Central Coast - Paediatric Emergency Liaison CNC
Joint NCHN and Western Child Health Network funding enabled Central Coast Health to continue the position of Paediatric Emergency Liaison Clinical Nurse Consultant until June 30 2005 to provide:
- Liaison with Paediatric Networks and NSW Health to enhance consistency, continuity and the provision of high quality care to the families that present to Emergency Departments of Central Coast Health.
- Facilitating the development of numerous guidelines from the draft NSW Health Paediatric Clinical Practice Guidelines. These guidelines will be reviewed and amendments made as necessary due to the release of the final copies of all of the guidelines.
- The local adaptation of the bronchiolitis, croup, abdominal presentations and bacterial meningitis guidelines has taken place via working party meetings, continual collaboration, feedback and review. Furthermore, the completion of quality projects such as the Gastroenteritis and Asthma audits has taken place.
It was envisioned to extend the original position of Paediatric Liaison Nurse situated purely at Wyong Emergency Department to encompass both Emergency Departments on the Central Coast. The key aspects of this role are to facilitate efficient patient management, provide education to parents and staff, actively assist in advanced paediatric clinical procedures and education. The implementation of NSW Health's Paediatric Clinical Practice guidelines becomes paramount in achieving these key aspects.
The objectives of this position were to:
- Develop evidence-based resources to facilitate the continuity of care and implementation of the Department of Health Paediatric Clinical Practice Guidelines within a quality framework.
- Enhance existing knowledge and clinical skills of nurses in Emergency Departments throughout Central Coast Health, in the specialty of paediatrics.
- Participate in the direct specialist care of children, providing incidental clinical education in collaboration with existing education and consultancy nursing services, and provide education to parents accessing the Emergency Departments throughout Central Coast Health; and
- Establish and maintain ongoing consultation and negotiation with key stakeholders to maintain communication links across Paediatric areas within Central Coast Health.
The following has been achieved:
Number of in-service teaching, eg, as evidenced by the number of staff accredited to administer inhalation analgesia
- 26 in-services delivered, with 162 staff attending (an average of 6.2) since the commencement of the project.
- 10 additional staff accredited for Administration of Nitrous oxide. A further 16 staff have been given formal in-service in preparation for accreditation.
- 108 occasions of incidental clinical teaching sessions as recorded by diary entries.
- Since the commencement of the project 226 occasions of direct patient care have been attended as per diary entries.
The acute management of young children and infants with gastroenteritis
Documentation of severity of dehydration
An overall improvement in documented initial degree of severity of dehydration has occurred. This improvement has continued in 2005. Anecdotally, nursing and medical staff recorded the documentation of initial severity when the audit packs were used in 2004, however medical staff predominantly undertook the documentation in 2003 and 2005. This suggests the use of prompts such as the audit pack encouraged better documentation of assessment by all clinical staff.
Promote the use of DOH recommendations and increase 'trial of oral fluids' within 10- 30 minutes of presenting to triage
A 40% improvement in nursing staff commencing oral rehydration therapy prior to being reviewed by a medical officer in 2004 compared to 2003. A further 10% improvement was noted in 2005.
Promote the use of oral rehydration for children with mild-moderate dehydration
Whilst Oral Rehydration Therapy (ORT) has been recommended for several decades, it is often not well done by Emergency Departments outside major paediatric centres. Here at Central Coast Health, it has been shown that through constant education, development of clinical pathways, formal/informal teaching sessions and most importantly direct clinical support, that improvements in patient outcomes can be made.
The audit results 
(pdf 54K) revealed a 45% increase in the use of oral rehydration as an
initial treatment modality over the 2-year period, 97% of children presenting
with mild-moderate dehydration are receiving oral rehydration as their
initial treatment modality. A sustained reduction in the use of IV therapy
as initial treatment has been noted. Moreover, the findings indicated
a 36% improvement in appropriate ongoing treatment of gastroenteritis
presentations in Gosford Emergency Department from March/ April 2003 when
compared with the same time period in 2004.
Promote the use of nasogastric rapid rehydration for children
The promotion of rapid NG rehydration is ongoing. This is being achieved by incidental clinical teaching, role modeling via direct patient care, evidence based resource development, and formal in-service time. The audit results indicate that the overwhelming success of oral rehydration has negated the need to increasingly use rapid NG rehydration for children with gastroenteritis. Furthermore, there was a 14% reduction in the inappropriate use of intravenous rehydration during this time.
Reduction in admission rates/represents and length of stay
Current literature suggests that the failure rate for oral rehydration therapy is as low as 5%. 95% of children who present with mild to moderate dehydration, secondary to gastroenteritis, may potentially be successfully rehydrated via the oral route, thus avoiding hospital admission. The improvement in the discharge of gastroenteritis presentations from 74% during March /April 2003 to 85% during the same time period in 2005 was overwhelmingly positive. At Central Coast Health, these results prove a sustainable reduction in admitting children with gastroenteritis by at least 11%.
