Type:
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Guideline
1573
Emergency Medicine-
Paediatrics
Effective date:
KESSU admissions and processes
1 April 2015
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Dave Graham John Bonning
Dave Graham John Bonning
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CUL Child Health CD Emergency
CUL Child Health CD Emergency
1 April 2018
Waikato DHB, June 2015
1. Purpose
• The guideline outlines the criteria for utilisation of the Kids Emergency Short Stay Unit
(KESSU). The purpose of KESSU is to provide optimal extended care in an appropriate
environment of children who have an expected length of stay of more than 6 but less than 24
hours and offer a safe alternative to premature or high risk discharge of patients, and to un-
necessary inpatient admissions.
• KESSU is not an ancillary inpatient ward, nor an ED overflow ward.
• The guideline has been drawn up following discussion with EM, Paediatric Medicine &
surgery, and related subspecialty services.
2. Responsibility:
• The Departments of Paediatrics and Emergency Medicine have shared administrative
jurisdiction over KESSU. Their clinical teams work conjointly as necessary for mutual support
and patient benefit.
3. Guidelines:
• KESSU is a 6 bed monitored unit forming part of Kids’ ED
• The unit is intended for the management of patients who require a brief period of intense
management which would likely achieve safe discharge within 24 hours, but who require more
than 6 hours treatment. Patients expected to require admission for >24hrs should be admitted
to the ward.
• Patients may be identified as appropriate for KESSU (per criteria below) are transferred to
KESSU as soon as the clinical decision to do so is made. Various departments may admit to
KESSU, but the majority are expected to be Paediatric Medical followed by ED patients.
Paediatric Medicine is responsible for the effective and efficient clinical operation of KESSU,
working with other clinically involved services as appropriate.
• Any inpatient speciality other than Paediatrics must confirm with the Emergency Physician on
duty (or their designated SR overnight) that their patient conforms to accepted criteria as being
appropriate for KESSU. A clear plan of management must be agreed and documented by the
inpatient team for care and discharge within 24 hours of arrival in ED.
• The clock doesn’t drive the admission to KESSU, good care does. However, when a patient is
admitted to KESSU in accordance with these guidelines and lodged observed (KESSU) the
ED acute 6-hour clock will stop. Only patients meeting agreed criteria for KESSU and there
for clinically valid reasons can be lodged (KESSU).
4. Function of KESSU:
• Provides up to 24 hours of intensive treatment or further assessment and investigation
• Patients in KESSU must be on a defined care pathway with clear discharge endpoints
• Patients must be expected to be discharged safely after this period
5. Examples of conditions suitable for admission to KESSU:
• Gastroenteritis requiring rehydration
• Moderate LRTI
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KESSU admissions and processes
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• Moderate asthma
• Croup
• Bronchiolitis (usually those not requiring oxygen)
• Anaphylaxis responding to initial treatment
• Toxic ingestion
• Seizures, including febrile convulsion
• Patients with febrile illnesses (e.g. pneumonia, pyelonephritis, tonsillitis) requiring further brief
focussed treatment (fluids, antibiotics, steroids) prior to discharge.
n.b the need for supplemental oxygen is not in itself a contraindication to KESSU admission.
General Issues
• The duty Paediatrician will adjudicate as to whether the patient should be admitted to hospital
in unclear cases.
6. Exclusions:
• A patient where the management plan is unclear (the diagnosis may still be unclear)
• Any patient who from the outset needs admission for longer than 24 hours
• Any patient merely awaiting a ride home but not requiring a bed (should be discharged to the
waiting room)
7. KESSU Admission and Discharge Process
• When children are first and subsequently assessed in Kids’ ED, after the assessment the
doctor must indicate whether the patient is going to be (i) admitted to inpatients; (ii) admitted to
KESSU; (iii) discharged; (iv) reviewed (within a specified time and for specified purposes) prior
to disposal decision.
• Doctors and nurse-co-ordinators (NOT bed-managers) are encouraged to proactively identify
patient disposal to KESSU or inpatients
• The plan to admit to KESSU and expectation to discharge within 24 hours is discussed with the
patient and family/whanau.
• Clinical notes must include a diagnosis (or at least a differential diagnosis), management plan
including pathway to discharge within 24 hours, and parameters when the patient must be
reviewed including planned review time.
• All patients admitted to KESSU will be discussed with the Consultant prior to discharge, or as
soon as is practicable after discharge
• All patients should be medically reviewed regularly in a timely fashion as per the written plan.
Each review should state the time of the next review. They should regardless be reviewed at
handover/shift change to ensure they remain on a discharge pathway with an update in clinical
notes and electronic record. This plan must be documented in the notes.
• Nursing observations are recoded on the appropriate Paediatric Early Warning Score (PEWS)
chart.
• All patients must have a named doctor present in the hospital on iPM beside their name, and
this name is kept current (i.e. that of a doctor who is in the hospital and available to respond to
issues regarding the patient).
• An Electronic Discharge Summary (EDS) should be drafted by the admitting doctor. The
discharging doctor will review and update the EDS. Every paediatric patient who leaves ED
must have a discharge letter with time and action-specific instructions in the hands of their
carer.
• Patients meeting pre-specified criteria may be discharged by a nurse without a final medical
review if this is clearly documented in the notes and an EDS and prescription (if needed) can
be printed and given to the patient – they don’t have to wait for a designated “discharge round”.
• If the patient has an injury the ACC (ACC45) form must be completed.
• Patients discharged from KESSU will have their clinical notes sent for clinical coding.
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8. Quality control of KESSU patients
• Prolonged waits for investigations or results are not acceptable and must initiate discussions
with relevant services (e.g. Laboratory, Radiology) to facilitate improved service delivery,
including immediate phone calls to that service and incident forms.
• Discharge (home) rate from KESSU (<24hrs) is expected to be >80%. It is accepted that
some patients will “fail” their planned stay of less than 24 hours and subsequently need
admission.
• Use of the KESSU and ‘OBS’ will be audited regularly by senior Paediatric and ED clinicians
and management for appropriateness and effectiveness of use.
• KESSU is not to be used as a surrogate inpatient ward, or as a Kidsplace ED overflow.
• Effective use includes “right patient, right treatment, right time” and as such quality indicators
should include appropriate placement, and reduction in un-necessary or inappropriate
investigations and treatment.
Disclaimer: This document has been developed by Waikato District Health Board specifically for its
own use. Use of this document and any reliance on the information contained therein by any third
party is at their own risk and Waikato District Health Board assumes no responsibility whatsoever.
