Direct Access Policy for Children’s Assessment and Treatment (CAT) Unit

• Aims
• Background
• Procedure method

Aims

To standardise and optimise the referral process for Direct Access to the CAT unit, and to ensure that children attend safely and appropriately. 

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Background and indications for standard operating procedure/protocol

The Children’s Assessment and Treatment (CAT) Unit is a Paediatric Unit open 24/7, 365 day a year, and is run by the Paediatric Medicine team.  We see around 15000 children a year on the unit and accept referrals from the Paediatric Emergency department, Primary Care and other health care professionals.  We have limited isolation facilities.  We are not designated as a Trust High Dependency or resuscitation area and the two beds in PUMA (Paediatric Urgent Management Area) are for blood-taking/procedures as well as management of patients who may be more unwell.

Some children and young people will have Direct Access for their parent or carer to bring them to the CAT unit without being referred by a healthcare provider.   This document aims to improve the clarity for referrers and families to understand what is expected by the family, referrer and unit in various scenarios.  It will also outline situations in which children will not be accepted to the unit in order to maximise safe management. 

Please note that this SOP is not about referrals to the CAT Unit from other specialty healthcare professionals, which we continue to try to support as possible. 

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Procedure method (step by step)

Children and young people (CYP) re-attending after recent discharge

• CYP who have been seen and discharged from the CAT unit within the last 24 hours will automatically have Direct Access.  
• At a senior clinician’s discretion some children may be given a longer period of Direct Access (e.g. early bronchiolitis) and this will have been specified on the CAT/ward discharge letter (usually up to 72 hours).
• Families are expected to call the CAT unit nursing co-ordinator on 0113 3920920 to notify of their intention to return.  Staff taking phone calls should not provide any advice about remote management and should direct families to 111 or Primary Care services if advice is required.
• If families arrive without telephoning beforehand, and are eligible, they will still be seen.

CYP with certain conditions
The following groups do not need a formal referral for CAT unit Direct Access, but the responsible consultant must ensure that families are aware of the specific criteria to attend CAT, the CAT nurse co-ordinator telephone number (0113 3920920) and also when it is not suitable (see box 1).   

• Henoch-Schönlein Purpura (HSP): Children with a diagnosis of HSP made by the Paediatric Medicine team or the Paediatric Emergency Department have Direct Access to CAT for complications of HSP.  The family should call the unit as advised on the LTHT guideline “Henoch-Schönlein Purpura in patients under 16 years”.
• Cystic Fibrosis (CF) and Primary Ciliary Dyskinesia (PCD): Children with CF/PCD have Direct Access for complications of CF, although advice should be sought from the respiratory team prior to attendance, as we may be unable to accept due to infection control reasons.  Children with CF/PCD need to be medically assessed prior to subsequent admission to the respiratory ward.  The Respiratory Consultant on-call will liaise with staff about management options when there are several patients with CF on CAT or adjacent ward.
• Diabetes (DM): CYP with diabetes have Direct Access for complications of DM.  It is preferred, however, that families call ward L40 for advice, as the Paediatric Consultant on-call for diabetes may prefer to offer advice, or discuss with the Paediatric Emergency Department (PED) and admit to L40.
• Children with a displaced nasogastric tube:  Outside of normal working hours nursing staff on the CAT unit can replace a displaced or removed long-term nasogastric tube.  During normal working hours, however, the community nursing staff should be contacted for this.  Families should contact the CAT nurse co-ordinator telephone number (0113 3920920) prior to attending.  Children with displaced NGT do not need a formal referral however it needs to be clear from their electronic health records that they have a nasogastric tube in place at home usually.
• Metabolic: Children with a metabolic condition, including ketotic hypoglycaemia, all have Direct Access to the CAT unit for complications of the metabolic condition.  The named Consultant/team should, however send a referral letter (including named Consultant/reason to attend and emergency care plan) to leedsth-tr.CATDirectAccess@nhs.net.  It is important that any subsequent changes in management (especially for children who are managed outside of Leeds) are also emailed to leedsth-tr.CATDirectAccess@nhs.net so that our local records can be kept up-to-date.

Referrals from clinicians for specific cases

• Referrals for CAT unit Direct Access may be accepted from clinicians for CYP where the benefits outweigh the risks (including the patient and departmental risks). 
• Referrals for children who may be particularly unwell at presentation will not be accepted, and the family should be advised instead to attend the Paediatric Emergency Department.
• We are not currently able to receive children who are trache-ventilated.
• Clear instructions are required on the intended management when attending the CAT Unit and sub-specialty teams requesting Direct Access will be expected to be involved in the acute management of any attendees.
• The referring clinician is responsible for informing families about the Direct Access policy and when it is not appropriate to them to attend.
• Direct Access is suitable only for children who live/reside in the Leeds area.  CYP living elsewhere will be expected to attend their local hospital.
• CYP who arrive on the CAT Unit without an approved Direct Access agreement will be redirected. 

Box 2: Process to refer for Direct Access