Debi Allcock, MSc, BSc, RSCN Dip, is paediatric community matron, Cheshire East Community Health.
Allcock, D. (2009) Using a community respiratory service to reduce children's hospital admissions. Nursing Times; 105: 4, 22-23.
This article describes a new service in Cheshire East Community Health that aims to reduce respiratory emergency admissions. The service promotes an integrated package that delivers education to children and families in their own homes/environments. It uses support from a community matron to avoid unnecessary hospital admissions and improve parental education.
This initiative has shown that good communication skills and working together can change practice and improve patient care.
Although the original impetus arose from an identified service gap, the role now provides a blueprint for other PCTs to meet government policy outlined in Every Child Matters (HM Government, 2004).
Sufficient resources must be identified to provide high-quality, effective care.
Allocation of time is vital for nurses to participate in training and networking to ensure enhanced learning.
A community-based paediatric respiratory service was developed in response to local documented increases in admission rates among children aged 0-16 years. It aims to address the service gap between acute and primary care and provide a service closer to home for paediatric ambulatory care.
Our package offers a holistic approach to asthma/respiratory management by working with families to self-manage their child's condition better. Fundamental to this approach is empowering families through health education, support and advice. Each family receives a home visit in which their needs are assessed in terms of education, diagnosis and level of compliance. A history and full assessment of the child is carried out. Medication is reviewed and education provided, based on the social, lifestyle and environmental issues highlighted.
Our service has been developed to reduce or avoid unnecessary emergency admissions. Analysis has shown that many could be avoided and that patients could be cared for in the community under the care of advanced paediatric nurse practitioners.
Of the total local paediatric admissions in a three-month period, 39% were respiratory related. Our figures indicate that acute asthma admissions for 0-18 year olds in 2006-2007 cost Central and Eastern Cheshire PCT£270,027.
Asthma UK (2008) estimated that 75% of acute admissions could be avoided. According to local analysis, if our PCT reduced emergency admissions for asthma to the national average, the cost saving would be£93,381 per year.
Crewe is a fairly deprived area with high levels of unemployment, single parents and smoking. In the UK, 5.4 million people receive treatment for asthma of whom 1.1 million are children (Asthma UK, 2008). Based on this and local statistics, we estimated that Crewe would have approximately 1,367 children admitted each year for asthma.
With this in mind, we felt it was important to provide a service that bridges a known gap and helps parents to identify risk factors, building their confidence and skills to maximise health. Ultimately, this should make hospital admissions less likely and ensure our service is adopting best practice (Department of Health, 2006).
The service consists of one advanced paediatric nurse practitioner who undertakes a case-management role as a community matron. The service started as a two-year pilot project in 2007. Data is continually collected and analysed to track impact and quality measures. Key aims are reducing emergency admissions and reducing GP appointments by high-impact users for respiratory conditions.
The service is analysed by using a traffic-light system that shows at what level care is provided. Patients are triaged as red, amber or green, either before or during a visit. This allows the service to target patients who would otherwise face inappropriate admission to acute inpatient care.
Red days highlight that a condition has deteriorated to the point where intensive support is needed, warning that an emergency admission may take place. Amber is weekly contact that requires a patient to have more intensive support to reduce GP consultations. Green indicates that education and support have been maintained and the patient appears to be showing positive health that needs routine three to six-monthly reviews with a view to discharge.
This colour-coded data is collated daily and analysed at the end of each month. The data helps analyse performance. The monthly report shows: numbers on caseload; patients discharged and referred; hospital admissions and GP visits saved; failed attendances; and red, amber and green visits. In addition, a daily contact sheet collects data showing: reason for contact; actions (such as education, medication review, referral, hospital admission); outcome of visit; and whether it is the first contact, the reason, referrer and outcome of first visit. Red call-out days and routine visits that are changed to red are used to calculate potential cost savings.
Between July 2007 and June 2008, we potentially saved 53 emergency GP visits and 82 emergency admissions. This gives a potential saving of£26,435 (9% of the PCT's£270,027 cost of emergency admissions).
This is an unofficial costing. The figure is calculated using the hospital tariff and our personal judgement. We are in the process of producing official costing data.
The service has been evaluated using criteria data that looks at the time a referral is received, the date a patient is offered a review and when they are actually seen.
Within our service agreement, the target is that all patients are contacted within a week of our receiving a referral. Since there is only one practitioner, this is the most practical goal.
Asthma is widespread and has a significant impact on the economy, society and the NHS. The evidence shows that services need to be redesigned to minimise the effects of this condition (Asthma UK, 2008).
Research shows the projected cost of asthma could rise to as much as£80m per year through unnecessary emergency admissions (Dr Foster Intelligence, 2006).
The development of concepts such as management of contracts or shared responsibility between healthcare professionals and the person/family with asthma presents opportunities for improved compliance.
Joint working with acute and primary care has been widely embraced. Preliminary pathways have been set up between the paediatric unit, A&E and primary care services including GPs, health visitors and the wider multidisciplinary team.
More than two A&E attendances within the past six months.
One of our aims is to disseminate good practice and to influence service development across the PCT. Results of our patient satisfaction survey showed the service is clearly valued and welcomed by users, and is meeting targets set out in the original service agreement.
Over three-quarters (77%) said they had had to visit the GP less often and 69% felt the number of admissions had been reduced.
All (100%) said that having contact with the community matron was beneficial to their family. The positive comments provide us with hope that this will demonstrate to commissioning teams that patients have embraced the service and want to see it expanded.
We also audited education to measure if we were meeting the goal of increased knowledge. We used a questionnaire at initial appointments that asked standard questions around parents' knowledge of their child's condition, the number of admissions they had in the past year and how many times in the year they had seen the GP due to asthma. We repeated this questionnaire a year later. The clinical governance department analysed the data, which showed an improvement in educational knowledge, parental attitude surrounding dealing with exacerbations and reductions in GP and hospital visits.
Nursing practice is continually evolving, with changing and developing roles. Darzi (2008) set out clear challenges involving working with the local population to improve health and provide supportive services closer to home where possible. This report also outlined a vision for NHS services to reflect the needs of local communities.
We feel the service has succeeded in shaping itself around the needs of the local population and is therefore moving in the right direction towards these visions. It is innovative and important to the future development of our profession (as advanced nurses) within Cheshire East Community Health, since it is the only service of this type developed within the PCT. We hope the evidence from the evaluation will demonstrate the need to widen the service's scope.
Asthma UK (2008) For Journalists: Key Facts and Statistics. London: Asthma UK.
Darzi, A. (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2006) Our Health, Our Care, Our Say: A New Direction for Community Services.London: DH.
Dr Foster Intelligence (2006) Keeping People out of Hospital: the Challenge of Reducing Emergency Admissions. London: Dr Foster Intelligence.
HM Government (2004) Every Child Matters: Change for Children. London: TSO.
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