Context IgE mediated food allergy affects 6–8% of children and the prevalence is thought to be increasing. Current national guidelines for the diagnosis and management of these children include the use of oral food challenge (OFC). Recent evidence from the LEAP trial (Learning Early about Peanut Allergy), suggesting that immune tolerance to peanuts in ‘at risk’ infants may be possible through early ingestion, may also increase the burden on this service. Our large District General Hospital currently performs all oral food challenges on the day care unit, under direct supervision of a doctor.
Problem The current waiting time for OFC at our hospital is 8 months. This potentially prolongs dietary exclusion unnecessarily and does not allow us to perform early OFC (ie at 4–8 months of age) to facilitate safe early introduction of allergens as recommended in the LEAP trial.
Assessment of problem and analysis of its causes OFC against single allergens (egg, milk or wheat) were audited from hospital over one year. Waiting times and services provided were also reviewed. Gold standards of care from other centres were studied by reviewing their established guidelines and visiting other clinics.
62 OFC challenges were performed by a doctor – all could have been nurse led;
Current waiting time for OFC: 36 weeks;
Current waiting time for Allergy follow-up appointment: 21 weeks
Current waiting time for Allergy new appointment: 7 weeks
Intervention and Study design Analysis of the cost benefit ratio for a 0.6FTE (full time equivalent) specialist paediatric allergy nurse was performed. This role would enable nurse led oral food challenges, expanded follow-up clinics, and provide telephone support for paediatric allergy patients in the region. In addition, it would free up consultant time to expand new paediatric allergy clinics. See Figure 1 below which details the cost benefit, improvement in waiting times and improvement in quality that would be achieved by implementing this change.
1 Consultant clinic/month: 7 new patients (£232) + 10 f/u patients (£154) = 204 patients = £37,968 (based on multi-professional Paediatric OP tariff)
Nurse in clinic: 6 follow-up patients/week for 45 weeks/year = 270 patients at £154 = £41,580
Strategy for change Using data from the quality improvement project, a business case for a 0.6FTE paediatric allergy nurse was submitted to the Trust Management Board.
Measurement of improvement and Effects of changes
The Trust Board has approved the business case for a long term paediatric allergy nurse (0.6FTE) and the recruitment process has begun. This service expansion also involves the establishment of a regular multidisciplinary team meeting, new food allergy testing guidelines and the set-up of a patient database to enable further auditing of services.
Lessons learnt and Message for others This project demonstrates how QI methodology was used to identify potential cost savings and improvements. Cost/benefit ratios from this evidence provided a powerful argument to our Trust Board, resulting in a successful business case. This successful long term service improvement will not only improve the allergy services provided by the region, but has also taught the trainee a great deal about health care management and quality improvement.
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