Children's A&E department

New assessment tool to aid discharge and admission decisions in emergency care for children and young people

A new guidance tool will support decision-making in hospital urgent and emergency care departments, following a major research study involving more than 36,000 children and young people.

Using a clinical prediction modelling approach, the Paediatric Admission Guidance in the Emergency Department (PAGE) scoring system combines physiological measurements and clinical observation.

It is designed to support better decision-making about the need for admission and the safety of discharge of children in the emergency department (ED).

In particular, it will be of benefit to district general hospital EDs and those without the immediate availability of paediatricians. PAGE is based on data from three non-specialist hospitals (The Royal Oldham Hospital and Fairfield General, which both have emergency departments, and Rochdale Infirmary which has an urgent care centre. All are part of the Northern Care Alliance NHS Group).

The study which led to the new assessment tool was headed by Professor Andrew Rowland, Consultant in Children’s Emergency Medicine at North Manchester General Hospital and Honorary Professor of Paediatrics at the University of Salford and Dr Damian Roland, Consultant in Children’s Emergency Care at the University Hospitals of Leicester NHS Trust and Honorary Associate Professor in Paediatric Emergency Medicine at the University of Leicester. PAGE builds on previous work on the Paediatric Observation Priority Score (POPS) by Dr Damian Roland and on work published by the research team on The Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score (PAT-POPS). It was funded by a Research for Patient Benefit grant from the National Institute for Health Research (NIHR) and was the highest ever recruiting children’s study in the history of the NIHR Clinical Research Network.

Using information on routine observations, such as heart rate, temperature and breathing rate, Professor Rowland, Dr Roland and colleagues have developed guidelines to advise clinicians which children aged 0-16 should be admitted to hospital and which could be safely discharged home or signposted to a different service.

The PAGE tool incorporates these parameters:

  • Age in months
  • Heart rate (beats per minute)
  • Respiratory rate (breaths per minute)
  • Temperature (oC)
  • Oxygen saturation
  • Whether the child requires supplementary oxygen or not
  • Assessment of breathing
  • Assessment of recession
  • Assessment of behaviour
  • Nurse judgement regarding level of concern
  • Multi-morbidity (ie whether the child has a pre-existing condition)
  • Whether the child arrived by ambulance
  • Whether a medical professional advised attendance at the ED

PAGE is better able to predict the admission of children from the ED than PAT-POPS and the Manchester Children’s Early Warning Score System (ManChEWS).

Triage systems

Professor Rowland said: “With attendances at emergency departments (EDs) by children and young people now in excess of 4 million per year, it’s vital that they are treated in the most clinically appropriate environments and that systems are in place to identify those who need to be admitted and others who could be reassured and allowed home or who could access other services.

punishment, smacking, children

Professor Andrew Rowland, Consultant in Paediatric Emergency Medicine

“We have good triage systems in place to identify children who require further observation and investigation. Fuller assessments – often called Early Warning Scores – are increasingly used to detect which patients are more at risk of deteriorating. POPS and PAT-POPS are good examples of this and we have developed them further so the PAGE score is better able to predict outcomes in non-specialist centres, that is district general hospitals rather than major teaching hospitals, where EDs may be less likely to have paediatricians working in them. PAGE has a very strong scientific evidence base as we were able to include data from very large numbers of children and young people and it has been validated as part of the research study.”

The work was carried out through a partnership between the Universities of Salford, Manchester, and Leicester together with The Pennine Acute Hospitals NHS Trust and University Hospitals of Leicester NHS Trust.

Practical answers

Professor Tony Long from the University of Salford added: “Such established partnerships between senior clinicians and academic researchers are vital to the application of research to solve practical problems in patient care in a meaningful and effective manner.”

A paper based on the research has been published in BMJ Open: Observational cohort study with internal and external validation of a predictive tool for identification of children in need of hospital admission from the emergency department: the Paediatric Admission Guidance in the Emergency Department (PAGE) score

Resources developed from the study are available to download here and the research team would be keen to hear from other NHS organisations interested in using the PAGE system.

  • The research underpinning PAGE is independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0815-20034). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.