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:
- To enhance diagnosis and management of paediatric allergic disease* through telemedicine to non-indigenous and indigenous populations
- 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
- Response time for provision of anaphylaxis education to schools and preschool institutions will have a coordinated approach.
- Waiting times for review of paediatric patients with allergic disease will drop from twelve months to two months.
- 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.
- 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:
- Evidence of positive responses to patient/parent-teacher understanding and satisfaction surveys
- Evidence of reduction in waiting times for education sessions
- Evidence of reduction in paediatric allergy clinic waiting times for patients outside of the Newcastle/Lower Hunter Area
- 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
- 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 clinic 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. At times the education given was minimal due to limited consultation times. No education was provided to the school. Education regarding food avoidance and eczema management was provided by consulting doctor.
Skin Prick testing which provides additional information to confirm diagnosis of allergies was available only at John Hunter Children’s 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 ( Paediatric Allergy Liaison) 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.
Over the past 16 months clinics have been conducted clinics at Port Macquarie, Tamworth and Armidale. We have seen 58 patients at outreach sites. Our PAL nurse performed Skin Prick Test locally and provided education to patients and their families about anaphylaxis and eczema. The dietician provided education to the patients and their families, as well as the local dieticians.
- 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.
After consultation with local Paediatricians in the area, it became obvious that face-to-face consultation with the Paediatric Immunologist is what was required. The Paediatricians in Port Macquarie were quite keen to have someone just visit to attend skin prick testing, which was seen by the Outreach Team to be inappropriate, as this did not allow for interpretation of the tests.
- 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 initial visits we provided an education session to hospital based staff and general practitioners regarding anaphylaxis and the use of an Epipen. The local paediatricians have also been invited to attend our clinical sessions. We hope that this has empowered the local paediatricians in management of simple allergies. Local nursing staff, with an interest in Paediatric allergy and Anaphylaxis Educators for schools (through the DOH, DET, CEC specialised training programme), were invited to attend an Outreach clinic in Tamworth to assist them to increase their knowledge in Paediatric 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. The referral process from Emergency departments to our educator/clinician has been streamlined. Regular in-service is being provided to the wards and emergency nursing and medical staff, within the John Hunter, John Hunter Children’s Hospital as well as Maitland Hospital.
It was also identified that the Allergy/Anaphylaxis flowchart for the John Hunter Children’s Hospital required updating. This was developed in consultation with many experts.
A need was 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 to the families and access to over-the-phone support when required to enable the families to stay at home and care for their child, thus reducing the need for hospital admissions.
As part of the role of Anaphylaxis Educator for HNEAHS/NCH network, a large part of the PAL time is spent consulting with schools who require education, as well as those who are yet to receive education or need clarification of the guidelines of caring for children with risk of anaphylaxis.
The PAL nurse was contacted by a school in regards to a situation which occurred in their school in December, 2008. The situation was that a child was presenting with signs and symptoms of anaphylaxis, the school called the NSW Ambulance Service, the school was told not to give the child the schools generic EpiPen, which was not the information they had received from their prior Anaphylaxis Training. The PAL nurse followed the situation through via an IIMS form. The response from NSW Ambulance was good. They investigated the situation and recognised that it was against the NSW Policy to request that anyone receive a medication that was not prescribed for that patient. The outcome was that NSW Ambulance put out a ‘Clinical Safety Alert’ which stated that “the immediate use of a generic EpiPen should be strongly encouraged if available, such as the school situation, when there are moderate to severe symptoms, even without a history of anaphylaxis”
Intended outcomes for the project
- 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.
An average week sees the PAL (Anaphylaxis Educator) attending 2-4 schools/pre-schools a week.
- Waiting times for review of paediatric patients with allergic
disease will drop from 12 months to 2 months.
Although the project has enabled to see more families locally and be educated at the time of consultation, it appears that the waiting lists have increased. The reasons for this remain unclear, but we do know there has been an increase in allergies over the past few years. Along with this is the fact that the Outreach Team has introduced themselves to Outreach areas, which in turn has increased the number of referrals from those areas, as well as having a representative (PAL nurse) from the service attending education in the schools throughout the Hunter New England Area Health Service.
Satisfaction surveys conducted during our visits showed the overwhelming appreciation by the patients as it obviated a need for travel and reduced financial burden and the stress associated with travel.
- 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/Anaphylaxis Educator. Dr Reeves was able to attend the Outreach clinics at the commencement of the project, but due to huge demand on his own workload, with a change in his role to Director of HAPS for the Hunter New England Area Health Service he no longer was able to find the time to attend the Outreach clinics.
- 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 and thus we have commenced weekly meetings.
The team has developed educational packages to use during our visits.
A web page has been designed and was launched in June 09. This web page provides links to educational resources and information about our planed clinics and educational sessions.
Our previous visits helped us to develop healthy relationships and enabled us to identify the importance of open communication so that the needs of the rural sectors could be identified and consultancy and assistance could be given when required.