VOL: 97, ISSUE: 31, PAGE NO: 36
Helena Dunbar, BA, RN, RSCN, is advanced nurse practitioner, respiratory diseases, Leicester Royal Infirmary Children’s Hospital
Diane Postle, BSc, RN, HV, is clinical nurse specialist asthma/asthma coordinator, Leicestershire and Rutland Healthcare NHS Trust
Quality of care is the focus of the government’s plans for the new NHS. These centre on a drive to improve the delivery of health care, with radical changes in the pipeline as primary care groups move towards trust status.
Through the development of primary and community health care services and the commissioning of acute hospital care services, primary care trusts aim to be more responsive to the health needs of local communities. For this reason, nurses working in the community are being encouraged to work across service boundaries.
Our project demonstrates an integrated team approach between primary and secondary care practitioners. It shows how a particular need was identified in a specific patient group and quality of care improved as a consequence of the use of audit, collaboration, teamwork and standard setting. We also developed an educational package to help health professionals extend and improve their knowledge in this area.
The strategy group
The Leicestershire asthma strategy group was set up in 1993 in response to local concerns about the increasing prevalence of asthma in the county. It is made up of health professionals with an interest in asthma who meet quarterly to discuss progress and set objectives for the coming year. Its aims include:
- Reducing the number of deaths and the incidence of illness as a result of asthma;
- Acting as a forum for the district-wide management of asthma;
- Developing the provision of a consistent, quality local NHS service for patients with asthma by raising awareness of the disease and promoting the effective use of resources and expertise on it;
- Encouraging communication between the health professionals involved in the care of patients with asthma, particularly between primary and secondary care settings.
Several subcommittees were formed to focus on specific issues. The main reason for setting up a subcommittee for children and young people was to improve communication between the professionals involved and prevent the duplication of work. Its members included school nurses, practice nurses, health visitors and specialist asthma nurses.
The prevalence of asthma has increased dramatically over the past century and a National Asthma Campaign (1999) audit estimated that one in seven children in the UK aged between two and 15 have asthma symptoms that require treatment. GPs and paediatricians are seeing increasing numbers of anxious parents with wheezing children (O’Connor, 1998).
Children who wheeze can be divided into two groups: those who wheeze transiently and those who wheeze persistently and go on to develop asthma. A longitudinal study of newborns highlighted the fact that most such infants have transient conditions associated with diminished airway function at birth, but do not have an increased risk of developing asthma or allergies later in life (Martinez et al, 1995).
About 25% of children wheeze at some time in early life, but only about half of these go on to develop asthma (O’Connor, 1998).
A child with a diagnosis of asthma requires treatment to control the symptoms and prevent long-term damage to the airways, which can lead to problems in adulthood. For this reason it is essential to distinguish between the transient wheezer and the child with asthma (O’Connor, 1998).
Assessment and an ability to differentiate between the different patterns of wheezing and their severity are vital to determine an appropriate therapeutic regime (Silverman and Wilson, 1995). For example, children with purely episodic viral wheezing may respond less effectively to preventive treatment with inhaled corticosteroids than those with a persistent wheeze between episodes (Silverman, 1997). Alternative therapies may be more appropriate for preterm babies or patients with gastroesophageal reflux.
However, in general practice it can be difficult to differentiate between different types of wheezing. Often the only way to assess the difference between asthma and wheezing is by taking an accurate history and monitoring the child’s symptoms. Indicators may include recurrent or persistent night-time waking, a family history of allergy (atopy) and the identification of a known trigger.
This poses a challenge for health professionals caring for preschool children who wheeze. In the light of these issues we decided to carry out a clinical audit.
In 1997, Fosse Health Trust (now Leicestershire and Rutland Healthcare NHS Trust) audited health visitors’ knowledge of asthma. The aim was to educate health visitors on the management of asthma and wheezing, enabling them to teach parents and carers. The goal was to reduce the morbidity associated with asthma in children from birth to the age of five.
Three areas were evaluated in the audit - theory, assessment and practice - with the focus on a number of key points. The baseline audit highlighted significant gaps in the knowledge and skills of practitioners and identified the need to educate health visitors on the management of wheezing in the under-fives.
To achieve this, six health visitors were seconded to do a diploma in asthma care run by the National Asthma and Respiratory Training Centre. After completing the course they collaborated with school nurses to teach playgroups, nurseries and schools about the importance of good asthma management and to act as a resource on training and advice for the community. Education was initially targeted at teachers and nursery staff, after which focus groups were set up to educate parents.
To encourage continuing professional development, the authors organised a one-day conference in Leicestershire for health visitors. Seventy-five people attended and the evaluations for each presentation and workshop were excellent. An amended programme the following year was attended by 45 health visitors, 17 practice nurses and five others, including community children’s nurses and play specialists. Again, the evaluation was excellent and feedback was positive.
The conference’s effectiveness in terms of achieving changes in clinical practice is difficult to determine, but such initiatives can contribute to improving standards of care for preschool children who wheeze.
Clinical guidelines and standards
Two community-based respiratory clinics for children and young people were established in Leicestershire. To ensure the standardisation of procedures and consistency in the education on offer to families, they were set up on the premise of protocols based on guidelines. Each is run by a consultant community paediatrician with the help of a school nurse or health visitor.
It is anticipated that more clinics will be set up and that other professionals will be keen to expand their roles in them. In addition, guidelines are being developed to enable health visitors to access evidence-based information that will help them to care for children in the under-five age group who wheeze. These are currently being piloted in three areas.
The strategy group aims to standardise the documentation on asthma management, for example through self-management plans, educational materials and symptom diaries which are in the early stages of development. Another eight health visitors have been identified for secondment to a course on paediatric asthma care in the community.
To share good practice and encourage networking, the authors organised a national event last year which focused on allergy and asthma in children aged under five. More than 100 people attended, including health visitors, community children’s nurses, school nurses and two school medical officers. Keynote lectures were complemented by concurrent sessions on allergic diseases in the under-fives, tackling eczema, rhinitis and nut allergy. Again, evaluations were excellent.
Strategies to improve the management of asthma and other wheezing disorders in children aged under five have been shown to be effective in the short term. By recognising each other’s skills and knowledge, a productive working relationship has developed between different health professionals.
Collaboration and coordination has led to the development and implementation of changes in practice, improving standards of service. This integrated approach is a step forward in improving the quality of health care offered to children aged under five. The health visitor’s role is pivotal, and a primary factor in making the project a success was the collaboration and involvement of all primary and secondary health care professionals.