AdmitSend Home:Provide appropriate and clear guidance tothe parent / carer and refer them to the patient advice sheet.Confirm they are comfortable with the decisions / advice given and then think “Safeguarding” before sending home.

Green Action

Urgent ActionImmediate Paediatric Emergency Service Assessment, following local hospital referral pathwaySeek AssistanceOxygen if O2 Sats <92% or severe respiratory distressFluids 2

3 maintenance Oral NG IVStep up High Flow Oxygen Therapy / CPAP

Discharge plan criteriaOxygen Saturations maintained in air above locally agreed saturation parameters. Give patient advice sheet, confirm they are comfortable with the decisions / advice given and then think “Safeguarding” before sending home.

Bronchiolitis PathwayClinical Assessment / Management Tool for Children Younger than 2 years old with suspected Bronchiolitis

Yes

This guidance is written in the following context:

This document was arrived at after careful consideration of the evidence available including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.

Also think about...

Do the symptoms and/or signs suggest an immediately life threatening

(high risk) illness?

Suspected Bronchiolitis?

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Advice from Paediatrician-On-Call should be sought and/or a clear management plan agreed with parents.

Amber Action

Send Home

Bronchiolitic symptoms often deteriorate up to Day 3. This needs to be considered in those patients with other high risk factors.

Green - low risk Amber - intermediate risk Red - high riskBehaviour • Alert

• Normal• Irritable • Reduced response to social cues• Decreased activity • No smile

• Unable to rouse • Wakes only with prolonged stimulation• No response to social cues • Weak or continuous cry• Appears ill to a healthcare professional

Circulation and Hydration • CRT < 2 secs • Moist mucous membranes• Normal colour skin, lips and tongue• Normal - Tolerating 75% of fluid• Occasional cough induced vomiting

• CRT 2-3 secs • Pale/mottled• Pallor colour reported by parent/carer • Cool peripheries• 50-75% fluid intake over 3-4 feeds• Reduced urine output

• CRT > 3 secs • Pale/Mottled/Ashen blue• Cyanotic lips and tongue• <50% fluid intake over 2-3 feeds or appears dehydrated• Significantly reduced urine output

Features of Respiratory Distress:Respiratory rate Measured at rest for 30 seconds

• Under 12mths <50 breaths/minute • Over 12mths <40 breaths/minute • Increased work of breathing• All ages > 60 breaths /minute

• All ages > 70 breaths/minute

Chest Recession • No Chest Recessions • Moderate Chest Recessions • Severe Chest Recessions

Nasal Flaring • No Nasal Flaring • Moderate Nasal Flaring • Severe Nasal Flaring

Grunting • No Grunting • Moderate Grunting • Severe Grunting

Apnoeas • No Apnoeas • No Apnoeas • Apnoeas

O2 Sats in air** • >92% or above • >92% • <92%

Other • Satisfactory Social Circumstance • Pre-existing lung condition • Immunocompromised• Congenital Heart Disease • Age <6 weeks (corrected)• Re-attendance • Prematurity• Neuromuscular weakness • Safeguarding concerns

Complete PEWS for all patients

Table 1

Also think about...

Management - Acute Setting

You need urgent

help

please phone 999

or go to the nearest

Hospital Emergency

(A&E) Department.

Self Care

Using the advice

overleaf you can look

after your child

at homeIf none of the features in the red or amber boxes above

are present, most children with Bronchiolitis can be safely

managed at home.

You need to contact a

doctor or nurse today

Please ring your

GP surgery or call

NHS 111 - dial 111If your child has any One of these below:

decreased feeding (less than 2/3 of normal feeds)

passing less urine than normal or fewer wet nappies

than usualvomitingtemperature is above 39°C

is finding it difficult to breathe

or if your child’s health gets worse or you are worried

Some useful phone numbers (You may want to add some numbers on here too)

Further advice / Follow upName of Child

Age Date / Time advice given

Name of Professional

Signature of Professional

How is your child? (traffic light advice)

If your child has any One of these below:

blue lips and tongue

unresponsive or very irritable

breathing rapidly and struggling to breathe

pauses in breathing

an irregular breathing pattern

had no wet nappies for 12 hours

AMBER

GREEN

RED

Bronchiolitis Advice Sheet

(a cause of persistent cough, mild fever and feeding

difficulties in infants) Advice for parents and

carers of children younger than 2 years old

For online advice: NHS Choices www.nhs.uk (available 24 hrs - 7 days a week)

Family Information Service: All areas have an online service providing useful information for Families

set up by local councils

If you need language support or translation please inform the member of staff to whom you are speaking.

To feedback or for further information including how to obtain more copies of this document (Please Quote Ref: B1) we have one mailbox for these

queries on behalf of the South East Clinical Networks area (Kent, Surrey and Sussex). Please email: CWSCCG.cypSECpathways@nhs.net

GP Surgery

(make a note of number here)

......................................

.........

NHS 111 dial 111

(available 24 hrs -

7 days a week)

School Nurse /

Health Visiting Team

(make a note of number here)

......................................

.........

......................................

.........

