The development of a community nursing service for children with

an acute illness.

Carolanne GettyCommunity Children’s Nursing Sister

Aim:To describe the

development of an acute CCN service.

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.

Structure of Presentation

Evidence supporting acute CCN service development

Setting up the acute CCN Service in Homefirst

Dimensions of care CCN can bring.

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

“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

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

Public heathHealth protection and promotion

– working with children and families to improve health

and reduce the impact of health and disability

Continuing careChronic disease management and

achieving imperatives of Children’s NSF

Model for components of care CCN services can be expected to deliver.(Adapted from DH, 2002; RCN, 2002)

First ContactAcute assessment, diagnosis, treatment

and referral of children

Composition of Homefirst Community Children’s Nursing Service

Community Children’s NursesContinuing care team

Trust wide

Regional Children’sPalliative Care Nurse

Northern Board

Acute Community Children’s Nursing Team

Antrim/Ballymena

Children’s Diabetes Nursing Service

Trust wide

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

Questionnaire of potential service users

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

Stages of Service Development

1. Preliminary/ preparation stage

2. Implementation stage 3. Evaluation of service role

Preliminary stage Develop aims and objectives Develop operational policy

Develop evidenced based policies and procedures

Develop documentation

Logistical issues

Implementation Stage Establishing links in hospital and

community

Raising awareness

Identifying staff training needs

Staff development

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.”

Challenges

Not 24 hour slow rate of service referrals

Role Protectionism Staffing levels

Dimensions of care

1. Formal knowledge and skills2. Coordinating knowledge and skills3. Skills for managing workload4. Relational, interpersonal and

support skills5. Teaching skills6. Thinking skills

Proctor et al. 1998

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

“A thousand mile journey starts with a single step”

Lao-tsu, 604 - 531 BC

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)

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

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.

Caring for children receiving Caring for children receiving home intravenous antibiotic home intravenous antibiotic

therapytherapy

Dianne CookDianne Cook - Children’s Community - Children’s Community Specialist PractitionerSpecialist PractitionerCentral Manchester Primary Care TrustCentral Manchester Primary Care TrustElaine Salmons Elaine Salmons – Children’s Community – Children’s Community Team LeaderTeam LeaderQueen’s Medical Centre, NottinghamQueen’s Medical Centre, Nottingham

AIMAIMTo have an increased awareness of To have an increased awareness of administering IV antibiotic therapy in administering IV antibiotic therapy in the communitythe community

OBJECTIVESOBJECTIVES• To discuss advantages of IV’s in the To discuss advantages of IV’s in the

communitycommunity• To explore issues relating to To explore issues relating to

administrationadministration• To have a basic awareness and To have a basic awareness and

understanding of anaphylaxisunderstanding of anaphylaxis

The administration of IV drugs by The administration of IV drugs by Community nurses has become more Community nurses has become more

widespread in recent years. The widespread in recent years. The practice, having initially been classed practice, having initially been classed as an extended role of practice has as an extended role of practice has

now become part of the core skills for now become part of the core skills for general nursing practice. This general nursing practice. This

therefore allows an holistic approach therefore allows an holistic approach to care.to care.

Advantages of IV’s at homeAdvantages of IV’s at home• Reduction and prevention of hospital Reduction and prevention of hospital

admissionsadmissions• Reduced length of stayReduced length of stay• Increased independence from hospitalIncreased independence from hospital• Less disruption to family routineLess disruption to family routine• Continued schoolingContinued schooling• Reduced risk of cross infectionReduced risk of cross infection• Reduction of winter bed pressuresReduction of winter bed pressures• Cost effectivenessCost effectiveness• Payment by resultsPayment by results• Autonomy and empowermentAutonomy and empowerment

Range of Access routesRange of Access routes

• Peripheral Lines – Cannula, Peripheral Lines – Cannula, LonglinesLonglines

• Central Venous Routes - Hickman Central Venous Routes - Hickman LinesLines

• Subcutaneous Implantable Venous Subcutaneous Implantable Venous access devices – Portacaths access devices – Portacaths

‘‘The administration of medicines is an The administration of medicines is an important aspect of the professional important aspect of the professional practice of persons whose names are practice of persons whose names are

on the Council’s register. It is not on the Council’s register. It is not solely a mechanistic task to be solely a mechanistic task to be

performed in strict compliance with performed in strict compliance with the written prescription of a medical the written prescription of a medical practitioner. It requires thought and practitioner. It requires thought and

the exercise of professional the exercise of professional judgement…..’judgement…..’

Guidelines for the administration of medicines Guidelines for the administration of medicines NMC 2004NMC 2004

Children are not miniature Children are not miniature adults as they have different adults as they have different

pharmacokinetic profiles, pharmacokinetic profiles, which require specialist which require specialist

knowledge, awareness and knowledge, awareness and expertiseexpertise

The safe administration to The safe administration to children is a key area of children is a key area of

responsibility for responsibility for practitioners in child care, practitioners in child care,

and warrants extra vigilance and warrants extra vigilance in order to safeguard each in order to safeguard each

child’s safetychild’s safety

Clinical responsibility for a Clinical responsibility for a child receiving IV therapy at child receiving IV therapy at

home lies with the GP. If a GP home lies with the GP. If a GP is unwilling to accept is unwilling to accept

responsibility, the Consultant responsibility, the Consultant will normally continue this will normally continue this

rolerole

‘‘It is the nurse who is responsible It is the nurse who is responsible for the correct administration of for the correct administration of the prescribed drugs. Therefore, the prescribed drugs. Therefore,

they should know the they should know the therapeutic uses, dosage, side therapeutic uses, dosage, side

effects, precautions and contra-effects, precautions and contra-indications’indications’

(Guidelines for the administration of (Guidelines for the administration of medicines 2004)medicines 2004)

‘ ‘ The NMC welcomes and The NMC welcomes and supports the self-supports the self-

administration of medication administration of medication by carers wherever it is by carers wherever it is

appropriate….’appropriate….’

