The development of a community nursing

service for children with an acute illness.

Carolanne Getty
Community Children’s Nursing Sister
 Aim:
To describe the development of
an acute CCN service.
Objectives
 To understand the journey of service
development for an acute CCN team in
Northern Ireland.

 To appreciate benefits of such a service to

acutely ill children and their families.

 To consider the dimensions of care the CCN

can bring to children who are acutely ill.
 Structure of Presentation
 Evidence supporting acute CCN service
development

 Setting up the acute CCN Service in

Homefirst

 Dimensions of care CCN can bring.

GEOGRAPHICAL AREA
 Population 330,000

 Area 1,200 square miles

 Mixed urban and rural

 Largest community trust in Northern

Ireland

 Divided into 3 sectors

* Antrim/ Ballymena
* East Antrim
* Magherafelt/ Cookstown
“Children’s Community Teams including
Community Children’s Nursing Services need to
provide appropriate support to children, young
people and their families which responds to
local needs and takes account of the need to
prevent hospital admission, facilitate early
discharge, and care for children with complex
needs”

NSF (2004) standard 6 13.2

Evidence Supporting Service
Development
 World Health Organisation (1978) Health for all by the year 2000.

 United Nations Convention (1989) Un Convention on the rights of the child.

 House of Commons Select Committee (1997) Health Services for Children and Young
People in the Community : Home and School. Third Report.

 RCN (2003) Community Children’s Nursing: effective team working.

 Department of Health, Social Services and Personal Safety (1999) Nursing services for
the acutely ill child in Northern Ireland.

 Department of Health, Social Services and Personal Safety (2004) A healthier Future: a
20 year strategy

 Department of Health (2004) The National Service Framework for Children

 Model for components of care CCN services can
be expected to deliver.
(Adapted from DH, 2002; RCN, 2002)

First Contact
Acute assessment, diagnosis,
treatment
and referral of children

Continuing care
Chronic disease management and
achieving imperatives of Children’s NSF
Public heath
Health protection and promotion
– working with children
and families to improve health
and reduce the impact of health
and disability
 Composition of Homefirst Community
Children’s Nursing Service

Community Children’s Nurses Regional Children’s

Continuing care team Palliative Care Nurse
Trust wide
Northern Board

Acute Community Children’s Children’s Diabetes

Nursing Team Nursing Service
Antrim/Ballymena Trust wide
 MULTI-PROFESSIONAL
STEERING GROUP
ROLE OF STEERING GROUP
 Advise on setting up of the service

 Devise operational guidelines

 Report to the Inter-Trust

Child Health Forum

 Produce and disseminate

information / consult with all relevant groups

Questionnaire of potential
service users
 Team recruited
1 G grade with children’s qualification and Health
Visiting community experience (1 WTE)

3 E grade Staff Nurse’s with hospital based

experience (2 WTE)

 Model of CCN service delivery

Community based generalist team
Stages of Service Development
 1. Preliminary/ preparation stage

 2. Implementation stage

 3. Evaluation of service role

Preliminary stage
 Develop aims and objectives

 Develop operational policy

 Develop evidenced based policies and

procedures

 Develop documentation

 Logistical issues
Implementation Stage
 Establishing links in hospital and community

 Raising awareness

 Identifying staff training needs

 Staff development
 Evaluation

“This is an excellent service. It was offered at the right

time in the hospital and gave us confidence to bring
our son home where he made a quicker recovery but
with the appropriate care and support. It should be
available more widely and publicized as a model of
good practice.”
Challenges

Not 24 hour slow rate of

service referrals

Role Protectionism Staffing levels

Dimensions of care
1. Formal knowledge and skills
2. Coordinating knowledge and skills
3. Skills for managing workload
4. Relational, interpersonal and support
skills
5. Teaching skills
6. Thinking skills
Proctor et al. 1998
SERVICE DEVELOPMENT
 Amalgamation of Continuing Care
and acute CCN service.
 Senior Nurse Practitioner
 Rolling out of acute CCN service
and nurse bank to other sectors
 Expanding teams to provide a skill
mix
 Staff development
“A thousand mile journey
starts with a single step”

