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Nurse Led Discharge

JULIE FLAHERTY. Children’s Emergency Care Nurse Consultant. Nurse Led Discharge. Children’s Emergency Services. Presentation created by Candiss Nolan - Secretary. Aims of Session:. Present a working model of Collaborative Working across Acute Care and Primary Care

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Nurse Led Discharge

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  1. JULIE FLAHERTY Children’s Emergency Care Nurse Consultant Nurse Led Discharge Children’s Emergency Services Presentation created byCandiss Nolan - Secretary

  2. Aims of Session: • Present a working model of Collaborative Working across Acute Care and Primary Care • Present an overview of joint protocols for Acute and PCT working • Consider the efficacy of Collaborative Working

  3. WHY Change? • Audit of Children’s A&E Services showed; - unscheduled inpatient admissions – average length of stay reduced considerably < 23hrs - delayed discharge - evidence that most children’ clinical conditions stable and improve during first 4-6hr period of attending A&E - seasonal capacity problems with inpatient beds - profile of ward staff – majority E & D grade – relatively Junior Nurses

  4. Children's Emergency Services • National Perspective: • 3.5 Million children attend with injury or Acute illness • 30% of all A&E attendees are classified as children • 500 children die each year as a result of an accident • R.T.A is greatest cause of death in 11-16yr olds • 10,000 children became permanently disabled each year • 5,460 children – amputate finger • 1 in 20 children will have a fit in child hood • Cost to NHS is estimated at £100,000,000 million per annum • Personal cost is un-quantifiable

  5. FACTS & FIGURES CHILDREN’S A&E • 50% of all children attending under the age of 5yr • 20% under the age of 1 yr • Only 6% children brought to hospital in Ambulance • <0.25% children in A&E required PICU – ongoing care • 50% of 0.25% A&E – PICU children are carried in arms to A&E, private or public transport (taxi) • 90% of children attend between 10:00am-10:00pm • Twice as many boys than girl • Girls are more poorly and have greater acuity on arrival than boys.

  6. So…….. how do we get the right balance? • How do you know what you need to know, when you don’t know what there is to know in the first place? • Ask the Children • Ask the Parents/ Carers • Ask the Professionals • Hear the response • Action

  7. What Children want? • Notto be sat around waiting ages waiting to see adoctor • Not to be admitted to hospital • Not to see any blood • Not to be in pain • Not to hear/ see other children distressed or in pain • Not to be patronised – spoken down to • Not to see Doctors and Nurses looking “worried” not smiling • To understand what they are being told

  8. What do Parents/ Carers want? • For child to get better very quickly • To be told everything will be alright and to go home • To have investigations – X-ray, blood test etc • Least disturbance for whole family, to get back to normal • Reassurance their child will get better, - when it will get better (how long illness will last) - how to care for their child • To be heard when discussing their child • Prompt effective care

  9. Professionals - what do they Want? • See & treat children as quickly & efficiently as possible • Children to receive pain relief – analgesia • Where-ever possible for children to be kept at home • Reduce “length of stay” to less than 6 hours • Safe and comfortable environment – age & development appropriate • Maintain parental satisfaction • Maintain National standards and Imperatives

  10. Service perspective • Audit - 80% children attend with minor illness/ injury - as few as 6% - 16% referred to In-patient Services - 90% of children could be managed in Primary Care • Streaming - Self help - Primary Care - Minor Injury - Admissions - Majors • Workforce – daily 1. Senior Nurse – ‘G’ grade Clinical Coordinator 2. Assessment Nurse – ‘G’ or ‘F’ grade 3. Treatment Nurse 4. Admission & Observation Nurse Community Children’s Nurse SHO – Middle grade

  11. Freeing up Acute Capacity Involving Primary Care • Wherever possible to keep children at home • Reduce L.O.S <6 hrs • Service model redesign P.A.N.D.A • Seamless Service – Primary Care/ Acute Care • Collaboration with P.C.T – presentation of Audit findings • Investment – extra 3.00 WTE Children’s Community Nurse • Initial ideas – Children’s Community Nursing Team In reaching into A&E • Development of C C N’s assessment skills on par with A&E Nurse assessment skills • C C N’s to work in A&E 6 days a week 2:00pm-8:00pm then home visit children discharged from A&E up to 12 Midnight

  12. AIMS of PANDA • To provide a safe & comfortable environment for children presenting with injury/ illness who require a short period of observation before they can be safely discharged. • To improve bed efficacy & maintain effective use of hospital resources. • To maintain high patient turnover by achieving consistency with clinical management. • To maintain parental satisfaction & early return of the child with their family to the community. • To maintain national standards.

