Paediatric Critical Care

Develop and introduce a single early warning system for children across all hospitals in England. a NHS England and NHS Improvement (NHSE/I) and RCPCH to complete development and piloting of a new national paediatric early warning system and introduce it across all hospitals, once validated.

Ensure that specialist paediatric pathways are more closely aligned, so that a child with multiple comorbidities receives co-ordinated care in one tertiary hub whenever possible. a Establish a Children's Strategic Forum (CSF) in each region, with NHS England and NHS Improvement commissioning team oversight. The CSF should include clinical representation from each paediatric ODN and other non-ODN specialist pathways, as well as representation from spoke and hub hospitals. b Identify a 'principal hub' link for each spoke hospital to foster development of closer collaborative working, and to ensure that a child requiring multiple PICU admissions is admitted to the same PICU and hospital wherever this is clinically appropriate.

Ensure that paediatric critical care provision across England is equitable and appropriate to local demand, so that every child requiring PCC can receive care as close to the family home as possible. a Develop clear written criteria, to be used across all ODNs and transport services, to determine the appropriate destination PICU when a child requires urgent transfer from a spoke hospital into a hub PICU. b ODNs should monitor spoke to hub PICU transfers (both within ODN and out of ODN) to ensure that transfers comply with the principles of: i) admission to the 'principal hub' for that spoke hospital and/or ii) admission to the closest PICU, whenever it is clinically appropriate. c Establish a group with national oversight (NOG) of PCC services across England. This group should be responsible for providing recommendations to NHS England and NHS Improvement regional teams and ODNs regarding: i) ODN configuration and potential reconfiguration – to ensure that spoke hospitals sit within the most appropriate ODN, ii) L3 bed distribution – to ensure capacity in each hub is appropriate to demand, including unmet demand, iii) L2 bed distribution across ODNs, within both hub and spoke hospitals. The group should bring together national and local stakeholder knowledge and include, as a minimum, representatives from Royal College of Paediatrics and Child Health (RCPCH), Paediatric Critical Care Society, PCC Clinical Reference Group, PICANet, NHS England and NHS Improvement Women's and Children's Programme of Care board, and the PCC ODNs. d ODNs should notify their NHS England and NHS Improvement regional team, and the National Oversight Group (NOG), when lack of L3 capacity within a provider is considered to be a factor in reducing compliance with the principles of i) admission to the 'principal hub' linked to a spoke hospital and/or ii) admission to the closest PICU, where clinically appropriate.

Increase the number of L2 beds across both hub and spoke hospitals, to reduce strain on L3 beds, improve efficiency, and improve value for money. a Every L3 provider should have a commissioning contract with their NHS England and NHS Improvement regional team that captures commissioning of both L2 and L3 beds. b As a minimum one L2 bed should be commissioned in each hub for every two L3 beds. This should be considered a minimum and will need to be higher where data supports the need for additional L2 beds. c Each ODN should have a number of spoke hospitals that are designated as L2 providers, with this service commissioned by NHS England and NHS Improvement regional teams. It is not possible to be specific with how many spoke hospitals in each ODN should be designated as L2 providers, but an indicative number of 3-4 hospitals is proposed based on evidence from successful networks (though this could be fewer in smaller ODNs). Each designated L2 provider should be commissioned for a minimum number of 4 beds (to deliver efficient staffing given nurse:patient ratio of 1:2 for L2 beds). d Each ODN, through their PCC Network Board, should establish a clear plan and strategy for delivery of PCC across the ODN, at both hub and spoke level, including how this will be commissioned and funded. e This plan should consider how to integrate existing CCG commissioning relating to HDU beds, and the future role of ICS' in commissioning acute paediatric services (including L1 PCC).

