Gastrointestinal Imaging In Paediatric IBD- Claire Miller
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Presidents Update June 28th 2020: 1. Pause of BSPGHAN/RCPCH Quality Standards Audit; 2; Shielding Update 3. Innovations. 4. ACCEA update
Dear Members
- Pause of the National Audit of Quality Standards for Paediatric Gastroenterology, Hepatology and Nutrition (‘the PGHAN Audit’).
The RCPCH/BSPGHAN PGHAN Audit Project Team have put the audit on hold during the COVID-19 pandemic and will reinvigorate the audit in August. The pause has given us an opportunity to discuss consider potential changes to the dataset that might be required due to the effects of COVID-19 on the healthcare system and PGHAN services in particular.
I am grateful for all of your input and support with the PGHAN Audit to date. The dataset had been agreed and built into a data platform which was ready to pilot in May/June. The PGHAN Audit clinical lead had registered in around 45% of Health Boards and Trusts across the UK by the end of April.
Please can I ask you to contact your Medical Director if you haven’t recruited a PGHAN Audit clinical lead.
The pause in the audit has offered us chance to reflect on its purpose in the context of BSPGHAN’s strategic intentions-
- To continue to examine PGHAN professional networks and see how BSPGHAN can support research, education and training,
- To allow us to consider the impact and value on PGHAN health care provision that the BSPGHAN Clinical Standards provide,
- To reflect critically on BSPGHAN’s function, to promote national best practice and outcomes of our patients especially moving forward from paused activity,
- To harness opportunities to support service resetting and recovery post COVID-19, and how this may be done at a national level,
- To harness opportunities to sustain any positive changes in the way we work, capturing innovations that have been rapidly developed during the pandemic (Please still feedback to me on innovations. See below **).
Additionally, it is timely to reflect on further intentions-
- To accelerate BSPGHAN’s national education strategy to develop virtual learning opportunities for trainees and members,
- To use our new website to share education / clinical updates; to measure the impact of the content of our new site;
- To build on the closer links that have arisen during the pandemic when writing joint rapid updates for example; for BSPGHAN to work more closely with key stakeholders such as the BSG, Royal College and charitable partners
- To support the productivity of BSPGHAN “task and finish” projects– using virtual get togethers. I hope that remote meetings will encourage participation from more members from devolved nations and foster rapid outputs from council and working groups.
2. Shielding Update
I know most will have seen the latest shielding letter from the Chief Medical Officer & NHS Medical Director AVAILABLE HERE which provides New clinical evidence on children
Recent experience and knowledge of the impact COVID-19 infection has on children and young people with comorbidities suggests not all those on the Shielded Patient List need to be shielding. RCPCH recently published updated guidance which paediatric patient groups they think should be advised to shield. They have identified three groups:
- children and young people who are cared for just in primary care are very unlikely to need to continue to shield;
- a small group of children who are clinically extremely vulnerable due to their pre-existing condition will need to continue to shield; and
- a further larger group of children exists who due to their underlying condition may need to shield and the decision to continue to shield would normally result from a discussion between the clinician, the child and their family.
RCPCH expect that all patients who need to continue to shield will be seen in a specialist centre before September 2020 (but not all those with specialist appointments will need to shield). Decisions on shielding will generally be led by a specialist, balancing the clinical and social impact of shielding. Patients should only be removed from the Shielded Patient List by their GP or specialist following consultation with the child and their family, and other clinicians where appropriate.
Further guidance on having conversations with children and families can be found on the RCPCH website The Government works closely with the RCPCH and welcomes their valuable scientific input. We recommend that clinicians follow up with children (and their parents) on the Shielded Patient List to discuss what RCPCH guidance means for them.
Risk stratification (adults) A team academics have been working with clinicians to develop a predictive risk model that reflects a wider range of factors such as demographics alongside long-term health conditions, to better understand cumulative risk of serious illness for individuals if they catch COVID-19. The COVID19 risk stratification model will be set out in the BMJ soon . It will only be for people aged 18 years as fortunately there’s a paucity of data for modelling in children and young people — see the publication of the research protocol
3. Feedback from members on Service Innovations **
I mentioned a few weeks back, I am keen to capture service changes relevant to our patients.
