Children are at greater risk of harm than many other patient groups because of their age, developmental capacity and reduced ability to speak up for themselves.
Why does this standard need special consideration by health service organisations that provide care for children?
Children's physical, cognitive and mental health needs also vary considerably from those of adults, with family being fundamental to their decision-making and wellbeing. These characteristics bring with them complexities that require special consideration by clinicians to determine children’s expressed goals of care, and the effect of their health issues on their life and health outcomes.
Criterion: Clinical governance and quality improvement to support comprehensive care
Systems are in place to support clinicians to deliver comprehensive care.
Integrating clinical governance
Implementing quality improvement systems could include providing members of the workforce and families with access to training and education that cover topics such as:
- Screening, assessing, preventing and managing physical, cognitive and mental health conditions in children
- Cross-team planning for complex patients
- Advance care planning for children, including taking into account special circumstances, such as the child’s and their family’s wishes and activity levels.
Designing systems to deliver comprehensive care
Health service organisations that operate in rural settings should consider the availability of on-site expertise in paediatrics. If this is not available, the health service organisations should ensure that there is access to 24-hour paediatric-specific advice and guidance, and ongoing education for the workforce.
Criterion: Developing the comprehensive care plan
Integrated screening and assessment processes are used in collaboration with patients, carers and families to develop a goal-directed comprehensive care plan.
Screening of risk
When developing comprehensive care plans for children, health service organisations should consider the use of validated, age-appropriate physical, cognitive and mental health screening and assessment tools to identify children at risk, including those who will require trauma-informed care.
Screening of risk requires consideration of a child’s cognitive and mental health needs because:
- They may have an existing or recently acquired condition that affects their cognitive functioning, including their language, thinking, judgement, memory and behaviour
- They may experience global developmental delay or a diverse variety of specific cognitive difficulties, which may increase their risk of harm
- They may be seriously ill and at risk of developing acute cognitive impairment or delirium41
- The presentation, causes and appropriate management of mental illness may be very different from those of adults
- They may be more likely to exhibit disturbed behaviour, such as aggression, because of
- age-related variations in cognition, interpersonal skills, impulse control and defence mechanisms
- developmental delays and learning difficulties
- mental health disorders such as separation anxiety
- loss of meaningful contact with family
- restrictions on their ability to play42
- trauma resulting from domestic violence.
Screening will also require assessment of parental status and capability, other dependent children, and family support needs and how these may affect the child receiving care.
The screening and assessment tools used should be evidence based, and appropriate to the child’s age and development, and the process of screening should engage children and their families.
Developing the comprehensive care plan
The process of care planning should take into account the preferences of the child and their family. When developing a comprehensive care plan for children, clinicians should also consider their innate needs, including their need for attachment, which allows them to connect with and gain reassurance from their family during times of need or distress.43 Children who have family who respond sensitively to their needs during such times have better outcomes relating to emotional and social development, mental health and educational achievement.43 Health service organisations should ensure that strategies to support, develop and enrich attachment are used and are tailored to the child’s developmental age – for example:
- Supporting skin-to-skin touch soon after birth
- Supporting breastfeeding practices
- Enabling supportive touch from family members during procedures
- Enabling families to provide their own meals, toys, clothing and bedding
- Providing rooming-in facilities (if appropriate)
- Enabling flexible visiting arrangements
- Enabling family members to accompany a child through transitions of care – for example, to the medical imaging department.
Developing the comprehensive care plan involves planning for discharge from the health service organisation. Health service organisations that provide care for children should consider:
- Engaging with families about care required post-discharge
- Identifying any services, equipment and follow-up that may be needed to safely send the child home
- Developing processes to ensure that follow-up arrangements are made before a child is discharged from the health service, including communications with general practitioners and other providers of primary care
- Developing processes to ensure prompt referrals – for example, mandatory reporting of suspected child abuse and neglect to government authorities as per state and territory requirements
- Developing processes to inform the family and other providers and agencies, such as schools and childcare centres, of ongoing care requirements.
