The Royal College of Paediatrics and Child Health (RCPCH) supports this view and has highlighted the acute assessment unit as an example of best practice in the management of acute paediatric illness, which can prevent inappropriate admissions (RCPCH 1998). Such units are often sited adjacent to inpatient wards or within emergency departments and rely on skilled children’s nurses. Meates (1997) has outlined the crucial role that they play in helping parents to provide self-care, thus reducing the need for overnight admission. Perhaps the most important objectives in establishing a Paediatric Emergency Assessment Unit (PEAU) are to place the child at the centre of care and to recognise the importance of the family in contributing to the care of their child (Department of Health (DoH) 2003).

Children admitted to hospital for assessment are often seen in inappropriate areas, such as Emergency Departments without designated paediatric areas or treatment areas on wards. Of great concern to nurses and paediatricians is the risk of premature discharge of children without the opportunity to evaluate treatment and monitor improvement at home for 24 hours. The key objectives in establishing a PEAU are to:

This chapter and the companion PowerPoint presentation will follow an ill child from the initial consultation with the GP, admission to a PEAU, observation, discharge planning for care at home, follow-up next day telephone call and communication with other healthcare professionals.

Many PEAUs have been designed to enhance services to local GPs and a study by Aitken et al (2003) demonstrated that the majority of admissions were initiated from this source. The changing nature of initial contact between a family and the health service is ensuring that triage or the determination of urgency of healthcare intervention is taking place in a variety of geographical locations and mediums.

The use of the telephone by nurses has grown enormously in the UK since the inception of NHS Direct, and telephone nursing reflects the growth in the use of the telephone in contemporary British society (Glasper & Wilkins 1998). The safety and effectiveness of nurse telephone consultations was described by Lattimer et al (1998) who, in a seminal randomised controlled trial of equivalence between GPs and nurses, found that there were no adverse outcomes for patients.

Birch et al (2005) reported a survey of GPs following a nurse-led initiative of accepting direct referrals. Following the introduction of a new nurse-led telephone referral service to a dedicated PEAU, they conducted a study to determine the views of GPs who used their service. The PEAU used to operate between 10am and 10pm on weekdays and between 10am and 6pm at weekends. The unit initially had four beds and treatment and stabilisation areas, plus associated services in a dedicated area of a regional child health unit. The study utilised a faxed questionnaire over a 1-month period to all consenting GPs using the PEAU with a postal questionnaire follow-up. Non-parametric Likert scores and qualitative data were used to determine levels of satisfaction with the service and the subsequent management of the referred children. Sixty-nine GPs referred 80 children to the PEAU via the service over a period of 1 month. All consented to participate and were sent a faxed questionnaire, which generated 39 (57%) responses. A follow-up questionnaire sent to the 39 respondents achieved a return of 25 (64%) responses. Thirty-four GPs agreed that referral via the dedicated nurse telephone service was easier than the previous senior house officer referral system.

This clearly demonstrated that GPs are happy to refer sick children to a PEAU via a dedicated telephone referral system. Although not all acute assessment units provide this service, the advantage of the GP speaking to the nurse ultimately receiving the child provides a clearer picture of the nature of the condition. This saves time for both the family and GP and therefore enhances a seamless service through the healthcare system.

Children’s nurses working with ill children and their families are required to develop a wide range of advanced skills that meet the expectations of paediatric emergency assessment (Box 22.1). It is important that the nurse establishes a good professional relationship on meeting the child and family. This will enable the nurse to carry out a full nursing assessment to include a physical, developmental and social history and negotiate a plan of care. The very nature of childhood illnesses can result in some children presenting with a life-threatening condition and it is therefore essential that all staff undertake a recognised paediatric advanced life support course.

As the role of the children’s nurse develops, the skills become more enhanced and the paediatric nurse practitioner will be first-line assessing and managing ill children. Although the majority of paediatric episodic illnesses are relatively benign and resolve completely, the implications of a missed diagnosis could become life threatening. Therefore, regardless of the type of illness, the basic information and skills required in the acute assessment of an ill child are for the most part the same in all children. Before the history-taking process begins it is essential that the nurse who is looking after the child and family introduces him- or herself, puts them at their ease and makes them feel welcome. A child-friendly environment should be encouraged, with age-appropriate toys and distraction. Privacy should be ensured throughout.

A well-taken and documented medical and social history of an ill child is crucial for the diagnosis and management of care for both the child and family. Open-ended questions should be used to ensure a full response from the child and family. At all times children should be encouraged to participate and tell their ‘own story’. During the history-taking process it is helpful to maintain as much eye contact as possible with the child and family.

Nurses working in an emergency assessment environment are frequently practising at a nurse practitioner level, which includes physical assessment, history taking, venesection, cannulation and prescribing (Box 22.2) (Dearmun and Gordon, 1999, Rushforth, 2002 and Rushforth and Glasper, 1999

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