Future-Proofing PEM

Authors: Liz Herrieven / Editor: Charlotte Davies / Codes: SaC2, SLO11, SLO12, SLO5, SLO7, SLO8, XC1 / Published: 23/11/2022

I was tasked with talking about the future of PEM at this year’s EMTA conference. Now, if you’re not a PEM sub-specialist or interested in the field, please don’t switch off. Paediatric care is a hugely important area of emergency medicine in mixed departments too, and many of the challenges faced by the sub-specialty will also be recognised by generalists.

So, where does PEM fit in with EM? Children make up about 25-30% of attendances to mixed EDs nationally, so all EM consultants must possess at least basic paediatric skills¹. Emergency Medicine trainees, therefore, have to be appropriately trained and given adequate exposure to a wide range of paediatric conditions (plus plenty of well children) to enable them to gain proficiency. That’s not enough on its own though – the management of paediatric emergencies also requires appropriately trained nursing staff, a wide range of equipment, appropriate facilities and space and the necessary pathways and protocols. There’s good evidence that it’s worth doing though – the right management saves lives².

To properly think about the future, we need to first think about the past.

The Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings was founded in 1999 and since then both Emergency Medicine and Paediatric Emergency Medicine have evolved with PEM becoming a designated specialty in 2002. It has its own section of the EM curriculum, and the PEM sub-specialty syllabus has also been refined and is shared between RCEM and RCPCH³. There have been several iterations of the national standards that guide emergency care for children and young people and, after the latest update in 2018⁴, huge investments in facilities and staffing for the management of paediatric emergencies in mixed EDs and in DGHs. This may be seen as an improvement by many, but by some as causing a potential division between EM and PEM – different waiting areas, different clinical rooms, different staff. But PEM remains intertwined with EM and, in my opinion, it always must. Paediatricians bring a wealth of child-related experience to the table when it comes to PEM, but Emergency Physicians bring a vast array of emergency skills, including assessment of the undifferentiated patient, balance of risk, team leadership, crisis management, procedural skills, management of trauma and injuries and communication in complex situations to name but a few. Be proud of your EM roots and the unique mix of skills you have.

There are certainly lots of challenges faced by both EM and PEM at present, and we need to unpick these in order to think about the future. We’re seeing higher attendances than ever before with some departments reporting 50% more children in summer months than pre-pandemic⁵, and an average 15% more through the door nationwide⁶. There have been several attempts to try to unravel the reasons behind this and we’ll touch on these in a moment.

Of course, paediatric EDs aren’t seeing crowding issues to the extent that general or adult departments are. Adults EDs are seeing greater attendances per year, a greater proportion of patients arriving by ambulance, higher acuity patients and a greater number of patients leaving without being seen. Paediatric departments, or areas within mixed EDs, when compared to adult areas, do see similar numbers of patient arrivals per treatment space or per clinician hours⁷.

We don’t have the same queues of ambulances waiting to offload or the same extent of patients waiting for beds on wards. We do see the impact of these though. Ambulance response times are steadily worsening. Category One calls, the life-threatening ones, should be at scene within 7 minutes. Latest figures have this at 9 minutes and 35 seconds. For Category Two – those who need urgent intervention or urgent transportation – 90% should be at scene within 40 minutes. Latest figures have this at 2 hours 17 minutes. Patients at Category Three, who might need pain relief for a leg fracture, for example, should expect to see an ambulance within 2 hours. Currently they are waiting 8 hours and 22 minutes⁸. Much of this is related to long waits at EDs for ambulances to offload patients. In 2019 one in fifty ambulances waited over one hour. In 2022 it’s greater than one in ten (and often several hours, at that)⁹.

Children are, of course, often portable. Parents frequently decide to bring their very sick children to ED by car. That itself has implications for all departments, which have to be ready to receive critically ill children to resus without any warning.

Speaking of parents, parental and societal expectations have a huge impact on ED pressures. Mainstream media, with sensational stories about horrific illnesses and missed opportunities, has a role to play in influencing parents about healthcare choices, as does the rise of social media¹⁰. This has allowed everyone to have a loud opinion about everything and it can be difficult to work out who to listen to and who to get advice from. Fever fear spreads like wildfire through Facebook and soon parents can feel they have no choice but to seek urgent medical help, whatever their own gut feeling. Many hospital trusts use social media to try to divert patients away from EDs, but there is little evidence that these campaigns are successful. It is often difficult for experienced clinicians to know what might be a significant symptom, so it is not unsurprising that the public struggle with this too.

The four-hour target brought great, and positive, changes to emergency medicine, but also the expectation of turning up at your own convenience and being assessed, investigated, diagnosed and treated all within a manageable time frame. Why would you choose a slower route for your sick child?

Parents also expect, if attending hospital, to see a specialist. Whilst some of us may be specialists in emergencies, many of our colleagues are junior trainees in a wide variety of specialties, with far less experience in managing children than the average GP.

Parents want, understandably, to have their concerns and fears addressed. If we don’t achieve that, then they are left anxious and confused, with a higher chance of reattending¹¹. Discharge advice needs to be specific to the situation at hand, and precise when it comes to triggers and actions.

