P-ACE Handbook

Bristol Royal Hospital for Children (BRHC) Children’s Emergency Department (CED) accepts patients up to their 16th birthday (i.e. aged 15 years or under).

Exception:
Young people aged 16 or over may be accepted if they are:

• Presenting with the same clinical problem they are already known to a BRHC specialist team for.

For current prescribing guidance, refer to the BNSSG Antimicrobial Prescribing Guidelines, available on Remedy:

🔗 BNSSG Antimicrobial Guidelines

• These guidelines support safe and effective antimicrobial prescribing across the region.

• Always ensure antibiotic use is clinically justified and aligned with local policy.

Blood Tests
Arranging Outpatient Bloods at BRHC

To arrange outpatient blood tests at Bristol Royal Hospital for Children (BRHC), follow this process:

1. Request the bloods on EMIS (ICE system)

   • GPs should request bloods as they routinely would for any patient.

2. Email BRHC Phlebotomy Team

   • Send an email to BCHbloods@uhbw.nhs.uk including:

     • Patient details

     • Confirmation that the bloods have been requested on ICE

     • Urgency and expected timeline for when the tests should be done

     • Whether ECG and bloods should be performed at the same appointment (for coordinated scheduling)

Note: There may be a wait of several weeks during times of high demand.

Useful links to commonly used resources.

For assessment or advice on burns:

• Contact the Burns Clinical Nurse Consultant (CNC) or Burns Registrar on call

  • Via BRHC Switchboard: 0117 923 0000

• Upload referrals and images via MDSAS

  • Create an account at: referrals.mdsas.com

  • This platform is used for submitting burn referrals and sharing images securely with the burns team.

To request an ECG or cardiology input:

1. Submit an eRS Referral

   • Referral should be sent to General Paediatric Cardiology via the e-Referral Service (eRS).

2. Include Detailed Clinical History

   • All referrals are triaged by a paediatric cardiologist, so clear and thorough clinical information is essential.

3. Patient Contact

   • The BRHC cardiology team will contact the patient directly to arrange the ECG and any necessary appointments.

4. Coordinating with Blood Tests

   • If blood tests are also required, please state clearly in the referral that both tests should be scheduled on the same day, where possible.

Forwarding Medical Notes to BRHC CED

For all children referred to BRHC Children’s Emergency Department (CED), it is essential that medical notes are shared via the UHBW electronic patient record system.

Process:

• Clinicians must upload notes directly to Careflow EPR

• Access is via remote login to the UHBW system using Pulse VPN

Refer to the attached guide for step-by-step instructions on uploading notes: P-ACE Process -upload case to Careflow EPR via REMOTE VPN Desktop

Note: Timely uploading ensures continuity of care and supports safe handover to the hospital team.

CLEO is the clinical records system currently used by BrisDoc.

• If you encounter issues using Adastra, please speak to the Shift Manager for support.

• Text messages should be sent through CLEO wherever possible, as this ensures an audit trail is recorded.

  • Instructions on how to do this can be found can be found here.

CLEO Training:

Online CLEO training can be completed on the BrisDoc Development Hub - see HERE

NOTE: if you havde not been given a login for the BrisDoc Development Hub, please email workforcesupport@brisdoc.org

The Clinical Coordinator is the senior GP on shift and can provide support with a range of clinical and operational queries.

• They are a useful point of contact for general concerns or issues affecting workflow.

• For queries that are paediatric-specific or require specialist input, it is preferable to discuss these directly with a CED consultant.

Clinical Guardian is the platform used to support ongoing clinical governance and feedback.

Access Clinical Guardian via BrisDoc Weblinks or use the following link:  https://authenticate.clinicalguardian.com/

• You will receive your login details after your first clinical shift.

• Your first 20–25 cases will be audited in full by the Clinical Guardian team.

  • If no concerns are identified, approximately 4% of anonymised cases will be audited routinely going forward.

  • If clinical concerns are raised, a senior paediatric colleague will contact you to review the case.

    • In this instance, 20% of your cases will be audited, and a follow-up discussion will be arranged.

Feedback Process:

• Feedback is provided directly within the Clinical Guardian platform.

• You will receive a monthly email reminder prompting you to log in and review any new feedback.

• You are encouraged to respond to feedback within the system if you have reflections, clarifications, or queries for the Clinical Guardian team.

The process is designed to be supportive and developmental, promoting continuous improvement and shared learning.

For same-day dermatology advice, GPs should:

• Email: bridermatologyoncall@uhbw.nhs.uk

• Include the following in the email:

  • Patient details

  • Relevant clinical history

  • Clinical images (where available and appropriate)

This service is intended for urgent advice and should not replace routine dermatology referral pathways.

