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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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.