Audit of High Dependency Care for Children and Young People in ...

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TABLE OF CONTENTS...................................................................................................................................................... II
TABLE OF FIGURES, CHARTS AND TABLES ...............................................................................................................IV
SCOTTISH GOVERNMENT RESPONSE TO AUDIT OF HIGH DEPENDENCY CARE FOR CHILDREN AND YOUNG
PEOPLE IN SCOTLAND ...................................................................................................................................................VI
1. EXECUTIVE SUMMARY........................................................................................................................................... 1
1.1 BACKGROUND..................................................................................................................................................... 1
1.2 SUMMARY OF CORE DATA ................................................................................................................................... 1
1.3 RECOMMENDATIONS FOR NHS BOARDS................................................................................................................ 2
1.4 RECOMMENDATIONS FOR REGIONAL PLANNING GROUPS (AND NHS BOARDS).......................................................... 3
1.5 RECOMMENDATIONS FOR THE SCOTTISH GOVERNMENT, NHS EDUCATION FOR SCOTLAND, NHS QUALITY
IMPROVEMENT SCOTLAND, SCOTTISH AMBULANCE SERVICE, NATIONAL SERVICES DIVISION, REGIONAL PLANNING GROUPS AND
NHS BOARDS................................................................................................................................................................... 4
2. INTRODUCTION AND CONTEXT ............................................................................................................................ 6
2.1 PAEDIATRIC HIGH DEPENDENCY CARE IN SCOTLAND................................................................................................ 6
2.2 PAEDIATRIC HIGH DEPENDENCY CARE IN ENGLAND AND WALES ............................................................................... 7
2.3 PAEDIATRIC INTENSIVE CARE IN THE UK ................................................................................................................ 7
2.4 ORGANISATION OF CRITICAL CARE ........................................................................................................................ 8
3. AIMS & OBJECTIVES .............................................................................................................................................. 9
3.1 AIMS.................................................................................................................................................................. 9
3.2 OBJECTIVES ....................................................................................................................................................... 9
4. METHODOLOGY .................................................................................................................................................... 10
4.1 INTRODUCTION ................................................................................................................................................. 10
4.2 PILOT AND AUDIT ROLL-OUT................................................................................................................................10
4.3 INCLUSION / EXCLUSION CRITERIA ....................................................................................................................... 11
4.4 DATA COLLECTION METHOD................................................................................................................................11
4.5 VALIDATION OF DATA ......................................................................................................................................... 11
4.6 ORGANISATION OF CRITICAL CARE ...................................................................................................................... 12
5. RESULTS................................................................................................................................................................ 13
5.1 SUMMARY OF RESULTS ...................................................................................................................................... 13
5.2 DEMAND FOR HIGH DEPENDENCY CARE............................................................................................................... 15
5.2.1 Demand for high dependency care – NHS Boards.......................................................................... 15
5.2.2 Demand for high dependency care – hospitals ................................................................................ 15
5.2.3 Activity over the calendar year............................................................................................................ 18
5.2.4 Demographics........................................................................................................................................ 22
5.2.5 Activity by calendar year and age-range ........................................................................................... 23
5.3 WHERE HIGH DEPENDENCY CARE WAS DELIVERED ................................................................................................ 24
5.4 PROVISION OF HIGH DEPENDENCY CARE ............................................................................................................. 27
5.4.1 Elective / emergency episodes ........................................................................................................... 27
5.4.2 Length of episode.................................................................................................................................. 28
5.4.3 Multiple episodes of high dependency care...................................................................................... 33
5.4.4 High dependency care criteria ............................................................................................................ 34
5.5 PATIENT PATHWAYS.......................................................................................................................................... 36
5.5.1 Location before high dependency care.............................................................................................. 36
5.5.2 Location after high dependency care................................................................................................. 39
5.5.3 Primary journeys ................................................................................................................................... 43
5.5.4 Secondary journeys .............................................................................................................................. 44
6. ORGANISATION OF CRITICAL CARE .................................................................................................................. 49
6.1 NHS BOARDS.................................................................................................................................................. 49
6.2 LEVEL 2 HOSPITALS ......................................................................................................................................... 50
6.3 LEVEL 3 HOSPITALS ......................................................................................................................................... 52
6.4 LEVEL 4 HOSPITALS ......................................................................................................................................... 55
7. DISCUSSION .......................................................................................................................................................... 58
7.1 DEMAND FOR HIGH DEPENDENCY CARE ............................................................................................................... 58
7.2 WHERE HIGH DEPENDENCY CARE WAS DELIVERED ................................................................................................ 59
7.3 PROVISION OF HIGH DEPENDENCY CARE .............................................................................................................. 59

7.4 PATIENT PATHWAYS .......................................................................................................................................... 61
7.5 ORGANISATION OF CRITICAL CARE ...................................................................................................................... 61
8. CONCLUSIONS ...................................................................................................................................................... 64
Demand for high dependency care.................................................................................................................... 64
Where high dependency care was delivered ................................................................................................... 64
Provision of high dependency care.................................................................................................................... 64
Patient pathways .................................................................................................................................................. 65
9. RECOMMENDATIONS ........................................................................................................................................... 66
RECOMMENDATIONS FOR REGIONAL PLANNING GROUPS (RPGS) AND NHS BOARDS............................................................ 66
RECOMMENDATIONS FOR THE SCOTTISH GOVERNMENT, ..................................................................................................... 67
NHS EDUCATION FOR SCOTLAND, NHS QUALITY IMPROVEMENT SCOTLAND (QIS), SCOTTISH AMBULANCE SERVICE, NATIONAL
SERVICES DIVISION (NSD), REGIONAL PLANNING GROUPS AND NHS BOARDS..................................................................... 67
GLOSSARY OF TERMS................................................................................................................................................... 68
APPENDICES................................................................................................................................................................... 71
APPENDIX 1.................................................................................................................................................................... 71
APPENDIX 2.................................................................................................................................................................... 72
APPENDIX 3.................................................................................................................................................................... 73
APPENDIX 4.................................................................................................................................................................... 74
APPENDIX 5.................................................................................................................................................................... 75
APPENDIX 6.................................................................................................................................................................... 78
APPENDIX 7.................................................................................................................................................................... 79
APPENDIX 8.................................................................................................................................................................... 81
APPENDIX 9.................................................................................................................................................................... 83
APPENDIX 10.................................................................................................................................................................. 86
REFERENCES.................................................................................................................................................................. 93
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FIGURE 1 CHILDREN RECEIVING HDC IN NHS BOARD & NO. OF NHS BOARD RESIDENTS WHO RECEIVED HDC............................ 14
FIGURE 2 NUMBER OF CHILDREN AND YOUNG PEOPLE RECEIVING HIGH DEPENDENCY CARE PER HOSPITAL..................................... 24
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CHART 1 NUMBER OF CHILDREN & YOUNG PEOPLE AND EPISODES IN THE CHILDREN’S HOSPITALS – ECF LEVELS ARE IN BRACKETS16
CHART 2 NUMBER OF CHILDREN & YOUNG PEOPLE AND EPISODES IN ECF LEVEL 2 AND 3 HOSPITALS (2 = URBAN LEVEL 2, 2R =
RURAL LEVEL 2)......................................................................................................................................................... 17
CHART 3 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE ...................................................................................................... 18
CHART 4 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE – REGIONAL ANALYSIS...................................................................... 19
CHART 5 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE – URBAN LEVEL 2 HOSPITALS ........................................................... 19
CHART 6 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE – RURAL LEVEL 2 HOSPITALS ........................................................... 20
CHART 7 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE – LEVEL 3 HOSPITALS ...................................................................... 20
CHART 8 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE – CHILDREN’S HOSPITALS................................................................. 21
CHART 9 DEMOGRAPHY OF CHILDREN & YOUNG PEOPLE IN THE HDC AUDIT............................................................................... 22
CHART 10 MONTHLY DEMAND FOR HIGH DEPENDENCY CARE BY AGE-RANGE .............................................................................. 23
CHART 11 ELECTIVE / EMERGENCY EPISODES......................................................................................................................... 27
CHART 12 SUMMARY OF BED DAYS PER HOSPITAL (LOGARITHMIC SCALE) - HOSPITALS PRESENTED BY ECF LEVEL........................ 28
CHART 13 AUDIT SUMMARY – LENGTH OF EPISODE SUMMARY................................................................................................... 31
CHART 14 LENGTH OF EPISODE SUMMARY – URBAN LEVEL 2 HOSPITALS................................................................................... 31
CHART 15 LENGTH OF EPISODE SUMMARY – RURAL LEVEL 2 HOSPITALS................................................................................... 32
CHART 16 LENGTH OF EPISODE SUMMARY – LEVEL 3 HOSPITALS.............................................................................................. 32
CHART 17 LENGTH OF EPISODE SUMMARY – CHILDREN’S HOSPITALS ........................................................................................ 33
CHART 18 AUDIT SUMMARY – LOCATION PRIOR TO EMERGENCY EPISODE OF HDC...................................................................... 36
CHART 19 LOCATION PRIOR TO EMERGENCY HDC EPISODE - URBAN LEVEL 2............................................................................ 37
CHART 20 LOCATION PRIOR TO EMERGENCY HDC EPISODE - RURAL LEVEL 2............................................................................ 37
CHART 21 LOCATION PRIOR TO EMERGENCY HDC EPISODE – LEVEL 3 HOSPITALS..................................................................... 38
CHART 22 LOCATION PRIOR TO EMERGENCY HDC EPISODE – CHILDREN’S HOSPITALS ............................................................... 38
CHART 23 AUDIT SUMMARY – DESTINATION AFTER EPISODE OF HIGH DEPENDENCY CARE ............................................................ 39
CHART 24 DESTINATION AFTER HIGH DEPENDENCY CARE – URBAN LEVEL 2............................................................................... 40
CHART 25 DESTINATION AFTER HIGH DEPENDENCY CARE – RURAL LEVEL 2............................................................................... 40
CHART 26 DESTINATION AFTER HIGH DEPENDENCY CARE – LEVEL 3 HOSPITALS......................................................................... 41
CHART 27 DESTINATION AFTER HIGH DEPENDENCY CARE – CHILDREN’S HOSPITALS ................................................................... 42
CHART 28 PRIMARY JOURNEY BY EMERGENCY/ELECTIVE EPISODE TYPE .................................................................................... 43
CHART 29 SECONDARY JOURNEY TYPE FOR TRANSFERS BETWEEN HOSPITALS ........................................................................... 44
CHART 30 SECONDARY JOURNEY – REFERRING HOSPITAL LOCATION......................................................................................... 47
CHART 31 SECONDARY JOURNEY – DESTINATION HOSPITAL LEVEL ............................................................................................ 48
CHART 32 HIGH DEPENDENCY CARE BED DAYS – URBAN LEVEL 2 HOSPITALS ............................................................................ 76
CHART 33 HIGH DEPENDENCY CARE BED DAYS – RURAL LEVEL 2 HOSPITALS ............................................................................ 76
CHART 34 HIGH DEPENDENCY CARE BED DAYS – LEVEL 3 HOSPITALS (EXCLUDING NINEWELLS) .................................................. 77
CHART 35 HIGH DEPENDENCY CARE BED DAYS – CHILDREN’S HOSPITALS.................................................................................. 77
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TABLE 1 AUDIT COHORT BY NHS BOARD OF RESIDENCE, RATE PER 1000 (0- 15 POPULATION) ................................................... 15
TABLE 2 NUMBER OF CHILDREN & YOUNG PEOPLE RECEIVING HDC BY AGE-RANGE. ................................................................... 22
TABLE 3 DISTRIBUTION OF EPISODES OF CARE BY AGE-RANGE AND EMERGENCY CARE FRAMEWORK HOSPITAL LEVELS ................. 25
TABLE 4 LOCATION OF TREATMENT FOR HIGH DEPENDENCY CARE ............................................................................................. 26
TABLE 5 TOTAL HOURS AND EQUIVALENT BED DAYS BY HDC AUDIT DEFINITION........................................................................... 28
TABLE 6 AUDIT SUMMARY - LENGTH OF EPISODE ..................................................................................................................... 29
TABLE 7 MAXIMUM, MEDIAN, AVERAGE AND MINIMUM NUMBER OF HOURS PER HOSPITAL .............................................................. 30
TABLE 8 MULTIPLE EPISODES OF HIGH DEPENDENCY CARE ....................................................................................................... 33
TABLE 9 LIST OF THE TEN MOST COMMON HDC CRITERIA......................................................................................................... 34
TABLE 10 LIST OF THE TOP FIVE HDC CRITERIA – URBAN LEVEL 2 HOSPITALS........................................................................... 34
TABLE 11 LIST OF THE TOP FIVE HDC CRITERIA – RURAL LEVEL 2 HOSPITALS ........................................................................... 35
TABLE 12 LIST OF THE TOP FIVE HDC CRITERIA – LEVEL 3 HOSPITALS...................................................................................... 35
TABLE 13 LIST OF THE TOP FIVE HDC CRITERIA – CHILDREN’S HOSPITALS ................................................................................ 35
TABLE 14 DATA TABLE - PRIMARY JOURNEY BY EMERGENCY/ELECTIVE EPISODE TYPE ................................................................. 43
TABLE 15 SECONDARY JOURNEYS ......................................................................................................................................... 46
TABLE 16 INTRA-REGIONAL SECONDARY JOURNEYS................................................................................................................. 47
TABLE 17 ORGANISATION OF CRITICAL CARE – NHS BOARD RESPONSES – PATIENT PATHWAY GUIDANCE .................................... 49
TABLE 18 ORGANISATION OF CRITICAL CARE – NHS BOARD RESPONSES – TRANSFER PROTOCOLS............................................. 49
TABLE 19 ORGANISATION OF CRITICAL CARE – LEVEL 2 RESPONSES – ORGANISATION OF PAEDIATRIC EMERGENCY SERVICES........ 50
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TABLE 20 ORGANISATION OF CRITICAL CARE – LEVEL 2 RESPONSES – TRANSFER OF A CHILD REQUIRING HDC/PIC ..................... 51
TABLE 21 ORGANISATION OF CRITICAL CARE – LEVEL 3 RESPONSES – ORGANISATION OF PAEDIATRIC EMERGENCY SERVICES........ 52
TABLE 22 ORGANISATION OF CRITICAL CARE – LEVEL 3 RESPONSES – CAPACITY TO DELIVER HIGH DEPENDENCY CARE ................. 53
TABLE 23 ORGANISATION OF CRITICAL CARE – LEVEL 3 RESPONSES – TRANSFER OF CHILDREN WHO REQUIRE INTENSIVE CARE ..... 53
TABLE 24 ORGANISATION OF CRITICAL CARE – LEVEL 3 RESPONSES – RADIOLOGY/LABORATORY SUPPORT SERVICES ................... 54
TABLE 25 ORGANISATION OF CRITICAL CARE – LEVEL 4 RESPONSES – ORGANISATION OF PAEDIATRIC EMERGENCY SERVICES........ 55
TABLE 26 ORGANISATION OF CRITICAL CARE – LEVEL 4 RESPONSES – CAPACITY TO DELIVER HIGH DEPENDENCY CARE ................. 56
TABLE 27 ORGANISATION OF CRITICAL CARE – LEVEL 4 RESPONSES – TRANSFER OF CHILDREN WHO REQUIRE INTENSIVE CARE ..... 56
TABLE 28 ORGANISATION OF CRITICAL CARE – LEVEL 4 RESPONSES – RADIOLOGY/LABORATORY SUPPORT SERVICES ................... 57
TABLE 29 PARTICIPATING HOSPITALS BY EMERGENCY CARE FRAMEWORK LEVEL ....................................................................... 74
TABLE 30 OCCUPIED BED DAY SUMMARY BY HOSPITAL ............................................................................................................. 75
TABLE 31 SUMMARY OF NUMBER OF EPISODES PER CHILD........................................................................................................ 78
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Paediatric high dependency care (HDC) is the foundation for the management of critical illness in
children; all hospitals receiving critically ill children must have the expertise and resource to
resuscitate and stabilise them.
Building a Health Service Fit for the Future, a National Framework for Service Change in the NHS
in Scotland (The Kerr Report) was published in 2005; it recommended that an audit of the provision
of high dependency care for children should be conducted to assess demand for this type of care.
National Services Division (NSD) were tasked to carry out this audit. The audit was designed to
quantify demand for paediatric high dependency care and assess the services available in
hospitals across Scotland. The audit has captured data on children using a broad definition of high
dependency care in a wide range of hospitals in Scotland; rather than detailed audit of the care
delivered within high dependency units (HDUs).
Analysis of the data offers key messages for planners within NHS Boards, Regional Planning
Groups and at a national level. Whilst the audit was not designed to measure clinical outcomes or
evaluate the quality of care provided it is expected that it will encourage the further development
and coordination of paediatric high dependency care within NHS Scotland and thus improve patient
care.
It is expected this improvement will be achieved by using information from the audit to:
formalise arrangements for local / regional access to paediatric high dependency care;
develop Critical Care Standards to support the delivery of high quality high dependency
care for children;
promote the design of improved patient care pathways.
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The audit data covered a 12 month period from 1st November 2006 to 31st October 2007. Returns
were received from the 14 territorial NHS Boards in Scotland; 38 hospitals and 113 general and
specialist adult and paediatric wards.
Data was analysed from 4,804 children who received 9,680 episodes of care; resulting in 538,003
hours of high dependency care being delivered (equivalent of 22,417 occupied bed days or 88
beds at 70% occupancy).
Most children (71%) received only one episode of high dependency care, however a small group of
children were responsible for a significant proportion of the total episodes. The table below
summarises this breakdown of children and episodes by episode multiple.
Children (%) Episodes (%)
10 or more episodes 115 (2%) 2460 (25%)
2 – 9 episodes 1287 (27%) 3818 (40%)
1 episode 3402 (71%) 3402 (35%)
The individual length of high dependency care episode ranged from 20 minutes to 316 days, the
median was 16 hours. Over a third of all episodes (35%) were less than 12 hours. 15% of
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episodes continued for more than 72 hours, and only 6% extended beyond 7 days. Very few
children had episodes of care over 4 days out with the Children’s Hospitals.
The demographic breakdown of the audit cohort showed that the largest individual age group were
children under 1 year of age (1170, 24%); demonstrating demand for high dependency care was
greatest for the youngest children.
Data is presented in line with the definitions within the Emergency Care Framework (ECF) (2006):
Urban Level 2 Hospitals – District General Hospitals with no in-patient paediatrics, within
urban cities;
Rural Level 2 Hospitals – District General Hospitals with no in-patient paediatrics, within
remote and rural communities;
Level 3 Hospitals – District General Hospitals with in-patient paediatric units;
Children’s Hospitals (Level 4 Hospitals) - Royal Aberdeen Children’s Hospital; Royal
Hospitals for Sick Children in Edinburgh and Glasgow (Yorkhill, RHSC) and Tayside
Children’s Hospital (Ninewells).
(Note: Tayside Children’s Hospital (Ninewells) is an ECF Level 3 Hospital, but for the purposes of the audit it is
included as a Children’s Hospital in this Report)
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In most NHS Boards this will be located within the geographical boundary, but if not, the Board
should agree care and transfer/ transport arrangements for children and young people if first
admitted to a local Level 2 Hospital.
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Most children and young people require only a single short episode of HDC, it is therefore
inappropriate to transport children to a specialist Children’s Hospital, unless clinically essential. An
example of devolved high dependency care would be to develop the capacity to deliver short term
non-invasive ventilation (CPAP) in Level 3 Hospitals. This model of care has been implemented
successfully in the English South West Region Critical Care Network.
It is important that the quality of care delivered within local facilities remains high, enabling HDC to
be provided as close to home as possible. This has the additional benefit of protecting beds in the
Children’s Hospitals for specialist procedures and children who require higher levels of high
dependency care. A key aspect to ensuring the quality of service delivery will be the development
of a regional critical care network, to coordinate and plan the delivery of inpatient paediatric care,
anaesthesia / intensive care, surgical services, diagnostics and imaging along with high
dependency care.
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Guidance should be published to inform parents and ensure that a consistent message is
communicated by the Scottish Ambulance Service, GPs, Out of Hours Treatment Centres, NHS 24
and Minor Injury Units. Communication could be assisted through the use of the Child Health
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Record (red book) and communication with Local Authorities. The audit demonstrated that the vast
majority (81%) of primary journeys (admission to hospital) were undertaken by Parental/Carer
transport, re-enforcing the need for clear communication.
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Children and young people can present at any hospital in an emergency situation, the audit
recorded unscheduled episodes of HDC in 38 hospitals in Scotland. Not all NHS Boards have a
Level 3 Hospital and significant geographical distances exist between many Scottish hospitals. It is
therefore important that all A&E Departments and Level 2 Hospitals have a multi-disciplinary team
with up-to-date resuscitation and stabilisation competencies, and the ability to provide short-term
high dependency care.
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The audit demonstrated that HDC was delivered across all NHS Boards. Nearly 22,500 occupied
bed days were delivered, equating to the use of approximately 88 fully staffed beds – assuming a
bed occupancy rate of 70%. This must not be seen as a target as most Level 2 Hospitals, and
many Level 3 general paediatric units will offer HDC from the generic bed provision. The critical
issue is to ensure access to appropriately trained staff within each unit (i.e. specialist nurse), and
effective transport arrangements (utilising specialist nurses/paramedics, supported within a
regional network).
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The HDC audit identified a variation in demand for HDC between NHS Boards (Table 1, p15), the
reasons for this variation are unclear from the evidence.
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ÇÉéÉåÇÉåÅó=Å~êÉK==qÜÉ=ÇÉîÉäçéãÉåí=çÑ=êÉÖáçå~ä=åÉíïçêâë=ëÜçìäÇ=~áã=íç=ÉåÜ~åÅÉ=
ÅçããìåáÅ~íáçå=ÄÉíïÉÉå=äçÅ~ä=Üçëéáí~äëI=áãéêçîÉ=äçÅ~ä=ëÉêîáÅÉ=ÇÉäáîÉêóI=~åÇ=ïçêâáåÖ=ïáíÜ=íÜÉ=
pÅçííáëÜ=^ãÄìä~åÅÉ=pÉêîáÅÉI=éêçîáÇÉ=ë~ÑÉ=~åÇ=ÉÑÑÉÅíáîÉ=êÉÖáçå~ä=íê~åëéçêí=~êê~åÖÉãÉåíëK=
The audit recorded emergency (or unplanned) admissions for HDC in 38 hospitals across Scotland.
The overall balance was 64% unplanned to 36% elective (planned) episodes. This bias towards
P

