Implementing paediatric emergency department clinical practice tools for asthma, gastroenteritis and fever: a collaborative approach

21 October 2005
Hunter/New England Area Health Service

This project was entered in the Baxter 2005 NSW Health Awards, Apprpriatenss of Care category.

Entries from the Baxter 2005 NSW Health Awards - full list

Authors

Louise Evans, HNEAHS 
Rhonda Winskill, HNEAHS

Date(s) project undertaken: December 2004-May 2005

Abstract

In December 2004, NSW Health released 12 paediatric clinical practice guidelines relating to the most common presentations to Emergency Departments. The Health Department at the time of release stated that: “Area Health Services are required to have local guidelines in place in all hospitals and facilities likely to be required to assess or manage children”. The NSW Clinical Excellence Commission established a number of pilot sites throughout the state to implement the guidelines using a staged approach over a one-year period. Using a collaborative approach, a working party, comprising both Hospital and General Practice staff from the three pilot hunter sites at John Hunter, Maitland and Dungog, was formed. The working party aimed to develop strategies to disseminate and monitor implementation of the guidelines. Baseline and post implementation audits were conducted and indicate that improvements have been made in relation to evidence based practice and provision of discharge information.

Aim

Improve compliance with evidence based guidelines for Asthma, Gastroenteritis and Fever by May 2005. This will be achieved by developing and implementing clinical practice guideline tools in pilot site emergency departments. Improvement will be demonstrated by comparing baseline and post guidelines implementation audits.

Background 

The current clinical practice guidelines for asthma, gastroenteritis and fever are lengthy documents and therefore difficult for clinical staff to access effectively. It was suggested a one-page clinical practice tool that contains key information for emergency staff would assist in providing timely and efficient evidence based care.

Baseline audits undertaken to measure compliance with current guidelines revealed:

• Gastroenteritis: discharge information provided to- 14%
• Moderately severe asthma: steroids given to- 57%
• Fever: axilla temperature taken and documented- 0%

These results indicated the need for review of current practices to achieve increased compliance with evidence based standards.

Methodology

The working party collaborated with local subject experts and frontline staff, health information managers, administrative assistants, public relations staff, online publishing staff, as well as colleagues from the other fifty pilot sites. The aim was to develop clinical tools that would be appropriate for both tertiary and rural sites. Using PDSA quality improvement principles, the clinical tools were trialled for a period and refined in line with feedback received.

Strategies used to inform staff about the guidelines and to seek their feedback on the tools include meeting forums, staff in-services, small group and individual sessions, electronic and print media (including a staff newsletter describing project progress and audit results).

It was identified early in the project that additional resources, beyond the scope of the working party, would need to be provided by Senior Management. This incorporated additional staff to help implement the tools, funds to purchase additional equipment and approval of release time from clinical duties.

General Practice liaison staff have also been involved in disseminating information to their rural and urban members and feedback indicates that rural general practice staff are also using the tools to facilitate the initiation of appropriate care as early as possible.

Planning the interventions and implementation

After identifying individual site preferences and learning from other successful pilot sites throughout the state, a number of diverse strategies were introduced. These are:

• One page clinical pathways initiated by the Triage Nurse to facilitate the delivery of a standardised approach to evidenced based care.
• Education posters developed which targets both staff and parents.
• Trial of oral fluid forms (for use by staff and parents in the waiting room) to record fluid intake and output.
• Additional equipment such as digital thermometers, hydralyte oral rehydration solution and hospital grade spacers for the administration of bronchodilators was obtained.
• Medical and nursing staff from the John Hunter Emergency Department and Children’s Hospital, were invited to complete a questionnaire designed to assess staff awareness of the gastroenteritis guideline and level of knowledge regarding evidence based practice.
• Staff at the Maitland Hospital attended a “Breakfast Launch”, where “colour coded” clinical pathway packs were introduced.
• Dissemination strategies for staff and the community have included online publishing through the Kaleidoscope website, Kaleidoscope staff newsletter, Emergency Department intranet and local print and radio media

The aim of the interventions was to improve both knowledge and use of the clinical practice guidelines. 

Outcomes and evaluation

Baseline and post implementation audits have indicated that improvements have been made (refer to Table 1) in care provided to children with asthma, gastroenteritis and fever. Emergency department staff have been provided with information about the guidelines, audit results and progress of the project.

Feedback from rural General Practice staff indicates that the tools are being used in the surgery thereby facilitating the initiation of appropriate care as early as possible. General practice staff nurses have received education about the guidelines.

Another strategy used at John Hunter Hospital was to invite all emergency and paediatric medical and nursing staff to complete a 12-item multiple-choice gastroenteritis questionnaire designed to assess staff awareness of the guideline and level of knowledge regarding best practice. The survey was administered (during meeting forums and grand rounds) without forewarning over a 2-3 week period. One hundred and fifty-three staff (66% of total staff) completed the survey. Results indicated that 71% of staff were aware of the guidelines and when all responses were collated those who had used the guideline in the past had a significantly higher mean test score of 73%, compared with 61% for those who had never used the guideline.

Future scope

Site appropriate tools have been developed for both rural and tertiary sites. The tools are easily photocopied and are available in hard and electronic copy and on the website. These tools will be easily adopted in all emergency departments throughout the area health service.
The remaining guidelines will be implemented using the same format and methodology and ongoing audits will be conducted to ensure that improvements are sustained. Future guidelines released by NSW Health would also be able to be effectively implemented using the processes that have been piloted in this project.

 The Tools developed during this project are attached below.

Attachments

  Paediatric Asthma Mangement in ED rural (81.8 KB) Hunter/New England Area Health Service; 2004
  Paediatric Gastroenteritis Management in ED rural (83.5 KB) Hunter/New England Area Health Service; 2004
  Paediatric Asthma Mangement in ED tertiary (79.3 KB) Hunter/New England Area Health Service; 2004
  Paediatric Gastroenteritis Management in ED tertiary (83.1 KB) Hunter/New England Area Health Service; 2004
  Trial of Oral Fluids (52.0 KB) Hunter/New England Area Health Service; 2004