Paediatric Ambulatory Care - The Way of the Future

Northern Sydney Central Coast Area Health Service

Abstract

Hospital admission is potentially very stressful for unwell children and their families¹. Innovative new paediatric models of care have been established at Wyong and Hornsby Hospitals in the last 2 years. Both models incorporate Paediatric Acute Review clinics (PARC). This model of care provides an alternative to inpatient admission for acutely unwell children.  Care is provided by specialist paediatric medical and nursing staff in daily acute review clinics. The Wyong clinic operates 7 days per week. The Hornsby clinic operates 5 days per week. The care provided has led to reduced hospital admissions and high levels of patient / parent satisfaction. There is potential for this model of care to be implemented widely across the state in the future.

 Download the presentation given at the 2008 NSW Health Expo (858 KB).

Aim

To provide high quality, appropriate, safe and supportive care for acutely unwell children with the aim of avoiding unnecessary hospitalisation and to provide high levels of parent satisfaction.  

Nature of the Problem

Acute illness is very stressful and disruptive for a child and family, especially when hospital admission is required.

Wyong Hospital (WH) has high numbers of paediatric emergency presentations without an onsite paediatric inpatient unit.  A significant number of children require transfer to Gosford (approximately 35 minutes away) for admission.   

The capacity of the paediatric inpatient unit at Hornsby Ku-ring-gai Health Service (HKHS) was reduced from 18 beds to 12 beds with the opening of the new ward in November 2006.  This created potential for access block, long waits in the Emergency Department and reduced capacity for elective surgery.

Extent of the Problem

Wyong Hospital Emergency Department (ED) has high numbers of paediatric presentations (~11000 per year).  Despite this, the hospital does not have a paediatric ward.  Any child requiring admission is transferred to Gosford (~1000 transfers per year).  The transfers are time consuming, expensive, inconvenient and stressful for the child and their family.  One solution would be to open a paediatric inpatient unit at Wyong, but this would require an injection of resources and staff.  An alternative solution was to establish the Paediatric Ambulatory Care Unit.  The unit began operating in August 2006.

With a 10% increase in paediatric presentations to ED and the reduction of bed numbers at HKH Paediatric Ward, a potential for access block, particularly during the winter peak was identified. A small working party was formed to develop strategies to minimise access block during winter and to use existing resources to develop new paediatric models of care.

Strategic Importance 

The project relates to NSW Health strategic direction 2: Create better experiences for people using health services².

Acute illness in a child is stressful for all involved. Paediatric acute review clinics (PARCs) provide timely access to specialist paediatric medical and nursing staff. We aim to provide high quality, safe, appropriate care as close to home as possible. The potential to avoid or reduce the length of an inpatient stay makes the patient journey less stressful for the child and family. The paediatric network within our Area Health Service is keen to expand this model and establish PARCs across the area.

Planning and Implementing Solutions

Wyong Hospital

The Wyong Hospital Paediatric Ambulatory Care Unit (PACU) opened in August 2006.  The model of care incorporates

The unit initially operated 5 days per week, extending to 7 days per week from March 2007.  Acute review clinics are held daily.  Children are referred to the PACU from the Emergency Department, local GPs, Gosford Children’s Ward and the tertiary children’s hospitals.  PACU nursing staff also audit the ED notes each day to identify children who may benefit from phone support or clinic review.

PACU nursing staff contacts the parents by phone and provide advice and reassurance.  If medical review is needed the child comes into the acute review clinic. On arrival a nursing assessment is performed and treatment initiated if appropriate (e.g. trial of oral fluids for a child with gastroenteritis).

Strong links are being developed with local GPs who can refer acutely unwell children directly to the unit rather than send them to ED.

HKHS

Planning for service implementation included:

Hornsby PARC commenced in June 2007. The clinic is run by a paediatrician and a registered nurse 5 days /week. Children are referred to the service by the ED, GPs, Paediatricians and the Children’s Hospitals. Children who are borderline for admission, especially overnight, can have treatment commenced including intravenous antibiotics, continued at home and reviewed next day. Children can also be discharged earlier from the ward and treatment completed as an outpatient.

Outcomes and Evaluation

In the 22 months since Wyong PACU commenced operation there has been:

In the 10 months since HKHS PARC commenced operation there have been:

Sustaining Change    

A key component to the success of both units is having a core group of skilled and enthusiastic clinicians and structured processes for patient management.

The Wyong PACU is providing a much needed cost effective paediatric service in an area of high population growth.  The service is flexible and adaptable to changing health requirements of local families.

The HKHS PARC was established and is operating within existing resources and demonstrates a cost-effective, sustainable model of care. 

There is ongoing collaboration between Wyong and HKHS in the development of their services.  Shared forms, guidelines and policies have been developed. 

Future Scope

This model of care illustrates an efficient way of assessing and managing acutely unwell children without the need for an admission.  There is potential to better utilise existing resources within paediatric inpatient units to incorporate PARCs. 

This model of care has potential wide ranging implications for future paediatric service planning. The collaboration between Wyong and HKHS in developing common forms, guidelines and procedures shows potential for collaboration and support for service development on a wider scale across NSW.  Consideration should be given to developing PARCs, short stay units, outreach care and telephone support to complement traditional inpatient models of care.

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