The following trusted resources can be shared with parents and carers to provide clear, evidence-based guidance on managing childhood illness and wellbeing:

Healthier Together
www.healthiertogether.nhs.uk

• • Comprehensive advice for common childhood conditions

  • Traffic light safety-netting system

  • Translation and audio options available via the blue ‘Speak or Translate me’ tab

Medicines for Children

www.medicinesforchildren.org.uk

• • Practical, parent-friendly information about children’s medicines

  • Developed by paediatric experts

HANDi App
brisdoc.co.uk/handi-paediatric-app

• • Free app for parents with advice on common childhood illnesses

  • Supports decision-making on when and where to seek help

HappyMaps
www.happymaps.co.uk

• • Mental health, behaviour, and emotional wellbeing support for children and young people

  • Resources for both families and professionals

These resources can be shared via text (preferably through CLEO), printed if needed, or recommended during consultations.

For guidance on assessing and managing fever in children, refer to the following resources:

• NICE CKS: Feverish Children – Risk Assessment & Management
  cks.nice.org.uk – Feverish Children

  • Based on the NICE traffic light system

  • Provides structured risk assessment and management advice

  • Applicable across primary and urgent care settings

• UHBW Guideline: Fever in Children Aged 3 Months to 5 Years
  UHBW Fever Guideline PDF

  • Applies to children presenting to Emergency Department

  • Useful reference for severity assessment, red flags, and escalation thresholds

These resources support safe clinical decision-making and should be used alongside clinical judgement and parental concern.

Clinical Guidelines – Key Resources

Use the following trusted platforms to access local, national, and international clinical guidelines relevant to paediatric care:

Remedy (BNSSG Local Guidelines)

https://remedy.bnssg.icb.nhs.uk/

• • Select “Children & Young People” from the dropdown for paediatric-specific guidance

  • Includes infection management, prescribing, and pathways

My Staff App (UHBW)

https://uhbw.mystaffapp.org/users/sign_in

• • Download the UHBW app to access local clinical guidelines

  • Useful for BRHC-specific protocols and ED pathways

RCH Melbourne Clinical Practice Guidelines

RCH Guidelines

• • Well-structured, evidence-based guidance

  • Generally applicable to patients in BNSSG

  • Particularly useful for acute paediatric presentations

Dermatology Resources

• • DermNet NZ – comprehensive dermatology reference

  • DFTB Skin Deep – paediatric-focused dermatology guidance from Don’t Forget the Bubbles

Bookmark these sites for quick access during clinical shifts. Always refer to local policy first where available.

P-ACE rota submission and updates

The P-ACE rota will be sent by UHBW PACE clinical leads to bnssg.brisdoc.rotateam@nhs.net every three months.

• The rota must be submitted at least two weeks before the rota start date.
• Once the rota has been sent, any subsequent changes must be communicated to the Rota Team.

The Rota Team will update the rota within one week of receipt and will then assume responsibility for filling and managing the rota.

P-ACE clinicians’ honorary contracts

All P-ACE clinicians must hold a valid and active Honorary Contract. The People Team is responsible for issuing and maintaining these contracts.

• A P-ACE clinician can only be active in RotaMaster once they are confirmed as eligible to work.
• A P-ACE induction must be added to the rota.
• Shifts can only be worked on or after the induction date.

P-ACE new starters

All P-ACE clinicians must hold a valid and active Honorary Contract. The People Team is responsible for issuing and maintaining these contracts.

• Clinicians may only be made active on RotaMaster once eligibility to work has been confirmed.

Before starting work in P-ACE, new clinicians must complete both a clinical induction and a session with the Training Support Team. The Training Support Team is responsible for documenting completion of all required P-ACE training prior to the clinician commencing work.

• A P-ACE induction must be added to the rota.
• Shifts may only be worked on or after the induction date.
• Once the induction has been arranged, an email must be sent to the Rota Team at bnssg.brisdoc.rotateam@nhs.net.

P-ACE clinicians’ same day or next day sickness

If a P-ACE clinician is unable to attend a shift on the same day or the following day, they must inform both UHBW via the normal routes and the Shift Manager by calling 0117 345 9083.

• The Shift Manager must escalate this to the Rota Team and record the absence on the shift report.
• The Rota Team will request cover via RotaMaster by sending a text to all P-ACE clinicians.
• If cover is secured for the same day, the Rota Team will update RotaMaster and inform the Shift Manager in person.
• The Shift Manager must document the cover on the shift report, including any changes to attendance times.

P-ACE clinicians’ planned absence

Any planned absence must be agreed with UHBW and notified to bnssg.brisdoc.rotateam@nhs.net.

• The Rota Team will remove the clinician from the rota and follow the standard rota fill process.

