Context The quality improvement involved development of a follow up service for patients presenting to a busy district general hospital with Henoch Schoelein Purpura (HSP). Follow up is recommended as the rare but important renal sequelae of the condition can be silent initially.

Problem In our department no follow up pathway existed for HSP. Patients were seen in either consultant outpatient clinics, with the majority of children being well, or discharged for primary care follow up which relies on general practitioners and families to organise ill defined follow up creating the potential to miss any renal sequelae

Assessment of problem and analysis of its causes The problem was identified during the acute assessment of patients presenting. Following discussion with senior staff about absence of evidence based local follow up procedures and subsequent literature review a structured pathway was proposed. It was felt that all children should have hospital review with consultant follow up focusing on children with complications

Intervention The aim was to standardise and rationalise care thereby improving department efficiency without compromising patient safety. A pathway for nurse led follow up which had been piloted elsewhere (1) was used as a model. Children were assessed at presentation and guidance was given for those needing admission or investigation. Otherwise they should be discharged home with urine dipsticks to check early morning urine and information about what concerning features should lead them to seek reassessment. All children were seen seven days later and stratified according to absence or presence of proteinuria, as a marker for renal involvement, to standard follow up (four in the year) and more frequent visits (seven in the year) if proteinuria present. If proteinuria developed in the standard group, they moved to more frequent follow up. Urinalysis was undertaken at each follow up visit and criteria for consultant review were clearly defined.

(1) Henoch Schonlein Purpura – A 5-Year Review and Proposed Pathway. Louise Watson, et al

Strategy for change During the development stage senior nursing and medical staff were consulted about the practicalities and possibilities of developing a similar pathway and a guideline was produced with department ratification. Only limited information about the pathway was disseminated to junior staff before its introduction.

Measurement of improvement Sixteen months on, an audit and service evaluation was undertaken with feedback from patients, their families and staff.

Effects of changes Of 22 children followed up none developed renal sequelae at any time.

Almost half did not use consultant clinic appointments for follow up with seven completing the pathway appropriately, two having extra nurse follow up and one who had nurse follow up at different intervals to those recommended.

Ten children had consultant follow up, which was not clinically indicated.

Staff feedback was positive. Parents expressed the benefit of more flexible and quicker appointments for monitoring.

Although incomplete concordance with guideline, the process of follow up appears acceptable and manageable to patients, parents and staff. There were clinic slots released and the department generates income for nursing clinic appointments at each review.

Lessons learnt The main lesson learnt was the difficulty in engaging a wide group of people in a change of practice once implemented. This was particularly so when junior staff starting the children on the pathway in the acute phase change frequently. Different ways of working take time to be embedded. To try and mitigate this in future, wider team education is vital at implementation to improve awareness of the change and improve its use in practice.

Message for others To effect change, involving all relevant parties is essential from the start. It is important to educate and inform the wider team when a change of practice is implemented and to have an open dialogue within the team to monitor effectiveness.