It can be tempting to blame GPs for our increase in workload, but that just doesn’t cut it. A study looking at trends in healthcare use by those under the age of 15, just before the pandemic, showed that, despite changes to make primary care consultations more accessible, there were fewer GP consultations for all children, except infants, and greater attendances at urgent and emergency care facilities¹². However, whether or not it actually is more difficult to get a face-to-face GP appointment, the perception gained from mainstream and social media will likely have had an influence too, causing families to choose ED rather than attempt something which seems destined to fail.

Approximately 21% of ED attendances in those under the age of 16 are non-urgent, with a greater proportion in those under 5 years of age¹³. Non-urgent patients tend to spend less time in the ED, with less likelihood of undergoing investigations or admission, but they still have an impact on flow and waiting times. These numbers go up even higher if we look at out-of-hours, when GP surgeries are likely to be closed, with calls to NHS111 regarding children also higher at these times. Paediatric staff handling calls at NHS111 does seem to have an impact on reducing the number of children who are sent to ED or paediatric assessment units¹⁴. It’s not just a flow and capacity issue when children are seen in ED with non-urgent problems. Those children often undergo unnecessary investigations and are more likely to be admitted to hospital, compared to those attending primary care settings with the same symptoms¹⁵. We can’t blame ED clinicians for that – we’re not trained to manage primary care problems and can only benchmark against our usual population of patients, which have a higher likelihood of serious acute illness compared to those in a primary care waiting room.

Evidence for placing primary care staff in EDs to see these non-urgent patients is inconsistent and insufficient, with no real evaluation of safety¹⁶. Co-located GPs can reduce waiting times, investigations, admission rates and healthcare costs for this group of patients, but with an associated increase in antibiotic usage^17,18. There’s also a small decrease in waiting times for higher acuity patients¹⁹.

For Urgent Treatment Centres based away from the acute hospital site, convenience plays a huge role when it comes to any impact on the ED, with both location and opening times being a key factor for parents when choosing a UTC over ED²⁰.

At the other end of the acuity spectrum, PEM also has a huge role to play in emergency preparedness. The Manchester arena attack showed how important it is to have plans in place for dealing with Major Incidents in which the majority of patients are children and young people, with the added challenge of parents to manage alongside. Again, this means our links with EM are vitally important. All EDs, no matter how large their usual paediatric patient population, need to consider how they would respond to a nearby paediatric Majax.

Another issue that seems to overwhelm the available resources is mental health problems in children and young people. The pandemic, with the associated fear, school closures and social isolation, has undoubtedly had an impact, but things have been escalating in this area for a while now. In 2021 one in six children aged 5 to 16 were identified as having a mental illness, compared to one in nine in 2017²¹. The number of ED attendances by children diagnosed with a mental illness tripled between 2010 and 2019. Paediatric mental health services, like many other health and social care services, are under-funded and short-staffed, with long waiting lists and families and young people struggling for support. It’s understandable that they are turning to EDs for help in a crisis.

Not only are we seeing an increase in young people with depression, anxiety, self-harm and suicidal ideation, we’re also seeing more families looking for help in crises related to behaviours that challenge. Waiting lists for autism and ADHD assessments are hitting two to three years. As families struggle and behaviours escalate, there is scarce support available for them in the meantime. The Emergency Department is often a last resort, but there is very little we have to offer except a safe space for a few hours. How safe and reassuring that space is, at the moment, with crowding and the sensory stimulation that brings, is another story.

Family units have changed in recent years. Whereas once, worried parents would have been supported by extended family members, more often now families are isolated and have lost that wealth of experience. The pandemic saw an increase in well babies being brought to EDs with issues traditionally managed by midwives and health visitors – feeding problems, minor skin problems, constipation – and these attendances are unlikely to go away. A consultation with new parents about a crying baby often takes more time to manage properly than an older child with a broken ankle or minor head injury.

The cost of living crisis and mounting levels of poverty also have an impact on PEM. There’s good evidence to show that those living in areas of deprivation are more likely to visit the ED, for a number of reasons. Lower health literacy, difficulties in taking time off work to get to planned appointments, costs of transport to clinics or surgeries further away, difficulties in affording heating, food, medications, poor air and living conditions including, as highlighted recently, mould²². Deprivation is linked to worse asthma control²³ and higher rates of lower respiratory tract infections²⁴in particular.

Speaking of infections, we have to mention the pandemic and the impact it had on PEM. COVID-19 hasn’t particularly caused severe illness in the majority of children, but there are many other areas in which it has affected children. School closures, social isolation, mental health issues, safeguarding problems, anxiety and fear amongst the clinically vulnerable, long covid, PIMS-TS…the list goes on. A pandemic with children directly clinically affected, too, is only ever just around the corner and PEM has to be ready for it. In the meantime we’re seeing changes in the seasonal pattern of some viral infections with RSV, parainfluenza and rhinovirus keeping us busy in the summer months of 2021²⁵. Vaccine hesitancy may also be an issue post-pandemic with parents’ view on vaccination changing after the introduction of covid vaccines and the volume of related misinformation²⁶.

