Paediatric Acute care Guidelines PMH Emergency Department

The ED Short Stay Unit (4E) is the 24-hour Observation Ward for the Emergency Department. There are 7 beds including one isolation room. It is suitable for patients who:

  • Are expected to be discharged within 24 hours with a defined diagnosis
  • Are > 8 months of age (provided they are fully vaccinated)
  • Are admitted under the ED consultant on call
  • Limited to 2 ward overflows at any one time

Conditions Suitable for ED Short Stay Unit (4E) Admission:

  • Moderate Head Injury – for neurological observations
  • Asthma requiring monitoring and medication stretching (salbutamol at least 45 minutely, and oxygen <2L via nasal prongs)
  • Gastroenteritis for rapid NG rehydration (requires the isolation room – so only one admission at a time)
  • Croup
  • Toxic ingestions and poisonings (can have cardiac monitoring)
  • Post procedural observations (e.g. Ketamine Sedation or IV sedation)
  • Anaphylaxis
  • Allergic reactions – for monitoring
  • Petechiae +/- Fever –  for observation.

Possible Indications for ED Short Stay Unit (4E) Admission:

  • Undifferentiated conditions (such as abdominal pain) being observed by ED doctors with a well developed management plan and only after discussion with the ED Consultant (at any hour of the day). These do not include patients that the surgical service wish to review the next day – they should be admitted under the General Surgical Team or even a joint admission under General Surgical and General Paediatric Teams.
  • Uncomplicated ward overflows (e.g. under the General Paediatric Team) in a stable condition may go into the ED Observation Ward until a bed becomes available – but remain the responsibility of the admitting team rather than ED. This is limited to two patients at a time.

Conditions Excluded from ED Short Stay Unit (4E) Admission:

  • Undifferentiated diagnosis without clear management plan
  • Children with significant social issues (includes intoxicated adolescents)
  • Bronchiolitis
  • Babies < 8 months
  • Requiring isolation as per the hospital isolation policy
  • Any child requiring spinal immobilisation/Philadelphia collars
  • Preschool children with no parent available to stay with them at all times
  • Boarder siblings
  • Complex medical issues requiring extensive nursing care (e.g. cerebral palsy, tracheostomy)
  • Mental Health patients (due to safety issues and length of stay whilst awaiting review)

All ED Short Stay Unit (4E) Admissions must have a bed requested on Enterprise Bed Management (EBM) and authorised by the ED consultant.

There are Criteria Led Discharge (CLD) Pathways for the following conditions which may allow patients to be discharged by the experienced ED Short Stay Unit (4E) nurse having met the pre-defined criteria:

  • Minor Head Injuries
  • Asthma and Viral Induced Wheeze
  • Gastroenteritis Rehydration
  • Croup
  • Toxic Ingestions
  • Allergic Reaction, Anaphylaxis
  • Post Ketamine Sedation

Please complete the CLD paperwork for this process on admission if the patient is suitable.

Medical Doctor’s Responsibility:

  • The ED Doctor admitting the patient to the ED Short Stay Unit will continue to manage them during their current shift
  • The designated 4E ED Registrar will take handover of all the current 4E patients at handover time, and be familiar with patients being admitted during their shift
  • All patients must be reviewed regularly during the shift and these reviews documented in the inpatient notes
  • Discharge decisions can occur at any time when appropriate
  • Care should be taken to ensure that patients are reviewed prior to shift handover to ensure iSoBAR handover is completed. 4E medical staff should seek advice and/or review by the ED Consultant on an as required basis and at the 4E ward round by the Support consultant on weekdays and the Floor Consultant on weekends following the morning handover at 0800.
  • 4E patients admitted after midnight should not routinely be discharged without ED consultant review at 0800. Patients seen by the ED consultant prior to midnight who will be suitable for discharge prior to 0800 must have a clear handwritten plan endorsed by the ED consultant.
  • Cases that are complicated or where the Registrar is not happy about the management should be discussed with and/or reviewed by the ED Consultant at handover at 0800

Discharge Summaries:

All patients discharged from the ED Short Stay Unit (4E), require a formal discharge summary (for coding and General Practitioner communication) using the TEDS (The Electronic Discharge Summary) System to be done at the time of discharge. To facilitate this in a timely fashion, please complete a draft TEDS summary at the time of admission, which can be finalised and submitted on discharge.

Transfers:

Children who deteriorate or are deemed unfit for discharge within 24 hours should be transferred to the ward with admission arranged under the admitting Consultant of the day (e.g. General Paediatric Team). The change over time for admitting Consultants is 0800 – call the appropriate team based on when the decision to transfer was made. The Registrar of the unit needs to be contacted for the admission as usual. Please inform the ED nursing patient flow coordinator to arrange the ward admission.

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