the management of unplanned care is greater in the Level 2 and 3 Hospitals (91%); nearly all
elective admissions occurred in the Children’s Hospitals.
^ää=oÉÖáçå~ä=mä~ååáåÖ=dêçìéë=ëÜçìäÇ=ïçêâ=íÜêçìÖÜ=íÜÉ=~ÖêÉÉÇ=êÉÖáçå~ä=åÉíïçêâë=íç=ÉåëìêÉ=
íÜÉêÉ=~êÉ=éçäáÅáÉë=ÑçêW==
~ÅÅÉëëáåÖ=~ÇîáÅÉ=êÉÖ~êÇáåÖ=íÜÉ=çåÖçáåÖ=ÅäáåáÅ~ä=ã~å~ÖÉãÉåí=çÑ=ÅÜáäÇêÉå=~åÇ=óçìåÖ=
éÉçéäÉ=êÉèìáêáåÖ=ea`=çê=mf`X==
~êê~åÖÉãÉåíë=Ñçê=íÜÉ=íê~åëÑÉê=çÑ=íÜÉ=ÅÜáäÇ=íç=~åçíÜÉê=Ñ~Åáäáíó=ïÜÉíÜÉê=íÜáë=áë=Ñêçã=
iÉîÉä=NLO=íç=iÉîÉä=PX=çê=Ñêçã=iÉîÉä=OLP=íç=çåÉ=çÑ=íÜÉ=`ÜáäÇêÉåÛë=eçëéáí~äëI=ÇÉéÉåÇÉåí=
çå=ÅäáåáÅ~ä=åÉÉÇK=
Table 16 (p47) highlights the number of regional secondary journeys that are occurring between
hospitals.
NKR= oÉÅçããÉåÇ~íáçåë=Ñçê=íÜÉ=pÅçííáëÜ=dçîÉêåãÉåíI=kep=
bÇìÅ~íáçå=Ñçê=pÅçíä~åÇI=kep=nì~äáíó=fãéêçîÉãÉåí=pÅçíä~åÇI=
pÅçííáëÜ=^ãÄìä~åÅÉ=pÉêîáÅÉI=k~íáçå~ä=pÉêîáÅÉë=aáîáëáçåI=oÉÖáçå~ä=
mä~ååáåÖ=dêçìéë=~åÇ=kep=_ç~êÇë=
^=é~åJpÅçíä~åÇ=åÉíïçêâ=ëÜçìäÇ=ÇÉîÉäçé=~=ãáåáãìã=ëÉí=çÑ=ëí~åÇ~êÇë=íç=ÅçîÉê=~ää=~ëéÉÅíë=
çÑ=é~ÉÇá~íêáÅ=ÅêáíáÅ~ä=Å~êÉI=Ñêçã=ÉãÉêÖÉåÅó=éêÉëÉåí~íáçåI=íÜêçìÖÜ=~åó=çåÖçáåÖ=áåé~íáÉåí=
ã~å~ÖÉãÉåíI=íç=ÇáëÅÜ~êÖÉ=Ñêçã=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Eáå=ÅçåàìåÅíáçå=ïáíÜ=íÜÉ=b`cFK====
==
The network should work to develop critical care standards and operate as a forum for best
practice. The network will ensure that standards relating to organisation, communication, and
transfer are developed across Scotland.
^=é~åJpÅçíä~åÇ=åÉíïçêâ=ëÜçìäÇ=ÄÉ=ÇÉîÉäçéÉÇ=íç=~ÖêÉÉ=~=ãÉÅÜ~åáëã=íç=éêçãçíÉ=íÜÉ=çåÖçáåÖ=
~ìÇáí=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=~åÇ=çìíÅçãÉëK=
At present there is no process to capture clinical outcomes for HDC. As part of the HDC audit, an
evaluation of existing provision of paediatric critical care was conducted within each NHS Board;
providing the foundation for the development of a comprehensive set of critical care standards and
audit. These national standards and a robust audit process would allow planners and managers to
determine the existing resource and identify gaps in the service. This review process would also
guarantee agreed standards of care; this work could fall under the remit of NHS Quality
Improvement Scotland.
kep=bÇìÅ~íáçå=Ñçê=pÅçíä~åÇ=~åÇ=oÉÖáçå~ä=tçêâÑçêÅÉ=aáêÉÅíçêë=ëÜçìäÇ=ÅçåÇìÅí=~å=ìêÖÉåí=
åÉÉÇë=~ëëÉëëãÉåí=~åÇ=ÇÉîÉäçé=~=ïçêâÑçêÅÉ=ëíê~íÉÖó=íç=ÇÉäáîÉê=ÇÉîçäîÉÇ=é~ÉÇá~íêáÅ=ÜáÖÜ=
ÇÉéÉåÇÉåÅó=Å~êÉ=áå=iÉîÉä=P=eçëéáí~äë=~åÇ=ã~å~ÖÉ=íÜÉ=ìåëÅÜÉÇìäÉÇ=éêÉëÉåí~íáçå=çÑ=íÜÉ=
ÅêáíáÅ~ääó=áää=ÅÜáäÇ=áå=iÉîÉä=O=eçëéáí~äëK==qÜáë=ëÜçìäÇ=áÇÉåíáÑóW=
=
íÜÉ=åìãÄÉê=çÑ=~åÇ=íóéÉ=çÑ=éçëíë=êÉèìáêÉÇX=
ÉÇìÅ~íáçå=~åÇ=íê~áåáåÖ=êÉèìáêÉãÉåíëX=
Åçëí=çÑ=Ä~ÅâÑáääX=
Å~éáí~ä=áåîÉëíãÉåíK=
=
qÜáë=ïçêâÑçêÅÉ=ëíê~íÉÖó=ëÜçìäÇ=ÄÉ=ëìÄãáííÉÇ=~ë=é~êí=çÑ=íÜÉ=ÄáÇÇáåÖ=éêçÅÉëë=Ñçê=íÜÉ=óÉ~ê=P=
ÇÉîÉäçéãÉåíë=çÑ=íÜÉ=k~íáçå~ä=aÉäáîÉêó=mä~åK======
Q

NHS Boards and Regional Planning Groups should consider the development of practice
exchanges to maintain the skills of staff working in Level 2 and 3 Hospitals. This is of particular
relevance to remote and rural communities; it highlights that the reciprocal rotation of a highly
skilled nurse from a Level 3 or Children’s Hospital to a Rural Hospital may be as appropriate and
effective than rotating a remote worker into a large hospital for an update. The ‘skills bus’ model,
which is currently being delivered by the PICU Retrieval team could also be extended maintain
HDC skills.
qÜÉ=pÅçííáëÜ=dçîÉêåãÉåí=ëÜçìäÇ=ÉåëìêÉ=é~åJpÅçíä~åÇ=éä~ååáåÖ=íç=ëìééçêí=ÉÑÑáÅáÉåí=~åÇ=
ÉÑÑÉÅíáîÉ=áåíÉêJÜçëéáí~ä=íê~åëéçêí=Ñçê=áää=~åÇ=áåàìêÉÇ=ÅÜáäÇêÉåK=
The audit recorded 910 secondary journeys, i.e. transfers between hospitals. At least 94% utilised
ambulances (6% unknown); 40% were accompanied by paramedics and 53% by either a paediatric
or neonatal specialist team, or medical and nursing staff.
It is suggested that if transport arrangements were improved (i.e. enhanced training of paramedics
and nurse practitioners), it would be possible to offer safe transfer within a regional network rather
than relying on the Transport of Critically Ill and Injured Children Service (PICU Retrieval). This
existing arrangement results in children being transferred (by default) to hospitals in Edinburgh and
Glasgow, causing transport issues for their family & carers and in most cases a return journey
following discharge. The audit data suggests that most HDC could be delivered in Level 3
Hospitals within a regional network structure; utilising PICU Retrieval when clinically necessary.
The expectation is that the majority of these high dependency transfers could be delivered by nurse
practitioners.
=
R

OK=
fåíêçÇìÅíáçå=~åÇ=ÅçåíÉñí=
High dependency care is an integral part of the provision of care for critically ill and injured children
and young people. Critical care represents the delivery of paediatric intensive care, transportation
of critically ill children and high dependency care.
OKN= m~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=áå=pÅçíä~åÇ==
Whilst action has been taken over the last ten years to rationalise the provision of paediatric
intensive care services; no such systematic approach has been taken to plan the provision of HDC
for children. High dependency care can be defined as “care provided to a child who may require
closer observation and monitoring than is usually available on an ordinary ward” (Department of
Health - England, 2001).
The spectrum of need for paediatric high dependency care is larger and less clearly defined than
that for paediatric intensive care. High dependency care can be required in association with a
planned admission for specialist treatment, or on an unplanned basis for a critically ill child
presenting in an emergency. There are associated transport issues that overlap with and impact
on, paediatric intensive care services.
In 2005, Building a Health Service Fit for the Future, a National Framework for Service Change in
the NHS in Scotland (The Kerr Report) was published. This report concluded that the provision of
paediatric intensive and high dependency care was an immediate issue for NHS Scotland. It
highlighted that high dependency care was the foundation for the management of critical illness in
children and that all hospitals receiving critically ill children must have the expertise and resource to
resuscitate and stabilise them.
In recognition that critically ill and injured children present to a wide range of hospitals in Scotland,
the Emergency Care Framework (2006) proposed a four tier model, defining levels of care and
services that should be available in each of the following:
iÉîÉä=NW Primary Care, General Practitioner, Community Hospital, Out of Hours Treatment Centre;
iÉîÉä=OW General Hospital with Accident & Emergency facilities, but no inpatient paediatric unit;
iÉîÉä=PW General Hospital with inpatient paediatric unit;
iÉîÉä=QW Specialist Children’s Hospital.
The Emergency Care Framework model, whilst emphasising the importance of inpatient paediatric
support (Levels 3 & 4), also recognised that many children receive emergency care in hospitals
without paediatric in-patient units. The Framework was developed to ensure that children and
young people who present for emergency care are treated effectively and safely within defined
standards for the reception and management of critically ill children.
The Kerr Report (2005) noted that an increasing number of children who required high dependency
care were being transferred by default to the Specialist Children’s Hospitals in Edinburgh or
Glasgow by the intensive care retrieval teams. It proposed that a more devolved model for the
delivery of high dependency care could result in appropriate care being delivered closer to home,
within the matrix of a Scotland-wide managed service network for paediatric critical care.
In 2006, National Services Division began the project management of a detailed national audit of
the provision of high dependency care for children and young people; aiming to quantify existing
demand and patient pathways, and provision of, high dependency care, as recommended by The
Kerr Report (2005). This audit project commenced in 2006 and concluded in 2008.
S

OKO= m~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=áå=båÖä~åÇ=~åÇ=t~äÉë=
Over the last decade, a number of key documents have influenced the provision of high
dependency care for children and young people across England and Wales.
As part of the implementation of a Framework for the Future (1997), the Department of Health
commissioned an expert advisory group to review the delivery of high dependency care in England.
The Report of the Expert Advisory Group (2001) recommended all hospitals providing paediatric
care should have arrangements in place to deliver high dependency care. This standard was
endorsed in the English National Service Framework for Children and Young People (2004) “Any
hospital receiving children must be able to initiate level 2 (intensive) care and stabilise whilst
awaiting retrieval.”
The Standards for the Care of Critically Ill and Critically Injured Children in the West Midlands were
published in 2002 and revised in 2004. These Standards were agreed by a local steering group
and complemented by peer review visits. They were designed to benchmark individual institutions
against a set of core and service specific standards, aiming to set: “a minimum level of care that all
institutions caring for acutely ill children should aim to achieve.”
The Health Commission in Wales has audited hospitals across Wales against their Caring for
Critically Ill Children Standards (2003). These standards were set up as a benchmarking tool and
formed part of the critical care audits conducted between 2003 and 2006 (Health Commission
Wales, 2006).
The Tanner Report (2006), The acutely or critically sick or injured child in the District General
Hospital: A team response was commissioned by the Department of Health to review critical care
delivered out with specialist Children’s Hospitals in England. The Report recommended that a
team-based approach should be used to provide paediatric critical care, with generic skills and
competencies drawn from different professional groups. It also recognised that clinical
communities have a responsibility to develop plans for paediatric emergency care to ensure that
sick children are taken to hospitals with paediatric expertise and equipment.
OKP= m~ÉÇá~íêáÅ=áåíÉåëáîÉ=Å~êÉ=áå=íÜÉ=rh=
High dependency care and paediatric intensive care have a close and interdependent relationship.
The model for the future delivery of paediatric intensive care (PIC) in Scotland was described in the
Scottish Paediatric Intensive Care Audit (1999). This audit recommended that intensive care
should be provided as a centralised service, delivered by the Royal Hospitals for Sick Children in
Edinburgh and Glasgow (Yorkhill, RHSC). This configuration was supported by the creation of the
national Transport of Critically Ill and Injured Children Service, in 2001. The Transport Service
retrieves 250-300 children each year from hospitals across Scotland to the intensive care units in
Edinburgh and Glasgow. Paediatric intensive care has been commissioned in Scotland by
National Services Division (NSD) since 2007 as a single service delivered on 2 sites, providing
care for over 1,100 cases per year.
A similar model of paediatric intensive care, based on centralised lead ‘hubs’, linked to regional
‘spokes’, was described in the English policy document Framework for the Future (1997) and
subsequently implemented in England and Wales.
The changes in the configuration of PIC across the UK have been monitored and benchmarked
through PICANet (2008), a national clinical audit. The ongoing audit process by PICANet
demonstrates that the centralised model of PIC has and continues to improve clinical outcomes for
children.
T

OKQ= lêÖ~åáë~íáçå=çÑ=ÅêáíáÅ~ä=Å~êÉ==
As part of the audit, an assessment tool was developed to map services available, within each
NHS Board, for the provision of high dependency care. The mapping tool was developed around
the format of the West Midland Guidelines (Standards for the care of critically ill and critically
injured children in the West Midlands, 2002) and incorporated the key elements of the Scottish
Emergency Care Framework (ECF) (2006).
The Emergency Care Framework provides a template for optimal paediatric emergency care,
based on a four level model of care:
iÉîÉä=NW The first contact for an acutely ill/injured child or young person with health services
is often their primary care provider (general practice), an out-of-hours service, ambulance
paramedics and increasingly, through telephone contact with NHS 24.
iÉîÉä=OW General hospitals with an Accident and Emergency Department but without a
Paediatric Inpatient Unit may have facilities for assessing and observing children and young people
over a period of time prior to making a decision about whether to discharge or not. However these
facilities are often open for a limited number of hours during the day and children and young people
who require admission need to be transferred to the local Inpatient Unit.
iÉîÉä=PW Emergency care should be available from a general hospital with a paediatric inpatient
unit which will have significantly more capacity to manage the unwell child or young person
than a hospital without such facilities.
iÉîÉä=QW Can be provided by specialist Children’s Hospitals or units, which provide paediatric
intensive care and/or advanced high dependency care, paediatric surgery and a range of specialist
services and advice, all of which are available on site.
The variation in NHS Board population requires different solutions to provide high dependency and
emergency care. The mapping tool was developed to reflect the services expected within ECF
Level 2, Level 3 and Level 4 Hospitals; an additional set of questions about the organisation of
critical care was developed for NHS Boards.
=
=
=
U

PK=
^áãë=C=çÄàÉÅíáîÉë=
PKN= ^áãë=
The aim of the audit was to quantify the demand for high dependency care and assess the services
available, in hospitals across Scotland. It was not designed to measure clinical outcomes or
evaluate the clinical care provided.
PKO= lÄàÉÅíáîÉë=
qÜÉ=~ìÇáíW=
measured the demand for high dependency care;
quantified the existing provision of high dependency care in Scotland;
delineated patient pathways.
The results from this audit should be used to inform:
kep=_ç~êÇë=çÑW=
the number of children requiring high dependency care;
the proportion of planned and emergency high dependency care;
where high dependency care for children is being provided;
the distribution of patient destinations.
oÉÖáçå~ä=mä~ååáåÖ=dêçìéë=çÑW=
the number of children requiring high dependency care;
the proportion of planned and emergency high dependency care;
the distribution of high dependency care by hospitals and NHS Boards within individual
regions;
inter-hospital admissions and transfers within regions;
distribution of patient destinations outside regional boundaries.
pÅçííáëÜ=dçîÉêåãÉåí=eÉ~äíÜ=aáêÉÅíçê~íÉë=çÑW=
the number of children requiring high dependency care;
the distribution of high dependency care by NHS Board, region, hospital;
the extent of inter/intra hospital admissions and transfers;
the distribution of location of care outside of high dependency units.
It was intended that the results from this audit would inform the development of critical care
networks to ensure that children are cared for in the most appropriate place, through the integration
of local, regional and national planning of critical care services.
=
V

QK=
jÉíÜçÇçäçÖó=
QKN= fåíêçÇìÅíáçå=
A steering group was set up to oversee the progress of the project and advise on clinical,
managerial and regional issues. This group consisted of lead clinicians, senior nurses, service
managers, regional planners, representatives from NSD and the Scottish Government Health
Directorates (full membership can be found in Appendix 1, p71).
Existing data sources were unable to provide information about the demand for high dependency
care for children and young people in Scotland. This prospective audit was designed to capture
baseline information about this area of care.
Definitions of paediatric high dependency care vary across the UK. In recognition that children
present to a range of hospitals in Scotland for HDC, the Steering Group refined 50 criteria, to
define ‘high dependency care’ within this audit. The finalised criteria and guidance notes are in
Appendix 2 (p72).
Representatives from participating hospitals were invited to be members of the User Group. The
User Group provided feedback on the audit methodology and the members operated as local coordinators,
promoting the audit and monitoring the quality of audit returns.
A data collection system and reporting tool was developed to record all elements of the dataset on
a centralised database. The two-sided audit form was designed to capture information on aspects
of the child’s clinical pathway and HDC episode (a copy of the final format is in Appendix 3, p73).
An adapted version was completed by remote and rural hospitals, to include A&E Departments.
The form captured the following dataset items: patient, hospital and ward, admission type,
admission from, end of care destination, episode start and end dates and times, HDC criteria and
primary and secondary journey details.
QKO= máäçí=~åÇ=~ìÇáí=êçääJçìí==
To ensure quantifiable and interpretable results, the methodology was piloted in a specialised
paediatric ward, a general paediatric ward and an adult ward. Modifications were made to the form
and process, following the results of the pilot exercise.
The roll-out of the audit commenced in October 2006, all hospitals were participating by early
November. Data was collected over a 14 month period, from October 2006 to the end of
November 2007. The aim of the audit was to present a summary of high dependency care activity
for a 12 month period; capturing the seasonal variation in activity.
Site visits were conducted, ensuring local staff and co-ordinators were aware of the objectives and
remit of the audit. Documentation was distributed to participating wards and posters were
displayed ensuring parents were aware of the audit (complying with Data Protection legislation).
NM

QKP= fåÅäìëáçå=L=ÉñÅäìëáçå=ÅêáíÉêá~=
All children and young people up to the age of 16, who met one of the high dependency care
criteria, were included in the audit.
=
qÜÉ=ÑçääçïáåÖ=ï~êÇ=~êÉ~ë=ïÉêÉ=áåÅäìÇÉÇ=ïáíÜáå=íÜÉ=~ìÇáíW=
paediatric wards – general, medical, specialist and surgical;
paediatric high dependency units (HDUs);
short stay wards;
paediatric and adult intensive care units (PICUs/ICUs) when used for HDC patients;
adult general and specialist wards;
adult HDUs;
adult acute medical receiving wards.
qÜÉ=~êÉ~ë=ÄÉäçï=ïÉêÉ=ÉñÅäìÇÉÇ=Ñêçã=íÜÉ=~ìÇáíW=
patients who required intensive care, i.e. endotracheal intubation, acute artificial ventilation;
A&E Departments (except within Remote & Rural hospitals);
Obstetric/maternity units;
Neonatal Intensive Care Units (NICUs);
Psychiatric wards;
designated theatre recovery areas;
homecare.
QKQ= a~í~=ÅçääÉÅíáçå=ãÉíÜçÇ=
Nursing Staff were instructed to complete an audit form when a child (up to age 16) met one or
more of the HDC criteria. The forms were completed every 12 hours (reflecting day and night
activity). All HDC delivered in the 12 hour period, was recorded by completing a tick box on the
reverse of the form. The 12 hour period varied between hospitals, but generally ran from 7.30am –
7.30pm for a day episode and 7.30pm – 7.30am for a night episode. An episode of care is defined
as a continual time period of high dependency care. Data was captured on children over the age of
16, if they were receiving their HDC within a paediatric environment.
Data forms for the adult wards were less detailed due to the small number of children and young
people qualifying for the audit in these wards. A summary of each HDC episode was completed on
a single sheet per month.
A central collection point operated in each hospital to co-ordinate the weekly returns to NSD. Local
co-ordinators were asked to review all forms, prior to submission to ensure accuracy. Returns from
the Adult wards followed the same protocol, but were returned on a monthly basis. All forms were
returned to NSD by Registered Post, double-enveloped with ‘Medical in Confidence’ on the inner
envelope.
QKR= s~äáÇ~íáçå=çÑ=Ç~í~=
Upon receipt, audit forms were reviewed for missing information and queries were followed-up with
the local co-ordinators and/or ward staff, to identify the missing elements. In addition to the weekly
review of returns, the local co-ordinators were asked to conduct a monthly cross-check of audit
returns with case notes, to ensure a consistent approach to data recording.
NN