P-ACE clinicians’ swaps

All P-ACE shift swaps must be arranged by the clinicians themselves.

• Swaps must be like-for-like.
• Swaps can only take place with another clinician holding a P-ACE role in RotaMaster, or against a vacant shift.
• Clinicians must notify bnssg.brisdoc.rotateam@nhs.net of all swaps.
• The clinician is responsible for notifying UHBW if the swapped shift forms part of their contractual hours.

If the swap occurs within the current week, the Rota Team must also email bnssg.iuc.managers@nhs.net. If the swap is more than one week away, no additional email is required.

P-ACE vacant shifts

Vacant shifts will be advertised regularly through multiple channels.

• All vacant shifts must have the status “Show in Shift Bookings” to allow clinicians to view and book them via RotaMaster.
• Once the three-month rota has been uploaded to RotaMaster, all vacant shifts will be emailed to P-ACE clinicians.
• This communication will be repeated every two weeks with updated vacancy information.
• The Rota Team will monitor upcoming shifts and send text alerts as needed.
• This review will take place each Monday for the following week’s shifts.

P-ACE escalation

If a shift cannot be filled, this must be escalated to the Rota Team Manager by Thursday of the week prior to the shift.

• The Rota Team Manager will review the situation and escalate to the Service Delivery Team if required.

Clinicians working on the P-ACE line should ensure they have access to the following IT systems
to support safe, effective practice:

Recommended systems and access

CLEO

• BrisDoc’s clinical system used for record-keeping and messaging.
• An NHS Smartcard is required to access CLEO.

EMIS Web

• Used to view and manage GP patient records. You need your own individual login.
• 
  EMIS training video (Out of Hours)
  

UHBW Remote Desktop (Pulse VPN)

• Access using your UHBW email login:
  https://desktop.uhbw.nhs.uk
• Required to access Careflow EPR and other UHBW systems remotely.

NHSmail

• Required for sending and receiving secure emails and communications.

Clinical Guardian account

• Ensure you have access to your Clinical Guardian account.

Toxbase account

• Create a personal login via:
  
  Toxbase registration page
  

MDSAS (Burns referrals)

• Platform for submitting burn referrals and uploading images.
• 
  MDSAS referrals – home page
  

If you experience I.T. issues while working on the P-ACE line:

1. Discuss the issue with the Shift Manager – they may be able to resolve it or advise on next steps.

2. Submit an I.T. Support Request via the BrisDoc portal:
   🔗 BrisDoc I.T. Support Request Form

Prompt reporting helps maintain service continuity and ensures timely resolution of technical problems.

To report a learning event or provide service feedback, use the dedicated BrisDoc form:

• Submit via the Learning Events & Service Feedback report form

• Accessible on the BrisDoc Weblinkshomepage

These reports help support service improvement, reflective practice, and shared learning across the team.

• For clinical advice or uncertainty around management of minor injuries, speak with a
  CED consultant for support.
• For practical guidance on assessment and management, refer to:
  
  RCH Melbourne Clinical Guidelines
  
  • A comprehensive, user-friendly resource covering a wide range of paediatric injuries and procedures.

Midos has been replaced with https://servicefinder.nhs.uk/ - Need to set up personal login/account

Observations
Normal Paediatric Vital Signs (APLS Guidelines)

Use the following reference ranges to interpret vital signs in children, based on Advanced Paediatric Life Support (APLS) guidelines:

Always interpret vital signs in the context of the child’s overall condition, including behaviour, work of breathing, perfusion, and parental concern.

Escalation:
If observations fall outside expected ranges or there are clinical concerns, escalate to the CED consultant for review and advice.

Key Phone Numbers

BrisDoc Contacts

• Patient Line: 0117 332 0653

• Professional Line: 0117 244 9283

Bristol Royal Hospital for Children (BRHC)

• Main Switchboard: 0117 923 0000

• CED Nurse in Charge (NIC): 0117 342 8207

• CED Advice Line: 0117 342 8666

  • Diverts to BrisDoc for the P-ACE clinician’s shift

Mental Health

• CAMHS Emergency Support Line: 0800 953 9599

Social Care

• Emergency Duty Team: 01454 615165

Weston Seashore Unit (WSM)

• Duty Consultant Mobile: 07502 709965

• Nurses’ Station: 01934 881371

General Paediatrics (Daytime Only)

• Consultant Mobile (09:00–17:00): 07825 283601

GP Backdoor Numbers

• Refer to the attached list, MiDOS, or ask the Shift Manager

Request photos within CLEO by clicking 'request media' from within the active case .  Click 'Refresh media' once photos have been uploaded by the patient/carer to see the image.

Tip:
You can ask the Shift Manager (SM) to request and upload photos to the CLEO case in advance of your consultation.

