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2004-05
Hunter - Project Officer - Guidelines, Standards and Protocols

Hunter - Project Officer - Guidelines, Standards and Protocols

It was established that in line with the Guidelines for Networking of Paediatric Services in NSW, safety and quality of services should be promoted through the consistent application of current guidelines, standards and protocols. These ensure that no matter where a child is treated, there would be a common approach to treatment. This would assist healthcare providers, particularly those staff likely to move between services, eg registrars, nurses, allied health.

These common approaches would also give parents and carers certainty that treatment plans would be unlikely to alter significantly, even if the child required transfer to a different centre. Over time, greater confidence in local services, strong links with the Children’s Hospital and improved access should be achieved.

The Project Officer was employed to develop and implement these documents.

Method

Needs assessment (relating to guidelines) conducted in both the acute and community sectors; reports with recommendations and action plan circulated to stakeholders and survey participants
Identified, facilitated/convened and participated on appropriate meetings at state, area and sector level (including combined Emergency Department Clinical Practice Guideline (ED CPG) implementation working party, JHH ED CPG implementation working party, Children’s Emergency Care Project (CECP) teleconference, combined Children’s Hospitals reference group, Clinical Excellence Commission (CEC) Children’s Emergency Care Project (CECP) state meetings, home visiting, restraint and area guideline development)
In collaboration with relevant working party members, developed and documented the systems used for:
- Area applicable guideline development, dissemination and implementation (this relates to existing guidelines that have been identified as being “applicable” area wide)
- Standardisation of area guidelines (relating to format and development process) and online publishing on Kaleidoscope Web site
- Review/development and ratification of procedures/guidelines for John Hunter Children’s Hospital
- Implementation of 12 emergency department clinical practice guidelines (CPGS)
Collaborated with colleagues throughout the area to develop guidelines, pathways and procedures for area use and online dissemination. Examples include:
- Kaleidoscope Restraint Guideline (in partnership with other members of the Restraint Working Party) including development of a briefing paper describing the development and consultation process and development of restraint resource folders for JHCH
- Facilitated the review of the tonsillectomy and traction guidelines (including literature review, liaison with specialists, consultants and clinicians and drafting of the documents)
Developed selection criteria and interview questions, and participated on the interview panel for the JHCH Project Nurse position
Mentored two Project Nurses, from JHH ED and JHCH, who have been employed to assist with the implementation of the CECP. Mentoring includes the provision of ongoing support (in person and via phone and email), provision of information and resources, clarification of processes relating to project management, assisting with quality improvement activities and advising on strategies relating to implementation success and dealing with barriers
Participated in quality improvement activities (eg literature search, networking with NSW colleagues, development of audit tools, data collection/analysis, presentation of results and provision of inservice education)
Provided regular reports to various forums including electronically to HUB, Kaleidoscoop, Inside News, HUDGP newsletter, News Net and What’s Up Doc; and to KEAG meetings, regular performance and NCHN project reports
Collaborated with John Hunter Children’s Hospital staff to review clinical practice guidelines and procedures and implemented changes to improve efficiency of the review process
Collaborated with to for quality award submission relating to CECP