Following entry onto the customised database, a number of quality assurance processes were
carried out. After each batch of data entry, a report was run to ensure the data fields had been
completed and a sampling system was used to certify the accuracy of the data entered onto the
database. A final assessment was conducted by producing monthly activity reports for each ward,
matching the data entry to the data output. These summaries also provided detailed information
for the wards on their monthly returns within the audit.
Analysis of the dataset was carried out using Business Objects Enterprise, with the assistance of
Information Services Division (ISD).
All audit forms have been securely held in a locked filing system to ensure compliance with data
protection legislation and Caldicott Guardian advice. They are filed in date order by ward and
hospital and will be disposed according to data protection guidance, after the data analysis has
been completed.
At the end of the data collection and quality assurance processes, presentations were conducted
with a number of hospitals as a further form of data validation. Ensuring that the data collected on
behalf of the hospital was a true reflection of activity and also provided direct feedback to individual
hospitals about their participation in the audit.
QKS= lêÖ~åáë~íáçå=çÑ=ÅêáíáÅ~ä=Å~êÉ=
A questionnaire was developed by the Project Board; utilising the West Midland Guidelines
(Standards for the care of critically ill and critically injured children in the West Midlands (2002))
and the Emergency Care Framework (ECF) (2006). The questionnaire was reviewed and signed
off by the Steering Group.
The terminology was changed from high dependency care to critical care for this part of the project,
to reflect other published standards and to ensure the responses were not limited to care delivered
in a high dependency unit.
A pathfinder exercise was conducted in 2 NHS Boards. Minor changes were made following
feedback from this process, before the questionnaire was issued nationally. All NHS Boards were
asked to return a summary on the hospitals within their Board area. The relevant questionnaire
were then issued to the appointed co-ordinators, who liaised with clinical colleagues and coordinated
the completion and return to NSD.
Appendix 4 (p74) summarises the ECF Levels of all the hospitals that participated in the audit. The
results of this survey were analysed for recurring themes and are summarised in tables in Section
6.
NO

RK=
oÉëìäíë=
RKN= pìãã~êó=çÑ=êÉëìäíë=
The audit data covers the 12 month period, from 1st November 2006 to 31st October 2007. For
the purposes of this report all references made to children, will include young people up to age 16.
= = = = =
^ìÇáí=êÉíìêåë=ïÉêÉ=êÉÅÉáîÉÇ=ÑêçãW=
=
all NHS Boards in Scotland (14);
38 hospitals;
113 general and specialist paediatric and adult wards.
a~í~=~å~äóëÉÇ=ÑêçãW=
=
4,804 children;
9,680 episodes of care;
538,003 hours of high dependency care.
=
=
=
=
NP

Figure 1 shows the number of children presenting for care in each NHS Board (location of delivery
of care) and NHS Board of origin for all children who received HDC in the audit. The colour-coded
key demonstrates the paediatric population within each NHS Board for comparison.
cáÖìêÉ=N=`ÜáäÇêÉå=êÉÅÉáîáåÖ=ea`=áå=kep=_ç~êÇ=C=kçK=çÑ=kep=_ç~êÇ=êÉëáÇÉåíë=ïÜç=êÉÅÉáîÉÇ=ea`
NQ

RKO= =
aÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
The aim of this audit was to assess the need for high dependency care on a national, regional,
NHS Board and hospital level.
RKOKN= =
aÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=kep=_ç~êÇë=
Facilities within NHS Boards are not always sufficient to provide HDC and a number of children
receive HDC out with their NHS Board. A postcode analysis reveals the rate of demand per 1000
for HDC. Table 1 reflects a variation in need between NHS Boards.
NHS Board of
residence
0 – 15 yrs
population*
0 – 15yrs
audit
cohort
HDC Cohort
rate per 1000
0 – 15 yrs
population
Ayrshire and Arran 65,385 237 4
Borders 20,107 62 3
Dumfries and Galloway 25,459 113 4
Fife 65,104 275 4
Forth Valley 54,223 366 7
Grampian 94,931 516 5
Greater Glasgow & Clyde 210,187 1,112 5
Highland 54,635 387 7
Lanarkshire 106,992 256 2
Lothian 138,937 755 5
Orkney 3,525 30 9
Shetland 4,362 24 6
Tayside 68,495 452 7
Western Isles 4,609 12 3
Total 916,951 4,597 5
q~ÄäÉ=N=^ìÇáí=ÅçÜçêí=Äó=kep=_ç~êÇ=çÑ=oÉëáÇÉåÅÉI=ê~íÉ=éÉê=NMMM=EMJ=NR=éçéìä~íáçåF==
GdÉåÉê~ä=oÉÖáëíÉê=lÑÑáÅÉ=Ñçê=pÅçíä~åÇI=OMMU=
It is difficult to draw any conclusions from a single year’s data; variations from the national rate of 5
per 1000 must be interpreted with caution. The Table excludes non-Scottish residents and children
16 years and over.
=
RKOKO= = aÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=Üçëéáí~äë=
The numbers of children and episodes varies significantly between hospitals. In order to present
comparable data, hospitals are classified in this report according to the Emergency Care
Framework definitions, i.e. Level 2 Hospitals (DGHs with no in-patient paediatric wards), Level 3
Hospitals (in-patient paediatric facilities) and Level 4 Hospitals (paediatric intensive care/advanced
high dependency facilities).
The Southern General Institute of Neuroscience data was included in the Level 3 Hospital analysis
and Ninewells Hospital (ECF Level 3) is included with the Level 4 Children’s Hospitals. Level 2
Hospitals are sub-divided into Rural (2R) and Urban (2) to differentiate between their patient casemix.
Rural General Hospitals regularly admit children as there is no alternative due to their
location, and Urban Level 2 Hospitals provide care in many NHS Boards for young people over 13
years.
Adult wards in Ninewells Hospital and the Southern General Hospital are included in Urban Level 3
Hospitals.
NR

The following charts show the total number of children and episodes of high dependency care
during the audit, per hospital. An episode of care is defined as a continual period of high
dependency care.
Total number of children and episodes - Children's Hospitals
Yorkhill, RHSC (4)
RHSC, Edinburgh (4)
Ninew ells Hospital, Dundee (3)
Royal Aberdeen Children's Hospital (4)
0 500 1000 1500 2000 2500 3000 3500 4000 4500
No. of Children
No. of Episodes
`Ü~êí=N=kìãÄÉê=çÑ=ÅÜáäÇêÉå=C=óçìåÖ=éÉçéäÉ=~åÇ=ÉéáëçÇÉë=áå=íÜÉ=`ÜáäÇêÉåÛë=eçëéáí~äë=Ó=b`c=iÉîÉäë=~êÉ=áå=Äê~ÅâÉíë=
NS

Stirling Royal Infirmary (3)
Raigmore Hospital, Inverness (3)
Wishaw General Hospital (3)
Crosshouse Hospital, Kilmarnock (3)
Victoria Hospital, Kirkcaldy (3)
Southern General Institute, Glasgow (3)
Dumfries & Gallow ay Royal Infirmary (3)
Belford Hospital, Fort William (2R)
Royal Alexandra Hospital, Paisley (3)
St John's Hospital At How den, Livingston (3)
Western Infirmary, Glasgow (2)
Dr Gray's Hospital, Elgin (3)
Perth Royal Infirmary (2)
Borders General Hospital, Melrose (3)
Balfour Hospital, Kirkw all (2R)
Caithness General Hospital, Wick (2R)
Queen Margaret Hospital, Dunfermline (2)
Royal Infirmary of Edinburgh at Little France (2)
Gilbert Bain Hospital, Lerw ick (2R)
Inverclyde Royal Hospital, Greenock (2)
Western General Hospital, Edinburgh (2)
Ninew ells Hospital (adult w ards), Dundee (2)
Hairmyres Hospital, East Kilbride (2)
Victoria Infirmary, Glasgow (2)
Dr Mackinnon Memorial Hospital, Broadford,
Lorn & Islands DG Hospital, Oban (2R)
Vale of Leven General Hospital, Alexandria (2)
Aberdeen Royal Infirmary (2)
Southern General Hospital, Glasgow (2)
Gartnavel General Hospital, Glasgow (2)
Glasgow Royal Infirmary (2)
Western Isles Hospital, Stornow ay (2R)
Victoria Hospital, Rothesay (2R)
Garrick Hospital, Stranraer (2R)
Total number of children and episodes - Level 2 Urban, 2 Rural and 3 hospitals (ECF)
0 50 100 150 200 250 300 350 400
No. of Children
No. of Episodes
`Ü~êí=O=kìãÄÉê=çÑ=ÅÜáäÇêÉå=C=óçìåÖ=éÉçéäÉ=~åÇ=ÉéáëçÇÉë=áå=b`c=iÉîÉä=O=~åÇ=P=Üçëéáí~äë=EO=Z=rêÄ~å=iÉîÉä=OI=Oo=Z=oìê~ä=iÉîÉä=OF=
NT=

RKOKP= =
^Åíáîáíó=çîÉê=íÜÉ=Å~äÉåÇ~ê=óÉ~ê==
The chart below demonstrates how many children received high dependency care each month and
the number of individual episodes each month, across Scotland. An episode of care can range
from minutes to months.
1200
1069
Monthly incidence of High Dependency Care
Children (6,682) and Episodes (9,680)
No Children/Episodes
1000
800
600
400
803
826
560
890
602
749 752
531 540
780 773
506 522
811 804 817
775
556
550 544
497
634
471
200
0
NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT
No. of Children
No. of Episodes
`Ü~êí=P=jçåíÜäó=ÇÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
Chart 3 demonstrates a continual demand for high dependency care during the calendar year in
Scotland. The highest level of demand for HDC appears in November 2006. Some children may
have had episodes in more than one month and will therefore be counted each month.
The need for HDC across the 3 regions in Scotland has been displayed in Chart 4. Analysis of
activity and demand has including returns from NHS Tayside in the North of Scotland region (NoS)
and NHS Forth Valley in the West of Scotland region (WoS).
NU

600
550
584
Regional Analysis of Monthly incidence of HDC episodes
No Children/Episodes
500
450
400
350
300
250
200
150
100
497
469
477 472
449
432
397
401 396
372
324
244
234
226
228
241
190
198
200 202 202
169 168
175
203
188
184 182
166
145 151
134 130
135
115
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07
NoS SEAT WoS
`Ü~êí=Q=jçåíÜäó=ÇÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=oÉÖáçå~ä=~å~äóëáë=
25
Urban Level 2 Hospitals - Monthly incidence of High Dependency Care
Children (181) and Episodes (188)
21
No Children/Episodes
20
15
10
18
16
19
18
17
19
18
17
15
14
16
9
10
14
12
10
5
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07
No. of Children
No. of Episodes
`Ü~êí=R=jçåíÜäó=ÇÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=rêÄ~å=iÉîÉä=O=eçëéáí~äë=
NV

25
23
Rural Level 2 Hospitals - Monthly incidence of High Dependency Care
Children (122) and Episodes (145)
No Children/Episodes
20
15
10
5
19
18
15
14 14
5
11
7
17
13
15
12
11
8
7
10
9
5
4
7
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07
No. of Children No. of Episodes
`Ü~êí=S=jçåíÜäó=ÇÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=oìê~ä=iÉîÉä=O=eçëéáí~äë=
=
The number of episodes and children are closely aligned in Level 2 Hospitals; this indicates that
only a few children received more than one episode of HDC within the Level 2 Hospitals.
300
276
Level 3 Hospitals - Monthly incidence of High Dependency Care
Children (1,327) and Episodes (1,539)
250
240
No Children/Episodes
200
150
100
95
83
116
103
107
99
147
132
109
101
126
107
142
98
103
97
82 85
124
116
97
81
50
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07
No. of Children
No. of Episodes
`Ü~êí=T=jçåíÜäó=ÇÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=iÉîÉä=P=eçëéáí~äë=
OM

The drop in the number of returns between November 2006 and December 2006 (66%) was
apparent in all Level 3 Hospitals (except St John’s Hospital); the fall in returns ranged between 39-
94% within individual hospitals.
The under-16 SMR01 data (excluding departments not included in the audit) shows a small
increase in paediatric admissions in November 2006, compared to December 2006. This does not
explain the significantly higher number of HDC returns received in November 2006; it is therefore
likely that this is an artefact coinciding with the start of the audit.
No Children/Episodes
800
700
600
500
400
300
200
752
528
Children's Hospitals - Monthly incidence of High Dependency Care
Children (5,052) and Episodes (7,808)
694
445
742
468
618
408
576
639
616
384 378 387
637
426
684
399
700
446
632
410
518
373
100
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07
No. of Children
No. of Episodes
`Ü~êí=U=jçåíÜäó=ÇÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=`ÜáäÇêÉåÛë=eçëéáí~äë=
81% of episodes occurred in one of the Children’s Hospitals (7808 / 9680 episodes); 16% of
episodes occurred in Level 3 Hospitals and the remaining 4% was delivered in the Urban and
Rural Level 2 Hospitals. The activity within the Children’s Hospitals shows slightly fewer numbers
of children during the summer months. The pattern of monthly demand within the Level 2 and 3 is
consistent with providing unscheduled care for critically ill and injured for ill children with
emergency presentations.
ON

RKOKQ= =
aÉãçÖê~éÜáÅë=
In assessing the need for HDC, it is important to understand the demographic breakdown of the
audit cohort. Chart 3 shows the split between boys (55%) and girls (45%); it also demonstrates
that the largest individual age group of children who require HDC are under a year of age (1170,
24%).
`Ü~êí=V=aÉãçÖê~éÜó=çÑ=ÅÜáäÇêÉå=C=óçìåÖ=éÉçéäÉ=áå=íÜÉ=ea`=~ìÇáí=
Table 2 shows the distribution of age-ranges for children captured in the audit.
Age Range Number of children Percentage
Admissions per
1000
< 1 year 1,170 24% 20
1 – 4 years 1,278 27% 6
5 – 12 years 1,514 31% 3
13 – 15 years 700 15% 4
>15 years 142 3%

RKOKR= =
^Åíáîáíó=Äó=Å~äÉåÇ~ê=óÉ~ê=~åÇ=~ÖÉJê~åÖÉ=
A further analysis was conducted to assess if the demand for HDC varied between the age-ranges.
With the exception of November 2006, chart 10 shows a stable pattern of demand.
300
Monthly incidence of HDC by age-range

RKP= tÜÉêÉ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ï~ë=ÇÉäáîÉêÉÇ=
Identifying where children and young people receive HDC was a key aim of the audit. Figure 2
geographically displays the returns from hospitals across Scotland. Appendix 4 (p76) summarises
the ECF Levels for the hospitals that participated in this audit.
cáÖìêÉ=O=kìãÄÉê=çÑ=ÅÜáäÇêÉå=~åÇ=óçìåÖ=éÉçéäÉ=êÉÅÉáîáåÖ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=éÉê=Üçëéáí~ä=
OQ

The table below shows the distribution of episodes by hospital type and age-range. Episodes
(rather than children) are analysed, as children may have care in more than one type of hospital.
This distribution demonstrates that a significant number of children in Rural Level 2 Hospitals are
less than 13 years (74%); this ratio is reversed in Urban Level 2 Hospitals where 74% are over 13
years of age.
Age at
start of episode
Children’s
Hospitals
Level 3
Hospitals
Urban Level
2 Hospitals
Rural Level 2
Hospitals
Totals
(%)
< 1 year 1,842 252 9 20 2,123 (22%)
1-4 years 2,154 397 12 40 2,603 (26%)
5-12 years 2,412 560 21 48 3,041 (32%)
13-15 years 969 300 138 35 1,442 (15%)
16-25 years 431 30 8 2 471 (5%)
Totals (%) 7,808 (80%) 1,539 (16%) 188 (2%) 145 (2%)
q~ÄäÉ=P=aáëíêáÄìíáçå=çÑ=ÉéáëçÇÉë=çÑ=Å~êÉ=Äó=~ÖÉJê~åÖÉ=~åÇ=bãÉêÖÉåÅó=`~êÉ=cê~ãÉïçêâ=Üçëéáí~ä=iÉîÉäë=
OR

Children and young people received high dependency care in a number of different wards; Table 4
shows the proportion of episodes that occurred in each type of ward.
=
Ward Type
No. of Episodes
% of Total
Episodes
Paediatric Medical* 1,783 18.4%
Paediatric HDU 1,639 16.9%
Paediatric (DGH wards) 1,505 15.5%
Paediatric Haematology &
Oncology
1,375 14.2%
Paediatric Renal 700 7.2%
Short Stay 564 5.8%
Neonatal Surgery 432 4.5%
PICU 108 1.1%
Paediatric Surgery 326 3.4%
Paediatric Cardiac 288 3.0%
Paediatric Neuro Sciences 240 2.5%
Paediatric Orthopaedics 201 2.1%
A&E 135 1.4%
Adult ICU 90 0.9%
Paediatric Burns & Plastics 72 0.7%
Paediatric ENT 46 0.5%
Adult Medical 43 0.4%
Adult HDU 26 0.3%
Adult Assessment 27 0.3%
Adult Orthopaedics 27 0.3%
Adult Surgery 31 0.3%
Adult Medical Specialist 17 0.2%
Adult Infectious Diseases 2 0.0%
Adult Neuro Sciences 2 0.0%
Adult Renal 1 0.0%
Total Episodes 9,680
q~ÄäÉ=Q=içÅ~íáçå=çÑ=íêÉ~íãÉåí=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ==
G=m~ÉÇá~íêáÅ=jÉÇáÅ~ä=ÇÉåçíÉë=íÜÉ=ÇÉëáÖå~íÉÇ=é~ÉÇá~íêáÅ=ãÉÇáÅ~ä=ï~êÇë=áå=oçó~ä=^ÄÉêÇÉÉå=`ÜáäÇêÉåÛë=eçëéáí~äI=
oep`=bÇáåÄìêÖÜ=~åÇ=vçêâÜáää=oep`I=dä~ëÖçïK=
OS

RKQ= =
mêçîáëáçå=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ===
The audit aimed to provide a greater understanding of the services available and the type of care
delivered, i.e. the proportion of planned and emergency high dependency care and the complexity
of the care delivered.
RKQKN= =
bäÉÅíáîÉ=L=ÉãÉêÖÉåÅó=ÉéáëçÇÉë=
The following chart indicates the proportion of scheduled and unscheduled care captured in the
audit. Not all episodes had an ‘admission type’ i.e. emergency or elective entered onto the
database (743 episodes). The chart therefore reflects an analysis of 8,937 episodes.
100%
ECF level by elective/emergency episode
90%
80%
70%
4100
5777
60%
50%
183
145
1349
40%
30%
20%
2993
3190
10%
0%
25
0
172
Urban Level 2 Rural Level 2 Level 3 Children's
Hospitals
HDC Audit Total
Elective
Emergency
`Ü~êí=NN=bäÉÅíáîÉ=L=ÉãÉêÖÉåÅó=ÉéáëçÇÉë=
=
In total 64% of all episodes were emergency admissions, 36% elective admissions. This division is
skewed by the number of elective episodes within the Children’s Hospitals. The vast majority of
episodes delivered in Level 2 and Level 3 Hospitals were unscheduled emergency episodes (91%).
Only 25 elective episodes (0.3% of the total) were delivered in Urban Level 2 Hospitals and 23 of
these were for adolescents.
=
=
=
OT

RKQKO= =
iÉåÖíÜ=çÑ=ÉéáëçÇÉ==
Occupied bed days provide a clear indication of the high dependency care delivered across
Scotland during the audit. Table 5 breaks this down by the high dependency care audit hospital
definitions; a summary for each hospital is in Appendix 5 (p75).
HDC audit hospital definition Total hours Occupied bed days
Rural Level 2 Hospitals 948 40
Urban Level 2 Hospitals 7,964 332
Level 3 Hospitals 52,882 2,203
Children’s Hospitals 476,208 19,842
All hospitals 538,003 22,417
q~ÄäÉ=R=qçí~ä=Üçìêë=~åÇ=Éèìáî~äÉåí=ÄÉÇ=Ç~óë=Äó=ea`=~ìÇáí=ÇÉÑáåáíáçå=
=
Summary of total bed days per hospital (Logarithmic scale)
Balfour Hospital, Kirkwall (2R)
Belford Hospital, Fort William (2R)
Caithness General Hospital, Wick (2R)
Dr Mackinnon Memorial Hospital (2R)
Garrick Hospital, Stranraer (2R)
Gilbert Bain Hospital, Lerwick (2R)
Lorn & Islands DG Hospital, Oban (2R)
Victoria Hospital, Rothesay (2R)
Western Isles Hospital, Stornoway (2R)
Aberdeen Royal Infirmary (2)
Gartnavel General Hospital, Glasgow (2)
Glasgow Royal Infirmary (2)
Hairmyres Hospital, East Kilbride (2)
Inverclyde Royal Hospital, Greenock (2)
Ninewells Adult Wards (2)
Perth Royal Infirmary (2)
Queen Margaret Hospital, Dunfermline (2)
Royal Infirmary of Edinburgh (2)
Southern General Hospital, Glasgow (2)
Vale of Leven General Hospital (2)
Victoria Infirmary, Glasgow (2)
Western General, Edinburgh (2)
Western Infirmary, Glasgow (2)
Borders General Hospital, Melrose (3)
Crosshouse Hospital, Kilmarnock (3)
Dr Gray's Hospital, Elgin (3)
Dumfries & Galloway Royal Infirmary (3)
Raigmore Hospital, Inverness (3)
Royal Alexandra Hospital, Paisley (3)
Southern General Institute, Glasgow (3)
St John's Hospital, Livingston (3)
Stirling Royal Infirmary (3)
Victoria Hospital, Kirkcaldy (3)
Wishaw General Hospital (3)
Ninewells Hospital, Dundee (Children's Hospitals)
RACH (Children's Hospitals)
RHSC, Edinburgh (Children's Hospitals)
Yorkhill RHSC, Glasgow (Children's Hospitals)
0
0
0
1
2
3
2
2
8
16
9
22
19
13
14
20
8
18
53
33
6
27
93
70
176
46
134
421
93
271
39
600
134
221
1,475
1,415
5,473
11,479
0 1 10 100 1,000 10,000 100,000
Bed days
`Ü~êí=NO=pìãã~êó=çÑ=ÄÉÇ=Ç~óë=éÉê=Üçëéáí~ä=EiçÖ~êáíÜãáÅ=ëÅ~äÉF=J=eçëéáí~äë=éêÉëÉåíÉÇ=Äó=b`c=iÉîÉä=
OU