Ensure any photos received are relevant, clear, and saved appropriately to maintain a robust clinical record.

Please manage cases in the following order:

1. SWAST paramedic calls
2. GP calls
3. System CAS

Please filter your calls in Cleo by selecting:

• Paediatrics
• ED Validation
• Ambulance

Due to indemnity and contractual arrangements, please DO NOT pick up any of the following cases:

• Under 2s
• Toxic ingestions
• Medication enquiries
• IUC OOH cases

Remedy can be accessed via BrisDoc weblinks or directly via this link https://remedy.bnssg.icb.nhs.uk/

Remote Consulting

Use the following resources to support safe and effective remote paediatric assessments:

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BrisDoc Resources

1. Paediatric Tips & Tripwires
   Practical advice and key safety considerations when consulting remotely
   🔗 BrisDoc Paediatric Tips & Tripwires

2. Training Video (BrisDoc Urgent Care)
   Covers essential skills and frameworks for remote consulting
   🔗 BNSSG Urgent Care Training

   • You can request login details from your line manager

   • No need to complete Section 4 (PACCS training)

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External Clinical Guidance

3. Healthier Together – Remote Assessment Guidelines
   Structured framework for remote paediatric consultations
   🔗 https://www.healthiertogether.nhs.uk/

4. Video Training & Webinars

   • Tips, Tools & Templates for Remote Paediatric Consulting
     🔗 Watch on YouTube

   • Guidance on Remote Consultations (Webinar)
     🔗 Watch on YouTube

   • Remote Paediatrics with Dr Victoria Agunloye – RCM #9
     🔗 Watch on YouTube

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These resources are designed to enhance clinical confidence, support safety-netting, and promote best practice in remote paediatric care.

To access UHBW systems (e.g. Careflow EPR) remotely:

• Go to: 🔗 https://desktop.uhbw.nhs.uk

• Use your UHBW login credentials to sign in via the AVD (Azure Virtual Desktop) platform.

• For setup instructions, refer to the attached AVD Remote Access User Guide.

Remote access is essential for uploading notes to Careflow and viewing hospital records during P-ACE shifts.

Clinicians must remain vigilant for safeguarding concerns during all contacts. The following resources support decision-making and escalation.

Key safeguarding resources

• BNSSG Safeguarding Guidelines (Remedy):
  
  Referral procedures and pathways
  
• Non-mobile baby injury policy:
  
  Clinical Toolkit – Non-mobile babies
  
  • Injuries in non-mobile babies should always raise concern and require further review.
• ICON crying baby resource:
  www.iconcope.org
  • Supports parental understanding of normal infant crying and aims to prevent abusive head trauma.

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Handover to CED

P-ACE clinicians are responsible for monitoring follow-up and ensuring appropriate escalation based on clinical or safeguarding risk.

Monitoring attendance

• A digitally generated ‘red-lining’ report is checked at least once per shift.
  • This highlights any P-ACE-referred children who have not attended CED within 24 hours.

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1. Patient without significant clinical or safeguarding concerns

• Advise the referring clinician (or family, if SCAS referral) of the need to attend CED.
• Have EPR open and verify whether the child has attended. If unclear, consider calling back the parents or referrer.
• Responsibility to attend lies with the parent or guardian.

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2. Patient with significant safeguarding concerns

• Discuss concerns with the referring clinician.
• Follow standard community safeguarding pathways, including:
  • Consultation with the Community Paediatrician on call for safeguarding.
  • Referral to Social Services if appropriate.
• Document thoroughly in EPR, including a clearly marked ‘Safeguarding Concerns’ section.
• Consider a courtesy call to the CED consultant to flag concerns before the child arrives.
• Responsibility to ensure attendance lies with the family, referrer, and any
  safeguarding professionals involved.

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3. Patient with significant clinical concerns

• Joint discussion between the P-ACE clinician and referring clinician to determine the safest conveyance method.
• Ambulance transfer should be the default for clinically unstable children.
• If an ambulance is not available or appropriate, the P-ACE clinician must:
  • Discuss with the CED consultant to agree an alternative plan.
  • This discussion also serves as a ‘pre-alert’ to the department.

T: Numbers

A T: Number is required to upload clinical notes to Careflow and the EPR system at UHBW.

When is a T: Number needed?

• If the patient has previously attended a UHBW service, they will already have a T: Number.

• If the patient has not had a prior care episode within UHBW, a T: Number must be created.

How to create a T: Number:

• Ask the Shift Manager (SM) or Clinical Hub (CH) team to arrange this.

• The SM/CH will call: 0117 342 1361 to request a new T: Number.

Always ensure a T: Number is in place before uploading notes to Careflow.