COMMON THEMES
47. During the course of this project a number of common themes have emerged from the research and discussions with individuals and organisations providing child health services in remote and rural areas.
48. The critically unwell child can be recognised by those with basic paediatric training. The child who has a mild illness and needs reassurance or short term observation can be recognised. Non-Paediatricians have difficulty recognising the child who has the potential to become more unwell. They have difficulty deciding how aggressive to be with investigation and treatment of these children and whether they should be moved to a mainland unit.
49. In an emergency situation with a critically unwell child it is not so much the initial resuscitation, but the stabilisation period which causes concern to those working in remote and rural areas. Whilst nobody feels completely confident with paediatric resuscitation, there are good protocols and a systematic approach to follow. However it may be several hours before a retrieval team arrives and it is this period with a sick child that is particularly worrying for local clinicians.
50. In both of the above situations it is vital to have robust links to expert support in mainland centres. Knowing the person to whom you speak and knowing that they understand the situation that you are working in is also very supportive. Video-linking to support the stabilisation of a critically ill child or neonate has not yet been tried, but is perceived by many clinicians to be of potential benefit.
51. It is important that medical and nursing staff in the mainland centres are aware of the working environment in the remote and rural areas referring children and babies to them. Often there will be no children's nurse available and usually there will be no Paediatrician. Generally there will be one doctor trying to deal with the child and contact the mainland for advice. In these situations it is important that the first point of contact in the receiving hospital is aware of the situation in the referring hospital and can act appropriately. It should be possible to access the retrieval teams (paediatric and neonatal) at a single point and not have to repeat the clinical story several times while searching for a bed. This is not only frustrating, but takes a lot of time away from a sick child in a vulnerable location.
52. The remote and rural areas do not have the necessary staff to escort a child to a mainland centre. They do not have staff with the expertise and they cannot afford to lose staff to the mainland (particularly as they may be stranded there overnight) as it leaves the local service vulnerable. This applies particularly to children who are not sick enough to require an intensive care team retrieval, but who need more than a paramedic escort. In practice these children often are moved by the intensive care retrieval team because of awareness that there is nobody else.
53. Children and babies who are moved need to be taken to the most appropriate location. This applies particularly to children from the Northern Isles who require High Dependency Care. This would most appropriately be carried out in Aberdeen where children and their families can meet the local staff who will likely be involved in ongoing care and recuperation. However if the intensive care retrieval team takes a child to Aberdeen the team may then be stranded there and be unable to return to base in Edinburgh or Glasgow.
54. We need guidelines for the treatment of common paediatric and neonatal problems that are evidence based and acceptable to the mainland units that the remote and rural areas feed into. Ideally these would be web based national guidelines. In addition to this we need robust guidelines about which children with which conditions can safely be kept in a remote location and which should be transferred off as soon as is safe and possible.
55. The number of severely ill children, infants and neonates is a very small part of the workload and it is therefore difficult to achieve and maintain skills. Courses need to be specifically designed with the remote and rural location in mind rather than adapted from an urban model. Designed this way the training and skills should be appropriate to the location in which they are to be used. Because of the small numbers of staff providing the service in remote and rural areas, it is difficult to release significant numbers at any one time for a course. By running the course locally the impact of travel time on time away from base is reduced and it is possible to capture greater numbers of staff.
56. Nurses with paediatric qualifications and experience are a vital part of the remote and rural child health team. Often these nurses are dual trained and are caring for adult patients as well as their paediatric caseload. It is important that their paediatric skills are recognised and supported with the opportunity for further training and maintenance of skills. They should have the opportunity to network with paediatric nursing colleagues in the larger centres and funding should be identified for this.
57. Courses need to be scheduled regularly to maintain skills and funding needs to be identified for this within each health board. Courses need to be of high quality and value for money. Telemedicine offers the potential to deliver education to a number of sites at a distance from each other and all at the same time.