Lao-tsu, 604 - 531 BC

References
 Callery, P. (1997) Paying to participate: financial, social and personal costs to parents
involvement in their children’s care in hospital. Journal of Advanced Nursing. 25: 746-752

 Casey, A., Gibson, F., Hooker, L. (2001) Role development in children’s nursing:
dimensions, terminologyand practice framework. Paediatric Nursing. 13(2):36-40

 Department of Health (2002) Liberating the talents, helping primary care trusts and nurses
to deliver the NHS plan. London: The Stationary Office

 Department of Health (2004) The national service framework for children, young people
and maternity services. London: DH www.publications.doh.gov.uk/nsf/children

 Department of Health and Social Services (1999) Nursing services for the acutely ill child in
Northern Ireland. Report of a working group. Belfast: The Stationary Office.

 Eaton, N. (2000) Community Children’s Nursing services: models of care delivery. A review
of the United Kingdom literature. Journal of Advanced Nursing. 32(1):49-56

 Euwas, P., Chick, N. (1999) On caring and being cared for. In: Madjar, I., Walton, J.A.
(eds.) Nursing and the experience of illness. London: Routledge (pp170-188)
References
 House of Commons Select Committee (1997) Health Services for children and young people
in the community: home and school. 3rd report. London: The Stationary Office

 Johnston, P. (2004) Community Paediatric Nursing Service Ballymena/Antrim: Review of

Service. Unpublished

 Neill, S. (2005) Caring for the acutely ill child at home. In: Sidey, A., Widdas, D. (eds.)
Textbook of Community Children’s Nursing (2nd Ed.).Edinburgh: Elsevier.

 Poulton, B. (1999) User involvement in identifying health needs and shaping and evaluating
services: is it being realised? Journal of Advanced Nursing. 30(6): 1289-1296

 Procter, S., Campbell, S., Biott, C., Edward, S., Moran, M., Redpath, N. (1998) Preparation
for the developing role of the community children’s nurse. Research highlights. London:
English National Board for Nursing, Midwifery and Health Visiting

 Royal College of Nursing (2002) Children’s community nursing: information for primary care
organisations, strategic health authorities and all professionals working with children in
community settings. London: RCN (publication code 001 959)

 Secretary of State for Health (1999) Saving lives; Our healthier nation. London: The
Stationary Office
References
 Slevin, O. (2003) Nursing models and theories: major contributions. In: Basford,L.,
Slevin,O. (eds.) Theory and practice of nursing: an integrated approach to caring practice.
(2nd ed.) (pp255-280) Cheltenham: Nelson Thornes

 Smith, F. (1995) Children’s nursing in practice: the Nottingham model. Oxford: Blackwell
Science Ltd

 United Nations Convention (1989) Un Convention on the rights of the child.

 Volprecht, A.; Flannagan, N.; Livingstone, A. (2001) What parents think about an acute
community paediatric nursing service. unpublished report

 While, A.E., Dyson, L.(2000) Characteristics of paediatric home care provision: the two
dominant models in England. Child Care Health Development. 26(4):263-275

 Whiting, M. (2005) Needs analysis and profiling in community children’s nursing. In:
Widdas, D. & Sidey, A. (eds) Textbook of community children’s nursing (2 nd ed.). (pp180-
194) London: Bailliere Tindall / RCN

 World Health Organisation (1978) Health for all by the year 2000.
Caring for children receiving
home intravenous antibiotic
therapy

Dianne Cook - Children’s Community

Specialist Practitioner
Central Manchester Primary Care Trust
Elaine Salmons – Children’s Community Team
Leader
Queen’s Medical Centre, Nottingham
AIM
To have an increased awareness of
administering IV antibiotic therapy in the
community
OBJECTIVES
• To discuss advantages of IV’s in the
community
• To explore issues relating to
administration
• To have a basic awareness and
understanding of anaphylaxis
 The administration of IV drugs by
Community nurses has become more
widespread in recent years. The
practice, having initially been classed as
an extended role of practice has now
become part of the core skills for
general nursing practice. This therefore
allows an holistic approach to care.
 Advantages of IV’s at home
• Reduction and prevention of hospital
admissions
• Reduced length of stay
• Increased independence from hospital
• Less disruption to family routine
• Continued schooling
• Reduced risk of cross infection
• Reduction of winter bed pressures
• Cost effectiveness
• Payment by results
• Autonomy and empowerment
Range of Access routes