Outcomes

Needs Assessments
- Acute sector - 24 staff interviewed, report written (pdf 441K) and circulated and identified issues (eg relating to communication and access) have been actioned
- Community sector- 19 staff interviewed, report written (pdf 181K) and circulated and identified issues (eg relating to communication and access) have been actioned
- John Hunter Children’s Hospital clinical practice manual staff survey - 36 staff interviewed (see attached report (pdf 75K))
Area Guidelines
- Facilitated the ratification of the following guidelines/protocols and their inclusion on the Kaleidoscope web site:
  - Traction
  - Tonsillectomy
  - Restraint
  - Home Visiting
  - Nasogastric Tubes - insertion and removal
- Facilitated the inclusion of the following guidelines/protocols on the Kaleidoscope web site:
  - Pain Management in Emergency Departments
  - Triage - recognition of a sick child
  - Oxygen Therapy
  - Admission and Transfer to Higher Level Facility
  - Gastroenteritis Assessment and Initial Management
Area Emergency Department Clinical Pathways (tertiary and rural site versions):
- Collaborated in the development and trial of the following pathways:
  - Fever
  - Asthma
  - Croup
  - Bronchiolitis
  - Bacterial Meningitis
  - Otitis media
  - Seizure
  - The tertiary site version for Head Injury, Abdominal Pain and Sore Throat pathways have been drafted but are awaiting further refinement before being trialled.
Audit Results
- Audits conducted in July and December, 2004 at JHH and Maitland (by members of the ED CPG Implementation Working Party) for the CECP demonstrate the following improvements:
  - JHH recognition of sick child “appropriate treatment given” to 100% (up from 88%)
  - JHH gastroenteritis “discharge information given” to 60% (up from 14%)
  - Maitland gastroenteritis “urinalysis taken” to 44% (up from 30%) and “oral feeding attempted to 81% (up from 60%)
  - Maitland asthma “written asthma plan given to” 9% (up from 0%) and steroids given in moderate asthma to 71 % (up from 57%)
Quality Activities

Collaborated with colleague to make quality award submission for HNE Health Quality Awards 2005: “Implementing Paediatric Emergency Department Clinical Practice Tools for Gastroenteritis, Fever and Asthma: a collaborative approach”
JHCH Clinical Improvement Project: John Hunter Children’s Hospital Clinical Practice Manual Staff Survey and Improvement Plan
Baseline and post-implementation audits for CECP: coordinating collection and collation of data and providing reports to the Clinical Excellence Commission for JHH
John Hunter Hospital Staff Gastroenteritis Quiz: questionnaire development, collaboration with author Neil Atherton on paper (titled: “Management of Paediatric Gastroenteritis: do clinical practice guidelines make a difference?”) and dissemination of results in staff newsletter
Participation on presentations provided to various quality committees throughout the area

Implementing the Children’s Emergency Care Project (CECP)
- Facilitated a combined working party to implement 12 NSW Health Paediatric Emergency Department guidelines
- Collaborated in the development of tools (clinical pathways and flow charts) for the 12 CPGs
- As a result of the increase in workload and educational requirements due to the CECP implementation, new Project nurse roles were developed for JHH ED and JHCH and mentoring has been provided by Project Officer. Their appointment demonstrates management commitment to the success of the project
- Staff newsletters developed and disseminated to staff regarding CECP progress and audit results
Systems Developed

In collaboration with other working party members, systems have been developed relating to:
- Area applicable guideline dissemination and implementation (this relates to existing guidelines that have been identified as being “applicable” area wide)
- Publishing standardisation of area guidelines (format and development process) and their online publishing on Kaleidoscope Web site
- Review and development of procedures/guidelines for John Hunter Children’s Hospital
- Implementation of 12 emergency department clinical practice guideline

Collaboration Outcomes
- Collaborated with a multidisciplinary team at JHCH to develop procedures and safe work practices relating to ward safety and general nursing care and safe use of Oxford cots
- Collaborated with Children’s Hospitals Australasia and JHCH staff to develop a procedure relating to fluid balance monitoring (draft 1 developed)
- Collaborated with Child and Family Health GNS nurses in the roll out of the use of PC tablets as a method of standardising information provided to parents
- Collaborated with and mentored staff responsible for developing and/or reviewing guidelines (examples include, review of JHCH neurology and orthopaedic procedures, oncology manuals, transition to adult health care providers for young people with a chronic condition and management of eating disorders)
- Collaborated with representatives from 2 other Children’s Hospitals (SCH and CHW) on guideline standardisation and resource sharing - currently updating the procedure on Intragam administration
- Appropriate area meeting forums identified and attended (eg Management, Quality/Safety, Clinical Improvement, CNC, Clinical Practice, Policy/procedure and unit team meetings) with presentations provided to First Steps Parenting, Upper Hunter Managers, Kurri/Cessnock Quality/Patient Safety, Kaleidoscope CNC and Kaleidoscope Executive Advisory Group (KEAG)
Negotiation Outcomes
- Senior management agreed to allocate extra hours to Webmaster to upgrade and maintain the Kaleidoscope web site
- Participated in negotiations with John Hunter Hospital ED management to allocate non clinical hours to nurse to help implement the CECP and to also allocate office space in ED
Staff Development
- Completed Certificate IV in Workplace Assessment and Training
- Attended 3 day Project Management course
- Regular attendance at Kaleidoscope Clinical Improvement meetings and grand rounds

