The development of a community nursing service for children with an acute illness. Carolanne Getty Community Children’s

1. The development of a community nursing service for children with an acute illness. Carolanne Getty Community Children’s Nursing Sister

2. Aim: To describe the development of an acute CCN service.

3. Objectives • To understand the journey of service development for an acute CCN team in Northern Ireland. • To appreciate benefits of such a service to acutely ill children and their families. • To consider the dimensions of care the CCN can bring to children who are acutely ill.

4. Structure of Presentation • Evidence supporting acute CCN service development • Setting up the acute CCN Service in Homefirst • Dimensions of care CCN can bring.

5. GEOGRAPHICAL AREA • Population 330,000 • Area 1,200 square miles • Mixed urban and rural • Largest community trust in Northern Ireland • Divided into 3 sectors * Antrim/ Ballymena * East Antrim * Magherafelt/ Cookstown

6. “Children’s Community Teams including Community Children’s Nursing Services need to provide appropriate support to children, young people and their families which responds to local needs and takes account of the need to prevent hospital admission, facilitate early discharge, and care for children with complex needs” NSF (2004) standard 6 13.2

7. Evidence Supporting Service Development • World Health Organisation (1978) Health for all by the year 2000. • United Nations Convention (1989) Un Convention on the rights of the child. • House of Commons Select Committee (1997) Health Services for Children and Young People in the Community : Home and School. Third Report. • RCN (2003) Community Children’s Nursing: effective team working. • Department of Health, Social Services and Personal Safety (1999) Nursing services for the acutely ill child in Northern Ireland. • Department of Health, Social Services and Personal Safety (2004) A healthier Future: a 20 year strategy • Department of Health (2004) The National Service Framework for Children

8. Model for components of care CCN services can be expected to deliver. (Adapted from DH, 2002; RCN, 2002) FirstContact Acute assessment, diagnosis, treatment and referral of children

9. Composition of Homefirst Community Children’s Nursing Service Community Children’s Nurses Continuing care team Trust wide Regional Children’s Palliative Care Nurse Northern Board Acute Community Children’s Nursing Team Antrim/Ballymena Children’s Diabetes Nursing Service Trust wide

10. MULTI-PROFESSIONAL STEERING GROUP ROLE OF STEERING GROUP • Advise on setting up of the service • Devise operational guidelines • Report to the Inter-Trust Child Health Forum • Produce and disseminate information / consult with all relevant groups

11. Questionnaire of potential service users

12. Team recruited 1 G grade with children’s qualification and Health Visiting community experience (1 WTE) 3 E grade Staff Nurse’s with hospital based experience (2 WTE) • Model of CCN service delivery Community based generalist team

13. Stages of Service Development • 1. Preliminary/ preparation stage • 2. Implementation stage • 3. Evaluation of service role

14. Preliminary stage • Develop aims and objectives • Develop operational policy • Develop evidenced based policies and procedures • Develop documentation • Logistical issues

15. Implementation Stage • Establishing links in hospital and community • Raising awareness • Identifying staff training needs • Staff development

16. Evaluation “This is an excellent service. It was offered at the right time in the hospital and gave us confidence to bring our son home where he made a quicker recovery but with the appropriate care and support. It should be available more widely and publicized as a model of good practice.”

17. Challenges Not 24 hour slow rate of service referrals Role Protectionism Staffing levels

18. Dimensions of care • Formal knowledge and skills • Coordinating knowledge and skills • Skills for managing workload • Relational, interpersonal and support skills • Teaching skills • Thinking skills Proctor et al. 1998

19. SERVICE DEVELOPMENT • Amalgamation of Continuing Care and acute CCN service. • Senior Nurse Practitioner • Rolling out of acute CCN service and nurse bank to other sectors • Expanding teams to provide a skill mix • Staff development

20. “A thousand mile journey starts with a single step” Lao-tsu, 604 - 531 BC

21. References • Callery, P. (1997) Paying to participate: financial, social and personal costs to parents involvement in their children’s care in hospital. Journal of Advanced Nursing. 25: 746-752 • Casey, A., Gibson, F., Hooker, L. (2001) Role development in children’s nursing: dimensions, terminologyand practice framework. Paediatric Nursing. 13(2):36-40 • Department of Health (2002) Liberating the talents, helping primary care trusts and nurses to deliver the NHS plan. London: The Stationary Office • Department of Health (2004) The national service framework for children, young people and maternity services. London: DH www.publications.doh.gov.uk/nsf/children • Department of Health and Social Services (1999) Nursing services for the acutely ill child in Northern Ireland. Report of a working group. Belfast: The Stationary Office. • Eaton, N. (2000) Community Children’s Nursing services: models of care delivery. A review of the United Kingdom literature. Journal of Advanced Nursing. 32(1):49-56 • Euwas, P., Chick, N. (1999) On caring and being cared for. In: Madjar, I., Walton, J.A. (eds.) Nursing and the experience of illness. London: Routledge (pp170-188)

22. References • House of Commons Select Committee (1997) Health Services for children and young people in the community: home and school. 3rd report. London: The Stationary Office • Johnston, P. (2004) Community Paediatric Nursing Service Ballymena/Antrim: Review of Service. Unpublished • Neill, S. (2005) Caring for the acutely ill child at home. In: Sidey, A., Widdas, D. (eds.) Textbook of Community Children’s Nursing (2nd Ed.).Edinburgh: Elsevier. • Poulton, B. (1999) User involvement in identifying health needs and shaping and evaluating services: is it being realised? Journal of Advanced Nursing. 30(6): 1289-1296 • Procter, S., Campbell, S., Biott, C., Edward, S., Moran, M., Redpath, N. (1998) Preparation for the developing role of the community children’s nurse. Research highlights. London: English National Board for Nursing, Midwifery and Health Visiting • Royal College of Nursing (2002) Children’s community nursing: information for primary care organisations, strategic health authorities and all professionals working with children in community settings. London: RCN (publication code 001 959) • Secretary of State for Health (1999) Saving lives; Our healthier nation. London: The Stationary Office

