Analysis of Model of Service Delivery in Paediatric Care

Analysis of Model of servicing Delivery in Paediatric Cargon victorious implementation of a pediatric community rest floor treat emolument as a model of service delivery in not bad(p) paediatric tendingAbstractAim The aim of this pilot service development was determine if CommunityChildrensNursingOutreach Team (CCNOT) service as a model of cover was hard-hitting in its delivery of reducing unscheduled caveat and admissions to infirmary and improving long-suffering satisfaction.Methods The adjacent outcomes were determined1)reducing length of hospital stay 2) reducing misadventure and Emergency admissions 2)reducing non-elective admissions 3) reducing readmissions and 4)improving persevering satisfaction.Results The information indicates that AE attendances had sign ond by 5% per month, NEL admissions had lessen by 15.8%, readmissions had reduced by 17.3% and the boilersuit LOS was increase by 2.3%. The results of the sheer satisfaction survey shows overall a high affected role satisfaction for the service.Conclusions Paediatric CCNOT service as a model of service delivery in acute paediatric cargon is strong in reducing hospital admissions and increases patient and misgivingr satisfaction with care provision for sick children in the theater environment. tombstone PhrasesPaediatric community home nursing service as a model of service delivery indoors acute paediatric care is effective in reducing AE admissions, non-elective admissions and readmissions.It importantly increases patient and carer satisfaction with care provision for sick children with appropriate conditions in the home environment.Paediatric community home nursing should be implemented with nurses deft in paediatrics and with make headway clinical governance, pathways and cast-iron corroboration.IntroductionPaediatric emergency admissions and length of stay in hospitals in the United Kingdom are increasing (Kyle et al. 2013). Community home nursing service or CommunityCh ildrensNursingOutreach Teams (CCNOTs) have been developed to manage acutely ill children athome, to reduce length on inpatient hospital stay andto reduce demand for unscheduled care (Hall et al. 2005). The CCNOT model of care has been shown in a previous randomize controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care as a clinically delicious form of care for management of acute paediatric illness (Sartain et al. 2002). Referral pathways to CCNOTs may reduce avoidable admissions and minimise the psychosocial impact of hospitalisation on children and families, and reduce the fiscal costs to the National health Service (NHS). Paediatricians and commissioners face considerable challenges in light of recent budget cuts in the NHS. Research undertaken by the University of Central Lancashire and the University of the tungsten of England for the Department of Health markd the importance of reliable, accessible expert community home nurs ing provision to families to enable them to care for their child at home and recorded the families deep frustration at the patchy, fragmented postcode lottery provision of go that currently exists (Department of Health 2011).BackgroundServices that meet the inescapably of children and their families must continue to be tryd in a safe, high quality and sustainable manner. In our desire to improve the quality of care in paediatric services in the face of rising public expectations, there is a need for change within new working hours and new ways of providing. The gaucherie for change can be complex, with decisions made to balance key areas of clinical effectiveness, best practice, patient safety, accessibility, staff retention and sustainability. The Royal College of Paediatrics and Child Health (RCPCH) recognises the importance of ensuring that services for children are designed to provide high quality care as slopped to home as possible and that such services need to adapt and respond to the demands and needs of the patient. The Colleges current work to model the future configuration of paediatric services discussed the move towards delivering acute care within the community such as community home nursing service (RCPCH 2005). The aim of this pilot service development was determine if CCNOT service as a model of care was effective and efficient in its delivery of reducing unscheduled care and admissions to hospital and improving patient satisfaction.MethodsClinical Commissioning Groups (CCGs) are responsible for planning and designing of the local health services in England. Within a dual-site integrated care organisation Southport and Ormskirk NHS Trust, a pilot CCNOT service was developed in March 2013 following negotiations between the Trust and the CCGs in Sefton and Lancashire. The remit of the pilot service specification aims were to determine the effectiveness of CCNOT in the following outcomes 1) reducing length of hospital stay 2) reducing Accide nt and Emergency admissions 2) reducing non-elective admissions 3) reducing readmissions and 4) improving patient satisfaction. Funding was sought for 7.2 WTE paediatric trained nurses at band 5 to 6 and 0.5 WTE admin and Clerical support staff.CCNOT referrals were taken from accident and emergency, the