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Key messages

• Winter pressures felt in children’s emergency care settings are not just confined to Children’s Emergency Departments; they are part of a whole system problem reaching downstream into community settings. In addition to increased acuity, increased demands on primary care during the winter means more parents seek care for their children in the Emergency Department for problems that are best treated in the community, especially out of hours.
• Increased respiratory infections, coupled with an increased acuity of illness, means more children with emergency care needs present to the Emergency Department, without sufficient resources to manage them.
• Health professionals caring for children in the emergency care setting are under pressure. This can lead to burn out and fatigue and, ultimately, staff sickness.
• Pre-existing rota gaps on both medical and nursing rotas cannot be filled, increasing the reliance on locum staff with extra carried risk of an inability to source quality locums to fill the gaps. This is particularly felt out of hours when attendances peak and senior staff are stretched thin adding to the risk of missing the sick child.
• Bed closures and higher acuity illness on inpatient wards impedes flow through the emergency department. This, coupled with a rise in attendance, results in overcrowding in the ED, challenging teams to deliver safe, quality care to children.
• The reallocation of paediatric space within Emergency Departments to address the surge in adult emergency attendance puts further pressure on an already stretched system. Emergency care settings must be designed and provided to accommodate the needs of children and their parents/carers.
• Children are not prioritised in emergency departments and members require support to advocate for them.

Survey methodology

Four questions were asked:

• What are the three main pressures you face in your Emergency Department (ED) during the winter period?
• Can you give an example of things in your local area that have increased winter pressures / made it more challenging to deliver paediatric emergency care?
• What additional systems were put in place last winter by your trust / health board to help with winter pressures for children?
• What three things could help alleviate winter pressures in Emergency Departments that treat children.

The survey collected 265 responses from consultants (53%), middle grade doctors (19%), senior nurses (11%) and band 5–6 nurses (8%). Responses came from across the UK with representation from units of all sizes, including remote and rural DGHs and large standalone children’s hospitals.

Responses were thematically analysed.

What are the three main pressures you face in your Emergency Department (ED) during the winter period?

Table 1: Three main pressures in Emergency Departments.

Workforce shortages

Over a third of responses reported staffing problems contributing significantly to winter pressures across all disciplines of junior and senior medical, nursing and allied health professionals.

• Shortages in nursing numbers are the biggest staffing problem in winter, both in the ED and on the ward (which results in bed closures).
• This is followed closely by a lack of senior decision makers available out of hours challenging the ability to ensure availability of senior staff during peak hours of attendance.
• In addition:
  • Higher pressures in the ED was cited as preventing staff from taking adequate breaks, resulting in staff burnout and fatigue.
  • Burnout and fatigue resulted in increased sickness, further compounding staffing difficulties.
  • Rotas throughout the year are already very tight, often with unfilled gaps. This surge in staff sickness significantly adds to pressure in children’s services in winter.

Bed shortages / space

Bed shortages on the wards are repeatedly cited as a major cause of exit block, impeding flow in the ED and resulting in overcrowding which, in turn, restricts patient flow.

Rise in attendances and acuity / primary care pressures

• Workforce and bed shortages are compounded by both a rise in acuity and attendance numbers as well as limited space within the ED.
• The inherent nature of more significant illness in winter means paediatric emergency attendances rise.
• Winter pressures are felt to impact the whole system:
  • GPs are under pressure and are unable to offer enough appointments to meet increased demand in winter, particularly out of hours.
  • Unable to access GPs for their children’s urgent care needs mean parents turn to the ED instead, adding to the already higher winter ED attendances.

Adult services taking staff and space from paediatrics

Several times, increased pressures to deliver care for adults is cited as contributing to pressures in treating children.

• Staff are pulled from treating children to deliver care to adults.
• Paediatric emergency space, both Paediatric Emergency Department (PED) and co-located Observation Bays, is closed and reallocated to adult ED.
• And in one case, PED is moved into a corridor so that adult ED can use the PED space to see adults.

Can you give an example of things in your local area that have increased winter pressures / made it more challenging to deliver paediatric emergency care?

Table 2: What increases winter pressures?