Ensure that there is equitable distribution of 'core' resources across the ten PCC ODNs, which is sufficient for them to achieve the key performance indicators set out by NHS England and NHS Improvement in the PCC national review recommendations, and sufficient for them to deliver the recommendations contained in this review. a NHS England and NHS Improvement to undertake a central review of what resources have been distributed in 2020/21, and what core network functions are being delivered with this resource in each ODN. Note should be taken of relative population size in each ODN, and the number of providers. b NHS England and NHS Improvement to consider the paucity of resource available for PCC educators across the ODNs, which presents a significant barrier to improving delivery of PCC across spoke hospitals, and consider allocation of additional resource for this function. c NHS England and NHS Improvement to review the additional recommendations contained in this review and consider allocation of additional resource to ODNs to ensure delivery of these recommendations.

Full addressee: NHS England and NHS Improvement

Adopt approaches to flex the number of L3 beds that can be opened, to better align staffing with predictable flux in demand, and improve winter surge capability. a NHS England and NHS Improvement regional teams to encourage/drive a flexible approach to managing bed capacity over the year, by incorporating differential activity targets (beds or bed days) to match anticipated seasonal demands within contracts. b L3 providers to implement a system that targets the opening of fewer L3 (and L2) beds over summer months and increased beds over winter months, through innovative staffing solutions. c ODNs to ensure that this approach is introduced by their L3 providers, and is able to deliver additional L3 beds over winter months across the ODN.

Ensure that monitoring is in place to identify a L3 unit that is under strain, so that a plan of remediation can be developed. a ODNs and NHS England and NHS Improvement regional team should review regularly (at least quarterly) the demand versus capacity balance of each L3 provider in the ODN. The following should be included in this review process: i) Occupancy of the unit – average occupancy target <85% ii) Adverse consequences of unit strain: Out of hours discharge (20.00 to 08.00) – target <10%; Cancelled elective surgery on the day due to a lack of a L3 bed – target <4% iii) Number, and proportion, of urgent referrals of children from ODN spoke hospitals, that cannot be accepted by the L3 ODN hub provider that is closest to the child and family home – target <5% of referrals (where L3 provider is clinically appropriate) iv) The unmet demand described in iii) should be incorporated into the review process, and any capacity modelling that is done. b Where these targets are not being met ODN and NHS England and NHS Improvement regional teams should work with the L3 provider to develop solutions. This may require commissioning of additional L3 activity if evidence suggests that existing L3 capacity is being used efficiently. c The ODN should notify the NOG where compliance with the above targets is not met.

Make revisions to improve the reporting of 'refused' admissions. a Encourage the use of alternative terms (and the avoidance of 'refusal') for a situation in which a L3 provider is unable to accept a PICU referral as a result of a lack of L3 capacity at that time, to provide a more detailed understanding and audit of this patient group. b Adaptation of the existing PICANet 'referral' dataset would provide the appropriate forum through which to capture and report this data. c Refusal (using current terminology) should not be confined to occurrences when a child is transferred out of ODN ('out of catchment'), but to the recording of every instance in which a child is not able to be transferred to the closest, clinically appropriate, L3 ODN hub. d ODNs should ensure that every PCC transport service is capturing this data and is reporting the revised dataset to PICANet, and to other relevant PCC dashboards.

Ensure clear, consistent reporting of bed occupancy metrics. a All bed occupancy metrics should be reported separately for L3 beds and L2 beds, in order to aid interpretation and benchmarking. b Occupancy should be defined as: i) The number of occupied beds at midnight (occupied bed days) divided by the number of funded beds. ii) The number of funded beds should consider all funding sources and not be confined to NHS England and NHS Improvement regional team funding only. c Explore development of a national, real-time, electronic PCC critical care bed occupancy dashboard populated directly by hospital PAS/EPR systems.

Undertake research to develop a comorbidity index for children (research recommendation). a National Institute for Health Research (NIHR) to consider commissioning research to develop a tool to identify children with important comorbidities, that can be used to improve coding, audit, and to improve mortality risk prediction in hospitalised children.

