Advanced practice in emergency care: the paediatric flow nurse

Advanced practice in emergency care: the paediatric flow nurse Development and implementation of a new liaison role in paediatric services in Australia has improved services for children and young people Correspondence martin.christensen@qut.edu.au Constance Gray is clinical nurse educator Michelle Hutch is nurse unit manager Both in the paediatric unit at Caboolture Hospital, Queensland Health, Caboolture, Queensland, Australia Martin Christensen is an associate professor in the acute and critical care nursing professorial unit, Queensland University of Technology, Caboolture, Queensland, Australia Date of submission August 9 2015 Date of acceptance December 23 2015 Peer review This article has been subject to open peer review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ ncyp-author-guidelines Abstract Children admitted to emergency departments (EDs) in Australia are often placed in an environment better suited to the treatment of adult patients. This can lead to problems because ED staff are unfamiliar with specialist paediatric care and children often find adult EDs frightening. The development of the paediatric flow nurse (PFN) role at Caboolture Hospital has meant children are treated and supported by a trained paediatric nurse and triaged and treated quickly and effectively. The PFN team collaborates with ED nursing and medical staff to start treating patients and to help move children from the ED to the paediatric emergency short stay unit or inpatient paediatric beds. Each week, the PFN team sees about 30-50 children, many of whom are cared for and discharged directly from the ED. Keywords child health, liaison nurse, flow nurse, emergency department, paediatric admissions CABOOLTURE HOSPITAL is a district regional hospital in south east Queensland located 50km north of Brisbane. The ED sees approximately 1,000 people every week; 25% are children, which equates to approximately 10,200 children admitted to the ED per year. Caboolture Hospital does not have a dedicated paediatric ED so the children are often treated alongside adults. The paediatric ward has only a few dedicated staff and a small bed allocation and, historically, its Australian National Emergency Access Targets (NEAT) scores have averaged approximately 40%, which is well below the accepted target of 75%. NEATs give EDs a framework to ensure patients presenting to the ED are seen, assessed, admitted and either transferred to another hospital or discharged within four hours of their arrival. The requirements of NEAT in relation to paediatric admissions prompted the development of the paediatric short stay unit (PESSU), a designated unit where children admitted into the ED could be monitored, admitted to the main paediatric unit or discharged. How children were screened to be eligible for the PESSU was challenging while trying to meet local and national targets; targets which had been implemented because of budgetary outlines and the NEAT requirements. This article outlines the development of the paediatric flow nurse (PFN) role. The PFN team works in collaboration with ED nursing and medical staff to start treating children and to help move them from the ED to the PESSU or an inpatient paediatric bed. The benefits the PFN role brings to the paediatric ED and the challenges encountered are reviewed. Background The literature contained little information on the role that the authors wanted to introduce to the ED. Articles had been written on flow co-ordination and sources of delay in the patient journey through EDs caused by ED processes (Doyle et al 2012, Popovich et al 2012). Popovich et al (2012) discussed two areas of the ED working simultaneously to bring about an improvement in ED patient flow. Popovich et al (2012) identified the need to classify internal benchmarks for patient movement from the ED and used published evidence with outcomes similar to our NEAT targets. Articles were found outlining development of paediatric triage tools (Almond 2000, Holt 2009, NURSING CHILDREN AND YOUNG PEOPLE May 2016 Volume 28 Number 4 33

Table 1 Results of trial of paediatric flow nurses in the emergency department* Paediatric flow nurse involvement (PFN) Number of patients % of total Total number of patients admitted 267 Patients admitted by a PFN 63 24 Patients seen by a PFN 138 52 Procedures assisted by a PFN 95 36 *Eight-week trial includes 21 days with no PFNs Prentiss and Vinci 2009, Department of Health 2013), but these did not answer the questions of who should provide care and whether EDs are able to provide this type of specialist care (Athey et al 2001, Cleaver 2003). For example, in a review on the process of caring for children in EDs, Prentiss and Vinci (2009) found that children should, ideally, be cared for in specialist paediatric trauma units. However, this review showed that the majority of children are cared for in