What are we trying to achieve?
Our emergency departments are getting busier and we have to find ways of working that are better, safer and faster in order to reduce the wait for sick children and their families.
Our main goals were to:
- help maintain our target of discharging or transferring patients to a ward within 6 hours of arrival in ED
- develop interventions that can improve the flow of paediatric patients through ED without impacting on quality of care
- develop standardised approaches for clinicians to manage common presentations for infants and children
What did we find?
Evidence suggests that there is disparity between how clinicians manage some commonly seen presentations within ED for infants and children. Delays usually occur between the time of assessment by a nurse and a clinician consultation to determine what investigations and treatment plan is required.
Patient flow through emergency departments
Care pathways have been used to standardise care in many areas of healthcare, but their success can depend on how well they are implemented and monitored.
What have we done?
We reviewed paediatric presentations within our emergency departments at North Shore and Waitakere hospitals and identified common conditions which would be:
- suitable for a structured management approach; and
- responsive to appropriate treatment
We selected the four following conditions for which to develop ‘best care bundles’:
- Wheeze (for over 1 year olds)
Each ‘best care bundle’ involved the development of the following resources:
- A policy / guidelines to outline the components of the ‘best care bundle’ for the condition
- A clinical document outlining the specific assessment and treatment protocols for the condition
- Paediatric clinical nurse specialist (CNS) competency requirements for them to undertake a clinician role in delivering care and treatment outlined in the bundle
- A relevant standing order for medication to facilitate faster treatment for the condition
- A workbook for registered nurses (RN) about the bundle
- Patient information sheet(s) to provide to patients and their families on discharge from ED
How do ‘best care bundles’ work?
Let’s look at the Croup BCB as an example:
We provided education on the BCB prior to implementation to medical teams, paediatric clinical nurse specialists and registered nurses.
2. Initiation of assessment nurse role
The assessment nurse role was initiated to identify patients to be placed on the BCB based on inclusion criteria.
3. Patient assessment at triage
- The BCB is initiated at triage in ED, when patient is assessed against inclusion criteria either by the assessment nurse or by a clinician
- If patient meets BCB criteria they are assessed for red flags, alternative diagnosis, and severity of the disease / process
- The results from the assessment will guide the appropriate treatment pathway. Treatment is given by the assessment nurse (or at clinician consultation if not started prior)
4. Discharge guidelines
If patient responds to treatment, guidelines are available for discharging patients who meet the discharge criteria.
Discharge information is provided to the patient and their family about their condition, treatment and how to provide care for the child at home.
Did we make a difference?
We reviewed paediatric presentations (6 months - 15 years old) to the emergency department at Waitakere Hospital and found that after the Croup BCB was introduced, there was:
- a 31% increase in croup / stridor identification
- a reduced average length of stay by 50 minutes
- an increase from 27% to 59% for patients treated with medication within 30 minutes
- a reduction from 38% to 19% in paediatric ward admissions
- a decrease from 2.4% to 1.9% in representations to ED
Reduced average length of stay for croup encounters by 50 minutes
32% increase in patients with croup treated within 30 minutes
19% reduction in paediatric ward admissions for croup
We have achieved all of the aims on introducing a ‘best care bundle’.