Develop network clinical pathways, which clearly describe aspects of care that are to be delivered within each spoke hospital, and implement regular monitoring of spoke activity and spoke to hub PICU transfers. a Develop written network pathways of care for at least the following, identifying aspects of care that should be delivered in spoke hospitals (L1, 2), and criteria for referral to L3: i) Care of a child with a tracheostomy ii) Care of a child on home non-invasive ventilation requiring admission to hospital iii) Care of a child on home invasive (tracheostomy) ventilation requiring admission to hospital iv) Care of an infant with bronchiolitis requiring acute continuous positive airway pressure (CPAP) v) Care of an older child requiring acute CPAP. b ODNs should ensure that positive aspects of current delivery are maintained as much as possible, as long as evidence supports safe, quality care and outcomes. c Where necessary the ODN should approve local deviation, or derogation, from current L2 guidance and standards where L1 spokes are approved to deliver elements of care that are above current definitions of L1 care. d ODN to monitor the frequency with which PCC elements of these and other pathways are being delivered within each spoke hospital, through regular collection and review of Paediatric Critical Care Minimum Dataset (PCCMDS) data. e ODN to monitor the rate of spoke to PICU transfer across their providers, and aim to drive down the rate through implementation of improved pathways and enhanced PCC education to spoke hospitals.

Ensure that L3 beds are used efficiently, with alternative pathways in place to minimise the use of L3 beds by patients who do not require L3 care. a Level 3 providers should develop a PCC system that enhances step-up and step-down pathways beyond PICU, thereby reducing the proportion of L0/1/2 activity delivered in designated L3 beds. b Monitor bed day utilisation to ensure that use of L3 beds to deliver L0/1 care is kept to a minimum. Target: <10% of bed days in L3 beds should be L0/1. c Hospitals providing paediatric services should have a single 'hospital wide group' responsible for the co-ordination and development of care for critically ill children (Paediatric Critical Care Society (PCCS) Quality Standard). d Within L3 providers this group should be actively involved in ensuring that effective step-up and step-down pathways are in place to avoid L3 admission as much as possible. e L3 providers should monitor and report delays in critical care discharge of greater than 24 hours from the time when the patient is deemed fit for critical care discharge. Target: <5% of discharges. f Consideration should be given to adding this metric to the NHS England and NHS Improvement Speciality Services Quality Dashboard (SSQD), and to PICANet and other relevant dashboards.

Develop improved long-term ventilation (LTV) pathways, to deliver hospital care, when it is necessary, as close to the child and family home as possible. a ODNs should develop a clear pathway for children on home ventilation who require hospital admission, aiming to deliver that care within an ODN spoke hospital close to the family home wherever possible. b Level 3 providers and ODNs should develop an improved pathway for children dependent on long-term ventilation that delivers care in a non-critical care environment unless the child is clinically unstable. c HRG data should be used to monitor whether care is being delivered in the right place. Indicative targets for patients recorded as receiving tracheostomy ventilation: L3 beds: <25% of related bed day activity should be L2 (XB06Z), <10% L1 (XB07Z). L2 beds: <20% L1. These targets are indicative and should be informed and modified by future data from the paediatric intensive care audit network (PICANet) using a best practice approach (target top quartile). d PICANet should consider adding coding terms with which to identify this cohort of patients within PCC national audit, ensuring that tracheostomy ventilated and non-invasively ventilated patients can be identified separately.

Implement strategies to improve early detection of patient deterioration and ensure timely paediatric critical care intervention. a All paediatric providers to implement the national paediatric early warning system when this becomes available. b Every L3 provider should put in place a system of 24/7 critical care outreach. c L3 providers should monitor rates of ward cardiac arrest, via data collated by the National Cardiac Arrest Audit (NCAA), and drive down the rate over time through improvements across the PCC pathway.

Undertake work to enhance the reporting of PCC outcomes, and deliver improved metrics of unit performance. a Undertake work to explore further improvements in mortality risk prediction, recognising additional risk factors beyond existing paediatric index of mortality (PIM) variables. b Develop models to allow presentation of risk adjusted outcome metrics, including length of ventilation and length of stay. c Deliver reporting that differentiates activity delivered through L3 beds and other (non-L3) beds, to improve the validity of L3 benchmarking comparisons.