short stay paediatric admissions unit (SSPAU), the inpatient ward and from the ordinal hospital Alder Hey Foundation Trust for patients residing in North Sefton, Formby and West Lancashire, which covers a population of approximately 300,000. Collaborations were made with Pharmacy, IT and specialist services to develop robust e-discharge summaries from the community and the ability for CCNOT to deliver three times daily intravenous antibiotics in patients homes 7 days a week. The service ran from 7am to 10pm seven-spot days a week. It was also necessary to set up all the operational aspects of the team including admission criteria, clear clinical governance and pathways, robust docu mentation and purchasing necessary equipment. The service was managed overall by the Paediatric and Neonatal matron.The CCNOT was led by the paediatric matron with regular supervision and mentorship of a lead CCNOT adviser Paediatrician. Clear clinical criterias for referrals made to CCNOT were developed and clinical pathways were followed to ensure that each referral pathway was safe and robust. (see Figure 1) Any referral was discussed with the CCNOT between a Registrar or a Consultant. Each diagnostic pathway was clearly followed by the CCNOT team with any deviation discussed with the lead Consultant Paediatrician. Daily handovers from the medical teams were attended by a lead CCNOT member of the day to ensure that any referrals made were handed over verbally and any potential referrals during the day were anticipated. The handovers were also an chance to discuss the progress of any patient who remained under the care of the CCNOT.A structured patient satisfaction questionnaire was conducted with participants who were referred to CCNOT at the time of discharge. Hospital admissions between April 1, 2012 and kinsfolk 30, 2013 from the Hospital Episode Statistics (HES) were obtained. HES is the national administrative database for hospital activity in England and contains data on all inpatient admissions in the National Health Service.ResultsThe data collected shows activity from April 2012 to September 2013. The results of the pilot service for 1) average length of hospital stay (LOS) 2) Accident and Emergency (AE) admissions 2) non-elective admissions (NEL) 3) and readmissions are summarised in Table 1 comparing the period before CCNOT was implemented (April to September 2012) and the period after CCNOT was implemented (April to September 2013), during the same months of the year. The data showed that there were 28.3% referrals made from AE, 38.7% from inpatient ward, 11% from SSPAU, 8.9% from outpatient clinics, 12.5% from the regional tertiary centre an d 0.6% from another district general hospital.The data indicates that following the implementation of the pilot, AE attendances had reduced by 5% per month, NEL admissions had reduced by 15.8%, readmissions had reduced by 17.3% and the overall LOS was increased by 2.3%. Figure 2 shows that there has been a 5% reduction in AE attendances since the introduction of the CCNOT team. NEL admissions was reduced by 15.8% a shown and although the drop in AE attendances will be reflected in the reduction in non-elective admissions, this will only account for 5% of the over 15% reduction. The readmission rate has significantly reduced by 17.3% since CCNOT service was implemented. The sources of referral overall were 28.3% from AE, 38.7% from inpatient wards, 11% from SSPAU, 8.9% from outpatient clinics, 12.5% from the regional childrens centre and 0.6% from other district general hospitals out of area. Overall patient satisfaction was very high and the results are shown in Table 2.DiscussionCC NOT pilot service had a positive impact on the performance of the paediatric department in reducing Accident and Emergency admissions, reducing non-elective admissions and reducing readmissions. It was far-famed that there was a very slight increase of LOS by 2.3% which were noted to be an average of 0.88 days compared to 0.9 days which were not significant. The CCNOT service also improved the patient and family check considerably from the results of the patient satisfaction survey. The confidence in CCNOTs competence to safely manage acutely ill children athomeand secure rapid referral to the medical team if a childs condition deteriorated were supported by clear clinical pathways and the regular supervision given by the matron and Consultant Paediatricians. The effectiveness of hometreatment were evident from the results of the patent satisfaction survey. The National Service Framework for Diabetes have sure clinicians and Trusts to achieve current targets by providing high qua lity care with novel strategies. One instrument to meet these challenges is the development of a paediatric community home nursing service with CCNOT teams as a service model of care in acute paediatrics in the face of reconfiguration of paediatric services.We have shown in this pilot service that CCNOT has been highly successful in achieving the targets for reducing length of hospital stay, reducing hospital admission from accident and emergency and improving overall patient satisfaction. CCNOT service compared to inpatient hospital stay have been found to be acceptable and preferable to parents