The length of episode relates to the continuous period of time that a child received one or more
high dependency care treatments, as per the audit criteria. Table 6 summarises the maximum,
median and minimum length of episode; range 20 minutes to 316 days.
Length of episode summary
Maximum
Median
7,591 hours (316 days)
16 hours
Minimum
< 1 hour
q~ÄäÉ=S=^ìÇáí=ëìãã~êó=J=iÉåÖíÜ=çÑ=ÉéáëçÇÉ
Table 7 provides this breakdown for the hospitals that participated in the audit.
Hospital Maximum Median Minimum Total Hrs
Urban Level 2 Hospitals
Aberdeen Royal Infirmary 395 31 6 532
Gartnavel General Hospital, Glasgow 218 117 12 464
Glasgow Royal Infirmary 39 11 4 54
Hairmyres Hospital, East Kilbride 119 25 8 302
Inverclyde Royal Hospital, Greenock 123 25 9 324
Ninewells Adult Wards 193 47 1 477
Perth Royal Infirmary 61 2 0 198
Queen Margaret Hospital, Dunfermline 90 27 4 436
Royal Infirmary of Edinburgh 275 63 1 1,280
Southern General Hospital 552 120 11 803
Vale of Leven General Hospital 20 9 1 58
Victoria Infirmary, Glasgow 57 16 12 154
Western General, Edinburgh 150 56 20 646
Western Infirmary, Glasgow 288 31 7 2,235
Sub-total 7,964
Rural Level 2 Hospitals
Balfour Hospital, Kirkwall 47 6 2 191
Belford Hospital, Fort William 47 3 1 373
Caithness General Hospital, Wick 7 2 1 49
Garrick Hospital, Stranraer 8 8 8 8
Gilbert Bain Hospital, Lerwick 40 7 1 219
Lorn & Islands DG Hospital, Oban 8 2 1 22
Mackinnon Memorial Hospital, Isle of Skye 34 12 1 78
Victoria Hospital, Rothesay 4 4 4 4
Western Isles Hospital, Stornoway 5 5 5 5
Sub-total 948
OV

Hospital Maximum Median Minimum Total Hrs
Level 3 Hospitals
Borders General Hospital, Melrose 768 8 1 1,668
Crosshouse Hospital, Kilmarnock 318 12 1 4,216
Dr Gray's Hospital, Elgin 174 14 1 1,115
Dumfries & Galloway Royal Infirmary 163 22 3 3,211
Raigmore Hospital, Inverness 888 16 1 10,100
Royal Alexandra Hospital, Paisley 176 24 2 2,230
Southern General Institute 695 22 1 6,498
Stirling Royal Infirmary 768 13 1 14,395
St John's Hospital, Livingston 172 12 1 942
Victoria Hospital, Kirkcaldy 129 16 1 3,210
Wishaw General Hospital 852 13 2 5,297
Sub-total 52,882
Children’s Hospitals
Ninewells Hospital, Dundee 4,609 17

HDC Audit - Individual Length of Episode summary
3500
3000
No. of episodes
2500
2000
1500
1000
500
0
28 days
Length of episode
`Ü~êí=NP=^ìÇáí=ëìãã~êó=Ó=äÉåÖíÜ=çÑ=ÉéáëçÇÉ=ëìãã~êó
90
Urban Level 2 Hospitals - Individual Length of Episode
summary
80
70
No. of episodes
60
50
40
30
20
10
0
28 days
Length of episode
`Ü~êí=NQ=iÉåÖíÜ=çÑ=ÉéáëçÇÉ=ëìãã~êó=Ó=rêÄ~å=iÉîÉä=O=eçëéáí~äë=
All the children who had episodes beyond 72 hours in the Urban Level 2 Hospitals were
adolescents over the age of 13.
PN

Rural Level 2 Hospitals - Individual Length of Episode summary
140
120
No. of episodes
100
80
60
40
20
0
28 days
Length of episode
`Ü~êí=NR=iÉåÖíÜ=çÑ=ÉéáëçÇÉ=ëìãã~êó=Ó=oìê~ä=iÉîÉä=O=eçëéáí~äë=
In the Rural Level 2 Hospitals, only 9 children (6%) had HDC for more than 24 hours; 5 were in
Gilbert Bain Hospital in Shetland; and 2 of these children were transferred to another hospital for
definitive care.
Level 3 Hospitals - Individual Length of Episode summary
500
450
400
No. of episodes
350
300
250
200
150
100
50
0
28 days
Length of episode
`Ü~êí=NS=iÉåÖíÜ=çÑ=ÉéáëçÇÉ=ëìãã~êó=Ó=iÉîÉä=P=eçëéáí~äë=
The data in charts 14, 15 and 16 show that only a small proportion of episodes (6%) go beyond 4
days in Level 2 and 3 Hospitals.
PO

The Children's Hospitals - Individual Length of Episode
summary
3000
2500
No. of episodes
2000
1500
1000
500
0
28 days
Length of episode
`Ü~êí=NT=iÉåÖíÜ=çÑ=ÉéáëçÇÉ=ëìãã~êó=Ó=`ÜáäÇêÉåÛë=eçëéáí~äë=
The distribution of episode length is greater in the Children’s Hospitals; over 12% of these episodes
last more than 4 days.
RKQKP= =
jìäíáéäÉ=ÉéáëçÇÉë=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
The audit highlighted a sub-group of children who have had multiple episodes of HDC, i.e. more
than one episode of high dependency care during the audit period. This is a group of children who
have complex care needs. Multiple episodes can occur as a result of a chronic condition, lengthy
treatment protocol, re-admission or a transfer to another hospital.
1,400 children (29%) had more than one episode of care, accounting for 65% of all episodes. This
inverse relationship is demonstrated in the table below, the majority (71%) experienced only one
episode of high dependency care; however the small proportion of children with 10 or more
episodes (2%) experienced 25% of all episodes.
Children (%) Episodes (%)
10 or more episodes 115 (2%) 2460 (25%)
2 – 9 episodes 1287 (27%) 3818 (40%)
1 episode 3402 (71%) 3402 (35%)
==q~ÄäÉ=U=jìäíáéäÉ=ÉéáëçÇÉë=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
Appendix 6 (p80) provides a full breakdown of the number of children by multiple episode category.
=
PP

RKQKQ= =
eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ÅêáíÉêá~=
All hospitals provided a wide range of high dependency care; even hospitals who had fewer than
10 children recorded a significant number of varied HDC categories.
The ten most common HDC interventions/conditions are described in Table 9. Many children had
more than one category recorded, during an episode of care.
Treatment code
No. of
children
Fluid balance 1819
ECG and Sa0 2 monitoring 1652
Multiple IV drugs or continuous infusion 1602
O 2 more than 40% 1464
Hourly neurological observations 791
Complex pain control 721
Severe asthma/bronchodilators 661
Airway intervention 455
Severe metabolic/fluid/electrolyte derangement 455
Septicaemia 420
q~ÄäÉ=V=iáëí=çÑ=íÜÉ=íÉå=ãçëí=Åçããçå=ea`=ÅêáíÉêá~=
=
=
The following tables demonstrate the five most common categories of HDC selected, within the
different levels of hospitals.
Treatment code
No. of
children
O2 more than 40% 57
Multiple IV drugs or continuous infusion 39
Sedation or GA for ward procedure 37
Fluid balance 31
Hourly neurological observations 25
q~ÄäÉ=NM=iáëí=çÑ=íÜÉ=íçé=ÑáîÉ=ea`=ÅêáíÉêá~=Ó=rêÄ~å=iÉîÉä=O=eçëéáí~äë=
PQ

Treatment code
No. of
children
O 2 more than 40% 37
Hourly neurological observations 26
Severe asthma/bronchodilators 20
Septicaemia 18
GCS 8-12 11
q~ÄäÉ=NN=iáëí=çÑ=íÜÉ=íçé=ÑáîÉ=ea`=ÅêáíÉêá~=Ó=oìê~ä=iÉîÉä=O=eçëéáí~äë=
=
=
=
No. of
Treatment code
children
O 2 more than 40% 437
Multiple IV drugs or continuous infusion 325
Hourly neurological observations 320
Severe asthma/bronchodilators 276
ECG and Sa02 monitoring 253
Total 1539
q~ÄäÉ=NO=iáëí=çÑ=íÜÉ=íçé=ÑáîÉ=ea`=ÅêáíÉêá~=Ó=iÉîÉä=P=eçëéáí~äë=
=
=
=
No. of
Treatment code
children
Fluid balance 1605
ECG and Sa0 2 monitoring 1397
Multiple IV drugs or continuous infusion 1258
O 2 more than 40% 975
Complex pain control 634
=
Total 7808
q~ÄäÉ=NP=iáëí=çÑ=íÜÉ=íçé=ÑáîÉ=ea`=ÅêáíÉêá~=Ó=`ÜáäÇêÉåÛë=eçëéáí~äë=
PR

RKR= =
m~íáÉåí=é~íÜï~óë=
The patient pathway provides data about the flow of patients; how children and young people
present for high dependency care, movement within hospitals, between hospitals and NHS Board
boundaries.
RKRKN= =
içÅ~íáçå=ÄÉÑçêÉ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
The following charts provide information about where a child presents, prior to high dependency
care. Data is only presented on the emergency patient pathway, i.e. 5,757 emergency episodes.
Adult HDU, 1, 0%
HDU, 168, 3%
ICU, 32, 1%
HDC Audit - Admission From:
PICU, 174, 3%
Emergency N = 5,757
Other Hospital, 495, 9%
Same Ward, 556, 10%
Other Ward, 818, 14%
Home, 1533, 26%
A & E, 1463, 25%
GP, 23, 0%
Home
GP
A & E
Short Stay
Other Ward
Same Ward
Other Hospital
Adult HDU
ICU
HDU
PICU
Short Stay, 494, 9%
`Ü~êí=NU=^ìÇáí=ëìãã~êó=Ó=äçÅ~íáçå=éêáçê=íç=ÉãÉêÖÉåÅó=ÉéáëçÇÉ=çÑ=ea`=
For emergency episodes, children were predominantly admitted from either home (26%) or an A&E
department (25%). The same ward/other ward category indicates children moving between wards
within hospitals and only 495 (9%) were transferred from another hospital. Admissions from shortstay
wards (9%) reflect local care pathways, not all Level 3 and 4 Hospitals operate short stay
wards for assessment and review.
PS

Urban Level 2 - Admission From:
HDU, 3, 2%
ICU, 1, 1%
Adult HDU, 1, 1%
Other Hospital, 6, 4%
Emergency N = 163
Same Ward, 5, 3%
Other Ward, 27, 17%
Home, 59, 36%
Home
GP
A & E
Short Stay
Other Ward
Same Ward
Other Hospital
Adult HDU
ICU
HDU
PICU
A & E, 61, 36%
`Ü~êí=NV=içÅ~íáçå=éêáçê=íç=ÉãÉêÖÉåÅó=ea`=ÉéáëçÇÉ=J=rêÄ~å=iÉîÉä=O=
Rural Level 2 - Admission From:
Other Hospital, 2, 1%
Emergency N =145
Other Ward, 10, 7%
Same Ward, 1, 1%
GP, 5, 3%
A & E, 19, 13%
Home, 108, 75%
Home
GP
A & E
Short Stay
Other Ward
Same Ward
Other Hospital
Adult HDU
ICU
HDU
PICU
`Ü~êí=OM=içÅ~íáçå=éêáçê=íç=ÉãÉêÖÉåÅó=ea`=ÉéáëçÇÉ=J=oìê~ä=iÉîÉä=O=
The proportion of unplanned activity, i.e. an admission from either home, A&E or via a GP to an
Urban Level 2 Hospital was 72% (120 episodes); in Rural hospitals this proportion was 91% (132
episodes).
PT

Level 3 Hospitals - Admission From:
HDU, 4, 0%
ICU, 11, 1% PICU, 2, 0%
Other Hospital, 85, 6%
Same Ward, 37, 3%
Emergency N = 1,349
Other Ward, 112, 8%
Short Stay, 56, 4%
A & E, 452, 34%
Home, 581, 43%
Home
GP
A & E
Short Stay
Other Ward
Same Ward
Other Hospital
Adult HDU
ICU
HDU
PICU
GP, 9, 1%
`Ü~êí=ON=içÅ~íáçå=éêáçê=íç=ÉãÉêÖÉåÅó=ea`=ÉéáëçÇÉ=Ó=iÉîÉä=P=eçëéáí~äë=
=
Children's Hospitals - Admission From:
Emergency N = 4,100
ICU, 20, 0%
PICU,
HDU, 172, 4%
161, 4%
Other Hospital, 402, 10%
Same Ward, 513, 13%
Other Ward, 669, 16%
Home, 785, 19%
A & E, 931, 23%
GP, 9, 0%
Home
GP
A & E
Short Stay
Other Ward
Same Ward
Other Hospital
Adult HDU
ICU
HDU
PICU
Short Stay, 438, 11%
`Ü~êí=OO=içÅ~íáçå=éêáçê=íç=ÉãÉêÖÉåÅó=ea`=ÉéáëçÇÉ=Ó=`ÜáäÇêÉåÛë=eçëéáí~äë=
PU

In Chart 22, 13% of children are from the same ward; this is predominantly a reflection of the
children who received multiple episodes of HDC treatments for chronic conditions. 20 children
received care in an adult ICU prior to HDC within a Children’s Hospital.
=
=
RKRKO= = içÅ~íáçå=~ÑíÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
The destination after the episode of high dependency care can indicate the trajectory of illness, i.e.
improvement or deterioration that requires a higher level of care.
The charts below show where children go after elective and emergency HDC episodes.
HDC Audit - End HDC Destination:
HDU, 280, 3%
PICU, 108, 1%
Other Hospital, 342, 4%
Died, 27, 0%
ICU, 35, 0%
Adult HDU, 1, 0%
Elective/ Emergency N= 9,680
Other Ward, 2047, 21%
Home, 2392, 25%
Home
Same Ward
Other Ward
Adult HDU
ICU
Other Hospital
HDU
PICU
Died
Same Ward, 4448, 46%
`Ü~êí=OP=^ìÇáí=ëìãã~êó=Ó=ÇÉëíáå~íáçå=~ÑíÉê=ÉéáëçÇÉ=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
The majority of children remain within the hospital after their episode of HDC (72%), i.e. on the
same ward or another ward; this is an expected pathway following HDC. Children went home after
HDC in a quarter of all episodes; 65% of these were elective admissions
A small number (388, 4%) went to either a high dependency unit (HDU) or paediatric intensive care
unit (PICU). A further 4% were transferred to another hospital; suggesting that either a higher level
of care was required or that the children’s condition had improved and they were transferred to a
hospital closer to home. 27 children died; 81% of these children were receiving end of life care.
PV

Urban Level 2 - End HDC Destination:
HDU, 4, 2%
Elective/ Emergency N= 188
Other Hospital, 37, 20%
Home
Same Ward
ICU, 1, 1%
Other Ward, 46, 24%
Home, 76, 40%
Other Ward
Adult HDU
ICU
Other Hospital
HDU
PICU
Died
Same Ward, 24, 13%
`Ü~êí=OQ=aÉëíáå~íáçå=~ÑíÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=rêÄ~å=iÉîÉä=O=
The most common end destination in this sub-group was home (40%); 86% of these episodes were
emergency admissions; all were over 13 years of age. They majority of these episodes occurred in
either an adult assessment ward or an orthopaedic ward.
Rural Level 2 - End HDC Destination:
PICU, 3, 2%
HDU, 1, 1%
Home, 4, 3%
Elective/ Emergency N= 145
Same Ward, 20, 14%
Other Hospital, 81, 55%
Other Ward, 36, 25%
Home
Same Ward
Other Ward
Adult HDU
ICU
Other Hospital
HDU
PICU
Died
`Ü~êí=OR=aÉëíáå~íáçå=~ÑíÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=oìê~ä=iÉîÉä=O=
QM

Over half the children (55%) receiving HDC in a rural general hospital were transferred to another
hospital; reflecting the importance of transfer protocols.
Level 3 Hospitals - End HDC Destination:
PICU, 5, 0%
Elective/ Emergency N= 1,539
ICU, 12, 1%
Adult HDU, 1, 0%
Other Hospital,
113, 7%
Died, 5, 0%
Home, 217, 14%
Other Ward, 134, 9%
Home
Same Ward
Other Ward
Adult HDU
ICU
Other Hospital
HDU
PICU
Died
Same Ward, 1052, 69%
`Ü~êí=OS=aÉëíáå~íáçå=~ÑíÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=iÉîÉä=P=eçëéáí~äë=
Many children receive high dependency care within a paediatric ward environment, rather than a
dedicated high dependency unit. This is demonstrated by the significant proportion of children who
remain in the same ward (Charts 26 and 27) after their HDC episode.
QN

Children's Hospitals - End HDC Destination:
Elective/ Emergency N= 7,808
Other Hospital, 111, 1%
ICU, 22, 0%
PICU, 100, 1% Died, 22, 0%
HDU,
275, 4%
Other Ward, 1831, 23%
Home, 2095, 27%
Home
Same Ward
Other Ward
Adult HDU
ICU
Other Hospital
HDU
PICU
Died
Same Ward, 3352, 44%
`Ü~êí=OT=aÉëíáå~íáçå=~ÑíÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ó=`ÜáäÇêÉåÛë=eçëéáí~äë=
Children can have episodes within different ward environments within the Children’s Hospitals.
Chart 27 demonstrates the number of children who are moved to a HDU, PICU or other ward within
the hospital.
QO

RKRKP= =
mêáã~êó=àçìêåÉóë=
A primary journey is defined as the means of transport from home to hospital. Chart 28 shows the
breakdown between the number of children who were transferred by either their parental/carer
transport or by ambulance for each episode. Not all episodes have primary journey information;
the chart below reflects 8,231 episodes (85% of all audit episodes).
Each category has been sub-divided into emergency and elective episodes; an elective episode
indicates a journey for a planned surgical procedure or treatment. Almost two thirds of all primary
journeys were emergency admissions (64%).
7000
Primary Journey by Elective/Emergency Episode
6000
5000
No. of Episodes
4000
3000
2000
1000
0
Emergency
m~êÉåí~äL`~êÉê=qê~åëéçêí
^ãÄìä~åÅÉ
Elective
`Ü~êí=OU=mêáã~êó=àçìêåÉó=Äó=ÉãÉêÖÉåÅóLÉäÉÅíáîÉ=ÉéáëçÇÉ=íóéÉ=
=
=
Parental / Carer
transport
Ambulance
Totals
No % No % No %
Emergency 3791 72% 1456 28% 5247 100%
Elective 2879 96% 105 4% 2984 100%
Totals 6670 81% 1561 19% 8231 100%
q~ÄäÉ=NQ=a~í~=í~ÄäÉ=J=mêáã~êó=àçìêåÉó=Äó=ÉãÉêÖÉåÅóLÉäÉÅíáîÉ=ÉéáëçÇÉ=íóéÉ=
=
81% of primary journeys were undertaken by parental/carer transport. The elective/emergency
division in the parental/carer transport is skewed by the significant proportion of elective journeys in
the Children’s Hospitals. Over 80% of parental/carer transfers to Level 2 and 3 Hospitals were
emergencies.
72% of journeys to emergency care were by parental/carer transport and only 28% by ambulance.
67% of emergency journeys to Level 2 and 3 Hospitals were by Parental/Carer transport.
Only 7% of primary journeys by ambulance were elective admissions; these were mainly to
specialist wards, i.e. oncology and renal wards.
QP

RKRKQ= =
pÉÅçåÇ~êó=àçìêåÉóë=
A secondary journey is defined as a journey between hospitals; this may indicate the need to
transfer a child to another hospital to receive definitive care, or to transfer a child back to a hospital
closer to home. 910 secondary journeys were recorded in the audit, i.e. admission from ‘other
hospital’ or end destination was ‘other hospital’.
The chart below displays the recorded methods of transport used for secondary journeys. It was
recorded that 42% of all secondary transfers have been undertaken by a specialised team, 7% of
transfers were to or from a maternity hospital and are shown separately in the chart below. It is
assumed that they were undertaken by the Neonatal Transport Teams. It is unlikely the
interpretation of ‘specialised team’ was restricted to only the PIC Retrieval Teams in this category
due to the high numbers recorded in this audit (annual retrieval activity is 250 – 300 transfers).
The 3 secondary transfers undertaken by parental/carer transport were from Remote and Rural
locations.
400
368
Secondary Journey Type
350
313
300
250
200
150
100
72 68
59
50
27
0
Ambulance
Specialised
Team (S.T.)
S.T. - Maternity
Hospitals
Nurse Unknow n Medical Parental/Carer
Transport
3
`Ü~êí=OV=pÉÅçåÇ~êó=àçìêåÉó=íóéÉ=Ñçê=íê~åëÑÉêë=ÄÉíïÉÉå=Üçëéáí~äë=
Table 15 (pp45-46) indicates the flows of patient journey, from one hospital on the left-hand side
column to the hospital on the right.
QQ

From hospital:
To hospital:
Non-Scottish Hospitals
Unknown
Glenlaw House
Hospice
Aberdeen Royal Infirmary
Forth Park Hospital, Kirkcaldy
Princess Royal Maternity Unit,
Glasgow
Queen Mother's Hospital, Yorkhill
Gartnavel General Hospital,
Glasgow
RIE / Simpsons
Glasgow Royal Infirmary
Hairmyres Hospital, East Kilbride
Perth Royal Infirmary
Non-Scottish Hospitals 2 3 5
Unknown 2 4 3 2 5 2 8 26
Arbroath Hospital 1 1
Armistead Hospital 1 1
Ayrshire Central Hospital, Irvine 2 2
Brechin Community Hospital 1 1
Crieff Community Hospital 1 1
Davidson Community Hospital 1 1
Glenlaw House 1 1
Golspie Community Hospital 1 1
GP 1 1
Montrose Community Hospital 1 1
Hospices 3 1 1 4 3 12
Aberdeen Maternity Hospital 2 2
Forth Park Hospital, Kirkcaldy 1 11 1 13
Princess Royal Maternity Unit 10 10
Queen Mother's Hospital, Yorkhill 20 20
RIE / Simpsons 40 40
Aberdeen Royal Infirmary 4 1 5
Ayr Hospital 1 1
Beatson West of Scotland, Glasgow 7 7
Falkirk and District Royal Infirmary 1 1
Gartnavel General Hospital, Glasgow 1 1
Glasgow Royal Infirmary 3 3
Hairmyres Hospital, East Kilbride 1 1 5 6 13
Inverclyde Royal Hospital, Greenock 2 1 4 7
Monklands Hospital, Airdrie 9 1 4 14
Perth Royal Infirmary 1 49 4 4 58
Queen Margaret Hospital, Dunfermline 2 4 6
Royal Infirmary of Edinburgh 1 1
Southern General Hospital, Glasgow 6 6
Stobhill Hospital, Glasgow 1 1
Vale of Leven General Hospital 1 4 5
Victoria Infirmary, Glasgow 1 4 5
Western General Hospital, Edinburgh 1 4 5
Western Infirmary, Glasgow 1 1 2
Southern General Hospital, Glasgow
Western General Hospital,
Edinburgh
Western Infirmary Glasgow
Belford Hospital, Fort William
Mackinnon Memorial Hospital, Skye
Borders General Hospital, Melrose
Crosshouse Hospital, Kilmarnock
Dumfries & Galloway Royal Infirmary
Raigmore Hospital, Inverness
Royal Alexandra Hospital, Paisley
Southern General Institute
St John's Hospital, Livingston
Stirling Royal Infirmary
Victoria Hospital, Kirkcaldy
Wishaw General Hospital
Ninewells Hospital, Dundee
RHSC, Edinburgh
Royal Aberdeen Children's Hospital
Yorkhill, RHSC
Total
QR=