Yet another challenge, not just to PEM but to the NHS at large, is staffing. Morale is low and seems to be dropping even further. The 2021 NHS Staff Survey (the 2022 version open at the time of writing this) revealed 34.3% of staff felt burned out and 31% were considering leaving their job²⁷. This isn’t something PEM can solve alone, but something we must factor in when planning for the future.

So, increasing attendances, primary care problems, parental expectations, mental health problems, lack of community support, staffing crisis – do we fight these or do we adapt and move on? I’m not sure it’s a fight we can win, so we have to be prepared to adapt, at least in part.

So what does the Paediatric ED of the future look like? These are only my thoughts, of course…..

PEM needs to consider staffing. There is a wealth of different professions we can learn from and work with. Primary care colleagues are the obvious ones, although we have already heard there are pros and cons of this, and primary care has its own staffing issues. Emergency medicine has a long history of working with nurse practitioners and now ACPs. Investing in those with paediatric and/or emergency experience can pay dividends with returns including a stable workforce, if managed properly. Pharmacists could be a valuable resource, as could mental health practitioners.

Along with thinking about the variety of staffing options, we need to consider training. Maybe it’s time to include more training about primary care conditions in the PEM syllabus? The description of a PEM doctor included in the syllabus talks about being able to manage children of all ages, with a wide range of undifferentiated conditions, including minor and major trauma, minor and serious illness and the worried well, so the premise is already there²⁸.

Perhaps we also need to think about the way we train. We work in teams, so maybe we should train in teams – alongside our allied health professional and nursing colleagues.

We need to look after our staff. Yoga sessions and fruit baskets are nice ideas, but what do our teams really need to function? Personally, I think we need to crack down on bullying and discrimination, and provide the basics like parking, lockers, lunch breaks and somewhere to eat that lunch. Time to learn and feel a part of a team can also improve morale.

We have to think about sustainability – both of the team and department, and on a wider, environmental scale. Tonnes of plastic waste during the pandemic and beyond, and our continued reliance on Entonox will have to be addressed at some point – sooner rather than later.

Diversity has to be embraced – both within our teams but also within our patient population. Immigrants and refugees face challenges accessing healthcare, particularly in an emergency. They may be unfamiliar with UK systems and may not know who, where or how to get help. There may be language issues, cultural challenges and variations in health knowledge and literacy. As emergency physicians we have an opportunity to identify and signpost our most vulnerable patients who may have needs including social support, housing, education and safeguarding. Don’t forget risks of trafficking and abuse and consider the mental health impact of being uprooted from your home and family during war or other social or political crisis²⁹. This may not be the exciting resus case you signed up to EM for, but a very real chance to make a difference to someone.

PEM also has a duty to be inclusive towards our patients with learning disabilities and those who are autistic. These patients are at increased risk of death from treatable causes and we have to acknowledge this in our training, along with making our departments a less stressful place to be, wherever possible³⁰.

Speaking of training, we need to ensure we address diversity in skin colour and the health inequalities that exist as a result³¹. Projects such as Skin Deep³², Mind the Gap³³ and Brown Skin Matters³⁴ are a great start³⁵.

And what about education for parents? We can’t blame the public for not knowing what constitutes a medical emergency if we don’t try to help them learn. Websites such as Healthier Together are a fab resource³⁶. Discharge information can make a difference when it comes to reattendance³⁷ and, particularly frequent attendance³⁸, but it has to be appropriate, specific and clear. Signposting to packages of support and education can also have a positive impact³⁹, but, as EM physicians, we need to know they are there in the first place. Health promotion is vital. How many of us avoid conversations about obesity, vaccination, or smoking, because it’s a busy shift when, actually, those things might just make a difference?

We need to have the right PEM protocols and pathways in place. Unusually, for emergency medicine, this can often mean doing very little for our patients. Studies such as FORCE⁴⁰ and CRAFFT⁴¹ and guidance around the management of bronchiolitis⁴² all encourage us to scale back our interventions in the knowledge that children often do very well without much interference when injured or ill. Some children might not even need to wait to be seen by a clinician. Many departments have started to introduce nurse-led pathways for discharge from triage for example for head injuries⁴³ or simple wounds.

At the same time, when we should do more, we should do more. Let’s once and for all forget about “brutacaine” and forcing children to undergo painful procedures that would challenge an adult, and get things like sedation, pain relief and play therapy right.

Paediatric EDs are the last resort for patients in mental health crisis, and yes, these patients can be difficult to properly support, but we have to think beyond what has become common practice, and provide comfort, safety and access to proper help. Too often young people are waiting in busy, chaotic and sometimes unsafe environments for days at a time for a mental health bed. There has to be a better way.

We need to learn from each other. There are some fabulous pockets of good practice being developed across PEM and EM, so let’s share those. We need to build a community of practice – partly for our departments and teams, to share that good practice, but also for our own personal support and wellbeing. I know I’m hugely grateful to my RCEMlearning and DFTB friends, even those I’ve never met in person, for helping me grow as a clinician and survive as a person. Are you, and your department, linked up with organisations, colleagues and friends that can do the same for you?

 

 

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