and children although there is limited evidence about the clinical and cost-effectiveness of paediatric home care (Sartain et al. 2001, Spiers et al. 2011,Bagust et al. 2002). Concerns have also been raised that childrens emergency admissions in England may indicate that parents often bypass primary care when seeking care for their acutely ill child, perhaps due to lack of availability of o ut of hours services within primary care (Gibson et al. 2010) The option of referral to CCNOT provides care to children at home by nurses with paediatric training, and has the potential to avoid some onward referrals and preventable admissions. The CCNOT service may be further expanded to provide support within primary care service, however, within the remit of our pilot service specification, the current funding is not sufficient to allow coverage for the populations of GP referrals unless the number of WTE staff is further increased. The relative success of our CCNOT in securing high referrals suggests that an incremental approach to encourage GP referrals is likely to result in increased GP referral rates. This development must be underpinned by financial and organisational investment.In light of modern NHS in England, and in similar health systems, it is generally hold that the main focus of paediatric acute services should be the care and support of vulnerable children and you ng people in the community and as close to home as possible (RCPCH 2009). Financial and organisational investment in the development of CCNOT in acute care pathways are a prerequisite for the success describe in this pilot scheme. It is anticipated that in the future, paediatric services will be delivered by consultants leading a team of trained doctors, nurses and health care professionals working within a multi-disciplinary and skill-mixed team delivering care in the community. Pressures in delivering acute paediatric care also relates to changes in the way junior doctors are trained and the recent years application of European Working Time Regulations have required an increase in numbers of trained doctors to provide 24/7 cover in hospital. This increase has sometimes been at the expense high vacancy rates for medical staff and in particular a national shortage of middle grade paediatric medical doctors is experienced across England, Scotland and Wales (Royal College of Paediatri cs and Child Health 2011). There remains limited alive research on the cost effectiveness, development, design and distribution of CCNOT service across acute paediatric care in the UK.ConclusionPaediatric CCNOT service as a model of service delivery in in acute paediatric care is effective in reducing AE admissions, non-elective admissions and readmissions. It also significantly increases patient and carer satisfaction with care provision for sick children with appropriate conditions in the home environment. Our findings identify key factors that may inform the development of a CCNOT service in acute paediatric care to safely manage children at home.Relevance to clinical practiceDelivering acute care within the community such as community home nursing service may reduce demand for unscheduled care and reduce the financial cost to the National Health Service in UK. Paediatric community home nursing service as a model of service delivery within acute paediatric care is effective in r educing AE admissions, non-elective admissions and readmissions. It significantly increases patient and carer satisfaction with care provision for sick children with appropriate conditions in the home environment. Paediatric community home nursing should be implemented with nurses trained in paediatrics and with clear clinical governance, pathways and robust documentation.ReferencesBagust A, Haycox A, Sartain SA, Maxwell MJ, Todd P. Economic evaluation of an acute paediatric hospital at home clinical trial.Arch Dis Child.200287489492.Department of Health 2011 NHS at Home Community Childrens Nursing Services.Gibson NP, Jelnek GA, Jiwa M, Lynch A-M. Paediatric frequent attenders at emergency departments a linked-data population study.J Paediatr Child Heal.201046723728.Hall D, Sowden D. Primary care for children in the 21st century.BMJ.2005330430.Kyle RG,Banks M,Kirk S,Powell P,Callery P.Avoiding inappropriatepaediatricadmission facilitating General Practitioner referral to Community C hildrens Nursing Teams. BMC Family Practice2013 Jan 5144Sartain SA, Maxwell MJ, Todd PJ, Jones KH, Bagust A, Haycox A, Bundred P. Randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care.Arch Dis Child.200287(5)371375Spiers G, Parker G, Gridley K, Atkin KP. The psychosocial experience of parents receiving care closer to home for their ill child.Health Soc Care Comm.201119(6)653660Supporting Paediatric Reconfiguration A Framework for Standards RCPCH 2009Sartain SA, Maxwell MJ, Todd PJ, Haycox AR, Bundred PE. Users views on hospital and home care for acute illness in childhood.Health Soc Care Comm.20019108117.Royal College of Paediatrics and Child Health 2011 Medical Workforce CensusTable 1 OutcomesTable 2. Results of the patient experience surveyNumber of responses 33 (54% return)LegendsFigure 1 Referral pathway to CCNOT serviceFigure 2 AE Attendances April 2012-September 2013