This guidance is for system leaders, commissioners and providers who are developing or improving paediatric SDEC services to reduce reliance on overnight admissions for patients who can safely be discharged home on the same day as arrival. It highlights the key principles and minimum standards for this service, including considerations for physical infrastructure, referral and access, workforce, diagnostics, discharge, counting and coding, and patient experience.

Summary

Paediatric same day emergency care (SDEC) aims to minimise and remove delays in the paediatric emergency patient pathway, allowing services to assess, investigate and diagnose patients on the same day of arrival, as an alternative to hospital admission. 

While paediatric SDEC is not a new concept or model of care and is among the most established of all the specialty SDECs, this guidance outlines key standards and considerations for system leaders, commissioners and providers to improve existing services or support implementation of a newly established service.

This guidance signposts to other important guidelines, quality standards and key performance metrics throughout and should be read in conjunction with the SAMEDAY strategy.

We are keen to develop and improve this guidance. Please send your comments to england.sdec@nhs.net.

Introduction

The NHS Long Term Plan set the ambition for every acute hospital with a Type 1 emergency department (ED) to move to a comprehensive SDEC model for a minimum of 12 hours a day, 7 days a week. More recently, the Delivery plan for recovering urgent and emergency care services further supports standardisation of SDEC in all hospitals across England. The delivery priorities are linked to 10 high impact improvements that highlight areas where system transformation is an imperative.

The approach for all SDECs, therefore, should focus on where connections can be made to improve patient flow. For example, direct access to SDEC should include the ability for paramedics to refer patients, where appropriate, via a single point of access (SPoA) so that there is a single, simple route for referral to hospital.

SDEC is a key service model to support flow, working in collaboration with EDs to provide the most efficient care. Much of the growth in admitted non-elective activity has been for patients who spend 1 or 2 days in hospital – many of them could be safely and effectively managed using an SDEC approach.

While it is recognised that there are variations in clinical practice, referral protocols, workforce capacity and experience, the types of emergency admissions in paediatrics are remarkably consistent between providers. This is both in terms of the nature of admission and increasing demand in EDs. The upward trend in lower acuity presentations in EDs for under 18s is increasing demand and as a result impacting on hospital flow.

Paediatric SDEC aims to minimise and remove delays in the paediatric emergency patient pathway, allowing services to assess urgent and emergency patients and plan their care within the same day of arrival to avoid hospital admission where appropriate. Depending on clinical need, this may include the need for follow-ups or next day care. Virtual ward referral may also be incorporated in these models. Creating clear processes from the first patient contact supports early decision-making, maximising the opportunity to complete patient care within the same day.

Throughout this guidance, the paediatric age range is children and young people up to the age of 18. However, a flexible approach is typically taken for 16–18 year olds, with the patient directed to adult or paediatric services based on clinical need and patient/carer preference.

Paediatric SDEC should be intrinsically linked to other key services that operate to keep patients at home or reduce their length of stay in hospitals. SPoA should be considered as part of the access into SDEC services, allowing clinical discussion and enabling early intervention. SDEC can be well aligned with virtual wards as either a continuation of care or, following discharge, joined up risk sharing between the two services provides an opportunity to further improve a patient’s experience. Respiratory conditions are commonly seen in paediatric SDECs, and where there is an acute respiratory hub (ARI) in the community it would be prudent to have clear pathways.

SDEC may already exist within a service but be located within ED, short stay units, assessment units or paediatric inpatient wards. While a paediatric SDEC and an assessment unit may in some sites be parts of the same wider model, they should be distinct: the priority of the SDEC service is to avoid admission and have a pathway for patient access to the right clinicians and diagnostics on the same day; an assessment unit that cannot guarantee a same day scan or investigation is not an SDEC service.

Rapid access clinics and hot clinics may also work in tandem with SDEC models or be co-located.

Key principles

The following principles should apply for all paediatric SDECs. They have been developed with paediatric clinical leads including regional and provider level representation, as well as the Royal College of Paediatric and Child Health (RCPCH). The detail for each key area is given in the minimum standards section.