When developing a comprehensive care plan, health service organisations need to consider how to support children whose gender identity and expression differ from the gender assigned at birth. Health service organisations can refer to the Australian Standards for Care and Treatment Guidelines for Transgender and Gender Diverse Children and Adolescents.44
Health service organisations should also consider implementing trauma-informed care to recognise the impact that traumatic events have on a child’s wellbeing. Clinicians should be aware of, and seek to prevent, the trauma occurring, and avoid triggers that can lead to traumatisation and re-traumatisation.45 Providing trauma-informed care involves:
- Understanding the impact of trauma on children and the family
- Providing care in a place that is physically and emotionally safe
- Ensuring the workforce is culturally competent and can implement practices that are respectful of cultural backgrounds
- Helping children who have been victims of trauma regain control of their day-to-day lives
- Including communities in governance processes and decision-making about the design of services
- Promoting safe relationship-building as part of healing and recovery.46
Health service organisations can improve the planning and delivery of care for children with complex care needs, including those with a developmental delay, intellectual disability, mental health condition or chronic disease, by:
- Developing care plan templates that are readily accessible and can be tailored to children’s individual needs
- Providing guidance on the best way to deal with common conditions
- Documenting the most effective method of engaging with children and their families
- Limiting the time children spend in unfamiliar environments to reduce agitation and the potential for aggression
- Considering the number and types of tests required and whether these can be performed at home.
Criterion: Delivering comprehensive care
Safe care is delivered based on the comprehensive care plan, and in partnership with patients, carers and families. Comprehensive care is delivered to patients at the end of life.
Using the comprehensive care plan
Health service organisations providing care for children need to work together with the child and their family to ensure that care is delivered in the most acceptable manner. This helps prevent the child feeling frightened, which may influence future healthcare-associated anxiety. The child and their family should be involved in the child’s care whenever possible, such as when procedures are performed and during clinical handover – unless the child expresses a wish otherwise.
Comprehensive care at the end of life
Delivering end-of-life care requires special consideration and sensitivity from health service organisations that provide care for children.47 In advance care planning, the needs of children are different from those of adults because of the need to:
- Ensure that the needs of the child and other organisations that provide care, such as schools and preschools, are met
- Involve and coordinate clinicians and nonclinical support members of the workforce with specialised skills in child and family health care, including general practitioners and other members of the primary care workforce
- Understand and anticipate the different responses of children to symptoms and treatments
- Deal with family and societal expectations that children will outlive their parents
- Deal with the uncertainty of prognoses for children and a tendency to focus on cure-oriented treatment.48
When end-of-life care is provided to children, the health service organisation should consider having policies, procedures and protocols to:
- Consult with children and their families when developing advance care plans that cover the child’s and their family’s preferences for future care
- Consider the legal capacity of children to make decisions about their care, understand their prognosis and express a view
- Ensure that clinicians understand their legal and ethical obligations, including determining the child’s capacity to understand and be involved in clinical decisions about end-of-life care
- Implement advance care plans that have been developed in the community
- Document advance care plans in the child’s healthcare record
- Inform clinicians in the care team of the existence of advance care plans
- Periodically review or amend advance care plans.
When end-of-life care services for children are not available, the health service organisation should ideally have processes to refer children to appropriate services or build networks to obtain prompt specialist advice.47
Criterion: Minimising patient harm
Patients at risk of specific harm are identified, and clinicians deliver targeted strategies to prevent and manage harm.
Preventing and managing pressure injuries
Children may be at an increased risk of pressure injury because they may:
- Have an increased body temperature
- Have high or low body mass index and/or birth weight
- Be unable to verbalise their pain or discomfort
- Be incontinent
- Have immature skin
- Have mobility-limiting conditions or a neurological impairment
- Engage in active play that may inadvertently cause friction and self-harm
- Have medical devices that are firmly secured to reduce the risk of unintentional or intentional removal because of the active nature of children.49,50
To minimise the risk of harm from pressure injuries in children, health service organisations may:
- Develop a child-specific policy, procedure or protocol on friction or pressure injuries
- Describe and use prevention strategies and practices
- Develop processes to identify patients who are at risk of friction or pressure injuries through an initial assessment, and require regular and repeat assessments
- Ensure the use of validated, age-appropriate risk screening and assessment tools to determine children’s risk of developing a pressure injury and implement relevant mitigation strategies – for example
- the Glamorgan Pressure Injury Screening Tool (which includes a Paediatric Pressure Injury Risk Assessment Scale)51
- the Modified Braden Q Scale52
- the Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown (NSRAS)53
- Agree on risk-based care pathways and monitor their use
- Provide information to families on the prevention and ongoing management of pressure injuries, as many factors that cause childhood pressure injury may be present on discharge – for example, spina bifida, low birth weight and naso-gastric feeding tubes.
Preventing falls and harm from falls
Reducing the risk of falls for children requires special consideration because of:
- The different environmental factors that may influence a child’s risk of falling compared with an adult’s risk of falling, such as the height of beds and cots, and entrapment between mattresses and bed or cot sides
- Differences in physical factors, including coordination and body strength, and different communication skills of children compared with adults.
To minimise the risk of harm to children from falls, health service organisations may consider:
- Providing education and support to children and their families to identify risks and help prevent falls, including information on falls risk factors such as co-sleeping, the influence of medication and sedation, changes in blood pressure in adolescents, and reduced mobility during rehabilitation or recovery from injury and illness
- Educating families on the risks of harm from falls at home and in the community.
