Sydney Children’s Hospitals Network Community Acute and

Post Acute Care (CAPAC) The use of standardised paediatric hospital in the home management

plans

SCHN CAPAC

• Sydney metropolitan area

• First network service

• Two hospitals

– The Children’s Hospital at Westmead

– Sydney Children’s Hospital, Randwick

SCHN CAPAC

• Gradual process of service development built on the development of management plans for individual conditions

• Increase in the service has occurred over the two sites by gradually adding a further targeted condition

Standardised Management Plans

• Standardised management plans ?‘buzz’ word

• Very popular

• Started as financial imperative

• CAPAC commenced this way of progression due to history and the importance of illustrating success

Standardised Management Plans- Process of development

• Business plan developed to commence with targeted conditions

• Targeted conditions had data collected to look at numbers, costs, bed days

• Literature search performed

• Investigations to look at other sites guidelines

Standardised Management Plans- Process of development

• Often little formal literature available using hospital in the home for children

• Plans have been developed on the basis of consensus based medical practice

Standardised Management Plans- Process of development

• The plans have been developed as living documents that can be updated and modified regularly following

– Clinician feedback

– Patient and family feedback

– Clinical practice change

– Data analysis

Eczema management Plan

• 5 day plan

• Twice daily visits by nursing staff with wet dressings there times per day

• Medical review on day 5 prior to discharge

Eczema management Plan

• Standardised use

– Therapeutic creams

– Methods for wet dressings

– Education of family

– Review processes

Eczema Management Plan

Decision to admit

•Medical review in ED, OPD or private rooms

•Medically stable child

•Treatment required determined

Referral process

•Fulfill CAPAC Admission Criteria

•Call CAPAC 0409830213

•Complete Powerchart Referral form

•Complete medication chart

•Family consent

•Risk assessement

•Booked to commence tretment when bed available

Inpatient Day 1

•Formal skin assessment documented in Powerchart

•Photography

•Daily bath 2-3 minutes

•Twice daily nursing visits with TPR daily

•TDS topical steroids and emollients

•Wet dressings TDS morning and evening by nurses and parents at night

•Oral / IV antibiotics if required

•Parental education

•Weight attended

•Documentation in Powerchart using CAPAC note

Inpatient Days 2-4

•Twice daily visits by nursing staff with TPR daily

•Daily bath 2-3 minutes

•TDS topical steroids and emollients

•TDS wet dressings

•Antibiotics as required

Inpatient Day 5 -Review and discharge

•Medical review Day 5 in OPD or rooms

•Photography

•Follow up arranged

Eczema Management Plan

• Eczema: CAPAC Patient Management Practice Guideline to support management with more detail on how to do wet dressings

• Wet dressings homecare guideline for families

Eczema Management Plan - Evaluation

• Evaluation of management plan

• 75% of eczema requiring wet dressings now performed using HITH model

• Parent satisfaction surveys - results

Eczema Management Plan - Data

• Jan 2011-Dec 2012

• 202 episodes of care

• 1073 bed days saved

•

Eczema Management Plan - Data

• 20 (10%) children required readmissions – 1 child 3 further admissions

• 16 (80%) readmissions to CAPAC

• 4 children required hospital admission following CAPAC management (2%) – 2 children <4 weeks, 2 children >1 year

Eczema management plan - data

• CAPAC readmissions

– 3 at 1 month

– 3 at 3 months

– 3 at 5-6 months

– 4 at 8-12 months

– 3 at >12 months

Eczema management plan - data

• Adherence to the standardised management plan

– LOS – 1-3 days – 23 (11.5%)

– 4-5 days – 112 (55%)

– 6-7 days – 45 (22%)

– > 8 days – 23 (11.5%)

Eczema management plan - data

• Further work is to look at deviations and reasons for deviations, characteristics of patients and for those readmitted.

Cystic Fibrosis Management Plan

• Children with cystic fibrosis who require IV antibiotic therapy and increased physiotherapy for an exacerbation of their lung disease (tune up)

• Patients referred by CF clinicians or CNC

• Cystic Fibrosis: CAPAC Patient Management Practice Guideline explains detail

Cystic Fibrosis Management Plan

Decision to admit

•Review by CF Clinician or CNC

•Booked admission or as inpatient when becomes clinically stable

•Treatment required determined

Referral process

•Fulfill CAPAC Admission Criteria

•Call CAPAC 0409830213

•Complete Powerchart Referral form

•Complete medication chart

•Family consent

•Risk assessement

•Booked to commence tretment when bed available

Inpatient Day 1

•Insertion of CVAD or PICC line or access of IVAD

•Pre-treatment Pulmonary function testing

•Other required tests as per treating team

•Order medications and obtain ID approval

•Organise physiotherapy, dietitician, social worker, medical and CNC review

•May remain inpatient in hospital for 1-7 days

Inpatient Days 1-7 to 14

•Daily visits by nursing staff

•Daily respiratory assessment and observations - TPR and SaO2

•Daily IV antibiotics

•Twice weekly weights

•Care of CVAD, PICC, IVAD

•Daily or BD physiotherapy

•Nutritional, gastrointestinal and endocrinological management as required per patient

•Medical review Day 7 and 14

Inpatient Day 14 -Review and discharge

•Medical review Day 14 in OPD

•Post-treatment PFTs

•Pre-discharge modified shuttle test

•Weight on discharge

•Follow up arranged

CF Management Plan- Evaluation

• 45% of CF tune ups now occur with a CAPAC component

• Physiotherapy will now be available 7 days per week, BD on weekdays and soon to have the ability to do TDS IV antibiotics at home

CF Management Plan - Data

• 56 patients admitted CHW Feb 2010-Jan 2013

• Average age 11.55 years (range 0.75-18 years)

• Average FEV1 on admission – 74% (range 38%-105%)

• LOS 15.98 days, 6.59 days in hospital 9.39 days CAPAC

CF Management Plan - Data

• CAPAC compared with inpatient group

– Higher FEV1% at baseline

– Higher final FEV1%

– Higher proportion of CAPAC patients >90% baseline at discharge

– Ongoing analysis

CPAP Initiation in the home management plan

• Continuous Positive Airway Pressure for Obstructive Sleep Apnoea can safely and effectively be initiated at home.

