Context This quality improvement project as performed in a large District General Hospital, Children’s Emergency Department (CED). It reviewed the ‘Wheeze Pathway’ used to treat children presenting with acute exacerbations of wheeze. These children initially receive “burst therapy” – 10 puffs of a Salbutamol inhaler via a spacer device every 20 min for 1 h.
Problem A previous audit of the ‘Wheeze Pathway’ highlighted only 79% of children recieving burst therapy had their inhalers at the correct intervals and only 89% had appropriate observations. In a serious adverse event a child was transferred to the in-patient ward without a post burst therapy assessment, which necessitated eventual escalation to IV therapy and HDU admission. Within a busy CED it was difficult to easily establish which children were following the ‘Wheeze Pathway’ and at what time their inhalers, observations and assessments were due.
Assessment of problem and analysis of its causes Wheeze is a very common presentation to CED. Following the serious adverse event, nursing staff and doctors were consulted regarding the issues they felt contributed to the problems described.
Intervention Following a consultation process a ‘Pathway Checklist’ was developed (Figure 1). The checklist is a timeline of all treatments and assessments (medical and nursing) during the first 4 h of the ‘Wheeze Pathway’. It was also decided children had to remain in the CED during this time to ensure a complete assessment with timely escalation of treatment if necessary and stability prior to transfer to a definitive care bed.
Strategy for change The ‘Pathway Checklist’ was developed with significant input from the nursing team to ensure strong support for the change. Upon implementation both the Pathway and Checklist were publicised to all staff and education provided at team meetings.
Measurement of improvement A snap shot review of the ‘Wheeze Pathway’ and ‘Pathway Checklist’ was undertaken over a 10-day period in 2014 and 39 consecutive sets of patient notes were reviewed.
The implementation achieved a near perfect number of children receiving burst therapy at the correct intervals and 100% having complete observations as well as 37 (95%) cases having timely medical reviews.
Effects of changes As a consequence of its implementation there have been no further adverse incidents as children are now transferred to definitive care beds when stable and with clear plans. There is also now an unquantifiable improvement in how the department has a feeling of control and knowledge of all the children on the ‘Wheeze Pathway’, which has improved overall care of these patients. There is an allocated nurse to give all burst therapy and to provide education to families. There is also improved awareness amongst the nursing and medical teams regarding the need for escalation and which children we have greater concern for, leading to early identification of these patients.
Lessons learnt Implementation requires buy-in and consensus of the whole team. Next time I would provide more regular feedback of the success of change to ensure continued motivation of users and highlight areas for improvement.
Message for others An extremely simple intervention can help to improve efficiency and have a positive effect on patient care safety by prompting key points in patient management, especially in a busy environment.
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