Introduction Paediatric hospitals have recently experienced significant increases in the number of unplanned attendances. Several paediatric hospitals have decided to move to a ‘single front door’ model to manage all patients in one physical location by a single medical team consisting of emergency medicine clinicians and general paediatricians.

This approach will be adopted in the new Leeds Children’s Hospital which has been commissioned to be built by 2030. Visits to other hospitals and meetings with departments who have adopted this approach were arranged as part of the planning process. Discussions in these encounters included topics such as staff models, layout design and recommendations for achieving success.

A recurring theme identified was the importance of establishing clear patient pathways with all inpatient and outpatient speciality teams. These pathways will be implemented immediately in Leeds, resulting in improved patient management and a smoother transition to the new model of working.

Aims and objectives of the research project or activity

1. To learn from clinical leaders in other NHS organisations regarding how they operate within a ‘single front door’ model.

2. To review how the current PED nursing and medical team perceive the existing referral processes, identifying any key areas for improvement.

3. To liaise with all community and inpatient paediatric speciality clinical leads to review existing referral processes.

4. To explore alternative patient pathways which avoids unnecessary admission or which better utilises other team members or resources.

5. To ensure referral pathways take into consideration patients and families who are the most vulnerable.

6. To collaborate with the new hospital planning team to ensure the patient pathways are futureproof and central to the planning processes.

Method or approach Virtual and face-face meetings were held with consultants from four different NHS hospital trusts with a ‘single front door’ policy. Notes were taken and shared with the team responsible for the planning of the Paediatric Emergency Department (PED) within the new Leeds Children’s Hospital.

Questionnaires were distributed to all appropriate nursing and medical staff who worked in the existing Leeds PED in August and September 2023. The questionnaire explored issues such as confidence levels referring to specialties, awareness of outpatient services and experience of effective pathways previously used.

All community and medical specialties were also contacted to provide information regarding referral options. This information was provided via completion of a separate questionnaire or verbally in meetings. Engagement in this project was encouraged through presenting at the Clinical Lead meeting, departmental meetings and more widely in meetings with members of the local Integrated Care Board and Public Health department.

The information regarding speciality referral options was collated into a ‘Patient Pathways Handbook’. This will be available on the CEM Books App, used by the ED team, and the Trust intranet.

Findings Questionnaires were completed by twenty-three members of the Leeds PED team. The level of confidence in referring was very variable with 26% of the medical team feeling not confident in referring a patient direct to speciality, 30% feeling neither confident or not confident, 26% feeling confident and 18% feeling very confident. A similar spread of results was also seen in response to a question on outpatient services. Rapid access clinic and community clinics were identified as the services which caused the most confusion. Twenty-one participants (91%) felt that it would be beneficial to have a handbook detailing available referral pathways.

The Leeds PED team consists of consultants and Advanced Nurse Practitioners, many of whom have worked in the department for several years. There is also a cohort of doctors and nurses who are allocated a rotation in PED as part of their training programme. It is therefore reasonable to assume that the variability in confidence levels can be largely attributed to the difference in time spent working in the department.

Key messages Previous research has identified three key barriers to successfully referring patients from emergency departments to specialties: variation in referral processes and information required, differences in organisational culture and communication issues. This handbook aims to minimise these barriers in Leeds PED through clearly identifying all inpatient and outpatient patient pathways between PED and all specialties.

The interactions with the speciality teams facilitated discussions regarding methods for appropriate admission avoidance. This included highlighting available community paediatrics services, identifying which outpatient services could be accessed by PED clinicians and identifying direct communication links between PED and speciality teams. The handbook has received widespread support from all Clinical Leads and is being expanded to incorporate paediatric surgical specialties.

This project highlights the importance of collaborating with leaders from across an organisation to optimise how different teams interact and ensure patients are seen by the right person, in the right place, at the right time.