From Hospital:
To Hospital:
Non-Scottish Hospitals
Unknown
Glenlaw House
Hospice
Aberdeen Royal Infirmary
Forth Park Hospital, Kirkcaldy
Princess Royal Maternity Unit, Glasgow
Queen Mother's Hospital, Yorkhill
RIE / Simpsons
Gartnavel General Hospital, Glasgow
Glasgow Royal Infirmary
Hairmyres Hospital, East Kilbride
Perth Royal Infirmary
Southern General Hospital, Glasgow
Western General Hospital, Edinburgh
Western Infirmary Glasgow
Belford Hospital, Fort William
Mackinnon Memorial Hospital, Skye
Borders General Hospital, Melrose
Crosshouse Hospital, Kilmarnock
Dumfries & Galloway Royal Infirmary
Raigmore Hospital, Inverness
Royal Alexandra Hospital, Paisley
Southern General Institute
St John's Hospital, Livingston
Stirling Royal Infirmary
Victoria Hospital, Kirkcaldy
Wishaw General Hospital
Ninewells Hospital, Dundee
RHSC, Edinburgh
Royal Aberdeen Children's Hospital
Yorkhill, RHSC
Total
Balfour Hospital, Kirkwall 1 4 8 2 15
Belford Hospital, Fort William 1 1 34 9 45
Caithness General Hospital, Wick 2 19 1 22
Garrick Hospital, Stranraer 5 1 6
Gilbert Bain Hospital, Lerwick 2 2 4
Lorn & Islands DG Hospital, Oban 6 2 8
Mackinnon Memorial Hospital, Skye 11 11
Portree Hospital, Isle of Skye 1 1
Victoria Hospital, Rothesay 1 1 2
Western Isles Hospital, Stornoway 1 1
Borders General Hospital, Melrose 18 1 19
Crosshouse Hospital, Kilmarnock 2 26 28
Dr Gray's Hospital, Elgin 3 1 1 14 1 20
Dumfries & Galloway Royal Infirmary 3 1 11 15
Raigmore Hospital, Inverness 1 1 1 17 3 7 30
Royal Alexandra Hospital, Paisley 1 1 1 26 29
Southern General Institute 1 1 1 3
St John's Hospital, Livingston 48 1 49
Stirling Royal Infirmary 1 1 13 46 61
Victoria Hospital, Kirkcaldy 2 26 4 32
Wishaw General Hospital 1 4 19 24
Ninewells Hospital, Dundee 2 1 1 1 47 1 20 73
RHSC, Edinburgh 3 5 4 3 5 1 1 4 3 15 1 2 7 54
Royal Aberdeen Children's Hospital 1 11 11 23
Yorkhill RHSC, Glasgow 5 4 1 2 1 1 1 1 2 4 12 6 2 4 8 1 55
Total 6 12 1 9 6 5 2 1 3 1 1 1 1 7 1 2 1 1 5 4 10 70 20 21 4 10 6 17 78 280 37 287 910
q~ÄäÉ=NR=pÉÅçåÇ~êó=àçìêåÉóë
QS=

One of the audit aims was to assess the inter-hospital transfers within regions. Data has been
extracted from Table 15 to show the intra-regional relationships between hospitals. Hospitals with
more than 10 transfers are shown in Table 16 (excluding maternity and inter-regional transfers):
Region Transferred From: Transferred To: Transfers
North of Scotland Perth Royal Infirmary Ninewells Hospital 49
North of Scotland Dr Grays Royal Aberdeen Children’s
Hospital
14
North of Scotland Belford Hospital Raigmore Hospital 34
North of Scotland Caithness Hospital Raigmore Hospital 19
North of Scotland MacKinnon Memorial, Skye Raigmore Hospital 11
South East and Tayside Borders General Hospital RHSC, Edinburgh 18
South East and Tayside St John’s Hospital RHSC, Edinburgh 48
South East and Tayside Victoria Hospital, Kirkcaldy RHSC, Edinburgh 26
West of Scotland Crosshouse Hospital Yorkhill, RHSC 26
West of Scotland Dumfries & Galloway Yorkhill, RHSC 11
West of Scotland Royal Alexandra Hospital Yorkhill, RHSC 26
West of Scotland Stirling Royal Infirmary Yorkhill, RHSC 46
West of Scotland Wishaw General Yorkhill, RHSC 19
q~ÄäÉ=NS=fåíê~JêÉÖáçå~ä=ëÉÅçåÇ~êó=àçìêåÉóë
Chart 30 demonstrates that 31% of secondary journeys undertaken originated in Level 1/hospices
and Level 2 Hospitals. Not all of these hospitals participated in the audit, but were recorded as the
referring hospital, on the HDC audit form. This represents a significant proportion of all secondary
journeys; demonstrating the need for effective assessment and transfer protocols. It is estimated
that 9% of all the journeys recorded were made to and from maternity hospitals.
350
Secondary Journey - Referring hospital location
310 (34%)
300
250
200
205 (23%)
150
141 (15%)
115 (13%)
100
85 (9%)
50
23 (3%)
26 (3%)
0
Level 1/Hospice Maternity Level 2 Urban Level 2 Rural Level 3 Children's
Hospitals
5 (1%)
Non-Scottish
Hospitals
Unknow n
`Ü~êí=PM=pÉÅçåÇ~êó=àçìêåÉó=Ó=êÉÑÉêêáåÖ=Üçëéáí~ä=äçÅ~íáçå=
QT

700
Secondary Journey - Destination hospital level
682 (75%)
600
500
400
300
200
167 (18%)
100
0
10 (1%)
17 (2%)
14 (2%)
2 (0%)
Level 1 Maternity Level 2 Urban Level 2 Rural Level 3 Children's
Hospitals
6 (1%)
Non-Scottish
Hospitals
12 (1%)
Unknow n
`Ü~êí=PN=pÉÅçåÇ~êó=àçìêåÉó=Ó=ÇÉëíáå~íáçå=Üçëéáí~ä=äÉîÉä
Chart 31 indicates that the vast majority (75%) of children are transferred to one of the Children’s
Hospitals, for care. It also indicates some of the 8% ‘back transfer’ destinations, from the Children’s
Hospitals (Table 15).
=
=
=
QU

SK=
lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=
As part of the audit, a questionnaire was developed to map services available, within each NHS
Board, for the provision of high dependency care.
The questionnaire was developed from the West Midland Guidelines and placed within the context of
the levels of care outlined in the Emergency Care Framework, to provide a Scottish perspective.
Appendices 8-10 (pp81 – 92) detail the full list of responses.
SKN= =
kep=_ç~êÇë====
These self-assessment questions were designed to identify the organisational structure of paediatric
critical care across each NHS Board.
The questionnaire was sent to all 14 NHS Boards, completed responses were received from 12 NHS
Boards.
kep=_ç~êÇ=ÖìáÇ~åÅÉ=çå=é~íáÉåí=ÇáêÉÅíáçå=
A key question was to identify if NHS Boards provided formal guidance on the patient pathway of a
child or young person who is critically ill or injured.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
Guidance issued to parents/GPs/NHS 24/SAS
regarding which hospitals are “open to children” *
11 1 0 12
Do formal communication methods exist to inform
NHS 24, primary care teams, out-of-hours services
and the Scottish Ambulance Service about the
2 9 1 12
emergency paediatric facilities
q~ÄäÉ=NT=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=kep=_ç~êÇ=êÉëéçåëÉë=Ó=é~íáÉåí=é~íÜï~ó=ÖìáÇ~åÅÉ=
* A number of NHS Boards confirm that this question has been (or will be) addressed as part of the implementation
of the Emergency Care Framework.
Appendix 8 (pp81 – 82) summarises the hospitals within each NHS Board area, classified as ‘open’ to
receive critically ill children and young people.
kep=_ç~êÇ=çêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
Appendix 9 (pp83 – 85) provides a map of children’s services provided across each NHS Board and
the ECF Levels of care that are being provided in each hospital.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
In recognition that children may be taken to Minor
Injury Units or A&E department without paediatric
support, are protocols in place to support the transfer
6* 3 3 n/a 12
of a critically ill child or young person
q~ÄäÉ=NU=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=kep=_ç~êÇ=êÉëéçåëÉë=Ó=íê~åëÑÉê=éêçíçÅçäë=
G=O=kep=_ç~êÇë=ÅçããÉåíÉÇ=íÜ~í=íÜáë=ï~ë=ÄÉáåÖ=êÉîáÉïÉÇ=~ë=é~êí=çÑ=íÜÉ=áãéäÉãÉåí~íáçå=çÑ=íÜÉ=b`cK====
QV

SKO= =
iÉîÉä=O=eçëéáí~äë=
Level 2 Hospitals do not have in-patient paediatric units on-site, however critically ill or injured
children or young people may present there in an emergency. Level 2 Hospitals encompass a wide
range of hospitals: teaching hospitals, urban district general hospitals and rural district hospitals.
The returns from the NHS Boards identified 23 hospitals as Level 2 facilities; from these hospitals we
received 13 returns, a response rate of 56%. The analysis below is based on the returns from 13
hospitals in 9 NHS Boards.
lêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
The questionnaire asked specific questions about the provision of paediatric resuscitation, relating to
staffing provision and training.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
24 hour access to anaesthetic cover 12 1 0 13
Multi-disciplinary team available 24 hours with up-todate
paediatric resuscitation training
11 2 0 13
Nominated Consultant to oversee paediatric training
(including up-to-date resuscitation training) (Level 2)
4 7 2 13
Nominated senior nurse to oversee paediatric training
(including up-to-date resuscitation training)
10 2 1 13
Named personnel responsible for policies and
procedures relating to the emergency treatment of
children, i.e. an A&E Consultant, Consultant
5 5 3 13
Anaesthetist or Surgeon.
Nominated Consultant is responsible for protocols
covering the assessment and management of the 6 4 3 13
critically ill child
Appropriately designed and age specific equipped area,
(or mobile equipment), for the resuscitation and
13 0 0 13
stabilisation of critically ill children and young people.
Paediatric protocols covering treatment of all major
paediatric conditions, including head injuries,
meningococcal infection, asthma and status epilepticus
11 0 2 13
q~ÄäÉ=NV=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=O=êÉëéçåëÉë=Ó=çêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
RM

qê~åëÑÉê=çÑ=ÅÜáäÇ=ïÜç=êÉèìáêÉë=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉLáåíÉåëáîÉ=Å~êÉ=
In recognition that Level 2 Hospitals cannot provide definitive care for children who require high
dependency/intensive care; these Standards assessed how many hospitals have protocols in place to
access advice and provide a safe environment for children prior to transfer.
Organisation of Critical Care questionnaire Yes No
Protocols to access advice from local paediatric
inpatient medical unit
No
response
Total no.
returns
5 7 1 13
Protocols to access advice from a lead PICU 11 2 0 13
Protocol to cover the transfer of a child to a PICU 8 3 2 13
Transfer protocol includes local guidelines on the
maintenance of intensive care for a critically ill child
until the retrieval team arrives.
6 4 3 13
q~ÄäÉ=OM=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=O=êÉëéçåëÉë=Ó=íê~åëÑÉê=çÑ=~=ÅÜáäÇ=êÉèìáêáåÖ=ea`Lmf`=
RN

SKP= =
iÉîÉä=P=eçëéáí~äë==
The ECF stipulates that Level 3 Hospitals should provide advanced life support and paediatric high
dependency care; the ECF recommendations include A&E departments and diagnostic facilities.
Questions relating to the reception of critically ill children and the diagnostic capacity were included in
the Level 3 questions.
There are 11 NHS Boards with Level 3 Hospitals; NHS Orkney, NHS Shetland and NHS Western
Isles do not have this facility. Returns were received from 9 Level 3 Hospitals. For the purpose of this
analysis Ninewells Hospital chose to designate as a Level 3 Hospital.
lêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
The questionnaire asked specific questions about the provision and training relating to paediatric
resuscitation, airway management and the organisation of emergency treatment.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
24 hour Consultant Paediatrician cover 9 0 0 9
24 hour Consultant Anaesthetic cover 8 0 1 9
24 hour availability of medical staff with up-to-date
resuscitation skills.
9 0 0 9
24 hour availability of nursing staff with up-to-date
resuscitation skills.
8 1 0 9
Protocols for alerting and organising paediatric
resuscitation and trauma teams.
8 0 1 9
Lead A&E Consultant with responsibility for policies and
procedures relating to emergency treatment of children 9 0 0 9
in A&E.
Access to advice between A&E Department and on-site
or off-site paediatric medical unit.
9 0 0 9
Appropriately designed and age specific equipped area,
(or mobile equipment), for the resuscitation and
9 0 0 9
stabilisation of critically ill children and young people.
Consultant Anaesthetist with responsibility for policies
and procedures relating to the emergency treatment of 7 2 0 9
children.
Consultant Surgeon with responsibility for policies and
procedures relating to the emergency treatment of 6 3 0 9
children.
Provision of up-to-date paediatric resuscitation training
for medical and nursing staff.
9 0 0 9
q~ÄäÉ=ON=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=P=êÉëéçåëÉë=Ó=çêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
=
RO

`~é~Åáíó=íç=ÇÉäáîÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
Protocols covering the assessment and management of
the critically ill child
8 1 0 9
Multi-disciplinary team responsible for policies and
procedures relating to high dependency care?
3 6 0 9
24-hour on-site access to a nurse with paediatric high
dependency skills and training.
9 0 0 9
Capacity to provide nursing care to children with high
dependency needs on a 0.5:1 or 1:1 level?
9 0 0 9
Protocols for the treatment of all major paediatric
conditions, including head injuries, meningococcal 9 0 0 9
infection, asthma and status epilepticus.
Resuscitation and stabilisation protocols. 6 2 1 9
Appropriately designed and equipped area to provide
high dependency care for children of all age*
7 2 0 9
Protocol to access advice from a lead Paediatric
Intensive Care (PIC) centre, i.e. a written protocol for
24-hour advice, including referral protocols and contact
numbers.
9 0 0 9
q~ÄäÉ=OO=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=P=êÉëéçåëÉë=Ó=Å~é~Åáíó=íç=ÇÉäáîÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
*Variation in response to this question related to the issue of a designated area, all hospitals had appropriate
equipment, but most operated this facility on an ad-hoc basis.
=
qê~åëÑÉê=çÑ=ÅÜáäÇêÉå=ïÜç=êÉèìáêÉ=áåíÉåëáîÉ=Å~êÉ=
Level 3 Hospitals are expected to provide paediatric high dependency care, however some children
will require a higher level of care that can only be delivered within a paediatric intensive care unit
(PICU). It is the referring hospital’s responsibility to maintain critically ill and injured children until they
are retrieved by the PICU Transport Team.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
Transfer to lead PICU protocol. 8 1 0 9
Transfer protocol includes a Consultant-to-Consultant
dialogue.
8 1 0 9
Does the transfer protocol include guidance about
where a child, who requires intensive care, should be 7 2* 0 9
managed?
q~ÄäÉ=OP=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=P=êÉëéçåëÉë=Ó=íê~åëÑÉê=çÑ=ÅÜáäÇêÉå=ïÜç=êÉèìáêÉ=áåíÉåëáîÉ=Å~êÉ=
=
* The management of children, who require intensive care, is dealt with on a case by case basis, rather than a
single protocol stipulating where the children will be cared for, i.e. A&E, adult ICU, and theatre recovery.
RP

o~ÇáçäçÖó=L=ä~Äçê~íçêó=ëìééçêí=ëÉêîáÅÉë==
The 24 hour availability support services, i.e. radiology and pharmacy, are important to a hospital’s
ability to provide high dependency care.
Organisation of Critical Care questionnaire Yes No
24 hour access to Pharmacy
No
response
Total no.
returns
7 2 0 9
24 hour access to Biochemistry 9 0 0 0
24 hour access to Haematology 9 0 0 9
24 hour access to Imaging 9 0 0 9
24 hour access to CT Scans 9 0 0 9
24 hour access to Physiotherapy 7 2 0 9
q~ÄäÉ=OQ=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=P=êÉëéçåëÉë=Ó=ê~ÇáçäçÖóLä~Äçê~íçêó=ëìééçêí=ëÉêîáÅÉë=
One of the hospitals who did not have 24 hour access to pharmacy and physiotherapy confirmed it
had on-call access.
RQ

SKQ= =
iÉîÉä=Q=eçëéáí~äë==
=
Level 4 Hospitals are expected to provide paediatric intensive and/or advanced high dependency
care, paediatric surgery and a range of specialist services and advice, all of which are available on
site.
There are 3 NHS Boards with specialist Children’s Hospitals that meet the definition of “Level 4”
Children’s Hospitals: Royal Aberdeen Children’s Hospital, Royal Hospital for Sick Children, Edinburgh
and Yorkhill, Royal Hospital for Sick Children. All of these Children’s Hospitals operate a dedicated
paediatric A&E department.
lêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
The questionnaire asked specific questions about the provision and training relating to paediatric
resuscitation, airways management and the organisation of emergency treatment.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
24 hour Consultant Paediatrician cover 3 0 0 3
24 hour Consultant Anaesthetic cover 3 0 0 3
24 hour availability of medical staff with up-to-date
resuscitation skills.
3 0 0 3
24 hour availability of nursing staff with up-to-date
resuscitation skills.
3 0 0 3
Protocols for alerting and organising paediatric
resuscitation and trauma teams.
3 0 0 3
Lead A&E Consultant with responsibility for policies and
procedures relating to emergency treatment of children 3 0 0 3
in A&E.
Access to advice between A&E Department and the onsite
paediatric medical unit.
3 0 0 3
Appropriately designed and age specific equipped area,
(or mobile equipment), for the resuscitation and
3 0 0 3
stabilisation of critically ill children and young people.
Nominated Consultant Anaesthetist with responsibility
for policies and procedures relating to the emergency 3 0 0 3
treatment of children.
Nominated Consultant Surgeon with responsibility for
policies and procedures relating to the emergency 3 0 0 3
treatment of children.
Provision of up-to-date paediatric resuscitation training
for medical and nursing staff.
3 0 0 3
q~ÄäÉ=OR=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=Q=êÉëéçåëÉë=Ó=çêÖ~åáë~íáçå=çÑ=é~ÉÇá~íêáÅ=ÉãÉêÖÉåÅó=ëÉêîáÅÉë=
RR

`~é~Åáíó=íç=ÇÉäáîÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
Organisation of Critical Care questionnaire Yes No
Protocols covering the assessment and management of
the critically ill child
Multi-disciplinary team responsible for policies and
procedures relating to high dependency care?
24-hour on-site access to a nurse with paediatric high
dependency skills and training.
Capacity to provide nursing care to children with high
dependency needs on a 0.5:1 or 1:1 level?
Nominated Senior Nurse with responsibility for
protocols covering the assessment and management of
the critically ill child
Protocols for the treatment of all major paediatric
conditions, including head injuries, meningococcal
infection, asthma and status epilepticus.
No
response
Total no.
returns
3 0 0 3
2 1 0 3
3 0 0 3
3 0 0 3
2 1 0 3
3 0 0 3
Resuscitation and stabilisation protocols. 3 0 0 3
Appropriately designed and equipped area to provide
high dependency care for children of all age
3 0 0 3
Protocol to access advice from a lead Paediatric
Intensive Care (PIC) centre, i.e. a written protocol for
24-hour advice, including referral protocols and contact
1 0 N/A - 2 3
numbers.
q~ÄäÉ=OS=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=Q=êÉëéçåëÉë=Ó=Å~é~Åáíó=íç=ÇÉäáîÉê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
qê~åëÑÉê=çÑ=ÅÜáäÇêÉå=ïÜç=êÉèìáêÉ=áåíÉåëáîÉ=Å~êÉ=
The following questions regarding the transfer of children, who require intensive care, are only
applicable to Royal Aberdeen Children’s Hospital.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
Transfer to lead PICU protocol. 1 0 0 1
Transfer protocol includes a Consultant-to-Consultant
dialogue.
1 0 0 1
Does the transfer protocol include guidance about
where a child, who requires intensive care, should be 1 0 0 1
managed?
q~ÄäÉ=OT=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=Q=êÉëéçåëÉë=Ó=íê~åëÑÉê=çÑ=ÅÜáäÇêÉå=ïÜç=êÉèìáêÉ=áåíÉåëáîÉ=Å~êÉ=
=
RS

o~ÇáçäçÖó=L=ä~Äçê~íçêó=ëìééçêí=ëÉêîáÅÉë==
The availability of 24 hour support services, i.e. radiology and pharmacy, are important to a hospital’s
ability to provide high dependency care.
Organisation of Critical Care questionnaire Yes No
No
response
Total no.
returns
24 hour access to Pharmacy 3 0 0 3
24 hour access to Biochemistry 3 0 0 3
24 hour access to Haematology 3 0 0 3
24 hour access to Imaging 3 0 0 3
24 hour access to CT Scans 3 0 0 3
24 hour access to Physiotherapy 3 0 0 3
q~ÄäÉ=OU=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=Ó=iÉîÉä=Q=êÉëéçåëÉë=Ó=ê~ÇáçäçÖóLä~Äçê~íçêó=ëìééçêí=ëÉêîáÅÉë=
All hospitals had 24 hour access to the above facilities, however a number were available on an oncall
basis out of hours, i.e. pharmacy and physiotherapy.
RT

