Paediatric Best Care Bundles: Streamlining Care in the Emergency Department
Jane Key
Paediatric Clinical Nurse Specialist
Dr Stefan Van Der Walt
Paediatric Emergency Specialist
Before we start…
The CNS in ED – What do we do?
Patients with minor injuries and illnesses
Take history, examine, order investigations (whiteboard clinician)
Diagnose and treat injuries and illness
Disposition – discharge or referral
Clinical oversight by ED Specialist
Discuss ALL patients to endorse/validate/ consult on decisions
Prescribing
The Adult CNS in ED Patients with minor injuries and illnesses Treatments/interventions Manipulation of fractures/dislocations Local and nerve infiltration for analgesia Suturing/wound management/burns I & D abscess Removal of foreign bodies (ears/eyes/nose/soft tissue)
Epistaxis management Dental emergencies Joint aspirations (diagnostic) Minor medical presentations WDHB – some Best Care Bundle presentations
The Paed CNS in ED Patients with minor injuries and illnesses Treatments/interventions
Medical Presentations: Respiratory illness (cough/wheeze/SOB/croup/pharyngitis)
Gastrointestinal illness (gastro/constipation)
GUI complaints (UTI etc)
Skin complaints (eczema, abscess, cellulitis, rashes)
Undifferentiated presentations (e.g. febrile)
Injury presentations: Head injuries
Wounds, burns and fractures
Foreign bodies (ears/eyes/nose/soft tissue)
Best Care Bundle (BCB)s
What they are
How they work
How they make a difference
EDs are getting busier
6 hour targets
We need to do more, better
and faster
KEEP CALM
6 HOURS TO GO
Patient Journey through the ED
Assessed by a Nurse -Vital signs -Urgent needs addressed
Clinician Consultation -Investigations -Treatment Plan -Disposition
Arrive
Triaged
DELAY
Move to appropriate
area
Disparity
A Best Care Bundle (BCB) is…
A collection of resources aimed
at improving patient care and
reducing process delays for
suitable clinical presentations.
Paediatric Best Care Bundles
Croup Wheeze >1year
Rehydration Bronchiolitis
Components of a BCB?
Croup BCB
How it works
Inclusion Criteria
Red Flags
Severity
Focused History Clinical Notes - completed by Dr or PCNS
Focused Examination
Patient Journey through the ED
Clinician Consultation -Investigations -Treatment Plan -Disposition
Arrive
Triaged
Move to appropriate
area
Treatment
Prompts Disposition
Assessed by a Nurse -Vital signs -Urgent needs addressed
How They Make a Difference
Purpose of BCBs:
Reduce process delays in ED
Reduce treatment disparities for certain conditions
Reduce admission rates
No increase in returns to ED (representations)
Increase consistency of data (for audit)
81
106
0
20
40
60
80
100
120
Pre BCB Post BCB
Compared Encounters
WTH only Croup Age 6m -15yrs Pre BCB Group: 1 Mar – 30 Sep 2013 Post BCB Group: 1 Mar – 30 Sep 2014 Sample includes: ED patients Paediatric
medical
31% increase in croup/ stridor identification
(pop increase in
same period = 3%)
0.0 5.0 10.0 15.0
Overall
PaedMed
EM
Mean Length of Stay (LOS)
Pre-bundle Post-bundle
Shorter
00:50
12 minutes
282 minutes
0.0 1.0 2.0 3.0 4.0 5.0 6.0
Night
Day
Overall LOS
Mean Hours to Discharge (from ED or ward)
PreBCB Post BCB
Shorter 00:50
Shorter 00:18
Shorter 01:24
59%
27%
41%
73%
0% 20% 40% 60% 80% 100%
Post BCB
Pre BCB
Time to Treat with Dexamethasone (TTT)
Improved by 118%
0-29 minutes 30+ minutes
Electronic Dispensing Data
Corresponding Pyxis entries identified:
Pre BCB Data 44%
Post BCB Data 56% - Awaiting re-audit.