  13. P. A. N. D. A Paediatric Assessment ‘n’ Discharge Area • 6 Bedded Assessment Area • 12md – 10pm – Initial now expanded 10:00am – 12mn • PANDA Nurse • Criteria for PANDA: • A&B Saturation of >92% in Air • C Haemodynamically Stable • D G C S of >13 • Exclusion Criteria for PANDA: • N. A. I. • Acute Psychotic or Aggressive Children

  14. Collaboration;Primary Care Organisation / Emergency Medicine • Agreement on joint Protocols/ Guidelines, both medical and Nursing staff from PCT and Acute • Identify clear - Acceptance criteria - Admission Criteria - Parent Information - Guidelines for CCN home care • Common Presentations - Asthma - Gastroenteritis - Bronchiolitis - Herpes Stomatitis - Constipation - Pyrexia - Croup - Ankle Injury - Febrile Convulsion - Wrist Injury - Wound Care

  15. Criteria for Acceptance of an Infant/Child with Croup The child is suitable for home care if: A provisional diagnosis of croup is made Sa 02 > 93% in air No strider at rest Normal air entry: No nasal flaring No tracheal tug No severe recession Normal colour – according to parent/carer – no cyanosis Well hydrated – skin turgor normal – fontanel not depressed Child is taking and tolerating fluids Respirations <40 bth/min No h/o PICU for similar problem Tripartite agreement, parent/ child/ nurse A&E/ CCN or medic

  16. Criteria for Return to Acute Care of Infant/ Child with croup The child should be returned to A&E if: There is a marked deterioration from previous assessment • Stridor when awake and at rest • Sa o2 < 93% in air • Poor colour – pale – cyanosis • Agitated or reduced level of consciousness • Refusing or not tolerating fluids signs of dehydration • Increased respiration and pulse • Significant recession

  17. Seasonal Variations Winter Summer

  18. WHAT have we achieved? • Winter – 533, children discharged under joint protocol Acute/ PCT within 4-6 hrs of attending A&E - reduction in bed usage based on 23hr stay = 533 bed days costing £20,627 • Summer - 487, children discharged under joint protocol Acute/ PCT within 4-6hrs of attending A&E - received Care Closer to Home - reduction in bed usage based on 23hr stay = 487 bed days costing £18,847

  19. WHAT have we achieved? Cont: • Alleviated some pressure on in-patient beds and for the in-patient on-call teams • Diagnostic Service – X-rays, Bloods & tests • Least disturbance for family – reassurance child will get better • Appropriate Medications

  20. What Next? • Increase capacity through PANDA in Nurse Led Discharge • Decrease in-patient admissions < 23 hours • Earlier Discharge from 23hr stay 8hrs 12hrs • Nurse Led discharge on Acute General wards using joint PCT and Acute Protocols • Open PANDA for longerperiods …….overnight?

  21. Case Study • Monday 12th January 2004 – 13:23pm Boy child 04/06/01 weight 14kgs Presentation – chesty cough. S.O.B – triage YELLOW History from mother – cough for 2 months – today worse with temp. P/H/O – normal healthy little boy normal developmental milestones no major illnesses no known allergies – no family pets Immunised as per scheduled – not had T.B

  22. On examination – wheezing & coughing throughout examination Triage initial Obs/ Clinical Assessment – - Fine respiratory wheeze throughout - decreased air entry over right middle lobe

  23. Diagnostics & Care Plan Some changes in X-ray - Fluid in right middle lobe - No consolidation, no collapse - Probable chest infection Urine - blood +, protein +16:30pm require 2nd urine – before antibiotics Paracetomol 280mgs16.45pm OBS pre-discharge – Sa o2 95% Pulse 128 Temp 37 3 0c

  24. Diagnostics & Care Plan • X – ray review - Fluid in right middle lobe - No consolidation, no collapse - Probable Chest Infection • Urine – Blood & Protein 16:30pm - Require 2nd urine before commencing antibiotics • PLAN, home in Care of Children’s Community Nursing Team Visit that evening & follow-up telephone before midnight • Amoxycillin 125mg – Paracetamol 280mg CLINICAL PICTURE

  25. How Do We Stop Children Being Admitted to Hospital? By Natasha Baena and Peggy Sherwood North Middlesex Hospital at Great Ormond Street

  26. Introduction to our Team • Employed by GOSH as of April 2005 • Based at North Middlesex Hospital • In post - 4.8 Generic nurses (1 seconded to Community Healthcare Degree) plus 1 Diabetic Nurse Specialist and 1 Sickle Cell Nurse Specialist • Part of the North central sector CCN forum • Have access to a community based Palliative care team (employed by C&I)

  27. Where Do Our Referrals Come From? • Tertiary referral centres, such as GOSH and UCLH • Referrals from Day Surgery Unit • Collect referrals daily from A&E and the children’s ward at the trust • Team attends psychosocial meetings on SCBU, children’s ward and the Whittington Hospital

