Leading change

The matron of the Community Children’s Nursing Team at Whittington Health NHS Trust led the implementation of a new service within the Hospital at Home service, offering home based phototherapy to babies with physiological jaundice. The Hospital at Home service is part of the Community Children’s Nursing Team, delivering nursing care to acutely unwell children at home.

Where to look

Midwives and Accident and Emergency (A&E) Nurses identified a high number of neonates attending their services leading to hospital admissions, following a diagnosis of physiological jaundice. Babies were also often readmitted to hospital after birth following identification of jaundice by a community midwife. Once jaundice is recognised, nationally there is widespread variation in the use of phototherapy. The nurses and paediatric leads at Whittington Health NHS Trust identified an opportunity to provide services in a different way when phototherapy treatment was indicated, which would contribute to improving the delivery of phototherapy locally.

What to change

The recommended treatment for babies with physiological jaundice is phototherapy (PT), which is traditionally delivered in hospital by overhead phototherapy units. Babies lie under lamps and are only taken out for brief periods of feeding. PT treatment is typically for around four days depending on severity, cause of jaundice and response to treatment. Readmission to hospital is disruptive to family life and can cause high levels of stress within families.

The matron and colleagues in the Hospital at Home team researched alternative treatment options available and identified Light Emitting Diode (LED) phototherapy blankets to deliver effective PT. These blankets wrap around a baby for a prescribed length of time and allows them to be held, cuddled and fed as they normally would. Using Intensive Light LED Blanket phototherapy during feeding helps to prevent interruption of intensive phototherapy for feeding/bonding purposes (Clinical Guideline 98.1 (Neonatal jaundice) Evidence review and recommendations). The device means that some babies can receive PT at home with parent support.

The matron and paediatric leads identified this would be an opportunity to provide services to patients and families in a different way, utilising services and resources in a more effective way.

How to change

The matron identified that the Hospital at Home service had capacity to manage babies with physiological jaundice at home as part of its objective to reduce length of stay for patients in hospital and improve service user satisfaction. They worked with the leadership team at the Trust to develop a business case for the purchase of equipment and to implement changes. LED/PT blankets were purchased and a representative from the manufacturer provided training on their use.

Nurses worked closely with A&E, paediatricians, neonatologists and midwifery colleagues to develop a new service within the Hospital at Home service that offers support to neonates with jaundice, with appropriate review/reporting and management of these babies whilst receiving treatment.

All cases are reviewed by a paediatrician within the emergency department prior to any treatment starting and referred if they meet safe criteria. Nurses manage home based therapy according to NICE guidance on the management of babies with physiological jaundice, which includes visiting up to three times per day to monitor and assess, including blood testing. There is a robust escalation procedure in place to ensure prompt urgent action if needed. Nurses have also undergone additional advanced assessment training and specific training on infant feeding, to offer the best support and advice to families. They visit the hospital daily to feedback patient progress and identify potential referrals. A patient is discharged once under the threshold for PT and bounce-back bloods are satisfactory.

Adding value

Better outcomes – There has been a reduction in hospital stays and a reduction in the average length of stay for patients with neonatal jaundice. April 2016 showed continued fluctuating levels above and below the average length of stay of 11 days. However, one year later by April 2017 a clear trend has been emerging of overall continued reduction in stay which by April 2018 had reached approximately 6 days on average.

Better experience – This new service enables parents to have continued contact with their neonate, providing an adaptable and effective service to parents and babies in their own home. There is consistent 100% positive feedback from service users and parenting time for families is not significantly impacted on. Parents have described feeling less stressed, more reassured and confident of the quality of care provided. Feedback has included:

• “Amazing service, very competent nursing staff. Being able to go home 4 days earlier was such a benefit to the whole family. Overall very impressed.”
• “The specialist nurses monitored our daughter and advised on next steps in treatment. This was extremely helpful and meant we did not need to go in touch with the hospital or the GP.”
• “This service exemplifies a high level of quality in care. Thank you!”

Better use of resources – Although there was an immediate financial outlay to purchase LED/PT blankets, there has been a corresponding reduction in the cost of using hospital resources. The blankets are a good investment as they will last for 10,000 hours before the lights need replacing. The service has expanded from having one blanket to three. The profile of the Hospital at Home service has been raised and it provides support to A&E and midwifery departments. The service is being expanded to include direct midwifery-led referral into the service to avoid A&E attendance for low risk babies. Good practice is being shared across other areas to enable them to develop similar systems. The proposal of enabling patients to come direct to the Hospital at Home Service rather than needing to be reviewed by the paediatrician is being explored.

Challenges and lessons learnt for implementation

• It is important to involve clinicians in the planning process to ensure partnership working and improve adherence to new processes;
• Collect patient feedback at every opportunity as patient stories have a big impact;
• Persevere if you believe that this is the right thing to do. If the pathway is robust and evidence based, concerns can be allayed and adjustments can be made. It is easier to adapt a service once it is up and running as you can see challenges as they occur and problem solve;
• Ensure robust data collection at the beginning so there is a clear baseline;
• Review what is going on nationally and if there are lessons to be learnt from other services who may have implemented this already.

Find out more

For more information contact:

• Zoe Tribble, Matron, Children’s Community Nursing and Hospital Team, Whittington Health NHS Trust, zoe.tribble1@nhs.net