Percentage increase 27%
8%
19%
6%
11%
38%
6%
0% 20% 40% 60%
Overall
PaedMed
EM
Percentage Admitted to Ward
Pre-bundle Post-bundle
24% reduction in
ward admissions post bundle
…and there is no down side
Representations Pre bundle – 2.4%
Post bundle – 1.9%
How do BCBs make a difference? Reduced process delays in ED LOS TTT
Reduced treatment disparity EM vs Paed Medical
Reduced admission rates No increase in representations Improved data capture “Croup” in presenting symptom field
Electronic dispensing data (Pyxis)
A Best Care Bundle (BCB) is…
How they work…
They DO make a difference
Acknowledgments Bundle Development: Stefan Van Der Walt Paed
EMS
Olwen Gilbert Paed EMS
Carmen Haines Paed NE ED
Jenny Crawford Paed Pharmacist
Jane Key PCNS ED
Jan Boyd PCNS ED
Jaye Fuller PCNS ED
Jenny Bindon Project Manager
Audit: Jane Key PCNS
Delwyn Armstrong
Health Intelligence Manager
Emma Batistich ED SMO
Stefan Van Der Walt Paed EMS
Olwen Gilbert Paed EMS
Jenny Bindon Project Manager
Any Questions?
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Hampers, L. C., & Faries, S. G. (2002). Practice variation in the emergency management of croup. Pediatrics, 109(3), 505-508. Julian Vyas. (2007). Croup. New Zealand Family Practice, 34(4), 266-269. Loew, D., Schuster, O., & Graul, E. H. (1986). Dose-dependent pharmacokinetics of dexamethasone. European Journal of Clinical Pharmacology, 30(2), 225-230. doi:10.1007/bf00614309 NHS England. (2014). Clinical audit. Retrieved from http://www.england.nhs.uk/ourwork/qual-clin-lead/clinaudit/ Nursing Council of New Zealand. (2008). Competencies for Nurse Practitioners: Nursing Council of New Zealand,. Retrieved from http://www.nursingcouncil.org.nz/content/download/336/1556/file/Competencies%20for%20nurse%20practitioners%20Sep%202008.pdf Pharmac. (September 2014a). Online Pharmaceutical Schedule Volume 21 Number 2: Dexamethasone. Retrieved 20th August, 2014, from http://www.pharmac.govt.nz/Schedule?osq=dexamethasone Pharmac. (September 2014b). Online Pharmaceutical Schedule Volume 21 Number 2: Prednisolone sodium phosphate. Retrieved 20th September, 2014, from http://www.pharmac.govt.nz/Schedule?osq=Prednisolone%20sodium%20phosphate Port, C. (2009). Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4. Dose of dexamethasone in croup. Emergency Medicine Journal: EMJ, 26(4), 291-292. doi:10.1136/emj.2009.072090
Chub-Uppakarn, S., & Sangsupawanich, P. (2007). A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. International Journal Of Pediatric Otorhinolaryngology, 71(3), 473-477. Dalcin, P. d. T. R., da Rocha, P. M., Franciscatto, E., Kang, S. H., Menegotto, D. M., Polanczyk, C. A., & Barreto, S. S. M. (2007). Effect of clinical pathways on the management of acute asthma in the emergency department: five years of evaluation. The Journal Of Asthma: Official Journal Of The Association For The Care Of Asthma, 44(4), 273-279 Dobrovoljac, M., & Geelhoed, G. C. (2009). 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emergency Medicine Australasia: EMA, 21(4), 309-314. doi:10.1111/j.1742-6723.2009.01202.x Dobrovoljac, M., & Geelhoed, G. C. (2012). How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emergency Medicine Australasia: EMA, 24(1), 79-85. doi:10.1111/j.1742-6723.2011.01475.x Donaldson, D., Poleski, D., Knipple, E., Filips, K., Reetz, L., Pascual, R. G., & Jackson, R. E. (2003). Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Academic Emergency Medicine: Official Journal Of The Society For Academic Emergency Medicine, 10(1), 16-21. Fifoot, A. A., & Ting, J. Y. (2007). Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emergency Medicine Australasia: EMA, 19(1), 51-58.
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