• Peripheral Lines – Cannula, Longlines

• Central Venous Routes - Hickman Lines
• Subcutaneous Implantable Venous
access devices – Portacaths
 ‘The administration of medicines is an
important aspect of the professional
practice of persons whose names are on
the Council’s register. It is not solely a
mechanistic task to be performed in
strict compliance with the written
prescription of a medical practitioner.
It requires thought and the exercise of
professional judgement…..’

Guidelines for the administration of medicines

NMC 2004
Children are not miniature adults
as they have different
pharmacokinetic profiles, which
require specialist knowledge,
awareness and expertise
 The safe administration to
children is a key area of
responsibility for practitioners
in child care, and warrants
extra vigilance in order to
safeguard each child’s safety
Clinical responsibility for a child
receiving IV therapy at home
lies with the GP. If a GP is
unwilling to accept
responsibility, the Consultant
will normally continue this role
‘It is the nurse who is responsible for
the correct administration of the
prescribed drugs. Therefore, they
should know the therapeutic uses,
dosage, side effects, precautions
and contra-indications’
(Guidelines for the administration of medicines
2004)
 ‘ The NMC welcomes and
supports the self-
administration of medication by
carers wherever it is
appropriate….’

(Guidelines for the safe administration of medicines,

NMC 2004)
 If responsibility is delegated then we
need to ensure that the patient, family
or carer is competent to carry out the
task
 Education
 Training
 Assessment
 Support
 Reviewed and reassessed periodically
‘Check that the patient is not allergic
to the medicine before
administering it’
NMC 2004

but…
 An allergic reaction does not
usually occur the first time a
person is exposed to a drug…It
is only after the body learns to
recognise the substance that an
immune system reaction is
triggered
It therefore, is essential, that
more diligence be taken
throughout the second and
subsequent administration of
drugs given via the IV route,
especially as these are often
administered in the community
Drug allergies occur as a result of
a variety of complex immune
system responses to specific
medications.
 In most cases, the reaction
involves relatively mild
symptoms, e.g. minor skin rashes
and hives, itching, generalised
flushing of the skin
 However, in some cases a life
threatening, acute reaction can
occur progressing quickly to
more severe symptoms, massive
swelling of the respiratory
tract, constriction of bronchial
smooth muscle and extreme
vasodilation
Anaphylaxis is a severe allergic
reaction, the extreme end of
the allergic spectrum. No
universally accepted definition
exists because anaphylaxis
comprises of a constellation of
features (Ewan 1998)
(Anaphylaxis, BMJ, 316, 1442-1445)
Anaphylaxis occurs in an acute and
unexpected manner. The true
incidence is unknown. Epidemiological
studies have shown differing results
owing to differences in both
definitions of anaphylaxis and the
population groups studied.
 Anaphylaxis seems to be
increasingly common, almost
certainly associated with a
significant increase in the
prevalence of allergic disease
over the last two or three
decades
Adrenaline (Epinephrine) is the
first line treatment for
anaphylactic reactions.
 Early intramuscular
administration of adrenaline is
essential for optimal action
• Adrenaline (Epinephrine) is
greatly under-used
• Although widely available in the
community, it is not given in a
timely manner when required

(Resuscitation Council UK 2005

The Emergency Medical Treatment of Anaphylactic
Reactions for First Medical Responders and for Community
Nurses)
‘Anaphylaxis is poorly managed’
Treatment Algorithm for
Children in the Community
Resuscitation Council (UK) 2006
(www.resus.org.uk/siteindx.htm)
 Although anaphylactic reactions
are rare, they cannot be
predicted and have the potential
to be fatal without treatment
(Martin 2000)
(Immunisation, Nursing Standard, 14, 30, 47-52)
Ideally therefore, no one should
give IV treatment without
access to adrenaline and
assistance
Discuss with management
Discuss within own Trust