Substituting community children's nursing services for inpatient care: a case study of costs and effects.

OBJECTIVE: To compare children's pathways to and through Community Children's Nursing Team (CCNT) care, and NHS costs, before and after relocation of inpatient services and extension of a paediatric Emergency Department and Observation and Assessment Unit (ED/OAU). DESIGN: Case study. Routinely collected data on activity and staffing were provided by the CCNT. Parents completed questionnaires about their child's use of healthcare services and satisfaction with care preservice reconfiguration (n=221) or postreconfiguration (n=210). The cost of service use was compared prereconfiguration and postreconfiguration. PATIENTS: Children referred to CCNT care. MAIN OUTCOME MEASURES: Healthcare service use and associated costs, satisfaction with CCNT care. RESULTS: The mean number of services used before referral to the CCNT reduced from 2.8 to 1.6, and the proportion using only one service increased from 26% (n=58) to 61% (n=128). Inpatient admission during CCNT care reduced from 6% (n=13) to 2% (n=4), and ED attendance from 37% (n=79) to 16% (n=31). There was a considerable fall (25%) in the cost of CCNT care, and a sharp fall (55%) in the average overall NHS cost of care. CCNT care was rated 'excellent' or 'very good' by 85% of respondents both prereconfiguration and postreconfiguration. CONCLUSIONS: A CCNT provided an alternative to hospitalisation when acute general paediatric services were reconfigured to substitute for a relocated hospital. Children's pathways to CCNT care were shortened. The average cost of CCNT care and overall NHS cost were lower following reconfiguration. Satisfaction remained high throughout.

Avoiding inappropriate paediatric admission: facilitating General Practitioner referral to Community Children's Nursing Teams.

BACKGROUND: Children's emergency admissions in England are increasing. Community Children's Nursing Teams (CCNTs) have developed services to manage acutely ill children at home to reduce demand for unscheduled care. Referral between General Practitioners (GPs) and CCNTs may reduce avoidable admissions and minimise the psychosocial and financial impact of hospitalisation on children, families and the NHS. However, facilitators of GP referral to CCNTs are not known. The aim of this study was to identify facilitators of GP referral to CCNTs. METHODS: Semi-structured interviews with 39 health professionals were conducted between June 2009 and February 2010 in three Primary Care Trusts served by CCNTs in North West England. Interviewees included GPs, Community Children's Nurses (CCNs), consultant paediatricians, commissioners, and service managers. Qualitative data were analysed thematically using the Framework approach in NVivo 8. RESULTS: Five facilitators were identified: 1) CCN/CCNT visibility; 2) clear clinical governance procedures; 3) financial and organisational investment in the role of CCNTs in acute care pathways; 4) access and out of hours availability; 5) facilitative financial frameworks. CONCLUSION: GPs required confidence in CCNs' competence to safely manage acutely ill children at home and secure rapid referral if a child's condition deteriorated. Incremental approaches to developing GP referral to CCNTs underpinned by clear clinical governance protocols are likely to be most effective in building GP confidence and avoiding inappropriate admission.

Comparison of the costs of care during acute illness by two community children's nursing teams.

OBJECTIVE: To compare the costs associated with care by two community children's nursing teams (CCNT). DESIGN: A case study incorporating questionnaire survey, analysis of routinely collected data and analysis of costs in the north-west England. PATIENTS: Children with acute illness referred for CCNT care. INTERVENTIONS: Two CCNT provided care for 273 children during acute illness in order to reduce the number and duration of hospital admissions. MAIN OUTCOME MEASURES: Costs of CCNT, other services and costs to families. RESULTS: The objectives of both CCNT included shortening and avoiding hospitalisations. Most (45 (58%) in case A and 150 (77%) in case B) children were referred for infections. There were differences in the proportion of children who had been hospitalised (45 (57.7%) and 78 (40%)), the mean number of services used before referral to CCNT (1.6 and 2.2) and the staffing profile of the CCNT. There was a statistically significant difference in the overall mean cost to the NHS of CCNT care (£146 and £238, 95% CI for difference of means 7 to 184), associated with higher proportions of children having telephone-only contact (two (3%) and 46 (24%)) and children using almost twice as many other health services during care by one CCNT (means 0.27 and 0.51). CONCLUSIONS: Costs of CCNT care can vary widely when all health service use is taken into account. Differences in the way CCNT are integrated with the urgent care system, and the way in which CCNT care is organised, could contribute to variations in costs.

