Nursingintheacutesettingstthomastalk2008

8/14/2019 Nursingintheacutesettingstthomastalk2008

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Haemoglobinopathy Nursingin the Acute Setting

St Thomas

London

2008


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Ethnic Demographics (2001 Census)

Birmingham

2.9%Mixed race

0.63%Other ethnic heritage

0.52%Chinese

6.1%Black/black British

19.5%British Asian

70.4%White( inc Irish/other white)


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Patient Demographics 2008

14

15

TM

(29)

4

9

TI/ET

(13)

16

15

HbSThal

(31)

7997Female

6081Male

HbSC

(139)

HbSS

(178)

SCD

(total

no)

Total number of registered patients -413


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Sickle Cell and Thalassaemia

Centre

Inner city hospital

Nurse led service-team of specialised nurses

Day case centre and outreach to wards for

inpatients

Monday- Friday (9-5)

Serve adult patients with disorder

Planned and unplanned patient activity Screening remit


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Ethos of Service

Swift assessment for complications

Appropriate analgesia plan

Avoid escalation of pain/ curtail crisisProtocol led

Education

Support/advice


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Acute Nursing Care

Specialist nurses

Continuing professional development

Extended rolesSupportive and proactive medical team/

management structure


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Structure and ResponsibilityClinical Lead Nurse

Development /policy

Deputy Lead Nurse

Service manager

Junior Sister

Staff Nurse Staff Nurse Staff Nurse

Clinical PsychologistHaematologist


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Thalassaemia

Planned activity

Blood transfusions and Chelation

managementMultidisciplinary team inc psychologist

Patient centred- flexibility


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Thalassaemia

Nurse to arrange date with patient and book BT

X- match and FBC- 48 hours prior to BT

Discuss chelation/ concordance

Arrange/coordinate prescriptions as required

Monitor concordance- weekly FBC/LFTs

Education - chelation, central line care, thumb

tacks, importance of drug monitoring


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Chelation

Rationale for Chelation

Information about dose, frequency,

storage and method of administration Importance of adherence

Potential side effects

When to seek help eg signs of infection Importance of attending for monitoring

and at least 3 monthly medical review


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Patients Experiences of

Hospitalisation

for sickle cell

patients, positive

experiences of

hospital care are theexception

mistrust

controlstigmatisation

neglect


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Sickle Cell Disorder

Largely unplanned activity except red cellexchange/ top up blood transfusions

Nurse led assessment within protocols

and operational policyEmergency admissionsDirect access

Day case assessment and avoidance ofadmission to hospital


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Assessment of Patient in Pain

Pain characteristics

Onset and duration of pain

Site of painNature of pain

Severity

Precipitating factorsComplicated/uncomplicated


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Complicated Crisis

Fever/rigors->38c Tachycardia/palpitations (despite analgesia) Neurological symptoms (also ophthalmic concerns) Chest pain (other than bony pain) tachypnoeic-hypoxia


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Evaluation

Baseline observations- + pain score, pulseoximetry hourly and then 2 hourly

Assess state of hydration

Cannulate if required Full infection screen- MSU, sputum, blood

cultures Routine bloods

Use patient controlled analgesia where possible Prepare for admission


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Complicated Crisis

Once initial nurse assessment and

treatment commenced

Refer to medics for admission

Arrange ambulance transfer to acute bed

on site

Nurses outreach daily to ward


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Uncomplicated Crisis

Baseline observations- + pain score,

pulse oximetry hourly and then 2 hourly

State of hydration

Analgesic history in preceding 8 hours

Use set protocols to administer analgesia

hand held treatment cards

Day case treatment- home


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Handheld Treatment Card

Defined treatmentprotocols

Protocol applicable toSWBHT only

Gatekeeper is the SCaTcentre

Protocols reviewed every2 years

Only for registered

patients Must have annual med

review


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Analgesic Response

Administer analgesia within 30 minutes- (mean10 mins)

Reassess after 30 minutes and 1 hour

Parenteral / oral analgesia Discharge home with appropriate oral analgesia GP summary within 24 hours Referral to community sickle nurses if required


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Advice on Discharge

Reassure

Caution about driving

How to take medication Fluid intake

Support at home

When to seek further help Inform of next OPA


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Last Seven Years

92%94%84%88%84%78%88%% Home

43

744

1696

Yr 6

05/06

400250150100Noregistered

patients

515554583713Admittedfrom D.C.

628342463351165107DC pain

14801568169617481344672Total DCactivity

Yr 7

06/07

Yr 5

04/05

Yr 4

03/04

Yr 3

02/03

Yr 2

01/02

Yr 1

00/01


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Day Case Model- Does it work?

2000- DC pain management accounted for90% of activity (5% of pt database)

2008- 50/50 split with blood transfusion andpain management

Majority of in-patient admissions are forcomplicated sickle cell crisis

Anecdotal evidence shows appropriateadmissions for SCD

Average no of bed days for SCS is 7-10d Patient safety- no deaths of any patient

following DC


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Service User Feedback (2008)

Things valued by service users- expertise,

warmth and support from nursing staff

Outreach service valued highly

Opening hours

Quick and efficient pain service

Flexibility of BT Liaison with primary care


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Concern about privacy when being

assessed

Shortage of nursing staff

Clinic appointments and waiting times

Dcor

Distance of other departments

Documents

Nursingintheacutesettingstthomastalk2008