58. The Public need to be aware of what can and cannot safely be provided locally. But this needs to be done in such a way that the Public has faith in their local service. Mainland centres must be supportive of care that is provided in remote and rural locations to maintain both staff and public morale.
59. In the island health boards there is a perceived lack of overall co-ordination for Community Child Health and of a clinical lead for child health in the larger community setting. The AHPs feel that they lack an identified individual to turn to when they have a query about an individual child.
60. Each island group has a very dedicated team of AHPs providing input to a group of children some of whom have very complex problems. It is important that these individuals have someone to give them peer support. Multidisciplinary team meetings are becoming more of a feature and provide a forum for discussing all the children on a case load. However peer support from within the profession usually needs to be via links to a larger centre. These links should be formalised and will therefore need appropriate funding.
61. Communication from the mainland centres to the islands could be improved. Often the AHPs do not receive information back from the mainland about patients that have been seen there. This may be because the letter goes direct to the GP who does not pass it on (and may not know which AHPs are involved with the child). In the Western Isles the Paediatrician is sometimes left out of the loop, information goes back to the GP, but not to the Paediatrician who sees the child in clinic and often has referred the child to the mainland.
62. There needs to be careful discharge planning for children with complex needs who are being discharged back to remote and rural areas. The mainland centres need to be aware that there are often no children's nurses available to these children and that equipment or unusual drugs or feeds take time to source. The Community nurses may need training, for example in tube feeding. Staff are willing to learn. Shetland has a Community Children's Nurse who is able to provide staff and families with training and advice. This facility is not available in the other areas of the project.
63. The health needs of looked after children and children on the child protection register could be better addressed. Currently these children have no input from a Paediatrician. For the younger children in particular development needs to be carefully assessed and if children are moving around a lot between carers it is important that somebody (the Paediatrician or Community Child Health team) maintains their health records. This vulnerable group of children is recognised as having higher than average mental health needs and currently early intervention for these problems is not readily available.
64. Ideally children should not have to travel big distances for examination in cases of child protection, but it should be remembered that, in a small community, privacy may be difficult and it might be necessary for this reason alone to move the child away for investigation and examination.
65. Mental health services for children and young people are extremely under-resourced. In places there are large gaps (no Psychiatrist for children under 13 years in Orkney) and in others there is a grossly insufficient provision.
66. Telemedicine in the form of videoconferencing is commonly used for meetings, fairly commonly used for educational purposes and infrequently used for clinical consultations in paediatrics. The potential for videoconferencing to improve the support available in an acute scenario is recognised. There are major concerns about the quality and reliability of the videoconference connection.
Training Resources
67. Children are not small adults and likewise training for remote and rural health care should not be scaled down urban training. The skills needed in remote and rural areas are more general and often less reliant on technology than those practised in a teaching hospital. We now have courses designed by remote and rural practitioners which are more relevant to these professionals than the courses delivered by the urban teaching centres. The proliferation of such courses is to be encouraged.
68. Telemedicine has seen the advent of teaching delivered simultaneously to a number of sites remote from each other. This substantially reduces travelling time, time spent away from base and subsistence costs for the remote and rural practitioner and allows many more individuals to benefit from the training. However it should also be recognised that informal contact at meetings and training events can be as important as the formal event itself. If all training were to be delivered by video-link, the remote practitioner would be unacceptably isolated. Balance needs to be achieved.
69. It is important to recognise that the majority of the training outlined below is multiprofessional and team working is actively promoted.
70. Resuscitation Training Officers ( RTO)s and Anaesthetists within individual health boards are working hard to maintain the resuscitation skills of as many staff as possible.
71. Paediatric updates for Anaesthetists are available in the larger paediatric centres.
72. Napier University send a team to the Western Isles Hospital in Stornoway every 6 months to coincide with the new intake of junior staff. They run a day of resuscitation training with moulage. This is repeated on the second day. Currently only the junior doctors and the Emergency Nurse Practitioners attend this training. If the Napier team can accommodate more people I would envisage it being offered to the ward nurses, both in Stornoway and Balivanich, and to GPs and Physicians.
