Name: Lucinda Armstrong
Job title: Sister
Specialty: Children’s nursing
Organisation: University Hospitals Bristol NHS Foundation Trust
Wheeze is a very common childhood presentation to Emergency Departments (ED) with a predictable clinical course. In our institution most are admitted to an observation unit to wean the frequency of inhaled medicines, a key step before discharge. Although nurses are allocated to this unit, medics and Emergency Nurse Practitioners (ENP) concurrently deliver care here and in the ED, which may create delays as children who are fit for discharge await their review.
Criteria Led Discharge (CLD) is a protocolised discharge process that empowers nurses to discharge pre-identified patients, and is identified as a method to support ED flow and reduces levels of crowding.
After implementing CLD for wheezy children we undertook serial evaluations to measure efficiency and safety using pre-defined time-related outcomes and safety measures. There was a significant reduction in the time to discharge, by over two hours per child, equivalent to a saving of 130 bed days per year; safety measures were stable pre and post-implementation.
Benefits have been sustained and amplified over three years, and expanded to include similar conditions; this has subsequently spread throughout our hospital and to other institutions.
Childhood hospital admissions are rising annually, especially for breathing problems, with wheeze the most common diagnosis. Most admissions are short; in our institution these children are admitted to our observation unit.
On average, every bed in this unit is used for 2.5 patients per day, reflecting high efficiency. However when fully occupied, suitable patients are admitted to inpatient beds, and flow from the ED is impeded. Targeting efficiency improvement here speeds discharge, improves ED patient flow, and reduces inpatient admission, contributing to financial benefits and improved patient/family experience. Learning from (a) this unit can be translated rapidly to other departments in our institution and similar units nationally, and (b) from wheeze to other appropriate conditions.
Observation unit nurses autonomously wean medication and deliver family education, including inhaler technique and recognition of severe breathing problems. We therefore implemented CLD for wheezy children in this unit, with a planned evaluation to measure efficiency (time to discharge compared to existing practice) and safety (unplanned return rate, reflecting quality of education and safety of discharge decision).
How did you initiate the work?
Prior to implementation, the CLD concept was supported by Senior ED Consultant, Nursing, and Management teams via our governance group. Input was sought from all nurses and medics during development of assessment proformas, checklists, communication and training materials, to encourage buy in. Families were not involved in CLD development, but are offered the opportunity to opt-out prior to discharge. Work is planned with families to explore whether any improvements can further enhance their experience.
When implementing CLD hospital-wide we engaged with general paediatric medics and nurses, management, and the hospital innovation team. CLD is covered in hospital induction and included in competency documents for all new doctors and nurses, with support and leadership from senior personnel. We anticipate this will safely improve efficiency hospital-wide, especially during seasonal illness outbreaks such as bronchiolitis, which place huge demands on resources nationally.
We share resources and experiences with paediatric departments and EDs who are keen to implement CLD; when doing so we strive to optimise successful implementation by discussing their infrastructure and common challenges.
Unsurprisingly many of the current issues and obstacles are identical; CLD appears to provide a deliverable solution to at least some of these.
What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?
Nursing staff feel empowered and more valued in taking ownership for patients on CLD pathways. The medical team value the use of CLD and the efficiencies it has delivered, identifying that it is patient friendly, family friendly and promotes wider team engagement.
Has the initiative or project made a difference to patients/service users and or staff?
CLD for wheeze was implemented in May 2016; serial evaluations demonstrate excellent adoption by staff.
2018 saw a 100% annual increase in use, with 32% of all patients discharged by CLD. We successfully expanded CLD to other conditions; comparing 2018 to 2017, the number of additional patients discharged by CLD equalled increases in admissions; despite an 18% annual increase in admission there was zero additional workload for medics.
For wheeze, evaluations consistently demonstrate CLD is efficient and safe. Compared to previously, time to discharge decreased by over 2 hours on average, from 140 to 15 minutes. This results in approximately 130 bed days saved per year. Generating this highly efficient turnaround improves ED flow and reduces inpatient admissions.
Safety measures included completion of an education checklist, a written wheeze plan, protocolised primary care communication, proportion removed from CLD pathways, and unplanned reattendance rates.
Completion of checklist, wheeze plan, and primary care communication are 100%; removal from CLD pathways occurs appropriately in 10% due to needing oxygen.
Unplanned reattendance rates remained stable before and after CLD at 1%.
What are the long-term aims for the work?
Dissemination has enabled spread in three main domains: (i) our observation unit, (ii) our hospital inpatient wards, and (iii) other similar institutions. Our dissemination strategy included peer-reviewed journal publication (Archives of Disease in Childhood Education & Practice, widely accessed by relevant healthcare staff), presentation at local, regional and national conferences, and social media.
In each forum we shared the results, implementation strategy, and assessment proforma, to enable easy uptake. We are engaging with our Academic Health Science Network to spread this more formally.
In our observation unit we expanded CLD to other conditions including procedural sedation recovery, bronchiolitis, head injury, accidental ingestion and gastroenteritis. In our hospital we worked with the General Paediatricians to support hospital-wide CLD implementation for wheeze and other conditions. This was implemented in late 2018, and is currently undergoing its first round of evaluation; the early signal is optimistic, with increasing numbers of children discharged safely on CLD through the first two months.
We have also trained and supported other paediatric teams, both regionally and nationally, resulting in CLD implementation for wheeze in their observation and paediatric assessment units. Whilst none of these have yet been formally evaluated, initial feedback is uniformly positive.