Deliver near real-time reporting of a set of core quality metrics relevant to critical care. a Develop a unified, single dashboard and portal through which data can be viewed, bringing together the expertise of relevant partners including GIRFT, Model Hospital, PICANet, NHS England and NHS Improvement (SSQD), and NHSX. The dashboard should contain up to date data, integrate relevant and existing data sources without requiring duplicate data entry, export data from EPR systems wherever possible, and be interactive and flexible. The dashboard must be easily accessible to all clinical staff working in PCC. b Ensure that key adverse events are captured in the dashboard, including: i) Rate of unplanned extubation, and requirement for reintubation after unplanned extubation. ii) Rate of central line associated bloodstream infection (CLABSI). c Ensure that key outcome measures are captured including: i) Risk adjusted mortality. ii) Risk adjusted length of invasive ventilation (via endotracheal tube). iii) Risk adjusted PICU length of stay. d Ensure that key performance and efficiency measures are captured including: i) Average L3 bed occupancy. ii) Rate of same day cancellation of elective surgery due to lack of a critical care bed. iii) Rate of delayed discharge >24hrs. iv) Rate of out of hours discharge (20.00 to 08.00). v) Use of L3 beds to deliver L0/1 care. vi) Use of L3 beds to deliver care to children requiring ventilation via a tracheostomy, including how often this care is L1, L2 and L3.

Ensure that clinical staff are available, in appropriate numbers and with relevant critical care expertise, and working to acceptable roster patterns. a Ensure that reporting of PCC staffing levels is adjusted to take into account the complexity of care being delivered, and reported according to staffing guidance and standards. (Separate reporting of whole-time equivalent staffing pertaining to L3 beds is recommended.) b Every L2 and L3 provider should have 24/7 access to a physiotherapist with paediatric respiratory competencies who is available to attend the bedside if required, and access to 24/7 advice from a pharmacist with knowledge of paediatric prescribing. c Consultants working in PICU should not be on duty for more than 25 consecutive hours. d No consultant should be providing clinical cover to a critical care unit and to the transport service at the same time.

Ensure that clinical staff working with critically ill children have access to appropriate PCC education and training. a Individual organisations and ODNs should have up to date knowledge of the number, and proportion, of their registered nursing staff that have completed an accredited high dependency course and are competent in delivery of L1 and L2 care. b It is recommended that >80% of registered nursing staff working in an HDU area should have completed a relevant HDU course. c All paediatric trainees should complete a period of at least six months' training in PCC prior to becoming a consultant in acute paediatrics. d ODNs should develop a clear, written strategy for delivering L1/2 education across their ODN. i) They should evaluate the staff resource required to deliver the strategy, working closely with PCC educators within L3 hubs to review areas of potential overlap and potential for collaborative working. ii) There should be clarity regarding the elements of L1/2 education delivery that will be the responsibility of the ODN, and those for which responsibility will lie with individual providers within the ODN. iii) They should ensure that HDC education across the ODN is delivered via PCCS-Education (PCCS-E) group approved courses and providers and follows the PCCS-E standards for education in paediatric critical care level 1 and 2 specialist nursing. e NHS England and NHS Improvement should consider the paucity of resource available for PCC educators across the ODNs, which present a significant barrier to improving delivery of PCC across spoke hospitals, and consider allocation of additional resource for this function.