Number of in-services, additional resources developed
- 13 in-services have been given, with an average of 3.8 staff attending incidental in-services/clinical teaching sessions.
- IV fluids chart reviewed and updated to reflect DoH guidelines.
- 39 incidental in-services/clinical teaching sessions regarding gastroenteritis management as recorded by diary entries.
- Ongoing provision of discharge advice to parents.
- Continuation of gastroenteritis pathway packages in both Emergency Departments. The package provides prompts for best practice, and both parent and staff education.
The Acute Management of Children with Asthma, Clinical Practice Guideline
It is important to note that this audit took place only four weeks after the implementation of the Asthma Guideline had taken place, and another one is planned to be undertaken at the same time in 2005 to monitor the progress of the project.
Nursing documentation of initial severity at triage
Whilst documentation of initial severity increased overall, there was a notable difference between the advances made by Gosford Emergency department to that of Wyong.
Initial treatment modality
The use of spacer devices for the administration of salbutamol to infants and children with asthma as first line management increased by a staggering 46% in Gosford Emergency Department over a four-week period, compared to a 9% increase by Wyong. It is important to note that at Wyong although initial treatment was mostly nebuliser therapy; there were a very large percentage of these children being changed over to spacer therapy during their emergency department visit.
Appropriate initial treatment
The results indicate that 71% of children who presented to Gosford Emergency department during the audit period received appropriate initial treatment (that is the very first treatment administered once in the department). In contrast, 32% of patients who presented to Wyong Emergency Department received appropriate initial treatment (they received nebuliser therapy instead of the recommended spacer therapy for mild to moderate asthmatics).
Appropriate length of observation
The audit results indicate that only 50% of patients are being observed for the recommended 3 hours, most are being discharged within 1-2 hours of treatment.
Disposition, asthma action plans and referrals
With up to 80% of all patients presenting with asthma during this time period being discharged, Central Coast Health is endeavouring to provide appropriate asthma action plans and community referrals to maintain the links whilst these children are managed in the community. There has been extensive involvement of the Community Paediatric Asthma Educator in developing resources and providing follow-up after discharge in assisting in reducing representation rates and improving appropriate management of children with asthma within Central Coast Health.
Increased number of opportunistic immunisations
- The aim of this is to increase awareness, knowledge of, and the number of opportunistic immunisations and the correct storage of vaccines in both Gosford and Wyong Emergency departments.
- The Paediatric Emergency Liaison CNC established a consultative relationship with immunisation professionals within Central Coast Health Child and Family Health and Public Health with goals to establish sustainable education and support in clinical practice.
- Furthermore an entire day where immunisation coordinators will provide direct clinical support and education to two staff representatives from both Gosford and Wyong Emergency Department took place on 27/01/05. This day endeavoured to develop resource folders, education sessions and establish a contact personnel in each department to address local needs.
- Resource folders were developed, regular meetings established and communication/education strategies formulated to address immunisation issues in Emergency.
Participation in the pilot site project run by the Clinical Excellence Commission
- Central Coast Health has been an active participant in the Children's Emergency Care Project (CECP)
- Presented at the Clinical Excellence Commission conference in Sydney, in October 2004 on achievements thus far.
- Audits sent out from Clinical Excellence Commission to obtain information on the management of Gastroenteritis, Asthma, Fever and sick children presenting to Central Coast Area Health service have been completed and sent back to Clinical Excellence Commission as requested. Post implementation audits are being collated.
- Pre-implementation audits for Bronchiolitis, Croup, Head injuries and Bacterial Meningitis due to commence.
- Local audit results for sustainable change in the Management of Infants and Young Children with Gastroenteritis presented back to Clinical Excellence Commission.
- Achievements in asthma management presented at Chronic Care Collaborative run by the Clinical Excellence Commission.
- Paediatric Emergency Liaison CNC an active team member in the development of Paediatric Companion Manual for the Rural Emergency Clinical Guidelines for Adults.
Discussion
Time has been spent establishing and maintaining ongoing consultation, negotiation and support with other network partners. Regular contact was made via e-mail, telephone or meetings arranged with individuals to provide mutual support and information sharing. This initiative sought to foster communication links across Area Health Services. Specific discussions with people have focused on the sharing of information and resources, experiences and ideas regarding the current locally adapted guidelines, education initiatives, barriers to implementation, and maintaining collaboration with all involved.
The team at Central Coast have completed the local adaptation of all 12 Paediatric Clinical Practice Guidelines, and actively educate, update and support staff to endeavour to ensure sustainability. The successes gained in the project are owed to the dedicated team members, who seek to constantly improve and provide high quality evidence based care to the children presenting to their Emergency Departments for treatment.
Major outcome
NSW Health have recognised the invaluable work of the Outreach CNCs and are now recurrently funding these positions across NSW.