23. References • Slevin, O. (2003) Nursing models and theories: major contributions. In: Basford,L., Slevin,O. (eds.) Theory and practice of nursing: an integrated approach to caring practice.(2nd ed.) (pp255-280) Cheltenham: Nelson Thornes • Smith, F. (1995) Children’s nursing in practice: the Nottingham model. Oxford: Blackwell Science Ltd • United Nations Convention (1989) Un Convention on the rights of the child. • Volprecht, A.; Flannagan, N.; Livingstone, A. (2001) What parents think about an acute community paediatric nursing service. unpublished report • While, A.E., Dyson, L.(2000) Characteristics of paediatric home care provision: the two dominant models in England. Child Care Health Development. 26(4):263-275 • Whiting, M. (2005) Needs analysis and profiling in community children’s nursing. In: Widdas, D. & Sidey, A. (eds) Textbook of community children’s nursing (2nd ed.). (pp180-194) London: Bailliere Tindall / RCN • World Health Organisation (1978) Health for all by the year 2000.

24. Caring for children receiving home intravenous antibiotic therapy Dianne Cook - Children’s Community Specialist Practitioner Central Manchester Primary Care Trust Elaine Salmons – Children’s Community Team Leader Queen’s Medical Centre, Nottingham

25. AIMTo have an increased awareness of administering IV antibiotic therapy in the community OBJECTIVES • To discuss advantages of IV’s in the community • To explore issues relating to administration • To have a basic awareness and understanding of anaphylaxis

26. The administration of IV drugs by Community nurses has become more widespread in recent years. The practice, having initially been classed as an extended role of practice has now become part of the core skills for general nursing practice. This therefore allows an holistic approach to care.

27. Advantages of IV’s at home • Reduction and prevention of hospital admissions • Reduced length of stay • Increased independence from hospital • Less disruption to family routine • Continued schooling • Reduced risk of cross infection • Reduction of winter bed pressures • Cost effectiveness • Payment by results • Autonomy and empowerment

28. Range of Access routes • Peripheral Lines – Cannula, Longlines • Central Venous Routes - Hickman Lines • Subcutaneous Implantable Venous access devices – Portacaths

29. ‘The administration of medicines is an important aspect of the professional practice of persons whose names are on the Council’s register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner. It requires thought and the exercise of professional judgement…..’ Guidelines for the administration of medicines NMC 2004

30. Children are not miniature adults as they have different pharmacokinetic profiles, which require specialist knowledge, awareness and expertise

31. The safe administration to children is a key area of responsibility for practitioners in child care, and warrants extra vigilance in order to safeguard each child’s safety

32. Clinical responsibility for a child receiving IV therapy at home lies with the GP. If a GP is unwilling to accept responsibility, the Consultant will normally continue this role

33. ‘It is the nurse who is responsible for the correct administration of the prescribed drugs. Therefore, they should know the therapeutic uses, dosage, side effects, precautions and contra-indications’ (Guidelines for the administration of medicines 2004)

34. ‘ The NMC welcomes and supports the self-administration of medication by carers wherever it is appropriate….’ (Guidelines for the safe administration of medicines, NMC 2004)

35. If responsibility is delegated then we need to ensure that the patient, family or carer is competent to carry out the task • Education • Training • Assessment • Support • Reviewed and reassessed periodically

36. ‘Check that the patient is not allergic to the medicine before administering it’ NMC 2004 but…

37. An allergic reaction does not usually occur the first time a person is exposed to a drug…It is only after the body learns to recognise the substance that an immune system reaction is triggered

38. It therefore, is essential, that more diligence be taken throughout the second and subsequent administration of drugs given via the IV route, especially as these are often administered in the community

39. Drug allergies occur as a result of a variety of complex immune system responses to specific medications.

40. In most cases, the reaction involves relatively mild symptoms, e.g. minor skin rashes and hives, itching, generalised flushing of the skin

41. However, in some cases a life threatening, acute reaction can occur progressing quickly to more severe symptoms, massive swelling of the respiratory tract, constriction of bronchial smooth muscle and extreme vasodilation

42. Anaphylaxis is a severe allergic reaction, the extreme end of the allergic spectrum. No universally accepted definition exists because anaphylaxis comprises of a constellation of features(Ewan 1998) (Anaphylaxis, BMJ, 316, 1442-1445)

43. Anaphylaxis occurs in an acute and unexpected manner. The true incidence is unknown. Epidemiological studies have shown differing results owing to differences in both definitions of anaphylaxis and the population groups studied.

44. Anaphylaxis seems to be increasingly common, almost certainly associated with a significant increase in the prevalence of allergic disease over the last two or three decades

45. Adrenaline (Epinephrine) is the first line treatment for anaphylactic reactions.

46. Early intramuscular administration of adrenaline is essential for optimal action

47. Adrenaline (Epinephrine) is greatly under-used • Although widely available in the community, it is not given in a timely manner when required (Resuscitation Council UK 2005 The Emergency Medical Treatment of Anaphylactic Reactions for First Medical Responders and for Community Nurses)

48. ‘Anaphylaxis is poorly managed’

49. Treatment Algorithm for Children in the Community Resuscitation Council (UK) 2006 (www.resus.org.uk/siteindx.htm)