Improve the accuracy and completeness of PCC data capture and flow. a All providers should implement a full electronic patient report (EPR). This should include automated data capture from ventilators, monitoring and infusion devices, and electronic prescribing. Ensure digital connectivity standards are specified to allow capture and automated upload of PCC activity. b Ensure that every paediatric provider has access to a digital solution, and necessary hardware, to support the routine capture of PCC activity (PCCMDS). Consideration should be given to whether PICANet can provide this solution. c Ensure that PCCMDS is collected in all PCC areas of each organisation. (As a minimum data should be captured in all L2 and L3 beds.) d Improve the accuracy of PCC activity data being submitted to the secondary users service (SUS), and to the national cost collection (NCC). i) Ensure that PCC activity data that leaves the organisation is sense checked by clinical, information and finance teams before submission. ii) Use PICANet data as the gold standard comparator for XB01Z to XB05Z healthcare resource group (HRG) data. e Expand the scope of PICANet to capture activity occurring in all L2 beds, in both hub and spoke hospitals. This will require additional funding. (In the longer-term consider further expansion to capture all PCC activity.) f NHS E/I to consider using PICANet, rather than SUS, as the preferred data source for PCC activity. (Alternatively develop a solution that automates the flow of PICANet data into SUS.) g Consider a future model in which a single high quality data source is used for multiple purposes, including audit, commissioning, pricing and payment. (Consider PICANet as a potential source.)

Ensure that there is a consistent approach to commissioning of PCC services across ODNs. a Establish a group with national oversight (PCC NOG) of PCC services across England. This group will be responsible for providing recommendations to NHS England and NHS Improvement regional teams and ODNs regarding: i) ODN configuration and potential reconfiguration – to ensure that spoke hospitals sit within the most appropriate ODN, ii) L3 bed distribution – to ensure capacity in each hub is appropriate to demand, including unmet demand, iii) L2 bed distribution across ODNs, within both hub and spoke hospitals. b Establish a clear and consistent approach to commissioning of PCC delivery across each ODN, with clarity over which aspects of PCC are the responsibility of CCGs, ICSs and NHS England and NHS Improvement regional teams. c Each ODN should have a limited number of spoke hospitals that are designated as L2 providers, with this service commissioned by NHS England and NHS Improvement regional teams. d Each ODN should review the pathway for children on long-term ventilation and consider whether or not to designate additional spoke hospitals, over and above L2 and L3 designated providers, to support this pathway. Consideration should be given to using a model of L1+ beds in this situation.

Ensure that there is up to date guidance to support a consistent approach to commissioning of PCC services. a Review, and update accordingly, the existing PCC relevant service specifications. Ensure that recent guidance and recommendations from the PCC national review and updated PCCS Standards are appropriately captured, in particular the key roles of the PCC ODNs. b Adopt a standardised approach to commissioning of L2 and L3 beds, which incorporates the following principals: i) Always use the HRG definition of a bed day when describing activity (not occupied bed day [midnight occupancy]) ii) Establish a separate contract for L3 beds, to that for L2 beds iii) State the target number of bed days being commissioned iv) State explicitly the corresponding number of beds being commissioned to deliver this target – 2.9 L3 beds are commissioned for every 1,000 bed days of contracted activity; 2.6 L2 beds are commissioned for every 1,000 bed days of contracted activity v) Take patient complexity into account in contracting and when calculating funding. c Introduce a standardised approach to payment for PCC services. i) Ensure that payment is adjusted for patient complexity (using PCC HRGs). ii) Take note of national PCC benchmark prices in agreeing local prices. iii) Consider whether a blended payment approach could be developed for future commissioning and payment, with a fixed and variable, HRG based, component to funding. d Change the label that is used for HRG XB09Z from 'enhanced care' to reduce potential confusion with L1 adult critical care. Consider using the term 'general care' as an alternative. i) Make recommendations about how XB09Z activity should be funded in future.

Reduce litigation costs through application of the GIRFT programme's five-point plan. a Clinicians and trust management to assess their benchmarked position compared with the national average when reviewing the estimated litigation cost per activity. Trusts should have received this information in the GIRFT 'Litigation data pack.' b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims that are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SI)/ patient safety incidents (PSI) and where a claim has not already been reviewed as SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including multi-disciplinary team (MDT) meetings, morbidity and mortality meetings, and regional service meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share examples of good practice where it would be of benefit to trusts.