Integrating community children's nursing in urgent and emergency care: a qualitative comparison of two teams in North West England.

BACKGROUND: Despite the policy principle that "children are best cared for at home whenever possible" children continue to have high rates of emergency department (ED) attendance and emergency hospital admission. Community Children's Nursing Teams (CCNTs) can care for acutely ill children at home but their potential to provide an alternative to ED attendance and hospitalisation depends on effective integration with other services in the urgent care system, such as EDs and Observation and Assessment Units (OAUs). Although challenges of integrating CCNTs have been identified, there has been no comparative assessment of the factors that facilitate or hinder integration of care of acutely ill children by CCNTs with the urgent care system. The aim of this study was to identify enablers and barriers to integration of CCNTs with urgent and emergency care. METHODS: Comparative case studies were conducted of two CCNTs serving Primary Care Trusts in North West England. Twenty-two health professionals including CCNT managers and staff; paediatricians; nurses; children's ward, ED and OAU staff; commissioners of children's services; GPs and primary care staff were interviewed between June 2009 and February 2010. Qualitative data were analysed thematically using the Framework approach. RESULTS: Barriers to integration included paediatricians' perceived lack of ownership of the CCNT, poor communication between consultants and community children's nurses (CCNs), and weak personal relationships. This prevented early referral to the CCNT as an alternative to hospital care. Enablers of integration included co-location and rotation of CCNs through urgent care settings including OAUs and EDs. This enabled nurses to develop skills, make decisions about referral to home care and gain the confidence of referring clinicians. CONCLUSIONS: Integration of CCNTs at multiple points in the urgent care system is required in order to provide an alternative to inappropriate ED attendances and emergency admission. The principal enablers and barriers are both aspects of normative integration, which involves shared understanding of the contribution of CCNTs and trusting relationships between practitioners. Co-location and rotation of CCNs through acute services can promote integration and appropriate referrals to CCNTs to support families to care for children at home.

Relationships between deprivation and duration of children's emergency admissions for breathing difficulty, feverish illness and diarrhoea in North West England: an analysis of hospital episode statistics.

BACKGROUND: In the United Kingdom there has been a long term pattern of increases in children's emergency admissions and a substantial increase in short stay unplanned admissions. The emergency admission rate (EAR) per thousand population for breathing difficulty, feverish illness and diarrhoea varies substantially between children living in different Primary Care Trusts (PCTs). However, there has been no examination of whether disadvantage is associated with short stay unplanned admissions at PCT-level. The aim of this study was to determine whether differences between emergency hospital admission rates for breathing difficulty, feverish illness and diarrhoea are associated with population-level measures of multiple deprivation and child well-being, and whether there is variation by length of stay and age. METHODS: Analysis of hospital episode statistics and secondary analysis of Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-being (CWI) 2009 in ten adjacent PCTs in North West England. The outcome measure for each PCT was the emergency admission rate to hospital for breathing difficulty, feverish illness and diarrhoea. RESULTS: 23,496 children aged 0-14 were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2006/07. The emergency admission rate ranged from 27.9 to 62.7 per thousand. There were no statistically significant relationships between shorter (0 to 3 day) hospitalisations and the IMD or domains of the CWI. The rate for hospitalisations of 4 or more days was associated with the IMD (Kendall's tau(b) = 0.64) and domains of the CWI: Environment (tau(b) = 0.60); Crime (tau(b) = 0.56); Material (tau(b) = 0.51); Education (tau(b) = 0.51); and Children in Need (tau(b) = 0.51). This pattern was also evident in children aged under 1 year, who had the highest emergency admission rates. There were wide variations between the proportions of children discharged on the day of admission at different hospitals. CONCLUSIONS: Differences between rates of the more common shorter (0 to 3 day) hospitalisations were not explained by deprivation or well-being measured at PCT-level. Indices of multiple deprivation and child well-being were only associated with rates of children's emergency admission for breathing difficulty, feverish illness and diarrhoea for hospitalisations of 4 or more days.