Impact

Increased communication and collaboration (eg between rural GPs and Paediatricians, Practice Nurses and hospitals, JHH and Maitland/Dungog, GPs and NCHN and between NUMs and CNCs)
Formation of effective and positive relationships with colleagues at Sydney Children’s Hospital and Children’s Hospital Westmead
Extensive collaboration between JHH ED and JHCH (including working together on quality improvement projects)
Increased subscription to NCHN Mailing List
Combined working party to implement 12 CPGs is working well as a team and a process exists to develop and trial tools, ratify, implement and publish pathways (for tertiary and rural sites) and flowcharts online
Area guidelines have been developed and ratified for area use and are available online
Multidisciplinary Working Parties have been formed and evidence based documents have been developed following extensive consultation with key stakeholders
Systems have been developed to facilitate and sustain achievements that impact on standardisation of care

Lessons Learned

Extensive and multidisciplinary consultation and careful attention to project planning/process mapping is required for successful outcomes
A Project Officer is required for coordinating large projects such as the implementation of 12 emergency department guidelines at multiple sites
It takes time to develop networks and to effectively negotiate with staff across a large area health service to reach consensus and work towards standardisation of care
To gain consensus, all parties must be focused on goals and be willing to compromise

Potential Applicability

If funding was to continue, the processes used to standardise clinical guidelines and procedures could easily be implemented throughout the NCHN and merged Hunter New England Area Health Service
The incumbent Project Officer has developed extensive networks and has already been collaborating throughout the NCHN and merged Hunter New England Area Health Service on several topics (such as home visiting, tonsillectomy care and insertion and removal of nasogastric tubes)
Areas of further need have been identified and relate to the transfer of children between non-acute services, implementing the 12 emergency department clinical practice guidelines in non-pilot sites, developing materials such as fact sheets that are culturally appropriate for Aboriginal people

Reasons for Good Outcomes

CECP:
- consistent and motivated membership of the working party
- working party members are willing to negotiate and compromise
- regular communication with frontline staff about project progress and audit results
- feedback is actively sought from frontline staff and their suggestions for improvement are incorporated in final documents
- a variety of strategies are used to facilitate guideline implementation
Other projects
- there has been a multidisciplinary approach and extensive feedback has been sought from all parts of the merged health service. The Project Officer sets and monitors timeframes and encourages others to implement these strategies
- Area Guideline Project Officer demonstrates effective communication and consultation skills and has had previous experience with project implementation and evaluation at an area level

Barriers

The following barriers were identified during the project but have been effectively managed:

Management needs to provide resources to improve and maintain the Kaleidoscope web site
Action: Webmaster has been allocated additional hours to upgrade and maintain the web site
Kaleidoscope staff responsible for writing/reviewing guidelines/procedures must have the necessary skills and confidence to be able to effectively manage this part of their role and the ratification process for completed documents must be streamlined
Action: this issue has been further explored during personal interviews and at appropriate meetings (such as the CNC meetings) and the Project Officer has allocated time with CNCs and other guideline developers to enhance their skills
Ongoing funding is required to build on achievements to date, to ensure that new systems become part of everyday practice and to further develop effective networks within the NCHN and merged area health service
Action: a proposal to extend this project has been submitted for consideration.