general EDs. An earlier survey of EDs ability to care for children arriving at EDs in the US (n=101), found that only 7% of EDs had a separate paediatric ED and that 75% of children had to be transferred to another hospital. Only 33% of hospitals surveyed had a paediatric unit or ward and only 10% had a paediatric intensive care unit (PICU) (Cleaver 2003). In Australia, the roles of specialist children s nurses in the ED are still being developed. The UK has led the way in ensuring that children are suitably cared for in the ED and EDs in the UK usually have registered children s nurses on site (Grant and Couch 2011, Willis et al 2011). The situation in Australia is similar because specialist children s nursing care is provided in the ED (Willis et al 2011), but improvements are still needed to support children, and provide an appropriate environment and trained practitioners. One solution would be a paediatric liaison nurse (Chaboyer et al 2003). Paediatric liaison nurses liaise between the wards and the PICU, and are involved with discharge of patients to minimise patient readmission to the PICU by providing support for ward staff to care for the post-picu patient and by supporting the patients by reducing the risk of transfer anxiety and the potential for complications (Chaboyer et al 2003, Chaboyer et al 2004). However, although Chaboyer et al s experiences were useful, the authors took a new approach for the PFN role needed in our paediatric service. Development and definition The PFN team works in collaboration with the ED nursing and medical staff to initiate treatment and help admit children from the ED to the PESSU or a children s inpatient bed. Therefore, the primary role of the PFN is to: Provide expert contemporary clinical care and patient assessment in the PESSU and the ED. Support the general function of the ED, PESSU and the main paediatric units through the application of the principles of best practice, education and leadership. Provide safe and timely paediatric admissions from the ED to the PESSU and paediatric inpatient beds. The authors organised a trial period for the PFN role. The trial involved three clinical nurses and ran from July 1 to August 30 2012. Using data on daily admission rates from the previous 12 months, the PFNs were allocated shifts to coincide with higher admission rates. The PFNs worked eight-hour shifts starting at 3pm and there were PFNs in the ED seven days a week. Due to staffing difficulties and the limited preparation time available for the trial, during the trial there were 21 days when the PFN role could not be filled. Trial results Clinical outcomes The data for the trial PFNs show that children in the ED were seen and supported by the PFNs (Table 1). These data demonstrate the potential of the PFN role in the ED. Additionally, an improvement in patient-associated procedure outcomes was observed; for example, increased numbers of correctly positioned nasal prongs, and correctly secured intravenous lines and nasogastric tubes. Before PFNs were introduced, the paediatric NEAT score was approximately 29%. The NEAT data showed a 10-30% improvement during the trial which was promising, especially since no PFNs were available for 21 of the 62 days of the trial. Staff feedback Feedback was requested from ED and paediatric service staff. During the trial there was a reported improvement in the relationships between staff in the ED and paediatric service. The nursing staff in the ED thought that the PFNs had supported them to care for the patients and they appreciated the assistance the PFNs provided. Nurses commented that the education provided by the PFNs on the job would be missed if the position was withdrawn. The initial feedback from the paediatric ward staff was not as positive. They thought the PFNs were making independent decisions on admissions 34 May 2016 Volume 28 Number 4 NURSING CHILDREN AND YOUNG PEOPLE

that were adversely affecting morale. They did, however, appreciate the support the PFNs gave them during busy periods. The clinical nurses (band 6) involved in the trial were recruited from the ED and paediatric service. It was noticed that the original workplace of the PFN determined which area, ED or PESSU, the individual PFNs spent the majority of their shift working in. All PFNs documented activity in both areas, but meal relief and further assistance tended to be focused in the area that the PFN had been recruited from. Implementation Refining the job description The job description in Chaboyer et al (2003) was used as a basis to define clear guidelines for the PFN role and draw up a list of responsibilities and areas of accountability. The role of the PFN is to: Show a firm commitment in maintaining paediatric skills, in line with the clinical nurse role and professional development requirements. Liaise with nurse unit managers and team leaders of ED, PESSU and paediatric units on child admissions. Work alongside