Title: Refining and testing the diagnostic accuracy of an assessment tool to predict admission and discharge of children and young people who attend an emergency department
Funder: Department of Health and Social Care

Abstract: Increasing presentations by children and young people to urgent and emergency care services creates a capacity issue for health services. The large majority of presentations require minimal investigation and the patient can be discharged with appropriate safety net advice. However, identifying those who have more serious illnesses can be challenging. While paediatric early warning systems, commonly known as PEWS, have been developed for ward-based care, there is not a validated system in emergency care. This research will develop a tool which we hope will be able to be used throughout the NHS to aid decision making in urgent care and emergency settings. These environments have particular characteristics. i. high patient loads, which vary depending on season and time of day; ii. diverse skill sets due to the large number of staff employed and high turnover rates; iii. the need for multiple handover or communication episodes due to the relatively rapid throughput of patients; iv. intense time pressures due to enforced target times or need to clear cubicle space to see new patients; and v. diagnostic uncertainty due to the acute nature of the presentation. This project aim is to assess the performance of PAT-POPS (the Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score) in assisting health care professional admission and discharge decision-making in urgent and emergency care settings. The project will determine whether a refined version of the existing PAT-POPS screening tool predicts admission and discharge and suggest appropriate cut-off points for other services which may wish to use the tool. The study will collect clinical data prospectively on presentation of 13,000 patients across 3 hospital sites in the Pennine Acute Hospitals NHS Trust. The data analysis will run in two phases. The first phase will refine the PAT-POPS tool using 6000 patients and determine cut-off points for admission with appropriate sensitivity and specificity. The second phase will validate this using a cohort of 7000 patients. A tool which can aid health care professional decision-making will benefit patients by: 1) Assisting in identification of the most unwell patients, including those who have sepsis, thereby reducing mortality and morbidity 2) Assisting in safe discharge decisions thereby increasing capacity in in-patients and reducing unnecessary hospital admissions for families, children and young people. 3) Reducing knowledge deficit: Most tools define an acceptable reference range for each physiological variable commonly measured. This assists junior staff, particularly if inexperienced with children. 4) Decreasing cognitive load: Graphical or numerical display of physiological observations, whether at the triage stage or repeatedly over time, allows clear identification of sick children. 5) Escalating seniority of review: Specific scores activate senior clinician involvement. 6) Improving communication: Handover is well known to be a high-risk transition for patients, and objectivity and alerts are possible using scoring systems.

Lay abstract: Increasing demand on urgent and emergency care services for children and young people means that children with serious illness are at risk of being missed, while there may be a tendency to admit children and young people who do not need hospital care. Neither of these scenarios is beneficial or acceptable to families, carers or children and young people and may result in avoidable harm to patients. Scoring systems which use observations such as a child's heart rate or breathing rate have been used on hospital wards to aid detection of children who require enhanced care. However, these systems as yet have not been deployed successfully in emergency departments. One system specifically designed for emergency and urgent care use (PAT-POPS: the Penine Acute Trust Paediatric Observation Priority Score) has shown early signs of being successful at recognising both the most unwell children but also those who may be safe and suitable for discharge. This study will examine the impact of PAT-POPS and determine whether it would be a useful tool to roll out across the NHS.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE