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A networked paediatric allergy service for the Northern Child Health Network (NCHN)

Specialist Paediatric Allergy Management services at the present time are centred in the John Hunter Children’s Hospital. Children and their parents travel considerable distances from throughout the NCHN to attend the John Hunter Children’s Hospital (JHCH) for management of allergic conditions, particularly severe food allergies. Currently the only specialist paediatric allergists, allergy nurses and allergy dietitians in the NCHN are situated in Newcastle.

Many of the procedures are suitable to be performed outside of the Metropolitan area if sufficient education and support were available at the nursing and dietetic level. We are proposing a model whereby this support can be provided. We will also use Telehealth via a video link-up to have combined nursing, medical and dietetic consultations. These Teleclinics will provide educational opportunities for health staff and obviate the current need for allergy patients to travel to Newcastle.

Aims and objectives

• To improve delivery of allergy educational, diagnostic and management services to the NCHN.
• Project Goals:
  1. To enhance diagnosis and management of paediatric allergic disease* through telemedicine to non-indigenous and indigenous populations
  2. To improve delivery of paediatric allergy services to the NCHN (and as a model for other CHN’s) by developing educational modules and continuing education services

  *Allergic diseases include asthma, rhinitis, anaphylaxis, urticaria, eczema, and food and insect sting allergy. They afflict up to 30% of the paediatric population. In the proposed model most emphasis will be on food and insect sting allergies as these are common, can be managed and appropriate allergy management can have a major impact on the outcome and utilization of health resources.

Expected outcomes

1. Response time for provision of anaphylaxis education to schools and preschool institutions will have a coordinated approach.
2. Waiting times for review of paediatric patients with allergic disease will drop from twelve months to two months.
3. Project will be driven by a team constituted of paediatric and adult allergists with paediatric credentials, an allergy nurse and a paediatric dietician skilled in the management of food allergies. There will be no duplication of services covered under existing funding arrangements.
4. Team-building and personal-professional development will be emphasised, with this project strictly confined to two years, but developing educational and Web-CD training packages which can be used by rural medical practitioners, nurses and dieticians thereafter. Consultation with non-metropolitan nursing, dietetic and medical staff to define needs will ensure relevance. The aim is to educate local nursing and allied health practitioners and provide liaison and back up.

Advantages of the system:

• Avoid need for multiple long trips to central site at Newcastle’s JHCH as this is the only site in the NCHN Public Health System where Skin Prick Tests are performed. Most paediatric food allergy patients are managed by annual skin tests to determine when the child has outgrown the food allergy. Future management decisions are based on the Skin Test results and the history of reactions and accidental ingestions over the previous 6 to 12 months and the previous skin test results. Family inconvenience and the costs and dangers of long distance driving could be circumvented without loss of quality if reliable Skin Prick Tests could be performed locally and the remainder of the medical and dietetic decision-making done via Telehealth link.
• Improved efficiencies and health service delivery
• Development of allergy training manuals and CD-Web-based educational material which will be available for use by allergy health professionals beyond the project’s two-year timeframe

Key performance indicators

The success of the project will be measured by:

1. Evidence of positive responses to patient/parent-teacher understanding and satisfaction surveys
2. Evidence of reduction in waiting times for education sessions
3. Evidence of reduction in paediatric allergy clinic waiting times for patients outside of the Newcastle/Lower Hunter Area
4. Evidence of reduction in hospital admission and Emergency Department attendance rates for allergic reactions

Progress

In mid-February 2008, a Clinical Nurse Consultant (CNC) was commenced in the position of CNC Paediatric Allergy Liaison (PAL) Nurse to assist in setting up the project to provide allergy outreach services to the NCHN.

Objectives of the project

1. To improve delivery of allergy educational, diagnostic and management services to the NCHN.
   
   Previous to mid-February 2008, the only education into allergy for children attending Immunology/Allergy clinics at the JHCH was during the consultation with the doctor. Education regarding the use of the Epipen was provided to the accompanying parent and an anaphylaxis action plan was completed for the school. No education was provided to the school. Education regarding food avoidance and eczema management was provided by the consulting doctor.
   
   Skin Prick testing which provides additional information to confirm diagnosis of allergies was available only at John Hunter Hospital in Newcastle.
   
   Specialist Paediatric Allergy Management services were centred in the John Hunter Children’s Hospital. Children and their parents needed to travel considerable distances from throughout the NCHN to attend the JHCH for management of allergic conditions, particularly severe food allergies.
   
   Since commencement of this project our PAL nurse is able to provide education to families regarding anaphylaxis and the use of the Epipen. She also has been able to provide education to preschools and schools and has been available as a contact person to provide support to families and schools.
   
   So far we have done a team visit to Tamworth where 9 patients were seen who previously travelled to John Hunter Hospital in Newcastle. Our PAL performed Skin Prick Test locally and provided education. The dietician provided support to the local dietician. Similar clinics to Port Macquarie and Armidale are being planned in the next quarter.
   
2. To enhance diagnosis and management of paediatric allergic disease through telemedicine to non-indigenous and indigenous populations.
   
   Many of the investigative procedures for diagnosis of allergies can be performed outside of the Metropolitan area if sufficient education and support were available at the nursing and dietetic level. We proposed a model whereby this support could be provided. We also planned to use Telehealth via a video link-up to have combined nursing, medical and dietetic consultations.
   
   In order to achieve this objective the team felt it necessary to visit the local sites to determine the needs on the ground. We visited Inverell, Armidale, Tamworth and had extensive discussions with Port Macquarie. During our visits we had discussions with General practitioners, Paediatricians, Nurse Unit managers, dieticians and managerial staff regarding setting up of our clinics. The consensus at the present moment is for team visits on a regular basis and nurse only visits on an occasional basis at each site. The visits will be determined on the basis of referrals - urgency and severity of disease. The nurse only visits will be supported by medical staff at John Hunter via telehealth.
   
3. To improve delivery of paediatric allergy services to the NCHN (and as a model for other CHN’s) by developing educational modules and continuing education services.
   
   At each of our visits we have provided education to hospital based staff and general practitioners regarding anaphylaxis and the use of an Epipen. The plan is to incorporate such educational sessions in each of our visits. During our visit to Tamworth, two local community health nurses who provide anaphylaxis education to the schools in the area were invited to attend the clinic with the doctors and PAL. This was to enhance their knowledge in the management of allergic disease. The local paediatricians have also been invited to attend our clinical sessions. This has been planned for our visit to Port Macquarie and future visits to Tamworth. We envisage that this will empower the local paediatricians in management of simple allergies.
   
   Locally our PAL has created an anaphylaxis information package for parents and provides education sessions to parents and extended families at the Hospital fortnightly in and out of working hours. This is in addition to education provided during clinics. We have also updated the clinical practice guideline for anaphylaxis management in the emergency department. Efforts are underway to streamline the referral process from Emergency departments to our educator/clinician. Regular in-service is being provided to the wards and emergency nursing and medical staff.
   
   A need has been identified to provide education and support to families whose children suffer from severe eczema and food allergies. Our PAL at present provides eczema management information and hands on demonstrations of management techniques, i.e. wet dressings, during clinics. She also provides emotional support. We are considering commencement of a multidisciplinary clinic for patients with eczema.

Intended outcomes for the project

1. Response time for provision of anaphylaxis education to schools and preschool institutions will have a co-ordinated approach.
   
   Children suffering from anaphylaxis are identified in clinic and referred to the PAL who then contacts the relevant school/preschools. Referrals from schools are received at Sydney and then passed on to the PAL. Some referrals are directly sent from the community to the PAL. The PAL then contacts the schools in a timely manner and organises education as soon as it is convenient for the school.
   
2. Waiting times for review of paediatric patients with allergic disease will drop from 12 months to 2 months.
   
   The project has enabled us to see more patients locally thus reducing the waiting period, though at present we are unable to determine by how much. Satisfaction surveys conducted during our visit to Tamworth showed the overwhelming appreciation by the patients as it obviated a need for travel and reduced financial burden and the stress associated with travel.
   
3. Project will be driven by a team constituted of paediatric and adult allergists with paediatric credentials, an allergy nurse and a paediatric dietician skilled in the management of food allergies. There will be no duplication of services covered under existing funding arrangements.
   
   The Allergy Outreach Team Consists of Dr Glenn Reeves- Adult/Paediatric Immunologist and Director of HAPS; Dr Rani Bhatia, General Paediatrician, Post FRACP trainee in Paediatric Allergy and Immunology; Denise Wong-See, Dietician, JHCH and Jan Belcher, Clinical Nurse Consultant-Paediatric Allergy Liaison Nurse /Anaphylaxis Educator.
   
4. Team building and personal-professional development will be emphasised, with this project strictly confined to two years, but developing educational and Web-CD training packages which can be used by rural medical practitioners, nurses and dieticians thereafter. Consultation with non-metropolitan nursing, dietetic and medical staff to define needs will ensure relevance.
   
   Our PAL has completed a Professional Certificate in Allergy nursing run through the University of South Australia. As mentioned above she has been involved in creating an anaphylaxis information package and developed eczema resources.
   
   During our team visits we have provided education to medical and nursing staff. Our Dietician has developed important liaisons with local dieticians and continues to share resources with them electronically.
   
   The PAL and clinician along with the dietician have identified the need for multidisciplinary team meetings which we are in the process of organising.
   
   The team is involved at present in developing educational packages to use during our visits.
   
   Our previous visits helped us to develop healthy relationships and stressed to us the importance of open communication so the needs of the rural sectors could be identified.

 

For more information contact:

Dr Rani Bhatia
Paediatric Allergy/Immunology Fellow
Kaleidoscope Children’s Hospital
02 4921 3667