Process

• Provides a high-quality and efficient care service for acute paediatric referrals in line with the organisation’s governance arrangements (also considering clear staffing, training, and policies and procedures to recognise a deteriorating child)
• Ensures safeguarding procedures are in place
• Patient experience and feedback is captured with regular audit at governance meetings
• Has infection prevention and control (IPC) measures in place to minimise the risk of nosocomial infection

Referral and access

• Has clear escalation pathways in conjunction with ED
• Provides direct referral guidance for colleagues across the healthcare system. This should give clear exclusion criteria for the service
• Referrals should be process driven rather than protocol driven, to ensure rapid and efficient direct referral of patients to paediatric SDEC

Staffing

• A senior clinician should be available to assess patients and make key decisions

Physical infrastructure

• While preferable, paediatric SDEC does not have to be confined to a dedicated unit. The principles of care can be delivered before an established unit is available
• Should be open for paediatric referral (direct or indirect) for a minimum of 12 hours a day, 7 days a week
• Opening hours beyond this should be determined by capacity profiling to meet peak demand and population/local needs, and extended when required and where possible to meet demand. Regardless of opening hours, patients should never remain in an SDEC area for longer than necessary
• It should provide a safe and appropriate environment for children and young people. NICE guideline [NG204] Babies, children and young people’s experience of health care provides detailed recommendations
• Where a designated physical space is possible, it should be protected from inpatient admissions and not be used as an escalation area or be bedded overnight
• Any use beyond that intended should be recorded and regularly reported though the agreed site-level escalation and auditing policy
• Should be accessible from ED but discernibly different, both in terms of physical space and workforce. Some models will be co-located within ED
• Have clear escalation pathways in conjunction with ED
• Have access to rapid diagnostics and treatment to facilitate rapid discharge. The turnaround time should be the same as ED targets (including reporting for radiological investigations)

The Facing the Future standards for acute and emergency paediatric care should be referred to for further guidance around core standards.

For children and young people who have mental health needs, SDEC models should incorporate learning from the framework for children and young people with mental health needs in acute paediatric settings. Systems should regularly review and develop their SDEC models to support their child and young person population as part of the wider urgent and emergency care transformation.

Minimum standards

Supporting the key principles that underpin the paediatric SDEC service, the following minimum standards and key considerations should be applied.

Referral and access

The paediatric SDEC service will be used predominantly to treat conditions with greatest opportunity for same day treatment. The patients selected for SDEC will typically be those who would otherwise have a 1- or 2-day length of stay in hospital and should include those who can be managed in the ED and directly discharged. 

• Referrals to paediatric SDEC should be process driven rather than constrained by restrictive protocols. Clear access criteria will facilitate direct referral, which encourages healthcare professionals to contact SDEC clinicians and directly refer
• Integrated care boards (ICBs) should align access criteria as far as possible across their SDEC services to support referrals from across the healthcare system
• The referral process should be designed to stream patients rapidly and efficiently
• SDEC and ED should have an agreed streaming/referral process and collaborate, especially at times of increased pressure and overcrowding
• Patients and staff should have prompt access to the appropriate specialties, including surgical, mental health, medical and radiology, to support rapid decision-making and discharge
• Paediatric SDEC units should not routinely be used for patients who would be better managed under other existing pathways, for example urgent cancer referrals, or who will require inpatient treatment at the point of referral
• Expert clinical decision-makers should receive referrals to ensure that patients are transferred to the correct area
• There should be no expectation that investigations have to be conducted in ED before a patient can be accepted by the SDEC. This needs to be clear to all referrers. Initial assessment followed by a clinical discussion should be an agreed process
• Patients who need to be admitted should not be moved to the SDEC unit to wait for an inpatient bed
• There will always be a proportion of patients referred to SDEC who need to be admitted. The possibility of conversion to an admission should not prohibit an SDEC attendance. Conversion rates can vary between 10% and 20%
• Where a referral to SDEC is not deemed appropriate, the clinical discussion about the patient should formulate and agree a suitable management plan for onward referral
• Referral to SDEC should be developed across all access routes as appropriate, including NHS 111/999, paediatric clinical assessment service (PCAS) and paramedic on scene. Referrals should only be made by clinicians and following clear criteria
• Paediatric SDEC services should be profiled in the Directory of Services (DoS) which drives the ‘service finder’ tool, supporting referral from primary and community care

Workforce

SDEC services should ensure the working patterns of clinicians are adapted so they can support early clinical review and decision-making at peak time of demand. This is inclusive of implementing treatment where needed and rapid access to diagnostic services, which is key to the success of the SDEC model.

Where paediatric SDEC is co-located with the ED or paediatric assessment unit (PAU)/children’s assessment unit, a separate workforce rota is generally more effective.