December 2016

Kent, Surrey & Sussex

Version

Children and Young PeopleSouth East Clinical Networks

For all patients, continue monitoring following PEWS Chart recommendation

Patient Presents Contact Paediatric Emergency Service as per local referral hospital pathwayMove to Resuscitation AreaResus Call (“2222”) for Paediatric Arrest

(APLS†)

< 1 year1-2 years

Respiratory Rate at rest: [b/min]

30 - 4025 - 35

Heart Rate[bpm]

110 - 160100 - 150

Table 2 Normal Paediatric Values:Systolic Blood

Pressure [mmHg]

70 - 9080 - 95

ThinkSepsis

• Bronchiolitis season• Coryzal prodrome for 1-3 days• Persistent cough with tachypnoea or chest recession or both• Either wheeze or crackles or both• Fever (usually < 39°C)• Poor feeding• Isolated apnoeas (particularly in those under 6 weeks)

Clinical Findings

December 2016

Kent, Surrey & Sussex Version

Consider differential diagnosis if:Temp > 39°C (sepsis / pneumonia) or sweaty / pale (cardiac) or unusual features of illness. Consider viral induced wheeze or early onset asthma in older infants.

Children and Young PeopleSouth East Clinical Networks

†Advanced Paediatric Life Support The Practical Approach Fifth Edition Advanced Life Support Group Edited by Martin Samuels; Susan Wieteska Wiley-Blackwell / 2011 BMJ Books.

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Glossary of Terms and AbbreviationsAPLS APLS Advanced Paediatric Life Support ED Hospital Emergency DepartmentB/P Blood Pressure HR Heart RateCPD Continuous Professional Development O2 SATS Oxygen Saturation in Air CRT Capillary Refill Time PEWS Paediatric Early Warning Score RR Respiratory Rate

Where can I learn more about paediatric assessment? We also recommend signing up to the online and interactive learning tool Spotting the Sick Child. It is free of charge. It was commissioned by the Department of Health to support health professionals in the assessment of the acutely sick child. It is also CPD certified.

www.spottingthesickchild.com

With many thanks to all those who have supported the development of our pathways including: Aaron Gain Amanda WoodCarole Perry Carolyn PhillipsCatherine Holroyd Chris MorrisChristine McDermott Claire O’Callaghan Clare Lyons Amos Denise Matthams Dr Amit BhargavaDr Ann CorkeryDr Anna Mathew Dr Catherine BevanDr Debbie Pullen

Dr Farhana DamdaDr Fiona Weir Dr Helen Milne Dr Neemisha JainDr Kamal KhoobarryDr Kate AndrewsDr Liz McCullochDr Maggie WearmouthDr Mike LinneyDr Miki LaznerDr Mwape Kabole Dr Nelly NinisDr Oli Rahman Dr Palla PrabhakaraDr Stuart Nicholls

Dr Tim FooksDr Tim TaylorDr Venkat Reddy Dr Mike LinneyFiona MackisonFiona WookeyJane Mulcahy Jeannie BaumannJoanne FarrellKaren Hearnden Kath EvansKathy Felton Kathy WalkerKim MorganLaura Robertson

Lois Pendlebury Lorraine MulroneyMatthew WhiteMelissa HancornMoira GardinerNicola MundyPatricia Breach Rebecca C ‘AiletaRosie Courtney Rosie RowlandsSarah West Sue Pumphrey Wang Cheung

Based on Bronchiolitis in children: diagnosis and management NICE guidelines [NG9] Published date: June 2015 https://www.nice.org.uk/guidance/ng9/resources/bronchiolitis-in-children-diagnosis-and-management-51048523717 and on Scottish Intercollegiate Guidelines (SIGN) 2006 Guideline No. 91 Bronchiolitis in children - www.sign.ac.uk/guidelines/fulltext/91/index.html

December 2016

Kent, Surrey & Sussex VersionSupporting Information

The Network

Dear Colleague,

We would like to introduce you to the Bronchiolitis Pathway Clinical Assessment / Management Tool for Children Younger than 2 years old – Acute Settings. This is one of a series of urgent care pathways developed by the Children and Young People’s Network for the most common conditions requiring primary and / or acute care.

The local clinical groups who played such an important role in creating these tools, starting from 2010, have included representatives from acute, community and primary care as well as parents, education and social care. In particular we would also like to thank Paediatrics and Emergency Medicine colleagues for their support in finalising these versions for circulation.

The professionals were all working towards four main objectives:

To promote evidence-based assessment and management of unwell children and young people. The pathway tools aim to ensure that accurate and prompt advice is available to assist health professionals to make safe decisions that can be taken quickly.

To build consistency across the Network area, so all healthcare professionals understand the pathway and can assess, manage and support children, young people and their families during the episode, to the same high standards, regardless of where they present.

To support local healthcare professionals to share learning and expertise across organisations in order to drive continuous development of high quality care

To build the confidence/resilience of parents to manage their child’s illness which should be increased with the consistent advice offered for unwell children and young people accessing all local NHS services in an emergency or urgent scenario.

This pathway is comprised of three elements: parental advice, a pathway for use in primary care and community settings and a pathway for use in acute (hospital) settings. Each part has been designed to be compatible with existing pathways in the acute sector and should be particularly valuable for use in Hospital Emergency Departments and primary care settings.

It is an expectation that these pathways will not only provide a guide for clinicians faced with an unwell child, but will also be used in training and disseminated across all relevant departments and team-members.

We hope you will find this a quality tool to be used within your practice. We look forward to hearing back on how the consistency of assessment and management of these children and the overall quality of practice and patient experience has been improved with this relatively simple but whole system initiative.

To feedback or for further information including how to obtain more copies of this document (Please Quote Ref: B3) we have one mailbox for these queries on behalf of the South East Clinical Networks area (Kent, Surrey and Sussex). Please email: CWSCCG.cypSECpathways@nhs.net

May we commend it to your use.

Yours sincerely QRCODE

Children and Young PeopleSouth East Clinical Networks

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