Childhood disadvantage and emergency admission rates for common presentations in London: an exploratory analysis.

AIM: To determine whether emergency hospital admission rates (EAR) for common paediatric conditions in Greater London are associated with measures of child well-being and deprivation. DESIGN: Retrospective analysis of hospital episode statistics and secondary analysis of the Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-Being (CWI) 2009. SETTING: 31 Greater London primary care trusts (PCTs). OUTCOME MEASURES: EAR in PCTs for breathing difficulty, feverish illness and/or diarrhoea. RESULTS: 24,481 children under 15 years of age were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2007/2008. The EAR for breathing difficulty was associated with the IMD (Spearman's rho 0.59, p<0.001) and IMD indicators of: overcrowding (Spearman's rho 0.62, p<0.001), houses in poor condition (Spearman's rho 0.55, p=0.001), air quality (Spearman's rho 0.53, p=0.002), homelessness (Spearman's rho 0.44, p=0.013), and domains of the CWI: housing (Spearman's rho 0.64, p<0.001), children in need (Spearman's rho 0.62, p<0.001), material (Spearman's rho 0.58, p=0.001) and environment (Spearman's rho 0.53, p=0.002). There were no statistically significant relationships between the EAR of children admitted for feverish illness and diarrhoea or aged under 1 year for any condition, and the IMD, either IMD indicators or CWI domains. CONCLUSIONS: Housing and environmental factors are associated with children's demand for hospital admission for breathing difficulty. Some associations are stronger with the CWI than the IMD. The CWI has potential to identify priority PCTs for housing and environment interventions that could have specific public health benefits for respiratory conditions.

Readmission in children's emergency care: an analysis of hospital episode statistics.

AIM: To compare rates of emergency readmission following discharge for common paediatric conditions from a range of hospital services. DESIGN: Retrospective analysis of hospital episode statistics (HES) and telephone survey of service provision. SETTING: Twelve hospitals serving a metropolitan area in the North West of England. OUTCOME MEASURES: Emergency admissions to hospital within 7 days of discharge for breathing difficulty, feverish illness and/or diarrhoea. RESULTS: HES were obtained for all children under 15 years of age discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2005/2006 (n=20,354) or 2006/2007 (n=23,018). The readmission rate for all hospitals in 2006/2007 was 5.5%. The percentage of same day discharges was associated with readmission (Kendall's tau(b) correlation=0.61, p=0.007). Readmissions were also associated with the proportion of same day discharges for breathing difficulty (Kendall's tau(b)=0.83, p<0.001) and feverish illness (Kendall's tau(b)=0.50, p=0.023) but not significantly so with diarrhoea (Kendall's tau(b)=0.37, p=0.098). The total number of admissions at a hospital in the year was associated with its readmission rate (Kendall's tau(b)=0.71, p=0.002). Most of the sample lived in the 40% most deprived areas in England, but there was no significant association between readmission and living in the 10% most deprived areas. CONCLUSIONS: Readmission rates are associated with higher numbers of annual admissions and higher proportions of children discharged on the day of admission. Variations between hospitals suggest that other factors can also affect readmission rates. Readmission rates calculated from HES can contribute to assessments of the outcome of emergency services.

Response of steroid-treated former preterm infants to a single dose of meningococcal C conjugate vaccine.

