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Putting wheezy children on a pathway to better health

Nurses have devised a programme that has cut the number of children re-admitted with breathing problems

Nurses have devised a programme that has cut the number of children re-admitted with breathing problems 

  • Trust report revealed children with wheeze or asthma accounted for most admissions, but care was variable
  • Wheezy care pathway has led to reduction in number of emergency department readmissions
  • Find out how you could use this model to empower patients and families
Nurse_Adama_Kargbo with_Daisy_ O’Leary
Clinical nurse specialist Adama Kargbo with patient Daisy O'Leary

Like many nurses across the country, paediatric junior sister Freydoh Rabin at Barnet Hospital’s children’s emergency department found her department increasingly hectic, with rising patient numbers.

‘Winter nights tended to be busiest, when just a few nurses might be treating up to 35 children, many with wheezy chests and breathing difficulties requiring in-patient admission,’ says Ms Rabin.

Indeed, a report from the Royal Free London NHS Foundation Trust, of which Barnet and Chase Farm hospitals are part, last year revealed that children aged 2-15 with wheeze or asthma accounted for most admissions yet received ‘a large variation in care’.

But, since last April, these children have made fewer trips to the trust’s emergency department, since its nurses and clinicians designed a wheezy care pathway (WCP). This aims to stream children into three categories of planned care within 15 minutes of admission, after which they are reassessed every 20 minutes, if needed.

Significant fall in volume

Since the WCP’s introduction, which enables children to receive better care sooner, the volume of children admitted and re-admitted with wheeze has fallen significantly, says former nurse Lorraine Gallagher, now the trust’s clinical practice group manager for women and children.

‘Two years ago, our clinical practice group, which uses the latest clinical evidence to ensure patients have access to the most effective and innovative treatment, standardised practice and care, identified high-volume areas of patient need, of which the number of wheezy child emergency admissions was one,’ she says.

To remedy this problem, a multidisciplinary team including nurses, was set up to:

  • ‘Process map’ or examine each wheezy child’s step-by-step journey from emergency admission to discharge.
  • Look at risk ‘hot-spots’ during a child’s hospital journey, such as variations in practice for dealing with emergency treatment waits.
  • Review literature to choose a best practice model.
  • Implement a mini-audit of children’s casenotes, assessing their clinical experience.
  • Design the WCP for wheezy 2-5 year olds and older children with asthma arriving at the emergency department.
  • Encourage patient, parent and staff input at every stage of the WCP’s design.
  • Hold fortnightly meetings to assess WCP progress and outcome measurements, for example volume of child admissions, their numbers in the system, time taken to administer steroids, length of patient stays, plus children’s emergency attendance and re-attendance within seven and 30 days of admission.

The right information

Asthma nurse specialist Caroline Byrne, who educated ward, outpatient and emergency staff trust-wide for the WCP’s launch and early implementation, believes children with breathing problems have tended to make repeat emergency visits because they had not been given the right care or their families had been poorly informed.

‘Since the WCP’s implementation we have seen fewer children returning to hospital, because families are given the right information and so are better able to manage their child’s condition at home. The key elements are having a management plan and knowing the medication and inhaler technique. Ensuring care is consistent means every patient can access the most appropriate care sooner. We hope this pathway can be adopted by other trusts,’ says Ms Byrne.

Fast facts

Three categories of planned care

Wheezy care pathway streams children into one of these categories every 15 minutes after being admitted to the emergency department

Every 20 minutes

Children are then reassessed

Fortnightly meetings

Held by staff to examine the progress and outcome measurements of the wheezy care pathway

 

Nurses working in children’s wards and in the community are also seeing the WPC’s effect on treatment. Though emergency staff were initially ‘a bit hesitant’ about the extra input involved, says Ms Rabin.

‘Now staff are familiar with the pathway, which involves giving children a WCP score for their breathing difficulty – after routine triage – and ensuring their treatment is begun within 15 minutes. We are finding this consistently implemented method of assessment and treatment more clinically effective.’

Impatient parents

Parents of children with wheeze or asthma understandably become impatient for their child to be seen, treated and discharged quickly, particularly those admitted at night. But, Ms Rabin says, when nurses explain how the new pathway works, parents feel reassured.

‘On admission, I tell parents that depending on how their child responds to treatment, they might be in A&E for four to five hours, will be reviewed regularly, but may be discharged much sooner if their condition improves. Consequently, because no child is sent home until we are completely satisfied their breathing is stabilised, we have reduced readmissions.’

Matron for the Royal Free Hospital’s paediatric ward and outpatients Ade Adama says involving parents and older children in the WCP’s design has had positive results,

‘We put up posters around the hospital asking what changes would improve their care and have had a good response. For example, some asked for ‘asthma passports’ to carry with them, teenagers wanted us to put asthma information on Instagram and Snapchat, while parents with younger children asked if we could find nicer-tasting asthma medicines. So, we are trying to introduce these changes for them.’

'We’ve found that dexamethasone is a sweeter, more minty-tasting medication, which children clearly prefer’

Indeed, parents’ dread of their wheezy child spitting out or vomiting back their vital steroid medication because it ‘tastes horrible’ had been a problem, says Ms Rabin.

‘Using our own evidence-based, informal research to trial different-tasting steroid syrups we’ve found that dexamethasone is a sweeter, more minty-tasting medication, which children clearly prefer.’

Adama Kargbo, atopy clinical nurse specialist with Camden Community Children’s Team, who liaises between the community and paediatric wards, educating staff on the use of the WCP, says before its introduction children could easily fall through the treatment net.

‘Because 2-5 year olds admitted to A&E with wheezy breathing triggered by viral illness are considered too young for an asthma diagnosis, they usually missed out on the follow-up review older children receive, so tended to be repeatedly re-admitted. But since our review picked this up, we give parents a leaflet clearly setting out what they should do if their child becomes wheezy again,’ she says.

Cutting admissions further

Ms Kargbo welcomes plans to extend the WCP to primary care. Here, she believes, a more robust, standardised, 48-hour follow-up within her own clinics and by practice nurses or GPs – whom she will train on the pathway’s use – could reduce re-admissions further.

Ms Rabin agrees and also provides parents with health advice before discharge. ‘Our wheezy patients can be very vulnerable at home, particularly if they live near busy, polluted roads, or with family members who smoke.’

Ms Kargbo says she loves her specialist asthma role, which she took up after noticing how many wheezy playgroup children, parents and nursery staff struggled to use inhalers correctly.

‘It’s important to empower parents and children with confidence to use their inhalers and manage their medication appropriately. And it has been exciting to see the volume of readmitted children with wheeze reduce significantly since the introduction of this pathway. Patients and their parents are more relaxed and friendly towards nurses, with a less anxious, more self-reliant attitude to their treatment.’


Catharine Sadler is a health writer

 

Find out more

Royal Free London Hospital Foundation Trust (2018) Quality Report

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