  28. How we stop children being admitted to hospital • Offer an acute and chronic service and our referrals reflect this • Our chronic caseload does overload the team • Nurse-led and Joint Nurse/Consultant Asthma Clinics • Should we be empowering parents to take on more nursing skills? This could reduce admissions! • Made great progress in working with local school nurses based at Special Schools - willing to do nursing treatments

  29. Continued….. • Need to have good relationships with the palliative care team, Symptom Care Team and our wards • Utilise a Fast-track facility for some of our children (Haem/Onc, Degenerative conditions) • Good discharge planning!!! NMH have recently placed a bid for a Discharge Liaison nurse who must have community experience! • Utilise CNS at Specialist Centres - we need to access other teams to develop our skills and knowledge

  30. Do all children really prefer to be at home? • Haringey has a high proportion of poor housing and deprivation (ranked No 13 out of 354 English Local Authorities for deprivation) • Can all families cope with sick children at home? Do all families want to? • Social Services and Housing often unwilling to help out • How can we overcome this?

  31. What skills do we need to nurse sick children at home? • Good clinical assessment skills vital • Excellent paediatric experience both clinical and managerial • Ability to cope with challenges and changes • Advanced skills ie Independent and Supplementary Nurse Prescribing BUT protocols in place before course is taken • Exceptionally good communication skills in our area – large non-English speaking community

  32. Continued…. • Good working relationships with Multi-Disciplinary Team especially GPs, Social Workers, Health Visitors • Good understanding of our own role – and use of Clinical Supervision ALL OF THESE THINGS ARE TIME CONSUMING BUT WORTH THE EFFORT!!

  33. National and Local Policy • Every Child Matters – key aim “to be healthy”, what does this really mean? • National Service Framework – CCNs helping to reduce admissions and duration of in patient stays, how can we achieve this? • Healthy Starts Healthy Futures (local policy for pregnant women, babies and ill children) states plan is to reduce number of paediatric in-patient beds across the sector and enhance CCN service

  34. The Way Forward! • Moving to Borough based Teams starting April 2006 • Utilising the Local CCN Forums and working collaboratively • Implementation of Children’s Trusts (has already happened in some London Boroughs) • Up and coming role of Public Health Nurse and how it effects general health, will this impact on CCN referrals?

  35. Case Study 1 • Ibrahim, 5 years old with I-cells disease • Referred via symptom care team following a PICU admission • Family aware of diagnosis and life expectancy • On O2 therapy and fed via NGT

  36. CCN Involvement • To check SpO2 levels • monitor his condition • act as a key worker • provide emotional support for the family

  37. Who else is involved? • Hospital symptom care team • Community palliative care team • Disabled children’s social worker • Dietician • School nurse • Children’s Hospice • Local ward staff • Child psychology team • Consultant at NMH • Consultant at referral hospital • Community paediatrician • GP

  38. How are we keeping him out of hospital? • Visiting as condition indicates • Preparing family for his end of life care • Empowering his family to be care givers • Encouraging his family to make choices about future treatment • Providing family centred care

  39. Case Study 2 • Maisie, aged seven years old. • Referred following an acute exacerbation of asthma from A/E Department. • Seen previous evening, discharged home on Salbutamol 4 puffs 4 hourly via pMDI and Volumatic, Beclometasone 200mcg BD via pMDI and Volumatic and Prednisolone 40mg OD for three days. • For review the following day by the CCN Team.

  40. How do CCNs manage this? • Initial telephone contact to review. • Visit arranged for that morning to:- • Do initial assessment to look at history and review of previous asthma management, • Monitor her current condition, • Review inhaler technique – pMDI being used without Volumatic, • Educate Maisie and parents in the management of asthma – to include concordance, inhaler review, how to recognise an attack and how to seek help. • Self management plan given.

  41. Future Management • Phone review over the following week until regular Salbutamol weaned off. • Nurse Led Asthma Clinic appointment in one month’s time. • Parents are aware to call the CCN team if they have any concerns.

  42. Nurse led Asthma Clinic • Further review and future management – inhaler changed to dry powder device to promote better compliance with preventor therapy.

  43. References and Key Reading • Coe, T. and Gallagher, A. (1999) “Home is Where the Care is” Nursing Times,Vol 95/3 • Department of Health (2004)Every Child Matters: Change for Children, London:Stationary Office • Department of Health (2004)National Service Framework – Children and Young People who are Ill Neighbourhood Statistics London:Stationary Office • Haringey Primary Care Trust (2005) Healthy Starts Healthy Futures • Neighbourhood Statistics www.neighbourhood.statistics.gov.uk • Sherwood, P. (2003) “The Paediatric Home-care Team and the Nurse-led Asthma Clinic” Nursing Times, Vol 99/33

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