Senior clinical leadership is imperative for a high functioning service, and ideally there should be access to consultants or senior decision-makers across opening hours. As a minimum, medical, nursing and paediatric senior clinical staff should together determine the needs of and the best pathways for urgent and emergency paediatric patients. Nurse-led services have been widely adopted across the country, with consultant or senior clinical leads available to support decision-making.

• There should be a dedicated point of contact for all referrals (usually a senior clinician) who is able to accept and triage referrals to manage both patient assessment and patient flow throughout the day
• There should be dedicated administrative support and nursing staff to ensure sufficient capacity to assess and triage and to maintain patient flow
• Workforce models should be assessed regularly and reflect the size of the unit and the number of patients and case mix of referrals
• A dedicated medical workforce is ideal to resource SDEC effectively, although it is recognised that this may not be possible for some providers
• Opportunities for rotation of staff between ED, PAU and SDEC need to be considered as part of maintaining acute skills, upskilling and retention of staff
• Opportunities for the nursing workforce to extend their skills through secondment or developmental roles should be encouraged, as well as opportunities for dedicated paediatric nurse practitioners, advanced clinical practitioners, physician associates and healthcare assistants

Physical infrastructure

Designated paediatric SDEC units should not be used for inpatient care. SDEC areas should also not be used for overnight admission by default within escalation plans, due to the impact this would have on flow. Their use as an inpatient unit should be a rare exception at times of surge activity when there is no other surge bed capacity in the hospital and in line with organisational business continuity plans.

There should be a mandatory reporting structure to record each time the area is used to accommodate overnight admissions.

• Any bedding of SDEC should be recorded and signed off by a senior director as part of the site-level escalation process
• The SDEC should have a mix of trolleys, cots and recliner chairs, and provide a comfortable and open waiting area in line with IPC rules and some space for privacy
• There should be capacity, including a procedure room, for ‘hot clinic’ provision for appropriate patients who can be directly referred
• Where temporary or small areas are used to implement the SDEC model, there should be medium to longer term plans to grow the service

Diagnostics

Clinical investigation and rapid access to the right diagnostics are key to the success of an SDEC model. For paediatric SDEC this means access to, at a minimum:

• radiology: the ability to undertake investigations with ultrasound as well as CT, plain X-ray and hot reporting (access to CT if not available on site)
• point of care tests, urinalysis, urine microscopy, blood gas
• point of care test for white cell count (WCC) and C-reactive protein (CRP)
• electrocardiogram (ECG)

Criteria for discharge and documentation

Every patient who is treated and discharged through a paediatric SDEC service should:

• not spend >8 hours in an SDEC. Decisions on same day care or to refer to inpatient admission should be taken rapidly to maintain patient flow and improve the patient experience, ensuring discharge if appropriate
• have a named clinician and a senior clinician who is accountable for decision-making
• have a formal discharge letter or other appropriate documentation detailing the working diagnosis, treatment received, results of pertinent investigations and follow-up plans
• have criteria for readmission within a determined period and methods for contacting the unit after discharge
• for patients managed within a ‘virtual ward’ setting linked to the SDEC service, should have regular remote, documented reviews and be assessed ‘in person’ before their formal discharge

Digital capability and electronic patient records should support the documentation of the child’s journey. Discharge take home drugs should be readily available during opening hours.

Counting and coding

From 2023/24 NHS England has required SDEC to be reported as Type 5 ED attendances, within the reporting structure of ECDS.

The way SDEC is recorded currently varies across the country, with sites either using Admitted Patient Care (APC) or the Emergency Care Data Set (ECDS). Sites should have ceased using outpatient datasets from 2020/21. Further guidance is available that identifies the preferred options for first attendance, planned follow-up in <7 days and in >7 days, unplanned follow-up and virtual consultation.

Patient experience

A good patient and carer experience is an important outcome for paediatric SDEC. Systems developing their paediatric SDEC models should involve children, young people and parents/carers in designing and improving the services. This will result in people who use the service being more engaged with their own healthcare, leading to improved patient and service user outcomes and productivity gains for the NHS.

A robust feedback system should be in place to identify, consider and support the needs of carers of people who use paediatric SDEC services. Patient feedback can be collected and measured with the Friends and Family Test (FFT) and NHS England’s experienced based design.

Publication reference: PRN00161