Workforce shortages / issues

• Reliance on locum doctors frequently cited because of pre-existing rota gaps and staff sickness
• Staff demoralised and stretched with low resilience and low morale
• Lack of senior support
• Difficulties recruiting onto nursing rosters
• Specific difficulty recruiting paediatric trained nurses
• One registrar covering multiple areas of the hospital out of hours (for example the PED, neonatal unit, inpatient wards, ambulatory units).

Primary care pressures

• Inability to offer enough GP appointments for winter surge
• Low GP confidence/GPs deskilled in paediatric problems so referral to PED for paediatric opinion

Increased attendance

• Increasing population size and rising parental expectations/parental anxiety. Particularly following sepsis campaigns parents are now presenting more with febrile children as they are concerned their child has sepsis/meningitis
• Decreased ability of GPs to manage winter surges
• A perception that acuity is climbing over consecutive winters
• Insufficient or confusing public health education so parents are not clear about which services to access for their child’s different health needs

Lack of beds

• Bed difficulties are mostly found in general paediatric wards but also in high dependency unit, paediatric intensive care units and CAMHS tier 4 beds.
• Managing very sick children and children requiring specialist psychiatric care on general paediatric inpatient wards requires increased resources on the wards.
• This results in additional bed closures on the ward with a knock-on effect back on the ED due to exit block.

What additional systems were put in place last winter by your Trust / Health Board to help with winter pressures for children?

Respondents were asked to comment on the following systems:

• Escalation plans
• Medical staffing
• Redirection of patients from ED
• Nursing staffing
• Observation / short stay
• Environment / space
• Inpatient beds
• Operational / process changes
• Other staffing
• Diagnostics
• Other
• None of the above

Escalation plans

46% of the 147 respondents said they were not aware of escalation plans that were put in place last winter, they either excluded children, were detrimental to EDs treating children or were ineffective, due to poor implementation or poor development.

Medical staffing

46% of the 147 respondents said either no additional medical staffing was offered or services had challenges in recruiting locum shifts, either because of financial constraints or poor uptake.

Redirection of patients from ED

58% of the 137 respondents said the redirection of patients from ED was limited, not effective or did not exist. Some plans included redirection of children to an out of hours GP, or co-located urgent care centre; others included employing a GP to see children in PED.

Nursing staffing

53% of the 133 respondents reported that no or limited additional nursing shifts were agreed by their trust or health boards. Where respondents did report an agreement of additional shifts or increased pay for agency / bank nurses, these were difficult to fill.  Some trusts hired winter pressures Emergency Nurse Practitioners or Advanced Nurse Practitioners.

Other staffing

Respondents reported that some trusts employed flow coordinators, physician associates and ancillary staff to help with cannulation, venesection and observations. One employed a winter pressures pharmacist in the department.

Environment / space

Positive changes included: additional triage rooms; opening clinical decision unit / observation area beds (although these are sometimes difficult to staff so not always utilised); additional inpatient beds; utilisation of fracture clinic as an overflow area; discharge lounges; using chairs rather than beds to increase capacity. Negative changes included: loss of paediatric space to adult ED and closure of ambulatory / short stay areas.

Inpatient beds

I wish these had been increased, but any provision is too late.

Closed beds due to recruitment and retention [staffing] issues.

What three things could help alleviate winter pressures in emergency departments that treat children?

Table 3: Solutions to alleviate winter pressures

Spotlight on whole system change

Plans about minimising elective procedures to open up beds for emergency admissions; introduction of rapid access clinics to take the pressure off ED; changing pathways so that GP referrals/surgical referrals are seen on the ward rather than in ED; next day reviews with GPs/hospital at home nursing services; introduction of equipment to allow higher acuity patients requiring treatment like Optiflow to be transferred to the inpatient ward rather than being managed in ED resus; redirection policies so children can be referred to GPs from the front door.

How can the RCPCH help support health organisations and professionals to manage winter pressures?

• Support us to implement Facing the Future: Standards for children in emergency care settings
• Help clinicians to prioritise children’s services within trust / health boards
• Provide best practice examples
• Develop shared planning guidance

Spotlight on other comments

• Strengthen the public health message about where to seek medical advice for minor ailments
• Support community services (GPs) as part of winter pressure plans
• Increase training numbers to minimise rota gaps
• Work with Royal College of Nursing to develop paediatric ED skills
• Work with Royal College of General Practitioners to improve paediatric training for GPs
• Advocate to ringfence funding for children’s emergency care services