Attenuated antibody responses have been reported in preterm infants who received neonatal dexamethasone treatment. The duration of immunosuppression may extend into later infancy. This study assessed the immune response of former preterm infants to a single meningococcal serogroup C conjugate (MCC) immunisation given after infancy. A cohort of 49 toddlers born at less than 33 weeks' gestation were given an initial dose of MCC vaccine at a median age of 13 months; 11 had received dexamethasone in the neonatal period. Sera obtained 4 weeks post immunisation were analysed for serum bactericidal antibody (SBA) and serogroup C-specific IgG antibody concentrations. Immune responses were compared with those of an historical cohort of 70 term toddlers given a single dose of the same vaccine at age 13 months. An SBA titre of > or =8 was taken to indicate a protective response. Following a single MCC dose, the SBA geometric mean titre (GMT) for former preterm infants was 249 (95% C.I. 111, 558), not significantly different from that of the historical term cohort whose SBA GMT was 141 (95% C.I. 89, 224) (p=0.06). A significantly lower proportion of former preterm infants achieved a protective SBA titre of > or =8 compared with term infants, 37/48 (77%) versus 64/70 (91%), (p=0.03). For steroid-treated and non steroid-treated subgroups, SBA GMTs were 1237 (95% C.I. 250, 6132) and 154 (62, 385), respectively, and numbers achieving an SBA titre of > or =8 were 10/11 (91%) and 27/37 (73%), (p=0.42). Most children born at <33 weeks' gestation mount a protective immune response to a single MCC vaccine dose given at age 13 months, but fewer former preterm infants attain a protective SBA titre of 8 compared with term infants. Previous neonatal dexamethasone treatment does not appear to attenuate immune response after infancy.

Antibody response to diphtheria-tetanus-pertussis immunization in preterm infants who receive dexamethasone for chronic lung disease.

OBJECTIVE: To study the effect of dexamethasone in preterm infants with chronic lung disease (CLD) on antibody response to routine immunization against diphtheria, tetanus, and pertussis (DTP). METHODS: Serum samples were obtained before and after immunization with DTP (Trivax-AD) from an unselected cohort of 93 preterm infants in the United Kingdom. Antibodies to diphtheria and tetanus and to 4 pertussis antigens (pertussis toxin, filamentous hemagglutinin, pertactin, and fimbrial agglutinogens 2 + 3) were measured by an enzyme-linked immunosorbent assay. Linear regression models were fitted to the natural log of antibody titers to compare the dexamethasone-treated and -untreated infants adjusting for potential risk factors. RESULTS: Sixty-seven (72%) of 93 infants received dexamethasone. Preimmunization geometric mean titers (GMTs) were comparable in both groups for all antibodies. The rise in GMT after immunization was reduced in the dexamethasone-treated group. Final GMT was significantly lower for tetanus, diphtheria, pertussis toxin, and fimbrial agglutinogens 2 + 3 but not for filamentous hemagglutinin or pertactin. Using the minimum protective titer of 0.01 IU/mL, there was no significant reduction in protection for diphtheria and tetanus in the dexamethasone-treated infants. Using the higher reference titer of 0.1 IU/mL, there was a 16% reduction in protection for diphtheria (95% confidence interval: 3%-27%) and a 9% reduction in protection for tetanus (95% confidence interval: -7% to 20%). CONCLUSIONS: The use of dexamethasone for CLD in preterm infants is associated with a reduction in antibody titer to routine immunization against diphtheria and tetanus. Antibody responses to 2 of 4 pertussis antigens are reduced, but the clinical significance of this observation is unclear. Protection against tetanus and diphtheria is not impaired when the lower reference value for protective antibody is used. On the basis of this study of UK preterm infants who were treated with dexamethasone for the management of CLD, we conclude that the current DTP immunization schedule is adequate and do not recommend additional booster protection against tetanus or diphtheria during early infancy. When diphtheria prevalence is increased, however, additional protection should be considered.