73. The Scottish Multiprofessional Maternity Development Group was established to take forward the training recommendations of the Expert Group on Acute Maternity Services. 19 In addition to working with the Scottish Neonatal Transport service on a course for pre-transport care (see below) the group has designed a course to train midwives in examination of the newborn. This course has been piloted and is now up and running in various centres.
74. The Scottish Neonatal Transport service together with the Scottish Multiprofessional Maternity Development Group have developed a course on post resuscitation care and stabilisation for transfer (Scottish Neonatal Pre-transport Care course) which will be delivered regularly to maternity units. The course is validated by NHS Education Scotland and will be piloted in Elgin.
75. The Paediatric Intensive Care retrieval teams (Edinburgh and Glasgow) have also developed a training package (Paediatric Outreach Study Day) aimed at giving local staff the skills to cope during the period of post-resuscitation stabilisation while waiting for the retrieval team. This training is funded by National Services Division. The course was piloted in Inverness and the first course was run very successfully in Orkney in June. The Western Isles will be the next centre to receive the course.
76. Both the post-resuscitation care packages will be delivered locally in the remote and rural areas. In addition to making the courses maximally available to local staff this will have the added benefit of introducing staff from larger paediatric centres to the reality of working in a remote and rural area. And it will enable individuals to get to know each other and establish a working relationship. These study days should also be seen as an opportunity for discussion and audit of individual cases, and local guidelines/protocols.
77. BASICS Scotland have, and are developing, courses aimed at health professionals in the more remote and rural areas. These courses are written by and designed specifically for rural practitioners, in contrast to many of the resuscitation courses which are largely hospital based. The teaching is evidence based. BASICS courses do not involve an exam and cannot be failed (unlike the various resuscitation courses). The courses aim to give individuals the skills to cope with sick patients in a remote and rural area and to build confidence. They are validated by NHS Education Scotland.
78. European Paediatric Life Support ( EPLS) and Advanced Paediatric Life Support ( APLS) courses are available in Scotland at various centres. However they tend to deal with resuscitation specifically rather than the ongoing care required over the several hours while more expert help is on its way. For neonates Neonate Life Support ( NLS) and Neonatal Resuscitation Programme ( NRP) are available. These courses have an exam and can be failed.
79. Mainland Consultants providing clinic time in the remote and rural areas are often happy to provide tutorial based sessions on paediatric topics for all staff although this opportunity has yet to be exploited. The most ideal time and venue needs to be identified and it would be helpful if the users of this service could come up with a list of topics. The Paediatrician for each individual area would also have training of other health professionals as an integral part of his job plan.
80. The Royal Hospital for Sick Children, Yorkhill, Glasgow has a programme of medical education running over the three terms of the academic year. Certain of the topics would be of interest to the non-paediatrician. A number of sites in the West of Scotland already video-link to these sessions.
81. 'Spotting the Sick Child' 20, a DVD written by an Accident and Emergency (A/E) Consultant in England, has useful teaching material for non-Paediatricians. I have distributed copies of the DVD to various individuals within the project area.
82. Social services in each area run multi professional courses on child protection issues.
83. NOSTEP (North of Scotland Tele-education Programme) provides a package of teaching aimed at various members of the health care community. NOSTEP is now funded by all the Northern Region Health Boards and has the potential to deliver a lot more education to remote and rural areas. Another benefit of NOSTEP is that practitioners in remote and rural areas can deliver the teaching from their own base, thus getting away from the model of urban units delivering teaching to the remote and rural areas. BASICS deliver some of their teaching using NOSTEP.
84. The opportunity for medical and nursing/midwifery staff to spend time at a larger centre to update their knowledge and skills is potentially there. Such time needs to be more structured than simply turning up for a period of time and should involve specific learning aims. Some of the midwives already arrange time at a larger unit on a fairly regular basis, but nurses do not seem to have made use of similar arrangements. It would be worth exploring whether nursing/midwifery staff in the larger centres would be interested in an exchange with a remote and rural area.
