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Trust introduces a service to deliver responsive treatment to children and young people for selected conditions in an appropriate community setting, preventing avoidable hospital attendance and admissions

Challenge

    • In Bradford, children and young people (CYP) account for 30% of ED assessments and 70% of them are discharged after initial observation
    • Majority of presentations are due to conditions like asthma, upper respiratory tract illness or fever due to viral infections that can be managed in a out-of-hospital setting
    • Reduce avoidable ED attendances and non-elective admissions to the paediatric unit

Action

    • Established the CYP’s Ambulatory Care Experience (ACE) service to deliver care within patients own home
    • Consultant Paediatrician managed CYP remotely and provided them remote access to the acute paediatric service
    • Recorded referrals and management of CYP electronically and shared information between primary and secondary care
    • ACE nurse provided a care bundle to educate families and CYP on self-care

Result

    • Received 107 referrals on the first pathway- the ‘wheezy child’ and saved 105 bed days
    • Allowed 83 children to remain at home during their acute illness, preventing hospital attendance/admissions
    • Improved collaboration between primary and secondary care
    • Resulted in respondents rating the service as ‘excellent’
    • 75% of local GP practices have been visited by the ACE team to promote the service

Outline:

In Bradford, children and young people (CYP) account for 30% of Emergency Department (ED) assessments and 70% of them are discharged after initial observation. Only 5% of patients seen are eventually admitted to a hospital bed. The majority of presentations are due to conditions like asthma, upper respiratory tract illness or fever due to viral infections.

This suggests that they could have been managed in a different way and in a different environment. The CYP’s Ambulatory Care Experience (ACE) team was set up in December 2017 as an alternative to a hospital referral or admission for CYP in Bradford who are unwell. It is a 12 month pilot project.

ACE provides care out of hospital - in a CYP’s own home. Consultant Paediatricians take clinical responsibility for these CYPs from the point of referral from primary care, ED and the Children’s Assessment Unit in a ‘virtual ward’. The delivery of this new service is the result of 10 years of increasing collaboration with primary care and commissioners.

Shared system wide pathways have been produced based on best practice/ national guidelines. Referrals and management of CYP are recorded electronically and information shared between primary and secondary care.

Ambition:

Bradford has a higher population of CYP than the UK average. This is expected to continue.

The objectives of the ACE service are to

1) provide high quality care for CYP in the most appropriate place for them designed around the family and CYP by

2) using evidence based system wide pathway that

3) provide efficient and seamless continuity of care and

4) value for money.

The ACE nurse also provides a ‘care bundle’ that includes education and training for families and CYP in self-care with the aim of reducing future attendances and admissions.

It is hoped that this innovative way of working will help us

1) reduce avoidable ED attendances and nonelective admissions to the paediatric unit

2) achieve better integration of paediatric acute and community services

3) develop competencies of a workforce able to work across both acute and community settings and

4) improve staff retention and recruitment by providing bespoke high quality training and appraisal for nurses.

By achieving these objectives we hope to mitigate the increasing healthcare demands of our young population and deliver recommendations of the NHS Five year forward view, the RCPCH Facing the Future standards and the Keogh Urgent and Emergency Care Review.

Outcome:

To the end of April 2018, 107 referrals were received for our first pathway the ‘wheezy child’. Hospital attendance and admissions were prevented for 83 children who remained at home for the duration of their acute illness. All CYP had remote access to the acute paediatric service and were managed remotely by a named Consultant Paediatrician.

To date a total of 105 bed days have been saved. We have now tested the ACE model for 6 months and have had no adverse events. We now plan to introduce 4 further pathways in the next 4 months including gastroenteritis, croup, bronchiolitis and neonatal jaundice.

There is a real sense of improved collaboration between primary and secondary care, enhanced team working and shared achievement that is building momentum. A neighbouring hospital is interested in replicating the project. Paper and electronic parent/carer and CYP feedback questionnaires have been developed. All respondents have rated the service ‘excellent’. An ACE focus group held at one of our local GP practices had a poor uptake. To address this issue we are exploring other feedback platforms.

Spread:

Evaluation of urgent paediatric ambulatory care in the UK is complex. There is little evidence to enable comparisons between different care models, leading to a variety of different services, resulting in variation in quality and inefficiencies. We therefore engaged with academics to help evaluate and develop the ACE project.

York University, funded by the Connected Yorkshire Health Cities Project are providing an independent service evaluation. Leeds University have provided help with future service modelling using novel software. Bradford University School of Health Studies are exploring the potential of developing our bespoke training programme for nurses in enhanced clinical skills. So far we have had face to face meetings with 75% of GP practices in Bradford to promote the service.

A promotional video has now been produced. In addition we recently launched on twitter. In conjunction with the NHS England West Yorkshire Urgent and Emergency Care Vanguard project we made a successful bid for a Leadership Fellow to start with us in February 2019. The main objectives of this post are to set up a Paediatric Urgent Ambulatory Care (PUAC) Network that will provide a platform to share good practice and undertake research into PUAC across 6 Acute Trusts.

Value:

The cost of a hospital admission is ten times the cost of a community nurse home visit. In addition a hospital admission is not only very disruptive to family life, but is hugely costly in other ways too. ACE nurses provide parents and carers with the necessary knowledge to manage future episodes of illness and nurses are also engaged with health promotion in the home. Families are encouraged to stay in touch with the service via twitter where further health promotion will be provided.

To the end of April 2018, 105 bed days were saved with our first clinical pathway. We are adding a further 4 more pathways in the next 4 months, with more planned in 2019. CYP and families rate the service as excellent. The project is supporting nurse career progression. It is hoped that this will help in staff retention and nursing recruitment.

CYP and families and referrers are encouraged to feedback to help in service development via face to face sessions and also through paper/electronic questionnaires. There is a real sense of improved collaboration between commissioners and providers and a shared achievement that is building momentum. A neighbouring hospital is interested in replicating the project.

Involvement:

The delivery of the ACE service has been the result of 10 years of increasing collaboration between Primary Care, two local CCGs-District and City and the Bradford Teaching Hospitals Foundation NHS Trust. This collaboration enabled the development and implementation of the ACE model in just over just 4 months from initial recruitment of nurses in August 2017 to ‘go live’ in December 2017.

This multidisciplinary, multi-professional and multiagency team, working to an agreed service specification and timeline, developed robust governance processes, work streams and a communication strategy that delivered the project to time. The project was presented at patient and family engagement events and received very positive feedback.

Service users (referrer, child and family) are asked to complete a questionnaire to provide feedback on the service to help in further development. The project team reports to the Bradford Urgent Care Programme Board on a regular basis. Updates are provided at CCG/ and GP Clinical forums and by newsletter to stakeholders. So far 75% of local GP practices have been visited by the ACE team to promote and develop the service. A Twitter page was recently launched to keep in touch with service users and allow on-going service feedback.

Key individuals

Dr Mathew Mathai