This is a polite nudge to ask those of you who haven’t got back to me, for your thoughts, so that I can make sure they’re captured.
See survey via this link or see the questions below
The survey asks the following four questions:
- What beneficial innovations/changes have occurred in your specialty and within patient pathways?
- Please describe the impact of these innovations/ changes (e.g. population health outcome, patient outcome, safety, wider system, efficiency, productivity). How did you measure the benefit?
- What is needed to sustain the change?
- What, if anything, hasn’t worked so well.
Thank you for getting back to me by 4pm on 30th June. If you can’t make this deadline, please still feedback as your input will be useful to harness and share improvements in patient pathways.
4. ACCEA secretariat update
Ministers agreed the suspension of the 2020 national Clinical Excellence Awards round https://www.gov.uk/government/news/extension-to-clinical-excellence-awards-due-to-expire-in-april-2021
Subject to Ministerial agreement, there will be an extended National awards 2021 competition, with a lengthened timetable from November 2020 until the end of January 2021.
Please stay well and as always, I welcome your involvement and your feedback.
Best wishes
Sue
Sue Protheroe
BSPGHAN President
28th June 2020
Email: President@bspghan.org.uk
Parenteral Nutrition in Children and Neonates- Elena Cernat
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President Update 14th June 2020
Dear members
COVID-19 has sadly shown that colleagues and patients from BAME communities have been disproportionately affected by COVID-19. Acknowledging and actively mitigating health inequalities is rightly high on our agenda. Recent events have additionally brought into sharp focus the need to tackle discrimination of any kind. Many young people have led the way and seized the opportunity to highlight these issues peacefully. Thinking of the young people we look after, an opinion piece in The Lancet Child & Adolescent Health https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30186-3/fulltext
has highlighted the damaging long term consequences of lack of face to face contact among young people and their peers.
We are now actively offering personalised discussions with families and young people to support continued shielding or easing of restrictions. Not all those children and young people who are currently advised to shield need to continue to do so and can return to school as it reopens where the benefits of school – in terms of access to therapies and developmental support – far outweigh the risk of infection.
This week, we will all wear face masks more widely and continue social distancing to keep our patients safe. The impact of the 2m social distancing rule in hospital impacts on our ability to reset, restore and recover health services. In England, today the Government announced that it is undertaking a review of 2m rule regarding economic recovery and we await their deliberation.
1. Shielding update for children and young people
On June 10th, the RCPCH released advice this advice on shielding guidance for children. Its aim is to support clinicians in their discussions with patients and their families/carers about the risks and benefits associated with shielding. It specifically considers children with paediatric gastroenterology, hepatology and nutritional problems using the available evidence More information is available from British Society for Paediatric Gastroenterology, Hepatology and Nutrition.
The update seeks to support the trusted relationship between patients and their doctors.
https://www.rcpch.ac.uk/resources/covid-19-shielding-guidance-children-young-people
RCPCH have offered advice regarding returning to school https://www.rcpch.ac.uk/resources/covid-19-talking-children-families-about-returning-school-guiding-principles
In England, the NHS sent a letter to NHS trusts and primary care on 4 June which outlines changes and the process for maintaining list of shielded patients (additions and removals) – see here: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0583-nhs-update-on-shielding-june-2020.pdf
1. Shielding update for children and young people
On June 10th, the RCPCH released advice this advice on shielding guidance for children. It’s aim is to support clinicians in their discussions with patients and their families/carers about the risks and benefits associated with shielding. It specifically considers children with paediatric gastroenterology, hepatology and nutritional problems using the available evidence More information is available from British Society for Paediatric Gastroenterology, Hepatology and Nutrition.
The update seeks to support the trusted relationship between patients and their doctors.
https://www.rcpch.ac.uk/resources/covid-19-shielding-guidance-children-young-people
RCPCH have offered advice regarding returning to school https://www.rcpch.ac.uk/resources/covid-19-talking-children-families-about-returning-school-guiding-principles
In England, the NHS sent a letter to NHS trusts and primary care on 4 June which outlines changes and the process for maintaining list of shielded patients (additions and removals) – see here: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0583-nhs-update-on-shielding-june-2020.pdf
Further advice is expected to be released this week from June 15th.