TK=
aáëÅìëëáçå=
TKN aÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ==
Information was collected on 4,804 children and almost 10,000 episodes of high dependency care.
This audit does not represent every child or young person who received HDC, but it provides the
clearest indication, to date, of the number of children who require this level of care across Scotland.
The audit represents a robust dataset and provides a reliable representation of national demand.
The incidence of high dependency care in the UK is estimated between 5-15% of paediatric
admissions (Department of Health, 2001). The audit demonstrates that HDC represents 9% of all
under-16 admissions (SMR comparison data) in Scotland. This translates to 20 admissions per 1000
children under 1 year and 3.8 admissions per 1000 children aged 1-15 years (General Register Office
for Scotland, 2008).
oÉÖáçå~ä=mä~ååáåÖ=dêçìéë=ëÜçìäÇ=ÉåëìêÉ=íÜ~í=íÜÉêÉ=áë=Éèìáíó=çÑ=~ÅÅÉëë=íç=é~ÉÇá~íêáÅ=ÜáÖÜ=
ÇÉéÉåÇÉåÅó=Å~êÉ=~Åêçëë=íÜÉ=kep=_ç~êÇë=ïáíÜáå=íÜÉáê=êÉÖáçåK=======
It is unclear why the incidence of HDC (Table 1, p15) is significantly higher in NHS Forth Valley,
Highland and Tayside and lower in NHS Lanarkshire, Borders and Western Isles compared to other
NHS Boards. The differences suggest a variable degree of reporting between hospitals. A number of
factors could affect the return rate: the recognition and perception of a child who meets the HDC
criteria will be influenced by the frequency or rarity of this occurrence; differences in local treatment
policy and interpretation of the HDC criteria will have an impact; and during very busy periods the
completion of audit forms might not have been seen as a priority. There is an underlying assumption
that paediatric demand should be equitable across NHS Boards; it is therefore recommended that
Regional Planning Groups should ensure that equitable access exists across NHS Boards within their
Region to high dependency care.
The audit showed a steady demand for high dependency care over the year, with little seasonal
variation. This is contrary to the pattern of paediatric intensive care where demand is highest during
the winter months, i.e. October to February (PICANet, 2008, Annual Reports from Scottish National
PIC Service. Greatest demand for HDC was seen in November 2006, the under-16 SMR01 data
showed a small increase in paediatric admissions in November 2006, compared to December 2006.
Demand for HDC was shown to be greatest for the youngest children, 24% of the cohort was less
than 1 year, 51% under 5 and 82% of all children were less than 13 years (Table 2, p22). This
pattern of demand is similar to that of other critical care datasets (Health Commission Wales, 2006;
South West Commissioning Group, 2008).
Adolescents (13-15 years) had 1442 episodes of HDC, only 154 of these episodes occurred in adult
wards (excluding A&E Departments). The need for HDC within the adolescent population is underrepresented
by this audit methodology. Ward Watcher, a national bed management system, is the
only other source of capturing demand in adult HDUs. During both 2005 and 2006 it recorded 270
admissions of young people under 16 (it should be noted that not all adult HDUs input to this system).
The high dependency care audit only reported on 26 episodes in Adult HDUs.
RU

TKO tÜÉêÉ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ï~ë=ÇÉäáîÉêÉÇ=
High dependency care was provided by 38 hospitals across Scotland: 9 Rural Level 2 Hospitals, 14
Urban Level 2 Hospitals, 11 Level 3 Hospitals and 4 Children’s Hospitals. 81% of all episodes were
delivered in the Children’s Hospitals.
Figure 1 (p14) reflects the number of children who travel to other NHS Boards to receive HDC. It is
difficult to assess what proportion of this relates to travelling to receive tertiary or quaternary specialist
care. The issue of hospitals transferring children to access a higher level of care, which could be
provided locally, is emerging as a significant problem not just in Scotland but across the UK.
The Kerr Report proposed that children and young people below the age of 16 should be cared for in
age-appropriate facilities. At the time of the audit, the specialist Children’s Hospitals had not
implemented this practice. In Scotland’s cities, therefore, it remains current policy and practice for
teenagers to be managed in adult wards. The audit demonstrates that 96% of episodes were
provided in a designated paediatric ward and 4% in adult wards (Table 4, p26). 401 children were
cared for in an adult ward; 50% were over the age of 13. Of the 200 children under 13, 108 were
cared for in Rural Level 2 Hospitals (including A&E Departments), the remaining 92 received HDC in
A&E departments, adult specialist wards or Adult ICU prior to transfer. However, 80 children were
admitted from an Accident & Emergency department within a hospital with no in-patient paediatric
facilities (Charts 19 & 20, p37).
Rural Level 2 Hospitals provided high dependency care to a wide age range of children. Whilst only
145 episodes (1.5%) occurred in Rural Level 2 Hospitals, 13% of secondary transfers originated in
Rural hospitals. Level 2 Hospitals must possess robust transfer protocols to facilitate the transfer of
children to receive definitive paediatric care. 103 of these episodes were from the A&E Departments
of 7 Rural Level 2 Hospitals. These presentations were all emergency in nature, and can place an
immediate burden on hospitals without in-patient paediatric support.
kep=_ç~êÇë=ëÜçìäÇ=ÉåëìêÉ=íÜ~í=~ää=^Cb=ÇÉé~êíãÉåíë=~êÉ=~ÄäÉ=íç=çÑÑÉê=áããÉÇá~íÉ=Å~êÉ=íç=
ÅÜáäÇêÉå=~åÇ=óçìåÖ=éÉçéäÉ=áå=~å=ÉãÉêÖÉåÅó=ëáíì~íáçåI=áåÅäìÇáåÖ=êÉëìëÅáí~íáçå=~åÇ=ëí~Äáäáë~íáçå=
ïÜáäëí=~ï~áíáåÖ=íê~åëÑÉê=íç=~=Üçëéáí~ä=ïÜáÅÜ=Å~å=éêçîáÇÉ=~=ÜáÖÜÉê=äÉîÉä=çÑ=é~ÉÇá~íêáÅ=Å~êÉK==qÜáë=
êÉÅçããÉåÇ~íáçå=ÉñíÉåÇë=íç=oìê~ä=iÉîÉä=O=eçëéáí~äëI=ïÜáÅÜ=ã~ó=Ü~îÉ=íç=éêçîáÇÉ=ÉãÉêÖÉåÅó=~åÇ=
çåÖçáåÖ=é~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Ñçê=äçåÖÉê=éÉêáçÇë=çÑ=íáãÉK===
TKP mêçîáëáçå=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
Information about the emergency/elective case mix is an important element of planning resources for
critical care services. The dominance of emergency care in the Level 2 and 3 Hospitals underlines
the flexibility required of these hospitals to provide unscheduled in-patient HDC. This balance also is
important to the operation of the Children’s Hospitals, as 94% of all elective episodes occurred in the
Children’s Hospitals.
The unscheduled presentation of a critically ill child in a Level 2 Hospital can have a significant effect
on the hospital, requiring substantial support and resource to care for the child. The intermittent
demand for HDC in Level 2 Hospitals, makes it essential that training policies are in place to ensure a
team of staff with up-to-date resuscitation and stabilisation skills. Formal links to access paediatric
advice and facilitate transfers when a higher level of care is required should also be established.
Skills can be maintained by the reciprocal rotation of a member of staff from a Level 3 or Children’s
Hospital to a Rural hospital; this arrangement may be as relevant as member of staff from a Rural
Level 2 Hospital for advanced training within a Level 3 or Children’s Hospital.
RV

NHS Boards and Regional Planning Groups must ensure that practice development programmes are
in place to maintain the skills of staff working in all Level 2 and in Level 3 Hospitals; working with the
Children’s Hospitals.
Emergency episodes accounted for 89% of the HDC episodes delivered in Level 3 Hospitals.
Children who require high dependency care, need a greater level of medical management and
nursing care. The scale of the demand from unscheduled care has a profound effect on the
resources and staffing required to provide flexible in-patient paediatric HDC.
The pattern of scheduled and unscheduled care is different in the Children’s Hospitals; 42% elective
and 58% emergency. This ratio demonstrates that the Children’s Hospitals are provide the bulk of
elective procedures that require HDC across Scotland. It is therefore essential that NHS Boards and
Regional Planning Groups develop formal plans to protect the elective specialist caseload, in
circumstances where access to HDC limits the capacity for elective work.
The average length of episode varies between hospitals, but most were short in duration; the median
episode duration was 16 hours. 35% of episodes were less than 12 hours, 59% less than 24 hours,
and 77% less than 48 hours. However, a small number of episodes (6%) had lengthy stays, primarily
in the specialist Children’s Hospitals.
The audit also identified a number of children who had a significant number of multiple episodes; 115
children (2%) had 10 or more episodes of HDC. Whilst this is a small number, the proportion of HDC
provided was significant. Almost a third of children (29%) received two thirds (65%) of the high
dependency care episodes provided. This sub-group received care in the oncology, medical, renal
and neurosciences wards within the Children’s Hospitals and in Raigmore and Stirling Royal Infirmary
(Level 3 Hospitals).
The audit was designed to capture information about demand using a broad definition of high
dependency care, rather than a detailed audit of the care delivered in High Dependency Units. The
four most common types of HDC recorded in the audit, i.e. fluid balance, ECG and Sa0 2 monitoring,
multiple IV drugs or continuous infusion and O 2 more than 40%; are representative of care delivered
in a wide range of ward areas out with designated HDUs.
The majority of children, who require generalist HDC, can be cared for in Level 3 Hospitals. However
formal communication links and transfer policies are required for children who need a higher level of
care or referral to a specialist service within a Children’s Hospital. Regional networks would provide
formal communication links between all levels of hospital.
^ää=kep=_ç~êÇë=ëÜçìäÇ=ÉåëìêÉ=íÜÉêÉ=áë=~ÅÅÉëë=íç=~=ÇÉëáÖå~íÉÇ=iÉîÉä=P=eçëéáí~ä=EaáëíêáÅí=dÉåÉê~ä=
eçëéáí~ä=ïáíÜ=áåé~íáÉåí=é~ÉÇá~íêáÅëF=ïÜáÅÜ=Å~å=çÑÑÉê=é~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=íç=íÜÉáê=
éçéìä~íáçåK
kep=bÇìÅ~íáçå=Ñçê=pÅçíä~åÇ=~åÇ=oÉÖáçå~ä=tçêâÑçêÅÉ=aáêÉÅíçêë=ëÜçìäÇ=ÅçåÇìÅí=~å=ìêÖÉåí=åÉÉÇë=
~ëëÉëëãÉåí=~åÇ=ÇÉîÉäçé=~=ïçêâÑçêÅÉ=ëíê~íÉÖó=íç=ÇÉäáîÉê=ÇÉîçäîÉÇ=é~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=
Å~êÉ=áå=iÉîÉä=P=eçëéáí~äë=~åÇ=ã~å~ÖÉ=íÜÉ=ìåëÅÜÉÇìäÉÇ=éêÉëÉåí~íáçå=çÑ=íÜÉ=ÅêáíáÅ~ääó=áää=ÅÜáäÇ=áå=
iÉîÉä=O=eçëéáí~äëK==qÜáë=ëÜçìäÇ=áÇÉåíáÑóW=
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íÜÉ=åìãÄÉê=çÑ=~åÇ=íóéÉ=çÑ=éçëíë=êÉèìáêÉÇX=
ÉÇìÅ~íáçå=~åÇ=íê~áåáåÖ=êÉèìáêÉãÉåíëX=
Åçëí=çÑ=Ä~ÅâÑáääX=
Å~éáí~ä=áåîÉëíãÉåíK=
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qÜáë=ïçêâÑçêÅÉ=ëíê~íÉÖó=ëÜçìäÇ=ÄÉ=ëìÄãáííÉÇ=~ë=é~êí=çÑ=íÜÉ=ÄáÇÇáåÖ=éêçÅÉëë=Ñçê=íÜÉ=óÉ~ê=P=
ÇÉîÉäçéãÉåíë=çÑ=íÜÉ=k~íáçå~ä=aÉäáîÉêó=mä~åK======
SM

TKQ m~íáÉåí=é~íÜï~óë=
The data presented on patient pathways demonstrates that the majority of children were admitted
from home (26%) or A&E (25%), rather than from another ward or hospital for HDC.
Parental or carer transport was the predominant means of primary journey (81%) to hospital, and
19% of episodes were by ambulance. The dominance of parental transport reinforces the importance
of informing parents and carers of which hospitals are equipped and staffed to care for critically ill or
injured children.
A key aim of the audit was to understand how many children were transferred between hospitals to
receive high dependency care. Over 90% of the transfers in Table 15 (pp45-46) were emergency
episodes. The data shows a referral pattern from Levels 1, 2 and 3 Hospitals to hospitals with greater
capacity to deliver HDC. Chart 31 (p48) demonstrates that 75% of transfers were to the Children’s
Hospitals. A further analysis reveals that 8% of secondary journeys were ‘return transfers’ from the
Children’s Hospitals.
qÜÉ=pÅçííáëÜ=dçîÉêåãÉåí=ëÜçìäÇ=ÉåëìêÉ=é~åJpÅçíä~åÇ=éä~ååáåÖ=íç=ëìééçêí=ÉÑÑáÅáÉåí=~åÇ=
ÉÑÑÉÅíáîÉ=áåíÉêJÜçëéáí~ä=íê~åëéçêí=Ñçê=áää=~åÇ=áåàìêÉÇ=ÅÜáäÇêÉåK=
The predominant method of transport between hospitals was ambulance and specialised team. The
audit cannot assess whether this type of transfer was clinically appropriate for the condition of the
child.
It is assumed that specialised team transfers to/from the maternity hospitals, were performed by the
Neonatal Transport Teams. Specialised team transfers between non-maternity hospitals, are
subjective to the interpretation of ‘specialised team’. Although the PICU Retrieval Teams conduct a
small number of HDC transfers, they were not responsible for all specialised team transfers
documented in the audit.
High dependency care transfers can be associated with unstable conditions. It is therefore essential
that ambulance crews and staff undertaking transfers have appropriate skills to care for this group of
children. It is suggested that if transport arrangements were improved (i.e. enhanced training of
paramedics and nurse practitioners) it would be possible to offer safe transfer within a regional
network rather than utilising the PICU Retrieval Service.
TKR= lêÖ~åáë~íáçå=çÑ=ÅêáíáÅ~ä=Å~êÉ==
As part of the audit, an evaluation of the provision of critical care was designed to map paediatric
critical care services, within each NHS Board and identify service delivery gaps. Its remit extended
beyond the audit’s definition of high dependency care and incorporated aspects of the Emergency
Care Framework (2006). This questionnaire can be utilised to develop a benchmarking mechanism
and develop a comprehensive pan-Scotland set of critical care standards. At present there is no
process to capture clinical outcomes from HDC.
^ää=kep=_ç~êÇë=ëÜçìäÇ=ÉåëìêÉ=íÜÉêÉ=áë=~ÅÅÉëë=íç=~=ÇÉëáÖå~íÉÇ=iÉîÉä=P=eçëéáí~ä=Eade=ïáíÜ=
áåé~íáÉåí=é~ÉÇá~íêáÅëF=ïÜáÅÜ=Å~å=çÑÑÉê=é~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=íç=íÜÉáê=éçéìä~íáçåK
The majority of NHS Boards who responded (11 out of 12), confirmed that guidance is issued about
the hospitals children should be taken to. However, only 2 out of 12 NHS Boards confirmed they
have formal communication methods about where to access emergency paediatric facilities.
^ää=kep=_ç~êÇë=ëÜçìäÇ=Ü~îÉ=~=ÅçããìåáÅ~íáçå=ëíê~íÉÖó=íç=ÉåëìêÉ=íÜ~í=íÜÉ=ÖÉåÉê~ä=éìÄäáÅI=
Åçããìåáíó=ÜÉ~äíÜ=~åÇ=éêáã~êó=Å~êÉ=éêçîáÇÉêëI=kep=OQI=~åÇ=pÅçííáëÜ=^ãÄìä~åÅÉ=pÉêîáÅÉ=~êÉ=
~ï~êÉ=çÑ=íÜÉ=ÇÉëáÖå~íÉÇ=iÉîÉä=P=eçëéáí~äëK==
SN

kep=_ç~êÇë=ëÜçìäÇ=Ñçêã~äáëÉ=íÜÉ=çêÖ~åáë~íáçå~ä=~åÇ=ÅçããìåáÅ~íáçå=ëíêìÅíìêÉ=Ñçê=íÜÉ=ë~ÑÉ=~åÇ=
ÉÑÑÉÅíáîÉ=ÇÉäáîÉêó=çÑ=é~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉK
In recognition that children may be taken to Minor Injury Units or an A&E department without
paediatric support, NHS Boards were asked if protocols were place to support the transfer of a
critically ill child or young person. Only 6 NHS Boards confirmed that transfer protocols were in place.
Only 6 out of the 13 Level 2 Hospitals who responded, had an identified consultant with responsibility
for protocols for the assessment and management of the critically ill child. The returns highlighted
that 11 out of 13 had protocols on how to access advice from the lead PICUs, where as links with the
local paediatric unit were significantly weaker (5/13); and only 8 out of 13 hospitals had transfer
protocols.
The responses from Level 2 Hospitals summarise a consistent approach to paediatric resuscitation,
however a number of policies need to be formalised. This process would by assisted by the
development of regional and pan-Scotland networks.
It is essential that Level 2 Hospitals have formal polices in place to ensure a team of staff with up-todate
resuscitation and stabilisation skills, communication protocols to access advice and facilitate
transfers when a higher level of care is required.
^ää=Üçëéáí~äë=ïáíÜçìí=áåJé~íáÉåí=é~ÉÇá~íêáÅ=ëìééçêí=ãìëí=ÉåëìêÉ=éçäáÅáÉë=Éñáëí=íç=ã~áåí~áå=
êÉëìëÅáí~íáçå=ëâáääë=~åÇ=ÉèìáéãÉåí=~åÇ=Ü~îÉ=éêçíçÅçäë=íç=~ÅÅÉëë=~ÇîáÅÉ=~åÇ=Ñ~Åáäáí~íÉ=íÜÉ=
íê~åëÑÉê=çÑ=ÅêáíáÅ~ääó=áää=ÅÜáäÇêÉå=íç=íÜÉ=ÇÉëáÖå~íÉÇ=iÉîÉä=P=eçëéáí~äK=
Level 3 Hospitals demonstrated an organised approach to the provision of skilled staff and facilities of
emergency paediatric services. All hospitals had 24 hour Consultant cover and training protocols to
maintain multi-disciplinary resuscitation skills.
Specific questions were designed to assess the capacity to deliver high dependency care. All Level 3
Hospitals confirmed they had nurses with the skills to provide high dependency care and protocols to
manage major paediatric conditions. Not all hospitals had a designated area to deliver HDC, but the
hospital that did not, had the equipment available to set up a temporary high dependency bed. Very
few hospitals (3/9) had a multi-disciplinary team responsible for policies and procedures relating to
high dependency care. All but one of the Level 3 Hospitals reported protocols in place to facilitate the
transfer of a child to PIC.
kep=_ç~êÇë=ãìëí=ÉåëìêÉ=íÜ~í=~ää=iÉîÉä=P=eçëéáí~äë=ÇÉëáÖå~íÉÇ=íç=êÉÅÉáîÉ=ÅêáíáÅ~ääó=áää=ÅÜáäÇêÉå=
Ü~îÉ=íÜÉ=Å~é~ÅáíóI=êÉëçìêÅÉë=~åÇ=Å~é~Äáäáíó=íç=çÑÑÉê=é~ÉÇá~íêáÅ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=íç=~å=
~ééêçéêá~íÉL~ÖêÉÉÇ=ëí~åÇ~êÇK
The questionnaire confirmed that Level 4 Hospitals had comprehensive facilities, skills and protocols
in place to support paediatric critical care. One of the Specialist Children’s Hospitals did not have a
multidisciplinary team responsible for policies and procedures relating to high dependency care.
jìäíáÇáëÅáéäáå~êó=íÉ~ãë=ëÜçìäÇ=ÄÉ=ÇÉîÉäçéÉÇ=ïáíÜáå=É~ÅÜ=kep=_ç~êÇI=ïáíÜ=áÇÉåíáÑáÉÇ=ëÉåáçê=
ãÉÇáÅ~ä=~åÇ=åìêëáåÖ=äÉ~ÇÉêëÜáé=êÉëéçåëáÄäÉ=Ñçê=íÜÉ=ÇÉîÉäçéãÉåí=çÑ=é~ÉÇá~íêáÅ=ÅêáíáÅ~ä=Å~êÉ=
éê~ÅíáÅÉK=
=
oÉÖáçå~ä=mä~ååáåÖ=dêçìéë=ëÜçìäÇ=ÉåëìêÉ=íÜ~í=äáåâë=~êÉ=ã~ÇÉ=ÄÉíïÉÉå=íÜÉ=çåÖçáåÖ=
áãéäÉãÉåí~íáçå=çÑ=íÜÉ=bãÉêÖÉåÅó=`~êÉ=cê~ãÉïçêâ=~åÇ=íÜÉ=áåJé~íáÉåí=éêçîáëáçå=çÑ=ÜáÖÜ=
ÇÉéÉåÇÉåÅó=Å~êÉK==qÜÉ=ÇÉîÉäçéãÉåí=çÑ=êÉÖáçå~ä=åÉíïçêâë=ëÜçìäÇ=~áã=íç=ÉåÜ~åÅÉ=
ÅçããìåáÅ~íáçå=ÄÉíïÉÉå=äçÅ~ä=Üçëéáí~äëI=áãéêçîÉ=äçÅ~ä=ëÉêîáÅÉ=ÇÉäáîÉêóI=~åÇ=ïçêâáåÖ=ïáíÜ=íÜÉ=
pÅçííáëÜ=^ãÄìä~åÅÉ=pÉêîáÅÉI=éêçîáÇÉ=ë~ÑÉ=~åÇ=ÉÑÑÉÅíáîÉ=êÉÖáçå~ä=íê~åëéçêí=~êê~åÖÉãÉåíëK=
SO