ED staff and paediatric service staff to enable quick and safe admission of patients to PESSU and the paediatric inpatient unit. Undertake advanced holistic patient care needs including assessment, planning, implementation and evaluation. Liaise with and assist ED staff with the care of children as necessary. Ensure effective record keeping for patients to required standards. Monitor capabilities of clinical staff and act as preceptors and mentors to new practitioners to develop their potential. Adhere to relevant standards and frameworks to ensure standard of care are met. Act as a resource for expert clinical care needs and conduct formal and informal education for staff in the ED and paediatric service. Provide professional education to clients and the community. Actively identify areas for improvement, planning and works to resolve problems with an awareness of the needs of the ED and paediatric service. Review and monitor data systems relevant to the paediatric service. Provide an assessment for the annual report that reviews and evaluates the PFN role. Possess high-quality communication, negotiation and conflict resolution skills and advanced knowledge of clinical skills and resuscitation for children. Introducing the role PFNs were introduced in the January before the paediatric short stay unit opened. This gave us time to identify any problems before the PESSU became fully functional. Good communication with staff in both clinical areas was a priority to ensure people knew what the PFN role was and what the PFNs could do for the staff. Once the PESSU opened the PFN role was well established, which meant that the support from the ED staff and the PESSU staff permitted trust and collaboration, resulting in children benefiting from the smooth transfer of care from one ward to another. Role description The PFNs co-ordinate moving children from the ED to either the PESSU or the inpatient ward. This ensures that all paperwork, observations and procedures required are completed before transfer. With their advanced clinical skills, PFNs can ensure that the children are re-assessed before transfer and that they are correctly allocated to either PESSU or the ward. The role has increased the quality of patient care by providing training and education in the ED environment. Initially, PFNs were available between 3pm and 11.30pm an eight-hour shift that incorporated the busiest periods in the ED. Subsequently, PFN shifts were increased to ten hours in the busier winter months, which meant that more staff had to be recruited from the paediatric unit to continue the seven-days-a-week coverage. Education and training The staff in our team of PFNs have different backgrounds and differing levels of experience and expertise. One PFN has had extensive experience at a senior level in a tertiary PICU at a tertiary centre and had participated in the paediatric retrieval process. Another was a senior member of the children s nursing team with many years of paediatric experience. As both were senior clinicians, it was decided to focus their education and training for the PFN role on introducing the working systems used for the role, including access to the emergency department interface system (EDIS) used to identify children in the ED who they might help. At this time, the PFN job was unique to Queensland Health, so the scope of the role had to be made clear to the staff involved. The PFNs and staff in the paediatric service were educated on the importance of the PFN role to moving children from the ED to the hospital s two paediatric areas. NURSING CHILDREN AND YOUNG PEOPLE May 2016 Volume 28 Number 4 35

Figure 1 Total discharges from the paediatric service, including the short stay unit 350-300 - Total number of patients 250-200 - 150-100 - 50-2013 2014 2015 0 January February March April May June Month July August September er October Novemberer December er (Department of Health 2015) 36 May 2016 Volume 28 Number 4 It was emphasised that, while the PFNs are available to assist with procedures, PFNs are not responsible for primary care provision, this remains with the clinical unit in which the child is situated. Challenges As well as the discussions about patient governance, a decision had to be made about which department should be responsible for the PFN team. Staff in the ED thought that, as the patients originated from there, it would be more efficient to run the PFN role from the ED. However, the PFN role was developed as a part of expansion of the paediatric service and the PFN role is funded from the paediatric budget, so it is controlled by the paediatric team. The PFNs liaise between the ED and the inpatient paediatric service and are responsible for the prompt movement of patients. New processes in the hospital have brought about delays in this process, with several notifications needed before the patient leaves the ED. Bed blockages can occur if medical rounds are not completed on time and/or decisions are made to review patients later in the day. The PFN duties include supporting the paediatric service and PFNs can, on occasion, be reallocated from PFN duties to assist in patient care activities on the paediatric service. The PFN is intended to act independently from either unit; however, PFNs spend most of their time in the ED. This can lead to confusion about who has responsibility for the patient and PFNs are often asked why they have not completed tasks, for example observations, for the patient when they have been seen talking to the patient and family in the ED. Effects of the role Reduction in unsuitable admissions Short stay units have an expected failure rate of approximately 10%. This failure rate includes patients who do not meet the admissions criteria for the unit or patients whose condition has deteriorated after admission. Introducing the PFNs was expected to produce a lower failure rate as units would have the advantage of the advanced skills of the PFNs to assess patient suitability before transfer. The failure rate was 2% in the PESSU after the introduction of the PFNs. Although PFNs are only on duty for eight hours a day, the failure rate has decreased. Patients are more frequently moved from the PESSU to the inpatient ward or are transferred out to the tertiary hospital because of deterioration rather than incorrect bed allocation. Numbers of paediatric short stay unit admissions Since PFNs were introduced in January 2014, there has been a significant increase in the number of patients admitted to the paediatric service, both inpatient and PESSU. Figure 1 gives the numbers of patients discharged from all the author s paediatric services in 2013-15. This increase is due, in part, to the population growth in the area (29% increase in the 0-16 age group (Department of Health 2015); but is, in part, due to the correct use of the PFNs and the associated PESSU. Support The support of the PFNs in the ED has provided much-needed development and maintenance of paediatric skills. The PFNs have supervised, assisted and educated staff when NURSING CHILDREN AND YOUNG PEOPLE

required and referred those requiring further assistance to the appropriate clinical nurse educator. As PFNs work independently, they are able to initiate evidence-based care as appropriate in the ED and paediatric unit and communicate with the appropriate medical team to secure the required treatment. Having PFNs in the paediatric ward has helped with accepting children from the ED. The staff on the paediatric ward have confidence that the PFN has assessed the patients as being suitable for the ward; but the paediatric team leader is still able to move the patient on admission, if warranted. When the ward is busy, the PFN will transfer, settle in the patient, do the first set of observations and obtain a history to enable ward staff to complete the care of the inpatients. Once staff are ready, a complete bedside handover occurs and the ward staff assumes responsibility for the patient, enabling patients to be transferred into the ward as soon as possible. If there is no PFN available, due to sick leave or during particularly busy periods, other staff in the ED notice their absence. National Emergency Access Targets scores Figure 2 shows the NEAT scores for the ED and both paediatric services. Since the PFN role was introduced the NEAT scores in the ED have been more than 70%; up from 63% in 2013. Lessons learned When introducing any new nursing position, it is important not to over expand the role too quickly and lose its focus. Data must be reviewed regularly to ensure that targets set at the outcome remain suitable and that achievements are consistent. As the PFNs all have different backgrounds, protocols were written to ensure that the PFNs approach tasks in the same way, to maintain continuity and stability of the role and to avoid other staff having unattainable expectations of the PFN role. Discussion continues on whether the funding might be better placed in the ED, although maintaining the paediatric skills, knowledge and team dynamics has helped with patient flow and speedy transfers. The PFN role is continuously being modified and a 12-month review recognised the effects the role has had on the paediatric service. Because of this, the PFN role will be developed further. For example, delays in transfer can occur because of certain procedures that require paediatric support and the PFNs have been asked to identify which of these procedures could be managed on the unit to provide children with safe, speedy transfers to the right place and care. Long stays in the ED are a primary cause of harm in a hospital environment (Richardson 2006, Sprivulis et al 2006, Hostetler et al 2007). Admissions to the ED always increase in winter and the hospital focuses on moving patients as quickly as possible. There is a full quota of medical staff allocated to the