.2. Updated shielding guidance for children with chronic liver disease and those on and those on immunosuppression (autoimmune liver disease and liver transplantation) June 11th https://bspghan.org.uk/wp-content/uploads/2020/06/Updated-shielding-guidance-for-children-with-chronic-liver-disease-and-those-on-immunosuppression_TG-1.pdf
In view of evidence and increasing knowledge in the COVID-19 pandemic, the 3 paediatric Liver Centres updated the advice to children and families with chronic liver disease. This advice is generated following communication with colleagues from other societies (BTS, BLT, BSG, BASL) and referencing to documents released by PHE, GOV, ERN-Rare Liver, RCPCH and NHSE.
- Exit strategy from the Coronavirus (Covid 19) lockdown and ‘enhanced social distancing’ (shielding) for children and young people receiving home parenteral nutrition (HPN); a decision making framework from the BSPGHAN Nutrition and Intestinal Failure working group
Key points
- children and young people receiving HPN were advised to ‘shield’ when lockdown commenced in March 2020
- it is now apparent that gastrointestinal manifestations of Covid19 in children are mild and self limiting
- we have not identified any reports of severe complications of covid19 in short bowel syndrome (SBS), intestinal failure (IF) or HPN from Covid19, in the adult and paediatric medical literature
- mental health of children required to take quarantine measures is well described with anxiety, distress and increased risk of major mental health disorders
- all HPN children should no longer be considered ‘extremely vulnerable’ since negative social and developmental effects would appear to outweigh protection
- patients and families should have a balanced conversation about returning to school. They may wish to take a tailored approach, such as following in two weeks behind their peers to assure that initial logistics of social distancing are being followed
- If a child has coexisting disease, e.g. cardio-respiratory, neurodisability, immunodeficiency, inflammatory bowel disease (IBD) or is on certain immunosuppressive treatment that would not in itself be severe enough to warrant shielding, clinicians may wish, in conjunction with other speciality teams and families consider that the patient should continue shielding from cumulative multi-organ risk.
- The BSPGHAN motility working group has produced guidance on
Restarting neurogastroenterology and motility investigations in paediatrics. BSPGHAN Motility Working Group guidance (June 2020).
This describes restoration of neurogastroenterology for the common GI functional testing based of the best available evidence
During the height of Sars-CoV-2 transmission there were almost complete halt to gastrointestinal motility investigations as they are considered non urgent aerosol generating procedures (AGP). With the infection rate recessing in the UK, most NHS Trusts are slowly increasing capacity for elective work. Particular attention is drawn to AGP to minimise the infection risk to children and healthcare professionals.
The Motility Working Group aim is to provide guidance for clinicians on the safe restoration of selected gastrointestinal motility investigations; this guidance is based on the current evidence but this is a rapidly evolving subject and the guidance many change over time. The working group will endeavour to update this document if new information become available
- ESPGHAN Advice Guide – Treatment of Chronic Hepatitis C Infection in children
- BSG advice
In guidance on restarting endoscopy services the BSG has suggested treating patients (< 55 years) with suspected coeliac disease and a tTG >x10ULN without biopsy.
Here is the protocol further detailing this advice, which is specific to the COVID-19 environment and has been issued as interim guidance pending the publication of the new BSG Coeliac Guideline expected to be published in 2021. https://www.bsg.org.uk/covid-19-advice/covid-19-specific-non-biopsy-protocol-guidance-for-those-with-suspected-coeliac-disease/
Management of acute severe ulcerative colitis (ASUC) during the novel coronavirus 2019 (COVID-19) pandemic presents significant dilemmas. The BSG panel includes members of BSPGHAN and aimed to provide COVID-19-specific guidance using current British Society of Gastroenterology (BSG) guidelines as a reference point.
With very best wishes to you all.
Sue
BSPGHAN President, e-mail President@bspghan.org.uk
June 14th 2020