Nutrition and hydration
To ensure proper nutrition and hydration of children, health service organisations may consider:
- Implementing processes to deal with allergies, including for complementary feeds
- Using child-specific fluid management balance and measurement charts
- Providing child-friendly foods that are both nutritious and attractive to children
- Using strategies that prevent children from disconnecting intravenous or feeding tubes
- Preventing the accidental interchange between enteral and intravenous equipment.
Preventing delirium and managing cognitive impairment
Many of the prevention and management strategies used for the adult population are relevant to children, such as a supportive environment and the active involvement of families.41 To minimise the risk of harm from cognitive impairment in children, health service organisations may also consider:
- Identifying children with cognitive impairment, understanding their specific communication and additional care needs, and implementing an individualised plan to minimise risks of harm and distress
- Identifying children at risk of delirium and incorporating delirium prevention strategies into the plan
- Assessing for delirium when there is any change to behaviour or thinking, and investigating and treating the causes of delirium
- Assessing and investigating changes in cognitive function, and treating the cause of cognitive impairment if appropriate
- Providing delirium information to families of children at risk of, or with, delirium; this may include information about cognitive impairment and other condition-specific information
- Ensuring clear communication with primary care providers at transitions, and when referring children for further assessment and treatment – especially when previously undiagnosed neurocognitive problems or learning problems are identified.41
Predicting, preventing and managing self-harm and suicide
Strategies to prevent and respond to suicide and self-harm should be appropriate to children, young people and adolescents.
Suicide prevention for Aboriginal and Torres Strait Islander children requires special consideration by health service organisations that provide care for children because the suicide rate among Aboriginal and Torres Strait Islander people aged 5 to 14 was 7.5 times that of other Australian children in 2011–2015.54 Therefore, health service organisations should consider:
- Implementing relevant recommendations and success factors identified in the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project final report55
- Referring to the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, which outlines strategies to build strengths and resilience in children and families to reduce the risk of suicide and self-harm.56
Predicting, preventing and managing aggression and violence
Children are at risk of experiencing negative physical and psychological outcomes as a result of coercive interventions such as restraint and seclusion.42,57 Therefore, health service organisations should employ child-specific strategies to deescalate aggression among children that are based on principles of:
- No restriction
- Fostering therapeutic relationships between clinicians and patients57
- Focusing on actively engaging children in their own care
- Including the family in the development of safe, long-term management strategies.
Health service organisations may consider developing policies, procedures and protocols on the acceptable and appropriate use of alternatives to restraint and seclusion to manage behaviours of concern in children. For example, health service organisations may consider ‘sensory approaches’ specifically tailored to children to minimise the chance of aggression and other behaviours of concern.58 Such approaches can be used to alter a child’s arousal level, making them alert or relaxed.58 The success of sensory approaches depends on the child.58 Some examples of sensory approaches to deal with aggression in children include:
- A calming setting with space to move around freely
- Therapeutic touch.
Therapeutic touch does not restrict movement, but rather provides a calming reassurance to children, especially when coupled with calming words, practical engagement strategies and practical refocusing. Organisations should set clear boundaries on what is appropriate and inappropriate therapeutic touch.
There are substantial risks associated with placing adolescents and young people with challenging behaviours, such as aggression, into adult mental health units. In such circumstances, health service organisations should be informed by relevant state and territory policy frameworks, and consider having policies in place to mitigate these risks.59 Preparations may include:
- Conducting a formal risk assessment of the unit, other patients and the child, including the likelihood of the risks occurring and consequences for the child
- Considering the conditions and their suitability for the child
- Obtaining clear agreements between the adult mental health service, the emergency department, and the child and adolescent mental health unit on care.59
Minimising restrictive practices: restraint; minimising restrictive practices: seclusion
There are marked risks associated with the use of restraint and seclusion in children, including injury and even death.57 The principles of minimising and, if possible, eliminating the use of restraint and seclusion of children are the same as those for adults. However, the risks of harm are increased for children because of their high level of mobility and the possibility they have not perceived the consequences before acting. The key to minimising use of restrictive practices is to be alert to changes in a person’s behaviour or demeanour that may suggest deterioration in their mental state. Strategies to engage and redirect behaviours may need to be considered to provide opportunities for both structured (for example, art) and unstructured (for example, going for a walk) diversion.
Whenever the use of restraint or seclusion does occur, health service organisations should follow policy that:
- Complies with relevant state or territory legislation on consent, restraint and seclusion
- Supports the review and removal of restraint as soon as practicably possible.