Facing the Future Together for Child Health: Children's Community Nursing Teams
Below are a range of practice examples from varying Community Children's Nursing Teams (CCNT) across the UK:
Child HealthCare Closer to Home (C3) - Calderdale and Huddersfield NHS Foundation Trust
Children’s Outreach Assessment and Support Team (COAST) - Solent NHS Trust
Extended hours community children’s nursing team - Islington CCNT
Healthcare at Home - King's College Hospital, London
Seven day community children’s nursing team - South Tyneside CCNT
Children’s journey into acute care is often fragmented, with the focus being around a specific professional and building rather than the family. Partners from Calderdale and Greater Huddersfield health and social care organisations have worked collectively to deliver improved services for local children, with the overall aim of developing enhanced paediatric provision and expertise closer to the child's home. C3 foundations lie in self-management, empowering families to have the confidence to manage their own health conditions and know when to escalate appropriately.
The C3model has been to set up two multi-professional care clinics with a paediatric consultant, advanced paediatric nurse practitioner, GP and community nurse. One of the clinics is delivered in a local GP surgery and the other in a local children’s centre, offering users a service in family friendly hours (4pm to 8pm). Referrals are accepted from pre-selected pilot site GPs with user and referrer experience being at the heart of the project. Interventions are recorded via an electronic shared record. This has aided timely communication across primary and secondary care. On the horizon there is a push in primary care to move towards 8am to 8pm and weekend opening, recognising the need for acute care for children closer to home.
The project has led and encouraged communication and shared learning with primary care and ensured health and self-care is high on the agenda of community services, families and children’s centres. C3 is also developing pathways of care, education and expertise for use within primary care.
Recommendations for consideration in setting up a similar service:
- Establish good relationships and buy-in from commissioners and providers at the start
- Change requires tenacity and enthusiasm
- You can never communicate enough
- Strong administration support is required
Further details: http://c3.cht.nhs.uk/
COAST is based within the Community Children’s Nursing Service and consists of two teams (Portsmouth and Southampton). Established in 2008, with the aim to facilitate early discharge from hospital and reduce unnecessary attendances and admissions to hospital. COAST is a distinct team of nurses within the Community Children’s Nursing Service and offers high-quality nursing assessment and follow-up, accepting referrals from GPs, the out-of-hours service, the emergency department and the paediatric in-patient wards. The remit of the team is to assess and monitor a child during an acute episode of illness whilst also providing support and education to the family.
The service operates seven days a week, 364 days a year (not Christmas day). The hours of service are 8am to 10pm, Monday to Friday, and 9am to 6pm on Saturdays, Sundays and bank holidays. The referral criterion is that the child must have had a ‘face-to-face’ assessment by a doctor/practitioner and a working diagnosis of one of 10 conditions. The key for referral is that the referrer is considering sending the child to hospital, therefore capturing ‘genuine’ hospital avoidance referrals.
One of the challenges facing the team is providing the assurance that these children, who would otherwise have been sent to hospital for assessment, are safe in their own homes. The development and auditing of robust evidenced-based protocols and ensuring the maintenance and currency of assessment skills of the team has resulted in no clinical safety incidents and no complaints for a total referral rate of over 5000 children.
Capturing meaningful data to evidence that COAST is making a difference to the local health economy is a challenge, but the commissioners report that there has been a ‘flattening’ of the number of referrals to hospital when compared to clinical commissioning groups that don’t commission COAST. Throughout its development the team has been faced with some significant challenges. Engaging GPs and primary care generally to ensure they utilise the service appropriately has proved to be an ongoing challenge.
For the future, expanding and enhancing COAST with the right workforce/skill set to take referrals from the ambulance service would be a useful development as well as the ongoing development of paediatric nurse practitioners within COAST to work alongside primary care to support the hospital avoidance agenda.
Recommendations for consideration in setting up a similar service:
- Develop clear and meaningful outcome measures
- Forge strong links with key individuals in primary and secondary care
- Have ‘champions’ for the service
- Recruit and select staff with the right skill set and experience
Further details:Kelly Owens, Clinical Lead COAST firstname.lastname@example.org
The Islington CCNT has tripled since its formation in 1997. The team provide a safe and comprehensive service with the aim of facilitating early discharge from hospital and preventing and reducing unnecessary attendances and admissions to hospital. The borough serves an estimated child population of 40,000, which is due to increase by approximately one-sixth by 2030.