^ää=oÉÖáçå~ä=mä~ååáåÖ=dêçìéë=ëÜçìäÇ=ïçêâ=íÜêçìÖÜ=íÜÉ=~ÖêÉÉÇ=êÉÖáçå~ä=åÉíïçêâë=íç=ÉåëìêÉ=
íÜÉêÉ=~êÉ=éçäáÅáÉë=ÑçêW==
~ÅÅÉëëáåÖ=~ÇîáÅÉ=êÉÖ~êÇáåÖ=íÜÉ=çåÖçáåÖ=ÅäáåáÅ~ä=ã~å~ÖÉãÉåí=çÑ=ÅÜáäÇêÉå=~åÇ=óçìåÖ=
éÉçéäÉ=êÉèìáêáåÖ=ea`=çê=mf`X==
~êê~åÖÉãÉåíë=Ñçê=íÜÉ=íê~åëÑÉê=çÑ=íÜÉ=ÅÜáäÇ=íç=~åçíÜÉê=Ñ~Åáäáíó=ïÜÉíÜÉê=íÜáë=áë=Ñêçã=iÉîÉä=
NLO=íç=iÉîÉä=PX=çê=Ñêçã=iÉîÉä=OLP=íç=çåÉ=çÑ=íÜÉ=`ÜáäÇêÉåÛë=eçëéáí~äëI=ÇÉéÉåÇÉåí=çå=
ÅäáåáÅ~ä=åÉÉÇK=
^=é~åJpÅçíä~åÇ=åÉíïçêâ=ëÜçìäÇ=ÇÉîÉäçé=~=ãáåáãìã=ëÉí=çÑ=ëí~åÇ~êÇë=íç=ÅçîÉê=~ää=~ëéÉÅíë=çÑ=
é~ÉÇá~íêáÅ=ÅêáíáÅ~ä=Å~êÉI=Ñêçã=ÉãÉêÖÉåÅó=éêÉëÉåí~íáçåI=íÜêçìÖÜ=~åó=çåÖçáåÖ=áåé~íáÉåí=
ã~å~ÖÉãÉåíI=íç=ÇáëÅÜ~êÖÉ=Ñêçã=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=Eáå=ÅçåàìåÅíáçå=ïáíÜ=íÜÉ=b`cFK====
SP

UK=
`çåÅäìëáçåë==
The aim of the audit was to quantify the demand for high dependency care and assess the services
available, in hospitals across Scotland. The Kerr Report proposed that paediatric high dependency
care could be provided closer to home within the matrix of a national network for paediatric critical
care; which would encompass elements of the high dependency care captured in the audit (endorsed
by Better Health, Better Care, 2007).
This project provides the largest dataset of children and young people in Scotland who require high
dependency care. As a result of this work, the Steering Group’s conclusions are as follows:
aÉã~åÇ=Ñçê=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
The audit identified 4,804 children who generated 9,680 episodes and 22,417 occupied bed
days of high dependency care in the 12 month period between 1 st November 2006 and 31 st
October 2007.
The largest individual patient group was children under 1 year of age. 82% of children were
less than 13 years and young people between 13 and 15 years accounted for 15%; 3% were
over 16 years
During the audit year, there was little evidence of seasonal variation in demand for high
dependency care
tÜÉêÉ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ï~ë=ÇÉäáîÉêÉÇ=
Ill children, requiring a high dependency level of care, presented to 38 hospitals in 14 NHS
Boards across Scotland.
In Rural Level 2 Hospitals the majority of high dependency care episodes were less than 12
hours in duration and no child received high dependency care for more than 48 hours in a
Rural Level 2 Hospital
The audit has demonstrated that the practice of providing age-appropriate care for children
and young people is being implemented; as the vast majority of children received care in a
paediatric ward environment.
mêçîáëáçå=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
A third of children received two thirds of the high dependency care delivered in the audit.
The audit demonstrated that paediatric high dependency care is delivered in a range
of hospitals across Scotland. Paediatric high dependency care delivered out with the
Children’s Hospitals was predominantly emergency in nature, with a significant
variation in demand. The vast majority of the elective episodes were delivered in the
Children’s Hospitals.
Most high dependency care episodes are short; the median duration was 16 hours. A small
number of patients had exceptionally long stays, or multiple admissions, primarily in the
Children’s Hospitals.
SQ

m~íáÉåí=é~íÜï~óë=
Parental/carer transport was used in 81% of all primary journeys. Ambulance journeys were
predominantly used for emergency admissions; 28% of all emergency primary journeys and
3.5% of the elective transfers, were by ambulance.
Three quarters of all secondary journeys were to the Children’s Hospitals
Nearly half of all secondary patient transfers (between hospitals) were carried out by
paramedics.
lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=
=
Whilst most health boards provided guidance on patient direction, there were few formal
mechanisms for communicating this information to health care professionals, parents and
carers.
The majority of Level 2 Hospitals confirmed they have a protocol to access advice from the
PICUs. All the hospitals confirmed they have links to local hospitals to access advice,
however these were not all formalised in a protocol.
Only a small number of Level 3 Hospitals have multidisciplinary teams responsible for the
development of high dependency policies and procedures.
The evaluation of existing standards identified the need to formalise policies and protocols
within Level 2 and 3 Hospitals, to ensure the safe and effective management of paediatric
critical care.
= =
SR

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däçëë~êó=çÑ=qÉêãë=
A&E
Accident and Emergency.
Admission type (Episode type)
Distinguishes between Emergency and Elective episodes of high dependency care.
Audit period
Data presented in the report spans between November 2006 and October 2007.
CEMACH
Confidential Enquiry into Maternal and Child Health.
Child/Children
For the purposes of this report, the term ‘child/children’ refers to children and young people, and
includes persons up to the age of 25.
Children’s Hospitals
This term refers to the four Scottish Children’s Hospitals: Ninewells (ECF Level 3); Royal Aberdeen
Children’s Hospital (ECF Level 4); RHSC, Edinburgh (ECF Level 4); and Yorkhill, RHSC (ECF Level
4).
Critical Care
This includes the delivery of paediatric intensive care, high dependency care and the transportation of
critically ill children.
CT Scan
Computerised Tomography Scan.
DGH
District General Hospital.
ECF
Emergency Care Framework (2006).
Elective episode
High dependency care resulting from a planned period of care.
Emergency episode
High dependency care resulting from an unplanned period of care.
ENT
Ear, Nose and Throat.
Episode
A continual period of high dependency care.
GP
General Practitioner.
GROS
General Register Office for Scotland.
SU

HDC/High dependency care
The Tanner report defines high dependency care as “Care provided to a child who may require closer
observation and monitoring than is usually available on an ordinary ward” (Department of Health,
2001). For the purposes of this audit, high dependency care was provided whenever one or more of
the 50 developed treatment criteria were provided (Appendix 2).
HDC audit hospital definition
Where used, this defines the participating hospitals upon their location and level of care as set out in
the Emergency Care Framework (2006). These definitions include ‘Urban Level 2 Hospitals,’ ‘Rural
Level 2 Hospitals,’ ‘Level 3 Hospitals’ and ‘Children’s Hospitals’.
HDU
High Dependency Unit.
ICU
Adult Intensive Care Unit.
ISD
Information Services Division.
IV
Intravenous.
Length of episode
Continuous period of time that a child received one or more high dependency care treatments.
Level 2 Hospitals
General Hospitals with Accident & Emergency facilities, but no inpatient paediatric unit.
Level 3 Hospitals
General Hospitals with an inpatient paediatric unit. Within the Results section, Level 3 Hospitals
exclude Ninewells, which has been included in the Children’s Hospital category.
Level 4 Hospitals
Specialist Children’s Hospitals as defined in the Emergency Care Framework.
Multiple episodes
More than one episode of high dependency care during the audit period.
North of Scotland Regional Child Health Planning Group
Comprises of NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland Isles, NHS Tayside and
NHS Western Isles.
NICU
Neonatal Intensive Care Unit.
NSD
National Services Division.
Paediatric
Birth to 16 years.
PICANet
Paediatric Intensive Care Audit Network.
SV

PICU
Paediatric Intensive Care Unit.
PICU Retrieval
Transport of Critically Ill and Injured Children Service.
Primary Journey
Means of transport from home to hospital.
NHS QIS Scotland
NHS Quality Improvement Scotland.
RACH
Royal Aberdeen Children’s Hospital.
RHSC
Royal Hospital for Sick Children.
RCHPG
Regional Child Health Planning Group. In Scotland, these comprise of the North of Scotland, South
East and Tayside and the West of Scotland.
Rural Level 2 Hospitals
Level 2 Hospitals (General Hospitals with Accident & Emergency facilities, but no inpatient paediatric
unit) within Rural Settings.
SASM
Scottish Audit of Surgical Mortality.
Secondary Journey/transfer
Journey between hospitals.
SMR
Scottish Medical Record.
South East and Tayside (SEAT) Regional Child Health Planning Group
Comprises of NHS Borders, NHS Fife and NHS Lothian.
Urban Level 2 Hospitals
Level 2 Hospitals (General Hospitals with Accident & Emergency facilities, but no inpatient paediatric
unit) within Urban settings.
West of Scotland Regional Child Health Planning Group
Comprises of NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Forth Valley, NHS Greater
Glasgow and Clyde and NHS Lanarkshire.
TM

^ééÉåÇáÅÉë=
^ééÉåÇáñ=N=
píÉÉêáåÖ=dêçìé=ãÉãÄÉêëÜáé=
Ms Julie Adams, Project Manager, National Services Division (from September 2006)
Dr Ian Bashford, Scottish Government Health Directorate (until Summer 2007)
Dr Charles Clark, Child Health Commissioner, NHS Lanarkshire
Ms Katherine Collins, Nursing & Quality Adviser, National Services Division
Mr Graham Haddock, Consultant, RHSC Glasgow
Mr Morgan Jamieson, National Clinical Lead for Children and Young People's Health in Scotland,
Scottish Government Health Directorate
Ms Heather Knox, West of Scotland Regional Planning Director
Dr Catherine Lees, Paediatric Consultant, Wishaw General Hospital
Dr Andrew McIntyre, Lead PICU Consultant, RHSC Glasgow
Mrs Winnie Miller, Service Manager, RHSC Glasgow (until Autumn 2007)
Mr Darren Mochrie, Operational Support Manager, Scottish Ambulance Service
Mr Chris Myers, Assistant Programme Manager, National Services Division (from August 2007)
Dr David Simpson, Lead PICU Consultant, RHSC Edinburgh
Ms Tammy Watchorn, Project Manager, National Services Division (until June 2006)
Dr Rosalie Wilkie, Consultant, Ninewells Hospital
Dr Graham Wilson, Lead Consultant HDU, Royal Aberdeen Children’s Hospital
TN

^ééÉåÇáñ=O=
eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ÅêáíÉêá~=C=ÖìáÇ~åÅÉ=åçíÉë=
TO

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eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=~ìÇáí=Ñçêã=EÑêçåí=~åÇ=Ä~ÅâF=
TP

^ééÉåÇáñ=Q=
m~êíáÅáé~íáåÖ=Üçëéáí~äë=Äó=bãÉêÖÉåÅó=`~êÉ=cê~ãÉïçêâ=äÉîÉä=
Hospital Location ECF Level HDC audit definition
Aberdeen Royal Infirmary 2 Urban Level 2
Balfour Hospital 2 Rural Level 2
Belford Hospital 2 Rural Level 2
Borders General Hospital 3 Level 3 Hospital
Caithness General Hospital 2 Rural Level 2
Crosshouse Hospital 3 Level 3 Hospital
Dr Gray's Hospital, Elgin 3 Level 3 Hospital
Dumfries & Galloway Royal Infirmary 3 Level 3 Hospital
Galloway Hospital (Garrick, Stranraer) 2 Rural Level 2
Gartnavel General Hospital 2 Urban Level 2
Gilbert Bain Hospital 2 Rural Level 2
Glasgow Royal Infirmary 2 Urban Level 2
Hairmyres Hospital 2 Urban Level 2
Inverclyde Royal Hospital 2 Urban Level 2
Lorn & Islands DGH 2 Rural Level 2
Mackinnon Memorial Hospital 2 Rural Level 2
Ninewells Hospital (Adult Wards) 2 Urban Level 2
Ninewells Hospital 3 Children's Hospital
Perth Royal Infirmary 2 Urban Level 2
Queen Margaret Hospital 2 Urban Level 2
Raigmore Hospital 3 Level 3 Hospital
Royal Aberdeen Children's Hospital 4 Children's Hospital
Royal Alexandra Hospital 3 Level 3 Hospital
RHSC, Edinburgh 4 Children's Hospital
Royal Infirmary of Edinburgh 2 Urban Level 2
St John's Hospital 3 Level 3 Hospital
Southern General Hospital 2 Urban Level 2
Southern General Neuroscience Institute (SGI) 3 Level 3 Hospital
Stirling Royal Infirmary 3 Level 3 Hospital
Vale of Leven General Hospital 2 Urban Level 2
Victoria Infirmary, Glasgow 2 Urban Level 2
Victoria Hospital, Kirkcaldy 3 Level 3 Hospital
Victoria Hospital, Rothesay 2 Rural Level 2
Western General Hospital 2 Urban Level 2
Western Infirmary, Glasgow 2 Urban Level 2
Western Isles Hospital 2 Rural Level 2
Wishaw General Hospital 3 Level 3 Hospital
Yorkhill, RHSC 4 Children's Hospital
q~ÄäÉ=OV=m~êíáÅáé~íáåÖ=Üçëéáí~äë=Äó=bãÉêÖÉåÅó=`~êÉ=cê~ãÉïçêâ=äÉîÉä=
TQ

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lÅÅìéáÉÇ=ÄÉÇ=Ç~ó=ëìãã~êó=Äó=Üçëéáí~ä==
ECF Level Hospital Location Total hours
Occupied
bed days
Urban Level 2 Western Infirmary, Glasgow 2,254 94
Royal Infirmary of Edinburgh 1,321 55
Southern General Hospital 803 33
Gartnavel General Hospital 785 33
Western General Hospital 718 30
Aberdeen Royal Infirmary 532 22
Ninewells Adult 477 20
Queen Margaret Hospital 436 18
Hairmyres Hospital 383 16
Inverclyde Royal Hospital 316 13
Victoria Infirmary, Glasgow 154 6
Perth Royal Infirmary 90 4
Vale of Leven General Hospital 58 2
Glasgow Royal Infirmary 54 2
Total - Urban Level 2 8,381 349
Rural Level 2 Belford Hospital 373 16
Gilbert Bain Hospital 219 9
Balfour Hospital 191 8
Dr Mackinnon Memorial Hospital 78 3
Caithness General Hospital 49 2
Lorn & Islands DGH 22 1
Garrick Hospital 8 0
Western Isles Hospital 5 0
Victoria Hospital, Rothesay 4 0
Total - Rural Level 2 948 40
Level 3 Stirling Royal Infirmary 14,923 622
Raigmore Hospital 8,367 349
SGI 6,607 275
Wishaw General Hospital 4,811 200
Crosshouse Hospital 3,540 147
Dumfries & Galloway Royal Infirmary 3,507 146
Victoria Hospital, Kirkcaldy 3,186 133
Royal Alexandra Hospital 2,323 97
Dr Gray's Hospital 1,115 46
Borders General Hospital 893 37
St John's Hospital 843 35
Total - Level 3 50,112 2,088
Children’s Hospitals Yorkhill, RHSC 274,330 11,430
RHSC, Edinburgh 142,502 5,938
Royal Aberdeen Children's Hospital 34,853 1,452
Ninewells Hospital 26,876 1,120
Total - Children’s Hospitals 478,562 19,940
Total - All Hospitals 538,003 22,417
q~ÄäÉ=PM=lÅÅìéáÉÇ=ÄÉÇ=Ç~ó=ëìãã~êó=Äó=Üçëéáí~ä==
TR

Urban Level 2 Hospitals - High Dependency Care Bed Days
Glasgow Royal Infirmary
Vale of Leven General Hospital
Perth Royal Infirmary
Victoria Infirmary, Glasgow
Inverclyde Royal Hospital
Hairmyres Hospital
Queen Margaret Hospital
Ninew ells Adult
Aberdeen Royal Infirmary
Western General Hospital
Gartnavel General Hospital
Southern General Hospital
Royal Infirmary of Edinburgh
Western Infirmary, Glasgow
2
2
4
6
13
16
18
20
22
30
33
33
55
94
0 10 20 30 40 50 60 70 80 90 100
Equivalent bed days
`Ü~êí=PO=eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ÄÉÇ=Ç~óë=Ó=rêÄ~å=iÉîÉä=O=eçëéáí~äë==
Rural Level 2 Hospitals - High Dependency Care Bed Days
Victoria Hospital, Rothesay
Western Isles Hospital
Garrick Hospital
0
0
0
Lorn & Islands District General Hospital
1
Caithness General Hospital
2
Dr Mackinnon Memorial Hospital
3
Balfour Hospital
8
Gilbert Bain Hospital
9
Belford Hospital
16
0 2 4 6 8 10 12 14 16 18
Equivalent bed days
`Ü~êí=PP=eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ÄÉÇ=Ç~óë=Ó=oìê~ä=iÉîÉä=O=eçëéáí~äë==
TS

Level 3 Hospitals - High Dependency Care Bed Days
St John's Hospital
Borders General Hospital
Dr Gray's Hospital
35
37
46
Royal Alexandra Hospital
97
Victoria Hospital, Kirkcaldy
Dumfries & Gallow ay Royal Infirmary
Crosshouse Hospital
133
146
147
Wishaw General Hospital
200
SGI
275
Raigmore Hospital
349
Stirling Royal Infirmary
622
0 100 200 300 400 500 600 700
Equivalent bed days
`Ü~êí=PQ=eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ÄÉÇ=Ç~óë=Ó=iÉîÉä=P=eçëéáí~äë=EÉñÅäìÇáåÖ=káåÉïÉääëF==
Children's Hospitals - High Dependency Care Bed Days
Ninew ells Hospital
1120
Royal Aberdeen Children's
Hospital
1452
RHSC, Edinburgh
5938
Yorkhill, RHSC
11430
0 2000 4000 6000 8000 10000 12000 14000
Equivalent bed days
`Ü~êí=PR=eáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=ÄÉÇ=Ç~óë=Ó=`ÜáäÇêÉåÛë=eçëéáí~äë==
TT

^ééÉåÇáñ=S=
jìäíáéäÉ=ÉéáëçÇÉë=çÑ=ÜáÖÜ=ÇÉéÉåÇÉåÅó=Å~êÉ=
No. of children
No. of episodes per
child
Total episodes
3,402 1 3,402
790 2 1,580
214 3 642
95 4 380
61 5 305
42 6 252
41 7 287
24 8 192
20 9 180
20 10 200
16 11 176
5 12 60
9 13 117
5 14 70
3 15 45
7 16 112
6 17 102
2 18 36
2 19 38
6 20 120
1 21 21
7 22 154
2 23 46
1 24 24
1 25 25
1 26 26
1 28 28
1 30 30
1 33 33
1 34 34
1 35 35
2 40 80
2 43 86
1 45 45
1 47 47
3 50 150
1 55 55
1 59 59
1 62 62
1 67 67
1 70 70
1 95 95
1 112 112
4,804 9,680
q~ÄäÉ=PN=pìãã~êó=çÑ=åìãÄÉê=çÑ=ÉéáëçÇÉë=éÉê=ÅÜáäÇ=
TU

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iÉåÖíÜ=çÑ=ÉéáëçÇÉ=Äó=Üçëéáí~ä=
The following charts demonstrate the range of episode lengths and the quartile values within each
hospital.
Level 2 Urban - Box and Whisker plot demonstrating minimum, Q1, Q2, Q3 and
maximum episode hours
Western Infirmary, Glasgow
Western General Hospital
Victoria Infirmary, Glasgow
Vale of Leven General Hospital
Southern General Hospital
Royal Infirmary of Edinburgh
Queen Margaret Hospital
Perth Royal Infirmary
Ninewells Adult
Inverclyde Royal Hospital
Hairmyres Hospital
Glasgow Royal Infirmary
Gartnavel General Hospital
Aberdeen Royal Infirmary
0 50 100 150 200 250 300 350 400 450 500 550 600
Hours
Level 2 Rural - Box and Whisker plot demonstrating minimum, Q1, Q2, Q3 and
maximum episode hours
Western Isles Hospital
Victoria Hospital, Rothesay
Lorn & Islands District General
Hospital
Gilbert Bain Hospital
Garrick Hospital
Dr Mackinnon Memorial Hospital
Caithness General Hospital
Belford Hospital
Balfour Hospital
0 10 20 30 40 50
Hours
TV

Level 3 - Box and Whisker plot demonstrating minimum, Q1, Q2, Q3 and maximum
episode hours
Wishaw General Hospital
Victoria Hospital, Kirkcaldy
Stirling Royal Infirmary
St John's Hospital
Southern General Institute
Royal Alexandra Hospital
Raigmore Hospital
Dumfries & Galloway Royal Infirmary
Dr Gray's Hospital
Crosshouse Hospital
Borders General Hospital
0 100 200 300 400 500 600 700 800 900
Hours
Children's Hospitals - Box and Whisker plot demonstrating minimum, Q1, Q2, Q3 and
maximum episode hours (logarithmic scale)
Yorkhill, RHSC
Royal Aberdeen Children's Hospital
RHSC, Edinburgh
Ninewells Hospital
1 10 100 1000 10000
Hours
UM

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pìãã~êó=çÑ=lêÖ~åáë~íáçå=çÑ=`êáíáÅ~ä=`~êÉ=èìÉëíáçåå~áêÉ=êÉëéçåëÉë=Ó=~êÉ=Üçëéáí~äë=ÚçéÉåÛ=íç=ÅÜáäÇêÉå\=
NHS Board
Ayrshire and Arran
NHS Board
questionnaire
returned
Yes
Hospitals
Arran Memorial Hospital
Ayr Hospital
Crosshouse Hospital
Davidson Hospital
Lady Margaret Hospital
ECF
Level
2
2
3
1
1
Open to
children
No
No
Yes
No
No
Questionnaire
returned by
hospital
No
Yes
Yes
Borders Yes Borders General Hospital 3 Yes Yes
Dumfries and
Dumfries and Galloway Royal Infirmary
3
Yes
Yes
Yes
Galloway
Galloway Community Hospital
2
Yes
Yes
Fife
No
Victoria Hospital, Kirkcaldy
3
Yes
Queen Margaret Hospital
2
No
Forth Valley No Stirling Royal Infirmary 3 No
Grampian
Yes
Aberdeen Royal Infirmary
Dr Gray’s Hospital
Royal Aberdeen Children’s Hospital
2
3
4
No
Yes
Yes
No
Yes
Yes
Greater Glasgow &
Clyde
Yes
Glasgow Royal Infirmary
Inverclyde Royal Hospital
Royal Alexandra Hospital
Yorkhill, RHSC
Southern General Hospital
Stobhill General Hospital
Vale of Leven General Hospital
Victoria Infirmary
Western Infirmary
2
2
3
4
2/3
1/2
1
2
2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
UN=