• Children need to be older than 1 year and have attended the hospital for mask fitting and have the equipment available.

• Carer competency must be assessed by a scientific officer or CNC Respiratory Support

CPAP Initiation in the home management plan

• The family receive education prior to the CAPAC admission regarding CPAP initiation and sleep hygiene. The child wears the mask for 10-20 minutes to get used to the feel of the mask.

• Due to the time of the evening visit, only one patient can be initiated at one time and the clinicians may need to prioritise.

CPAP Initiation in the home management plan

Decision to admit and referral process

•Sleep study performed and sleep physician decision to initiate CPAP

•Mask fitting arranged

•Equipment arranged and CPAP pressure determined

•Medically stable child

•Fulfill CAPAC Admission Criteria

•Call CAPAC 0409830213

•Complete Powerchart Referral form

•Family consent

•Risk assessement

•Booked to commence tretment when bed available

•Referral process

Inpatient Day 1

•Morning Home Visit

•Baseline TPR

•Weight recorded

•CPAP mask fitting reviewed to ensure good fit

•CPAP machine reviwed to ensure correct pressure is set up

•Trial CPAP mask and machine turned on for 10-20 minutes to assess for air leaks

•Distraction and play techniques

•Parental education re sleep routine

•Document child's behaviour patterns, current snoring, concentrationa and education difficulties

•Documentation in Powerchart using CAPAC note

Inpatient Day 1

•Evening Home Visit

•Approximately 7pm

•Discuss settling techniques and importance of adherence

•Educate family on CPAP machine

•Child settled for sleep CPAP commenced

•Vital signs

•Troubleshoot and mechanical problems

•Documentation

Inpatient Day 2

•Morning Phone Call

•Discuss previous night's CPAP use

•Documentation

•Evening Home Visit

•Same as previous night

Inpatient Day 3

•Morning Phone Call

•If patient tolerating >4 hours of CPAP needs continuous SaO2 monitoring

•CAPAC nurse to collect pulse oximeter from biomedical engineers

•Evening Home Visit

•Educate family on how to use oximeter and change saturation probe.

Inpatient Day 4

•Morning Home Visit

•Discharge if tolerating >4 hours CPAP

•Collect pulse oximeter and trouble shoot concerns.

•Return oximeter to biomedical engineering for download of oxygen reading and report sent to admitting doctor and CNC

•Discharge summary completed

CPAP Initiation in the home management plan - Evaluation

• 74% of new patients initiating CPAP are now managed at home with a CAPAC admission

• CPAP compliance is approximately 80% compared 60% as inpatient

Limb Cellulitis management plan

• First project as hospital avoidance strategy with an acute condition with transfer to CAPAC from ED

• Project currently in infancy due to lack of nursing time

Limb Cellulitis management plan Decision to

admit

•Clinical decision to consider CAPAC referral by ED consultant /Fellow

•Review by medical registrar

•Eligible patients

•Age over 1 year

•Limb cellulitis only

•No RED FLAGS

•Meet CAPAC criteria

•RED FLAGS

•Toxic appearance

•Foreign body

•Fluctuance

•Severe pain

•Joint proximity

•Post-op wound

•Animal bite

•Co-morbidity

Referral process

•Fulfill CAPAC Admission Criteria

•Call CAPAC 0409830213

•Complete Powerchart Referral form

•Complete medication chart

•Family consent

•Risk assessement

ED day 1

•Insertion of IV cannula

•Collect FBC and blood culture

•Mark, measure, swab and document cellulitis

•Nasal swab for S.aureus

•First dose IV antibiotic given

•Home following review by ED Fellow or Consultant

CAPAC inpatient Day

1

•Twice daily visits for observations and review of cellulitis

•Twice daily IV antibiotics

•If red flags develop or condition worsens refer to admitting medical team

•Documentation in Powerchart

CAPAC inpatient Day

2

•Medical review by admitting team in Acute Review Clinic

•Plan for duration of IV antibiotics

•Check cultures

•Twice daily visits for observations and review of cellulitis

•Twice daily IV antibiotics

CAPAC inpatient Day

3-4

•Continue IV antibiotics 48 -72 hours

•Twice daily visits for observations and review of cellulitis

•Twice daily IV antibiotics

•If requires more than 72 hours requires hospital admission

Discharge

•Review at 72 hours if required

•5 day oral course of antibiotics

•Final nursing review 24 hours after ceasing IV antibiotics and review cellulitis

•GP follow up aarranged

Limb Cellulitis management plan - Evaluation

• Small numbers currently – prospective data collection

Benefits of use of standardised management plans

• High lvel of patient safety

• Good staff satisfaction

• Easy detection of child deviating from usual path enabling quick escalation

• Ease of data collection

• Simplified adoption of plans by second hospital in Network

Acknowledgements

• Staff of CAPAC service including nursing, physio and clerical staff