The Hospital@Home service began in August 2014 and runs from 8am to 10pm. It has been developed with input from acute paediatricians and a referral criterion is that the child has a working diagnosis and physical signs and symptoms within set parameters. Accountability for the care of the child remains with the consultant paediatrician with a nurse-led discharge. The CCNT provide safety netting information following a visit and parents and carers can call the CCNT for advice from 8am to 10pm (support is provided by the Whittington Hospital outside these hours). GPs can refer directly to the CCNT and the CCNT also run primary care clinics supporting the education of practice nurses.
The CCNT is made up of 17.5 Whole Time Equivalent (WTE) nurses, 1.5 WTE administrative support and 0.5 WTE consultant paediatrician. From August to December 2014, 107 referrals were made with 376 face-to-face contacts. Positive feedback has been received through patient and parent surveys.
Recommendations for consideration in developing a similar service are:
- Be reasonable in your expectations
- Research how other services have developed their service and adapt local pathways
- Find a paediatrician to champion the service
- Consider involving other services such as physiotherapy and dietetics
- Develop a good working relationship with commissioners
‘This is an excellent service; the staff are very professional and friendly. They are really knowledgeable and made me feel confident to look after my child at home when he was unwell. I was so reassured that they did what they said they would do and acted as a link between hospital and home.’ Parent
Further details: Jeanette Barnes, Matron, email@example.com
In April 2014 a novel paediatric ambulatory service was established at King’s, with ‘Healthcare at Home’ (HAH). It is a clinical service providing consultant led, nurse delivered acute paediatric care in the home.
The HAH nurses are integral members of the general paediatrics team. They attend the morning general paediatric handovers 7 days a week and this serves to optimise the referral rate. Once a child has been referred, they meet with the family whilst they are still inpatients and this practice provides continuity of care for children and their families once their care is transferred to the home setting.
The nurses have facility to visit children up to four times a day, to administer medication, provide wound care, perform observations and provide clinical reviews. The care episode notes are all recorded electronically on tablets in the home and these notes are linked to the hospital based electronic patient record. All of the patients are reviewed during a daily consultant-led virtual ward round conducted in person with the HAH nurses. The innovative use of IT facilitates this process and provides an accessible, continuous record of patient care until their discharge date. The initial goal was to enable early discharges from hospital and this has been achieved. The service has subsequently evolved to facilitate direct admission to HAH from the paediatric emergency department (PED) following a paediatric consultant review. This new pathway thereby completely avoids hospital admission for some children. Children are accepted onto the service based on clinical need and capacity. This therefore ensures equity of the service which is available to children who reside in a range of boroughs.
Further details: Dr Omowunmi Akindolie firstname.lastname@example.org
The South Tyneside CCNT has grown and evolved according to the needs of service users and providers since its formation in 1998. The CCNT provides a safe and comprehensive seven day service, 8am to 6pm, 365 days a year, with the aim of preventing hospital admission and reducing length of stay. It provides direct nursing care and education in the community to support families with children during acute, chronic and palliative phases of illness. Referrals can come from anywhere, but the child must live within the borough and be within the specified age range.
An example of admission avoidance: Child A was brought to the Urgent Care Centre with symptoms of sepsis. A full septic screening was performed and intravenous antibiotics prescribed and administered. When Child A was clinically stable some hours later, the child was discharged from the Urgent Care Centre to the CCNT. The child was then visited daily for the administration of intravenous antibiotics and clinical review. The parents were encouraged to contact the CCNT if they had any concerns or, if the child deteriorated, to return to the Urgent Care Centre immediately. At the end of the prescribed course of treatment the child was assessed in the rapid review clinic by a consultant.
An example of reduction of length of stay: Child B was brought to the Urgent Care Centre with signs of sepsis and was clinically unstable. A full septic screen was performed and the Child was stabilised, then transferred to City Hospital Sunderland with a diagnosis of meningococcal meningitis for an inpatient episode. On day three, Child B was discharged into the care of the CCNT to continue the 10 day course of intravenous antibiotics. Child B’s follow-up was in the rapid review clinic locally.
Further details: Gill Gunn, Team Leader, 01912 022183