5. Department for Health. Statutory Guidance on Promoting the Health and wellbeing of Looked After Children. London : Department for Health, 2009.
  6. UASC Health. INITIAL HEALTH ASSESSMENT SUMMARY REPORT. Kent : UASC Health.
  7. Developing an integrated health pathway for unaccompanied minors in London. O’Donnell, Najette Ayadi. The Hague : IPSCAN European Regional Meeting, 2017.
  8. Home Office. Immigration Rules part 11: asylum. London : Home Office, 2016.
  9. Royal College of Paediatrics and Child Health . 14.3.1 Children from minority groups. Royal College of Paediatrics and Child Health. [Online] 03 October 2017. [Cited: 03 October 2017.] https://www.rcpch.ac.uk/child-protection-companion/143-children-minority-groups.
  10. NICE. TUBERCULOSIS NICE Clinical Guideline NG33. London : National Institute for Clinical Excellence, 2016.
  11. Public Health England . HIV: migrant health guide. GOV.UK. [Online] 31 July 2014. [Cited: 03 October 2017.] https://www.gov.uk/guidance/hiv-migrant-health-guide.
  12. National Institute for Health and Care Excellence . Hepatitis B and C testing: people at risk of infection. National Institute for Health and Care Excellence . [Online] December 2012. [Cited: 03 October 2017.] https://www.nice.org.uk/guidance/ph43/chapter/1-Recommendations#recommendation-4-testing-for-hepatitis-b-and-c-in-primary-care.
  13. Public Health England. Haemoglobin disorders: migrant health guide. GOV.UK. [Online] 31 July 2014. [Cited: 03 October 2017.] https://www.gov.uk/guidance/haemoglobin-disorders-migrant-health-guide.
  14. Public Health England . Vaccination of individuals with uncertain or incomplete immunisation status. s.l. : Public Health England, 2016.
  15. Department for Education. Care of Unaccompanied and Trafficked Children . s.l. : Department for Education, 2014.
  16. Royal College of Paediatrics and Child Health . 14.3.3 Children from minority groups; Female Genital Mutilation (FGM). Royal College of Paediatrics and Child Health . [Online] 03 October 2017. [Cited: 03 October 2017.] https://www.rcpch.ac.uk/child-protection-companion/1433-children-minority-groups#514.
  17. National Institute for Clincal Excellence. NG33: Tuberculosis. National Institute for Health and Care Excellence. [Online] May 2016. [Cited: 03 October 2017.] https://www.nice.org.uk/guidance/ng33.
  18. Public Health England. Helminth infections: migrant health guide. GOV.UK. [Online] 31 July 2014. [Cited: 03 October 2017.] https://www.gov.uk/guidance/helminth-infections-migrant-health-guide.
  19. ISSOP position statement on migrant child health. International Society for Social Pediatrics and Child Health. 1-10, Geneva : Wiley, 2017, Vol. Child Care Health Development .
Learning from Excellence – A Royal Free NHS Foundation Trust Experience

Learning from Excellence – A Royal Free NHS Foundation Trust Experience

Contacts

Dr Patricia Lutalo – Paediatric trainee

Dr Dominic Fenn – Paediatric trainee

Dr Shanthi Shanmugalingam – Consultant Neonatologist

 

Introduction

Taking the lead from Adrian Plunkett and his team at the Birmingham Children’s Hospital, the Learning from Excellence (LfE) Project was launched at Barnet Hospital’s Women’s Health and Children’s department in June 2016.  The project aims to capture and celebrate examples of high quality practice.  Traditionally the drive for optimising patient safety has focussed on adverse incident reporting.  The tendency to focus on the negative, while effective, can lead to second victim phenomenon adversely affecting those involved.  Humans innately obsess with the negative, yet there is a significant amount of positive practice which should be learned from and celebrated. 

 

Initially a simple paper based nomination system was adopted at Barnet Hospital to highlight everyday excellence with nominations placed in designated yellow boxes distributed throughout the piloting departments.  The nominees received email feedback from the lead consultant who was responsible for spearheading the initiative.  The nominees and nominations within the first few months of the project launch, as expected, came from within the piloting departments.  The good word, however, soon spread throughout the Royal Free Hospital NHS Foundation Trust with multiple disciplines either nominating or being nominated.  The progressive osmosis of other teams continued and by November 2016, with the tremendous support from the IT team, the LfE Project went viral with the introduction of electronic reporting.  This not only increased the number of nominations but also the diversity of nominees.

 

Nominations have been inclusive of clinical and non-clinical roles, inter and intra disciplinary and independent of hierarchy bias.  The recipients of nominations have expressed delight and commented about how this method of working together has contributed to enhancing morale and a positive working environment.  The common themes identified have included examples ranging from teaching, supportive non-clinical members of staff, appreciation of empathy, good team working and the management of resuscitation situations.

 

In a climate where there are multiple challenges facing the NHS and its staff, the LfE team at the Royal Free Hospital Foundation Trust hopes that by recognising individuals and the teams crucial to delivering and maintaining the high level of care seen at the Royal Free Trust, a positive learning environment can be promoted which can also serve to boost staff morale.     

 

Examples of a few responses received from nominees.

 

“Thank you. I was bowled over by that …It was a challenging situation and I really felt I was just doing my job…”

 

“Thank you so much. Has cheered me up!”

 

“Positive feedback gives us the impetus to work harder, feel valued and appreciated…”

 

“…importance of feedback…to hear it or have it written down motivates one to continue working harder and helps perpetuate a positive cycle of praise and appreciation in any team

SMART Objectives

Specific: 

The project aims to capture and celebrate examples of high quality practice and provide positive feedback to the nominees.

Measurable:

The number of nominees and information about their specific departments are collected. 

The themes of the nominations are recorded. 

Qualitative data on responses from the nominees is also captured.  

 

Achievable:

The project needs multi-disciplinary participation and champions in various departments in order to promote awareness and nominations.  This was achieved at the Royal Free Hospital NHS Foundation Trust and catapulted with the introduction of electronic nominating with significant input from the IT department.  

 

Relevant:

Traditionally the drive for optimising patient safety has focussed on adverse incident reporting.  There is a significant amount that can be learned from highlighting positive practice and this should be celebrated.  It has also been shown that a positive working environment improves staff morale.

 

Time bound:

No time limit as this is an on-going project which needs quarterly review of results.  

What has been learned from the project?

Multidisciplinary involvement from clinical, nursing and midwifery leads and the IT department is required to promote the initiative and garner enthusiasm from members of staff to provide nominations and encourage regular positive feedback.

Leadership from a consultant is required to influence uptake within a Trust.

Individuals who work in healthcare are dedicated and hardworking people who really value formal positive feedback and garner encouragement and resilience from it.

 

Take home message:

The Learning from Excellence Project is all about learning from and celebrating good practice within the health sector.  It is a positive, effective way of promoting education and staff morale.  

Resources:

Plunkett., 2016 Learning from Excellence: Start up guide, Birmingham Children’s Hospital. Available: http://learningfromexcellence.com

Leonhardt, J., Licu, T., Shorrock, S. 2013. From Safety-I to Safety-II. A White Paper. EUROCONTROL (European Organisation for the Safety of Air Navigation).

 Kelly N, Blake S, Plunkett A. 2016. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child 101:788-9