New England - CNC Paediatrics
This project involved the employment of a Child Health CNC for New England Area Health Service to assist in enhancing the long term health outcomes of infants and children by promoting the delivery of high quality paediatric, infant and child and adolescent health services. The CNC assists in developing sustainable partnerships between acute, specialist and primary health care services to infants, children and adolescents. A critical role for the Paediatric CNC is to support the New England Area Health Service in the implementation of the Paediatric Clinical Practice Guidelines. Initially, this work occurred in piloting the guidelines in the Emergency Departments of Tamworth and Armidale Hospital and Warialda MPS. The Paediatric Clinical Nurse Consultant was recruited to the position in May 2004. Funding was allocated through the Northern Child Health Network to employ the CNC two days per week during 2004/05. Additional funding was allocated from New England Area Health Service operational funds to enhance this position with a further two days per week. As a result, the Paediatric CNC has been working 4 days per week during 2004/05. Other objectives for the CNC include:
- Assisting in the development of the area Paediatric Services Plan which includes area-wide delivery of clinical services, such as outreach and visiting services.
- Developing and implementing an area professional education strategy for staff involved in the delivery of health care services to infants and children.
- Working collaboratively with the Northern Child Health Network and in particular the Paediatric Outreach CNC.
- Assessing and developing strategic responses to the primary health care needs of children across the New England region.
Since the Paediatric CNC was appointed she has achieved the following:
- The Asthma, Gastroenteritis, Croup, Fever and Bronchiolitis Guidelines have been implemented in Tamworth, Armidale and Warialda. Pre and post implementation audits have been conducted with positive results.
- A Steering Committee to coordinate the implementation of the Paediatric Guidelines in Health facilities within the New England region has been established. This includes 16 sites. The CNC is taking a lead role in coordinating local site implementation teams.
- A teleform has been implemented concurrently with the paediatric clinical pathways. The teleform collects 'live data' and has proved to be an effective monitoring and evaluation tool.
- The Paediatric CNC conducted 11 site visits and provided 21 paediatric inservices from January 2005 - June 2005. These included presentations at: 2 Paediatric Advanced Life Support sessions; 1 Graduate Nurse Education session; 1 FLECC Course presentation; 1 presentation at the Emergency Care Seminar; 1 presentation to the Area Respiratory Education; 3 Paediatric Advanced Resuscitation Workshops (PARS days - NETS and NCHN); and 2 Asthma Education sessions.
- The Paediatric CNC participated in the initial statewide Children's Health Priority Taskforce workshop.
- The Paediatric CNC was invited to present at two significant forums
during 2005 to discuss the implementation of the PCPGs within the New
England region. The forums were:
- Children's Hospitals Australasia Paediatric and Child Health Division, Royal Australian College of Physicians, Grand rounds and Round table with Paul Kurtin at Sydney Children's Hospital in February 2005
- Women's and Children's Hospitals Australasia Conference in Christchurch, New Zealand in May 2005.
- The Paediatric CNC participated in an education exchange program with the RN from Taree/Manning Base.
- The Paediatric CNC has submitted reports regarding the implementation of the PCPGs to the Clinical Excellence Commission, NCHN and to the Area Health Service as required and has attended 2 Clinical Excellence Commission Children's Emergency Care Program workshops.
- The CNC has actively participated in the statewide Rural and Remote Paediatric Clinical Practice Guideline Development Group. This group is responsible for the development of a companion volume of paediatric guidelines for rural and remote practitioners.
- The Paediatric CNC provides a consultancy and case coordination role in the management of 2 patients with complex needs in Moree and Armidale. The CNC has continued to support the paediatric outreach oncology clinic in Armidale.
Discussion
The Clinical Nurse Consultant has assisted in raising the profile of paediatric and child health concerns across the New England region. Since the appointment of the Paediatric CNC in May 2004, she has addressed previously unmet needs through training, education and reviewing standards and clinical practice in relation to the acute care of children, particularly in smaller health facilities. The AHS has made extensive use of the Paediatric CNC in providing paediatric clinical education in 'core' education programs. This is resulting in the 'cementing' of the position in the culture of the organisation.
Implementing the paediatric clinical practice guidelines in the pilot sites (Tamworth, Armidale and Warialda) has proved an overwhelming success. The Implementation teams comprising nursing staff and medical officers and/or GP's have worked cohesively and have positively engaged health staff in implementing the guidelines. The 6-month post implementation audit indicated improvements in:
- recognising and documenting the severity of asthma
- good use of asthma plans
- appropriate use of spirometry
- use of asthma facts sheets
- appropriate trial of fluids
- success with oral rehydration.
The introduction of teleforms used concurrently with pathways has proved a very successful strategy in monitoring the compliance with guidelines and as an evaluation tool. Pilot sites have also introduced croup, fever and bronchiolitis guidelines. In addition to implementing the guidelines, the pilot sites have identified successful components assisting with the process of guideline introduction. These include:
- the organisational structure and culture of the organisation
- the applicability of the guidelines to the triage process
- the practicality of the guidelines (Are they accessible and concise? Are they user friendly?)
- consistency of staffing
- engaging opinion leaders
- simplicity of guidelines - if they are lengthy/complicated they will not be incorporated in practice
When introducing the PCPGs in Warialda, the local GP was actively involved in this process. This proved to be a most successful strategy and has highlighted the importance of modifying practices in rural and remote communities to suit current modes of operation of rural doctors. GP involvement is central to the success of such a project in the rural areas, and the active participation by GPs has been identified as extremely vital. The learnings from Warialda will be applied when implementing the guidelines elsewhere in the region.
Major outcome
NSW Health have recognised the invaluable work of the Outreach CNCs are now recurrently funding these positions across NSW.