Single clerking: A more efficient paediatric admission process for the COVID-19 era and beyond

ABSTRACT

Background Traditionally, patients requiring admission from the Emergency Department (ED) are initially clerked by the ED team. Following this clerking they undergo a further clerking by a junior grade from the specialty team, and then they are reviewed by a senior member of the specialty team. This traditional clerking style creates duplication of work, reduces patient flow whilst awaiting further clerking and delays the time to review by the specialty senior decision maker. Objectives This is an evaluation of a new single clerking referral pathway for children and young people that require admission to General Paediatrics from the Paediatric Emergency Department at Royal Manchester Children's Hospital. It was introduced in October 2020 to streamline the patient admission journey and reduce duplicate clinician contacts in light of the increasing number of COVID- 19 cases. The introduction of the single clerking pathway meant that patients requiring admission were clerked by the ED team and then referred directly for review by a senior member of the paediatric team, avoiding a duplicate clerking from a junior paediatric grade. A senior grade was defined as an ST3 or above. Methods A retrospective review was undertaken of all referrals to general paediatrics from the ED for seven consecutive days (12th-18th October 2020) prior to the implementation of the pathway. Six weeks after implementation of the pathway a further seven consecutive days (6th-12th December 2020) of referrals were reviewed. The primary outcome was to determine the mean time from attendance to the ED to review by a paediatric senior grade clinician. Results 76 children were referred to general paediatrics from 12th to 18th October;21 of these cases had a traditional clerking. The mean time from attendance to the ED to review by a senior member of the paediatric team was 202 minutes. 17 of the remaining 55 cases had either a simultaneous clerking by junior and senior grade, or a direct senior review from the general paediatric team. The mean time from attendance to the ED to senior input for these patients was 170 minutes, suggesting that even prior to implementation of the pathway the single clerking structure streamlined the patient's journey. There were a total of 38 cases excluded from analysis due to incomplete documentation. During the week of 6th to 12th December, 80 children were referred to general paediatrics from the ED;25 admissions had a documented single clerking as defined in the new pathway. The mean time from attendance to the ED to review by a senior member of general paediatric team was 151 minutes. The remaining 55 admissions had either inadequate documentation or incorrect implementation of the pathway. Conclusions The introduction of a single clerking pathway has shown promising early data by demonstrating a 25% reduction in mean time taken for senior specialty input compared to a traditional clerking. The next stage will aim to address the reasons why the pathway was not implemented and strategies to improve documentation of clinical interactions as it is recognised that large number of cases were excluded due to inadequate documentation.