paediatric service and the aim is to move clinically stable patients requiring procedures to the inpatient ward or PESSU during PFN working hours to provide a safe service for our patients. It is planned to work with a partnering university to develop an advanced practice paediatric nurse course to provide staff with advanced assessment and management skills to support the PFNs and provide others with the skills to move into it, via accession planning. Conclusion The introduction and success of the PFN role could not have been possible without the support of the staff in the ward and ED. The PFNs have helped to increase the paediatric NEAT scores, and this has helped the hospital as a whole meet its targets. The supportive nature of the role enables staff to feel comfortable looking after children and ensures that the care given is evidence-based and safe. Since the introduction of the PFNs at Caboolture Hospital, children are being cared for in the most appropriate place and are being moved to these areas more quickly. The introduction of PFNs has brought many advantages; however, more research is needed to determine the outcomes for patients. The staff on the paediatric ward have found that the patients admitted Figure 2 National Emergency Access Targets data 2012-15 Emergency department Children s unit 80 - Paediatric short stay unit 70-60 - 50-40 - 30-20 - 10-0 2012 2013 2014 2015 Year (Department of Health 2015) Total number of patients NURSING CHILDREN AND YOUNG PEOPLE May 2016 Volume 28 Number 4 37

are more appropriately prepared; staff rarely have to seek out information about medications or the preparatory work-up enabling them the freedom to provide care from the moment of admission. Patient satisfaction has also increased. In particular, parents appreciate the communication from the PFN about what is happening, even when there are delays in seeing the doctor or care has been started in the waiting room. The inclusive nature of this process fits well with the family and patient-centred approach that is central to the care provided at Caboolture Hospital. Implications for practice Long stays in emergency departments (EDs) are detrimental to patients Children should be seen by specialised children s nurses Paediatric flow nurses (PFNs) liaise between EDs and paediatric services PFNs help reduce unsuitable admissions to paediatric wards PFNs provide support for families in EDs Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared References Almond C (2000) Issues in paediatric triage. Australian Emergency Nursing Journal. 3, 1, 12-14. Athey J et al (2001) Ability of hospitals to care for paediatric emergency patients. Paediatric Emergency Care. 17, 3, 170-174. Department of Health (2013) Emergency Triage Education Kit. DoH, Canberra ACT. Department of Health (2015) Population by Age and Sex. Regions of Australia. DoH, Canberra ACT. Chaboyer W et al (2003) The intensive care unit liaison nurse: towards a clear role description. Intensive and Critical Care Nursing. 20, 2, 77-86. Chaboyer W et al (2004) The impact of a liaison nurse on ICU nurses perceptions of discharge planning. Australian Critical Care. 17, 1, 25-32. Cleaver K (2003) Developing expertise: the contribution of paediatric accident emergency nurses to the care of children, and the implications for their continuing professional development. Accident and Emergency Nursing. 11, 1, 96-102. Doyle S et al (2012) Outcomes of implementing rapid triage in the paediatric emergency department. Journal of Emergency Nursing. 38, 1, 30-35. Grant K, Crouch R (2011) Who should nurse children requiring emergency care? International Emergency Nursing. 19, 4, 209-211. Hospital Based Corporate Information System (2014) Patient Administration System. Queensland Health, Australia. Holt K (2009) Developing a triage tool for paediatric care. Emergency Nurse. 17, 3, 12-17. Hostetler M et al (2007) Emergency department overcrowding and children. Paediatric Emergency Care. 23, 7, 507-515. Popovich M et al (2012) Improving patient flow through the emergency department by utilizing evidence-based practice: one hospital s journey. Journal of Emergency Nursing. 38, 5, 474-478. Prentiss K, Vinci R (2009) Children in emergency departments: who should provide their care? Archives of Disease in Childhood. 94, 8, 573-576. Richardson D (2006) Increase in patient mortality at 10 days associated with emergency department overcrowding. Medical Journal of Australia. 184, 5, 213-216. Sprivulis P et al (2006) The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia. 184, 5, 208-212. Willis R et al (2011) Paediatric extended emergency care (PEEC): establishing and evaluating a paediatric short-stay ward: a pilot study. Neonatal, Paediatric & Child Health Nursing. 14, 1, 3-8. RCNi Hub Journal articles From just 5.50 a month RCNi Portfolio Revalidation resources www.rcni.com 38 May 2016 Volume 28 Number 4 NURSING CHILDREN AND YOUNG PEOPLE