85. The School of Community Paediatrics, Edinburgh runs a programme of modules relating to Community Child Health. It also teaches the modules for the GP Paediatric Fellowship programme. There is potential for these modules to be videoconferenced to a wider audience. The skills taught at the School are ideal for a remote and rural GP with an interest in Community Paediatrics.
86. NHS Education Scotland ( NES) are responsible for commissioning and approving educational packages for all those working in the NHS. The Rural Educational Solutions Steering Group ( RESS), based in the Northern Region, will be looking specifically at the needs of remote and rural areas of Scotland.
Telemedicine
87. Telemedicine is being used increasingly in rural parts of Scotland for meetings and educational sessions. Its use in clinical situations has been slower to take off and tends to be the preserve of a few enthusiastic individuals. Those living and working in remote and rural areas are generally much more convinced of the potential benefits of telemedicine. Its potential for supporting the clinical care of sick children in remote and rural areas is recognised by most of the clinicians I have spoken to during the course of this project. However we have little experience of using it in this way.
88. A paper written specifically for the Western Isles but which is applicable to all remote and rural areas (Appendix 1) explores the potential uses of telemedicine in remote and rural paediatrics. A video-link in the acute setting also has the potential to improve safety both for the patient and for the retrieval team. The support offered by the larger centre to the remote and rural unit could potentially allow the retrieval to be delayed (avoiding adverse weather conditions) or cancelled altogether if the child was seen to improve.
89. Telemedicine is already being used throughout Grampian to link minor injuries units to A/E in Aberdeen. 21 Diagnostic imaging is transmitted via telemedicine both for clinical opinion and for formal reporting. There are dermatology services using telemedicine and many other examples both in Scotland and around the world of telemedicine linking remote and rural practitioners and patients to specialists. Telemedicine can also be used to keep families in touch when one member is in hospital at a distance and visiting is difficult.
90. A pilot project in England has looked at the possibility of using telemedicine in acute paediatrics. Images are transmitted from A/E to a Paediatrician in his office. The assessment made by video-link is compared with that done face to face. Results so far have been encouraging and the video-link definitely adds to the information that could have been relayed by telephone (Dr R MacFaul, personal communication).
91. The Scottish Paediatric Telemedicine Project (Project Manager Hazel Archer, Royal Hospital for Sick Children, Yorkhill, Glasgow) was established initially to improve accessibility to immediate cardiac diagnosis in neonates and to support joint management of neonates with surgical problems. By using video-links, Cardiologists in The Royal Hospital for Sick Children, Yorkhill, Glasgow have been able to support local clinicians in performing an echocardiogram and making a provisional cardiac diagnosis. This has reduced the number of babies travelling to Glasgow unnecessarily for a cardiac opinion.
92. The paediatric surgeons at Yorkhill have been able to offer shared cared for neonates with surgical problems and have also been able to talk to parents directly about their sick baby. This project has been very successful and has mushroomed beyond its original remit. The largest user of the telemedicine facility by clinical episodes has been the psychiatry service. Videoconferencing has allowed the specialist team at Yorkhill to conduct case conferences and some therapy sessions with clinicians and families at a distance from Yorkhill.
93. Telemedicine has great potential for distance education. Remote and rural areas tend to rely on a few individuals to deliver a service and it is often difficult to get locums. Travelling to training events involves considerable time away from base with the added cost of overnight accommodation. It is accepted that attendance in person at a training event allows one to interact with peers and gain a lot from the coffee room discussion in addition to that from the lecture theatre, but a mix of distance learning and actual attendance at events should be achievable. Much of the training outlined above is, or could be, delivered using telemedicine.
94. For the full potential of telemedicine to be recognised we need enthusiastic individuals to use it and spread the word to those that doubt its applicability. Only by using it will we discover what it can and cannot do and encourage the development of the technology to keep up with what we want it to do.