(Guidelines for the safe administration of (Guidelines for the safe administration of medicines, NMC 2004)medicines, NMC 2004)

If responsibility is delegated then If responsibility is delegated then

we need to ensure that the patient, we need to ensure that the patient, family or carer is competent to carry family or carer is competent to carry out the taskout the task

EducationEducation TrainingTraining AssessmentAssessment SupportSupport Reviewed and reassessed Reviewed and reassessed

periodicallyperiodically

‘‘Check that the patient is not Check that the patient is not allergic to the medicine before allergic to the medicine before

administering it’administering it’ NMC 2004NMC 2004

but…but…

An allergic reaction does not An allergic reaction does not usually occur the first time a usually occur the first time a person is exposed to a drug…person is exposed to a drug…It is only after the body learns It is only after the body learns

to recognise the substance to recognise the substance that an immune system that an immune system

reaction is triggeredreaction is triggered

It therefore, is essential, that It therefore, is essential, that more diligence be taken more diligence be taken

throughout the second and throughout the second and subsequent administration of subsequent administration of drugs given via the IV route, drugs given via the IV route, especially as these are often especially as these are often

administered in the communityadministered in the community

Drug allergies occur as a result Drug allergies occur as a result of a variety of complex of a variety of complex

immune system responses to immune system responses to specific medications. specific medications.

In most cases, the reaction In most cases, the reaction involves relatively mild involves relatively mild

symptoms, e.g. minor skin symptoms, e.g. minor skin rashes and hives, itching, rashes and hives, itching, generalised flushing of the generalised flushing of the

skinskin

However, in some cases a life However, in some cases a life threatening, acute reaction threatening, acute reaction

can occur progressing quickly can occur progressing quickly to more severe symptoms, to more severe symptoms,

massive swelling of the massive swelling of the respiratory tract, constriction respiratory tract, constriction of bronchial smooth muscle of bronchial smooth muscle and extreme vasodilationand extreme vasodilation

Anaphylaxis is a severe allergic Anaphylaxis is a severe allergic reaction, the extreme end of reaction, the extreme end of

the allergic spectrum. No the allergic spectrum. No universally accepted definition universally accepted definition

exists because anaphylaxis exists because anaphylaxis comprises of a constellation of comprises of a constellation of

featuresfeatures (Ewan 1998)(Ewan 1998)

((Anaphylaxis, BMJ, 316, 1442-Anaphylaxis, BMJ, 316, 1442-1445) 1445)

Anaphylaxis occurs in an acute and Anaphylaxis occurs in an acute and unexpected manner. The true unexpected manner. The true

incidence is unknown. incidence is unknown. Epidemiological studies have Epidemiological studies have

shown differing results owing to shown differing results owing to differences in both definitions of differences in both definitions of anaphylaxis and the population anaphylaxis and the population

groups studied.groups studied.

Anaphylaxis seems to be Anaphylaxis seems to be increasingly common, almost increasingly common, almost

certainly associated with a certainly associated with a significant increase in the significant increase in the

prevalence of allergic disease prevalence of allergic disease over the last two or three over the last two or three

decadesdecades

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

Early intramuscular Early intramuscular administration of adrenaline administration of adrenaline is essential for optimal actionis essential for optimal action

•Adrenaline (Epinephrine) is Adrenaline (Epinephrine) is greatly under-usedgreatly under-used

•Although widely available in Although widely available in the community, it is not given the community, it is not given in a timely manner when in a timely manner when requiredrequired

(Resuscitation Council UK 2005(Resuscitation Council UK 2005 The Emergency Medical Treatment of Anaphylactic The Emergency Medical Treatment of Anaphylactic

Reactions for First Medical Responders and for Reactions for First Medical Responders and for Community Nurses)Community Nurses)

‘‘Anaphylaxis is poorly Anaphylaxis is poorly managed’managed’

Treatment Algorithm for Treatment Algorithm for Children in the CommunityChildren in the Community

Resuscitation Council (UK) 2006

(www.resus.org.uk/siteindx.htm)(www.resus.org.uk/siteindx.htm)

Although anaphylactic reactions Although anaphylactic reactions are rare, they cannot be are rare, they cannot be predicted and have the predicted and have the

potential to be fatal without potential to be fatal without treatmenttreatment

(Martin 2000)(Martin 2000)

(Immunisation, Nursing Standard, 14, 30, 47-52)(Immunisation, Nursing Standard, 14, 30, 47-52)

Ideally therefore, no one Ideally therefore, no one should give IV treatment should give IV treatment

without access to adrenaline without access to adrenaline and assistanceand assistance

Discuss with managementDiscuss with managementDiscuss within own TrustDiscuss within own Trust