NHS Board
Highland
Lanarkshire
Lothian
NHS Board
questionnaire
returned
Yes
No
Yes
Hospitals
Belford Hospital
Caithness General Hospital
Campbeltown Hospital
Dunoon Hospital
Dr Mackinnon Memorial Hospital
Islay Hospital
Lochgilphead Hospital
Lorn and Islands General Hospital
Raigmore
Rothesay Hospital
Salen Hospital
Hairmyres Hospital
Monklands General Hospital
Wishaw General Hospital
Royal Edinburgh Hospital
Royal Hospital for Sick Children, Edinburgh
Royal Infirmary of Edinburgh
St John’s Hospital
Western General Hospital
ECF
Level
2
2
“1 plus”
“1 plus”
2
“1 plus”
“1 plus”
2
3
“1 plus”
“1 plus”
2
2
3
1
4
2
3
2
Open to
children
Yes
Yes
Yes
Yes
Yes for 13+
Yes
Yes for 13+
Yes
No
Questionnaire
returned by
hospital
Yes
Yes
Orkney Yes Balfour Hospital 2 Yes Yes
Shetland Yes Gilbert Bain Hospital 2 Yes Yes
Tayside
Yes
Arbroath Minor Injuries Unit
Ninewells Hospital
Perth Royal Infirmary
1
3
2
Yes
Yes
Yes
Yes
Yes
Western Isles
Yes
St Brendan’s Hospital
Uist and Barra Hospital
Western Isles Hospital
1
1
2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
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NHS Board
A&E Department –
refers children to
another A&E
Department
Ayr, South Ayrshire,
A&E Department -
accepts children
In-patient paediatric
facilities
Paediatric day surgery
unit
Paediatric high
dependency care
Ayrshire and
Arran
Arran War Memorial, Isle of
Arran
(Ferry access)
Crosshouse, East
Ayrshire
Crosshouse, East
Ayrshire
Crosshouse, East Ayrshire
Crosshouse, East Ayrshire
Borders
Dumfries and
Galloway
Fife
There are a number of
children referred via Berwick
infirmary
-
Borders General
Hospital
Dumfries and Galloway
Royal Infirmary,
Galloway Community
Hospital
Ward 15, Borders General
Hospital
Dumfries and Galloway
Royal Infirmary
Day Procedure Unit, Borders
General Hospital
Children nursed in Paediatric
Unit
Ward 15, Borders General
Hospital
Dumfries and Galloway Royal
Infirmary
Forth Valley
Grampian -
Peterhead Community
Hospital,
Dr Gray’s
RACH
Dr Gray’s
RACH
Dr Gray’s
RACH
UP=

NHS Board
A&E Department –
refers children to
another A&E
Department
A&E Department -
accepts children
Glasgow Royal
Infirmary
In-patient paediatric
facilities
Paediatric day surgery
unit
Paediatric high
dependency care
Greater
Glasgow &
Clyde
Western Infirmary
Inverclyde Royal
Hospital
Southern General
Hospital
Victoria Infirmary
Western Infirmary
Royal Alexandra Hospital,
Paisley
Southern General Hospital
Yorkhill, Royal Hospital for
Sick Children
Royal Alexandra Hospital,
Paisley
Yorkhill, Royal Hospital for
Sick Children
Royal Alexandra Hospital,
Paisley
Southern General Hospital,
Glasgow
Yorkhill, Royal Hospital for
Sick Children
Yorkhill, Royal Hospital
for Sick Children
Raigmore Hospital,
Inverness
Highland
No protocols in place as yet
Lorn and the Isles,
Oban
Caithness General,
Wick
Raigmore Hospital,
Inverness
Lorn and the Isles, Oban
Raigmore Hospital, Inverness
Raigmore Hospital, Inverness
Lanarkshire
Lothian
Royal Infirmary of Edinburgh
Belford Hospital, Fort
William
Monklands Hospital
Hairmyres Hospital
RHSC, Edinburgh
St John’s Hospital
Wishaw Hospital
RHSC, Edinburgh,
St John’s Hospital,
Royal Infirmary of
Edinburgh,
Western General Hospital
Wishaw Hospital
Monklands Hospital
Hairmyres Hospital
RHSC, Edinburgh
St John’s Hospital
Royal Infirmary of Edinburgh
Western General Hospital
Wishaw Hospital
RHSC, Edinburgh,
St John’s Hospital,
Princess Alexandra Eye
UQ=

Pavilion
Orkney - - - -
Ward 1 prior to transfer
Shetland - Gilbert Bain Hospital - Gilbert Bain Hospital Gilbert Bain Hospital
Tayside
Perth Royal Infirmary
Ninewells
Ninewells Ninewells Ninewells
Perth Royal Infirmary
Western Isles
Only critically ill/injured are
referred to mainland
hospitals
Yes Yes - -
UR=

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kep=_ç~êÇ=êÉëéçåëÉë=EÇÉåçãáå~íçê=NQF
Question Yes No
No
response
Is there a NHS Health Board Level lead for children’s services? 12 0 0 12
Does your NHS Health Board issue any specific guidance to parents / GPs / Out-of-Hours Drs /
NHS 24 / Scottish Ambulance Service regarding which hospitals critically ill children should be
taken to? For example indicating the hospitals that have the facilities to receive critically ill or
potentially critically ill children; i.e. “open” to children?
Do formal communication mechanisms exist to inform NHS 24, primary care teams, out-of-hours
services and the Scottish Ambulance Service about the emergency paediatric facilities that exist
within the NHS Board? For example, is there a policy that formally states where children should
be taken for emergency care?
If the NHS Board services include a Minor Injury Unit or an A&E Department that doesn’t accept
children; do they have a protocol in place to deal with a potentially or critically ill child presenting.
This protocol should detail the arrangements to transfer to an appropriate paediatric unit.
(denominator 22)
Total
no.
returns
11 1 0 12
2 9 1 12
6 3 3 n/a 12
iÉîÉä=O=êÉëéçåëÉë==
Question Yes No
No
response
Do you have 24 hour consultant anaesthetist cover? 12 1 0 13
Within the multidisciplinary team is there 24-hour availability of medical or nursing staff with up to
date paediatric resuscitation training?
11 2 0 13
Are there protocols for alerting and organising the paediatric resuscitation and trauma teams
within the hospital?
7 6 0 13
Total
no.
returns
As a site without a dedicated paediatric ward, do you have a protocol to access paediatric
medical advice agreed with a local paediatric medical unit? How often is this reviewed?
Is there a lead A&E Consultant (or designated A&E lead e.g. lead surgeon/anaesthetist) with
responsibility for policies and procedures relating to emergency treatment of children within the
A&E area?
5 7 1 13
5 5 3 13
US=

Is there a protocol to ensure the A&E department can access advice from the either on-site or offsite
in-patient paediatric medical unit?
Is there a nominated Consultant Anaesthetist with responsibility for policies and procedures
relating to emergency treatment of children? Are these policies produced in liaison with
Consultants from the regional tertiary Children’s Hospitals?
7 4 2 13
4 7 2 13
Is there a nominated Consultant Surgeon with responsibility for policies and procedures relating
to emergency treatment of children? Are these policies produced in liaison with Consultants from 4 7 2 13
the regional tertiary Children’s Hospitals?
Is there a nominated Consultant responsible for protocols covering the assessment and
management of the critically ill child?
6 4 3 13
Is there a nominated Consultant responsible for ensuring relevant medical staff have appropriate
paediatric training – including up-to-date resuscitation training.
4 7 2 13
Is there a nominated senior nurse responsible for protocols covering the assessment and
management of the critically ill child?
6 7 0 13
Is there a nominated senior nurse responsible for ensuring relevant nursing staff have appropriate
paediatric training – including up-to-date resuscitation training.
10 2 1 13
Do you have paediatric protocols covering admission? 5 8 0 13
Do you have paediatric protocols covering discharge? 3 10 0 13
Do you have paediatric protocols covering standard assessment method? 6 7 0 13
Do you have paediatric protocols covering treatment of all major paediatric conditions, including
head injuries, meningococcal infection, asthma and status epilepticus?
10 1 2 13
Do you have paediatric protocols covering treatment of resuscitation and stabilisation? 8 3 2 13
Do you have paediatric protocols covering accessing advice from a lead Paediatric Intensive Care
(PIC) centre, i.e. a written protocol for 24-hour advice, including referral protocols and contact 11 2 0 13
numbers?
Do you have paediatric protocols covering transfer to a lead PIC centre? 9 2 2 13
Does the transfer to a PICU protocol stipulate that transfer decisions must be taken by an
appropriate local Consultant with a PICU Consultant?
7 6 0 13
Does the transfer protocol include local guidelines on the maintenance of intensive care for a
critically ill child until the retrieval team arrives? These guidelines should stipulate the location/s
in which children may be maintained
If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include the circumstances under which a child will be admitted to and stay on the adult
intensive care unit?
6 6 1 13
0 1 12 13
If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include a children’s nurse should be available to support the care of the child?
1 1 11 13
UT=

If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include there should be a discussion with a PICU about the child’s condition?
If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include a paediatrician should be involved in the decision to move the child to the
intensive care unit and is available for advice during their stay there?
Is there an appropriately designed and age specific equipped area, (or mobile equipment), for
resuscitation and stabilisation of critically ill children and young people? Drugs and equipment
should be checked in accordance with local policy.
2 0 11 13
2 0 11 13
13 0 0 13
iÉîÉä=P=êÉëéçåëÉë==
Question Yes No
No
response
Do you have 24 hour Consultant Paediatrician cover? 9 0 0 9
Do you have 24 hour Consultant Anaesthetist cover? 8 0 1 9
Is there a 24-hour availability of medical staff, with up to date paediatric resuscitation training?
Total
no.
returns
9 0 0 9
Is there a 24-hour availability of at least one nurse on duty with up to date resuscitation training?
8 1 0 9
Are there protocols for alerting and organising the paediatric resuscitation and trauma teams
within the hospital?
8 0 1 9
Is there a Doctor who is paediatric airway competent available 24-hours a day? 8 0 1 9
Is there 24-hour on-site access to a nurse with paediatric high dependency skills and training?
Is there adequate nurse staffing to provide care for children requiring high dependency care at a
level of 0.5:1 or 1:1 if nursed in a cubicle?
Is there a lead A&E Consultant (or designated A&E lead e.g. lead surgeon/anaesthetist) with
responsibility for policies and procedures relating to emergency treatment of children within the
A&E area?
Is there a protocol to ensure the A&E department can access advice from the either on-site or offsite
in-patient paediatric medical unit?
Is there a nominated Consultant Anaesthetist with responsibility for policies and procedures
relating to emergency treatment of children? Are these policies produced in liaison with
Consultants from the regional tertiary Children’s Hospitals?
9 0 0 9
9 0 0 9
9 0 0 9
9 0 0 9
7 2 0 9
UU=

Is there a nominated Consultant Surgeon with responsibility for policies and procedures relating
to emergency treatment of children? Are these policies produced in liaison with Consultants from
the regional tertiary Children’s Hospitals?
Is there a nominated Consultant responsible for protocols covering the assessment and
management of the critically ill child?
Is there a nominated Consultant responsible for ensuring relevant medical staff have appropriate
paediatric training – including up-to-date resuscitation training.
Is there a nominated Senior Children’s Nurse responsible for protocols covering the assessment
and management of the critically ill child?
Is there a nominated senior nurse responsible for ensuring relevant nursing staff have appropriate
paediatric training – including up-to-date resuscitation training.
Is there a nominated Senior Children’s Nurse responsible for mandatory paediatric training
courses?
6 3 0 9
8 1 0 9
8 0
0
n/a -1
8 1 0 9
9 0 0 9
3 6 0 9
Do you have paediatric protocols covering admission? 6 2 1 9
2
7 1
Do you have paediatric protocols covering discharge?
n/a - 1
8
Do you have paediatric protocols covering standard assessment method? 6 2 1 9
Do you have paediatric protocols covering treatment of all major paediatric conditions, including
head injuries, meningococcal infection, asthma and status epilepticus?
9 0 0 9
Do you have paediatric protocols covering treatment of resuscitation and stabilisation? 6 2 1 9
Do you have paediatric protocols covering accessing advice from a lead Paediatric Intensive Care
(PIC) centre, i.e. a written protocol for 24-hour advice, including referral protocols and contact 9 0 0 9
numbers?
Do you have paediatric protocols covering transfer to a lead PIC centre? 8 1 0 9
Does the transfer to a PICU protocol stipulate that transfer decisions must be taken by an
appropriate local Consultant with a PICU Consultant?
8 1 0 9
Does the transfer protocol include local guidelines on the maintenance of intensive care for a
critically ill child until the retrieval team arrives? These guidelines should stipulate the location/s
in which children may be maintained
If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include the circumstances under which a child will be admitted to and stay on the adult
intensive care unit?
7 2 0 9
3 3
1
n/a -2
9
9
If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include a children’s nurse should be available to support the care of the child?
2 4
1
n/a -2
9
UV=

If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include there should be a discussion with a PICU about the child’s condition?
If the maintenance guidelines in the question above include the use of an Adult ITU, does the
protocol include a paediatrician should be involved in the decision to move the child to the
intensive care unit and is available for advice during their stay there?
4 2
4 2
Is there 24-hour access to pharmacy? 7 2 0 9
Is there 24-hour access to biochemistry? 9 0 0 9
Is there 24-hour access to haematology? 9 0 0 9
Is there 24-hour access to imaging? 9 0 0 9
Is there 24-hour access to CT scans? 9 0 0 9
Is there 24-hour access to physiotherapy? 7 2 0 9
Is there an appropriately designed and equipped area to provide high dependency care for
children of all ages available? Drugs and equipment should be checked in accordance with local
policy.
Is there an appropriately designed and age specific equipped area, (or mobile equipment), for
resuscitation and stabilisation of critically ill children and young people? Drugs and equipment
should be checked in accordance with local policy.
The nominated Consultants in Q17 (ii) should ensure that all relevant medical staff has
appropriate and up to date paediatric resuscitation training. How are training records maintained?
(level 2, 3 & 4)
1
n/a -2
1
n/a -2
7 2 0 9
7 2 0 9
8 0 n/a - 1 8
9
9
The nominated nurse in Q18 (ii) should ensure that all relevant nursing staff have appropriate and
up to date paediatric resuscitation training. Can training records be provided?
9 0 0 9
=
VM=

iÉîÉä=Q=êÉëéçåëÉë==
Question Yes No
No
response
Do you have 24 hour Consultant Paediatrician cover? 3 0 0 3
Do you have 24 hour consultant anaesthetist cover? 3 0 0 3
Is there a 24-hour availability of medical staff, with up to date paediatric resuscitation training?
Total
no.
returns
3 0 0 3
Is there a 24-hour availability of at least one nurse on duty with up to date resuscitation training?
3 0 0 3
Are there protocols for alerting and organising the paediatric resuscitation and trauma teams
within the hospital?
3 0 0 3
Is there a Doctor who is paediatric airway competent available 24-hours a day? 3 0 0 3
Is there 24-hour on-site access to a nurse with paediatric high dependency skills and training?
Is there adequate nurse staffing to provide care for children requiring high dependency care at a
level of 0.5:1 or 1:1 if nursed in a cubicle?
3 0 0 3
3 0 0 3
Is there a lead A&E Consultant (or designated A&E lead e.g. lead surgeon/anaesthetist) with
responsibility for policies and procedures relating to emergency treatment of children within the 3 0 0 3
A&E area?
Is there a protocol to ensure the A&E department can access advice from the either on-site or offsite
in-patient paediatric medical unit?
3 0 0 3
Is there a nominated Consultant Anaesthetist with responsibility for policies and procedures
relating to emergency treatment of children?
3 0 0 3
Is there a nominated Consultant Surgeon with responsibility for policies and procedures relating
to emergency treatment of children?
3 0 0 3
Is there a nominated Consultant responsible for protocols covering the assessment and
management of the critically ill child?
3 0 0 3
Is there a nominated Consultant responsible for ensuring relevant medical staff have appropriate
paediatric training – including up-to-date resuscitation training.
3 0 0 3
Is there a nominated Senior Children’s Nurse responsible for protocols covering the assessment
and management of the critically ill child?
2 1 0 3
Is there a nominated senior nurse responsible for ensuring relevant nursing staff have appropriate
paediatric training – including up-to-date resuscitation training.
3 0 0 3
Is there a nominated Senior Children’s Nurse responsible for mandatory paediatric training
courses?
3 0 0 3
Do you have paediatric protocols covering admission? 3 0 0 3
VN=

Do you have paediatric protocols covering discharge? 1 2 0 3
Do you have paediatric protocols covering standard assessment method? 2 1 0 3
Do you have paediatric protocols covering treatment of all major paediatric conditions, including
head injuries, meningococcal infection, asthma and status epilepticus?
3 0 0 3
Do you have paediatric protocols covering treatment of resuscitation and stabilisation? 3 0 0 3
Do you have paediatric protocols covering accessing advice from a lead Paediatric Intensive Care
(PIC) centre, i.e. a written protocol for 24-hour advice, including referral protocols and contact 1 0 2 n/a 3
numbers?
Do you have paediatric protocols covering transfer to a lead PIC centre? 1 0 2 n/a 3
Does the transfer to a PICU protocol stipulate that transfer decisions must be taken by an
appropriate local Consultant with a PICU Consultant?
1 0 2 n/a 3
Does the transfer protocol include local guidelines on the maintenance of intensive care for a
critically ill child until the retrieval team arrives? These guidelines should stipulate the location/s 1 0 2 n/a 3
in which children may be maintained
Is there 24-hour access to pharmacy? 3 0 0 3
Is there 24-hour access to biochemistry? 3 0 0 3
Is there 24-hour access to haematology? 3 0 0 3
Is there 24-hour access to haematology? 3 0 0 3
Is there 24-hour access to CT scans? 3 0 0 3
Is there 24-hour access to physiotherapy? 3 0 0 3
Is there an appropriately designed and equipped area to provide high dependency care for
children of all ages available? Drugs and equipment should be checked in accordance with local
policy.
Is there an appropriately designed and age specific equipped area, (or mobile equipment), for
resuscitation and stabilisation of critically ill children and young people? Drugs and equipment
should be checked in accordance with local policy.
The nominated Consultants in Q17 (ii) should ensure that all relevant medical staff has
appropriate and up to date paediatric resuscitation training. How are training records maintained?
(level 2, 3 & 4)
3 0 0 3
3 0 0 3
3 0 0 3
The nominated nurse in Q18 (ii) should ensure that all relevant nursing staff have appropriate and
up to date paediatric resuscitation training. Can training records be provided?
Is there a multi-disciplinary team responsible for policies and procedures relating to high
dependency care?
3 0 0 3
2 1 0 3
VO=

oÉÑÉêÉåÅÉë=
Department of Health (2001) High Dependency Care for Children – Report of an Expert Advisory
Group for Department of Health 2001 London : Department of Health available:
http://www.integratedcarenetwork.gov.uk/_library/Resources/ICN/Policy_documents/High_Dependen
cy_2001.pdf
Department of Health (2006) The acutely or critically sick or injured child in the District General
Hospital: A team response available:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_0
62668
Department of Health (2008) Commissioning Safe and Sustainable Specialised Paediatric Services
A Framework of Critical Inter-Dependencies available:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_0
88068
General Register Office for Scotland (2008) Mid-2007 Population Estimates for Scotland available
at: http://www.gro-scotland.gov.uk/statistics/publications-and-data/population-estimates/mid-2007-
population-estimates-scotland/list-of-tables.html
Healthcare Commission (2005) Improvement review Services for children in hospital Assessment
Framework Healthcare Commission available:
http://www.healthcarecommission.org.uk/_db/_documents/Assessment_framework_Childrens_Impro
vement_review.pdf
Health Commission Wales (2006) Caring for Critically Ill Children Annual Report 2005-2006 Mold :
Health Commission Wales, Specialist Services
Information Services Division Scotland SMR01 dataset
National Report of the Paediatric Intensive Care Audit Network
January 2005 - December 2007, PICANet, 2008
http://www.picanet.org.uk/Documents/General/Annual_Report_2008/PICANet%20National%20Repor
t%202005%20-%202007.pdf
Scottish Executive Building A Health Service Fit For The Future, A National Framework for Service
Change in the NHS in Scotland (The Kerr Report) (2005) Edinburgh : Scottish Executive
available: http://www.scotland.gov.uk/Resource/Doc/924/0012113.pdf
Scottish Executive Delivering a Healthy Future: An Action Framework for Children and Young
People’s Health in Scotland (2007) Edinburgh : Scottish Executive available:
http://www.scotland.gov.uk/Resource/Doc/165782/0045104.pdf
Scottish Executive Delivering for Health (2005) Edinburgh : Scottish Executive available:
http://www.scotland.gov.uk/Resource/Doc/76169/0018996.pdf
Scottish Executive Emergency Care Framework for Children and Young People in Scotland (2006)
Edinburgh : Scottish Executive available :
http://www.scotland.gov.uk/Resource/Doc/149108/0039634.pdf
Scottish Government Better Health, Better Care Action Plan (2007) Edinburgh : Scottish
Government available:
http://www.scotland.gov.uk/Resource/Doc/206458/0054871.pdf
VP

Scottish Intensive Care Society Audit WardWatcher Subgroup WardWatcher paediatric data 2005
and 2006
South West Commissioning Group South West Audit of Critically Ill Children Annual Report 2006-
2007 (2007) available:
http://www.picanet.org.uk/Documents/General/SWACIC%20ANNREP2007pd%20(2).pdf
Standards for care of critically ill and critically injured children in the West Midlands (2002)
Welsh Assembly Government (2003) Caring for Critically Ill Children: Standards. Cardiff: Welsh
Assembly Government.
Office of National Statistics (2006) Wales’ Population – A Demographic Overview, 2008: Welsh
Assembly Government available at
http://new.wales.gov.uk/topics/statistics/publications/walespop08/?lang=en
VQ