Haemoglobinopathy Nursing in the Acute

Setting

UK Forum
Coventry
2008
Geographical Boundary
 Ethnic Demographics (2001 Census)
Birmingham
White (inc Irish/other white) 70.4%

British Asian 19.5%

Black/black British 6.1%
Chinese 0.52%

Mixed race 2.9%

Other 0.63%
 Patient Demographics 2008
SCD HbSS HbSC HbSßThal TI/EßT TM
(total) (178) (139) (31) (13) (29)

M 81 60 15 9 15

F 97 79 16 4 14

Total -390
 In the Olden Days…….
• All admissions through A&E
• Inappropriate admissions
• In patient orientated
• Medical model of care
• No designated ward
• Uncoordinated
• Fragmented-little or no communication
between agencies
 Precipitants for Change…..
Patient Experience Iatrogenic

• Delays in A&E • Venous access- risks

• Length/frequency of of sepsis/thrombosis
admissions • Hospital acquired
• Lack of structured infections
specialist input • Opiate issues
• Lack of continuity of • Chronic pain
care on discharge management
• Lack of HBO
knowledge
 Sickle Cell and Thalassaemia
Centre
• Opened in July 2000
• Renovated supplies building
• Periphery of City hospital campus
• Monday- Friday (9-5)
• Nurse led
• Outreach to wards
• Adult patients with major HBO
Facilities
• 3 beds/ 2 trolleys
• 3 reclining chairs
• Fully equipped
resource area for
patients/visitors
• Private interview
room
Criteria for Access to Service….
• HBO
• Referral from GP or other
• Registered with service
• Medical review (minimum annually)
 Service Profile
• Planned/unplanned • Hub & spoke model
activity • Liaison with primary
• DC pain management care/vol sector
• BT/RBCX • Home review
• Education
• Monitoring
• In house training
• Multidisciplinary team
• Accredited HBO
• Antenatal/newborn course for nurses
screening
 Service Philosophy

• Bridge gap between home and hospital

• Avoid admission
• Promote productivity
• Individualised treatment plan
• Evidence based practice
• Education
• Support/advice
 Team Structure
Clinical Lead Nurse
Development /policy

Deputy Lead Nurse

Service manager

Junior Sister

Staff Nurse Staff Nurse Staff Nurse

Haematologist Clinical Psychologist

 Thalassaemia
• Flexible BT • Rationale for Chelation
arrangements • Information about dose,
• Monitor chelation/ frequency, storage and
method of administration
concordance • Importance of adherence
• Education - chelation, • Side effects
central line care, • When to seek help eg
thumb tacks, signs of infection
importance of • Monitoring
monitoring • Medical review
• MDT referrals
 Sickle Cell Disorder
• Largely unplanned activity except RBCX/
top up BT
• Emergency admissions
• Direct access
• Nurse led assessment within
protocols/operational policy
• Complicated cases admitted
 Evaluation
• Baseline observations
• History/ assessment
• Complicated/uncomplicated
• Establish venous access
• ?infection screen
• Bloods/ investigations
• ?PCA/intermittent parenteral/oral
analgesia
 Complicated Crisis
• Fever/rigors->38c
• Tachycardia/palpitations (despite analgesia)
• Neurological symptoms (also ophthalmic concerns)
• Chest pain (other than bony pain)
• Tachypnoeic-hypoxia <92% on air
• Priapism
• Pregnancy
• Abdominal pain
• Hypotension
• Uncontrolled acute pain
• Other
 Analgesic Response
• Administer analgesia within 30 minutes- (mean
10 mins)
• Pain score o/a, 30 minutes,1 hour and 2 hours
• Close monitoring for signs of respiratory
depression
• Titrate analgesia accordingly
• Adjunctive
 Handheld Treatment Card
• Defined treatment
protocols
• Protocol applicable to
SWBHT only
• Gatekeeper is the SCaT
centre
• Protocols reviewed every
2 years
• Only for registered
patients
• Must have annual med
review
 Feedback on Treatment Card
• Less delay in A&E
• Empowering
• Increased independence
• Increased feeling of security

Shaw, E. 2006
 Role of Outreach
• Daily review
• Assess and evaluate progress
• Recommend changes to treatment
• Reassure patient
• Liaise with family
• Discharge planning
• Educate ward staff
 Last Seven Years……
Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7
00/01 01/02 02/03 03/04 04/05 05/06 06/07
Total DC 672 1344 1748 1696 1568 1696 1480
activity
DC pain 107 165 351 463 342 744 628

Admitted 13 37 58 54 55 43 51
from D.C.

% Home 88 78 84 88 84 94 92
# Patients 100+ 150 250 400+
 Day Case Model- Does it work?
• 2000- DC pain management accounted for 90% of
activity (5% of pt database)

• 2008- 60/40 split with blood transfusion and pain

management

• Majority of in-patient admissions are for complicated

sickle cell crisis

• Average no of bed days for SCC is 7-10d

• Safety- no deaths following DC

 Service User Feedback (2008)
• Expertise, warmth and support from
nursing staff
• Outreach service highly valued
• Quick and efficient pain service
• Flexibility of BT
• Liaison with primary care
 Areas we need to improve on…..
• Concern about privacy when being
assessed
• Recent nursing shortages
• Clinic appointments and waiting times
• Décor
• Adjacencies of other depts- too far to walk
when in pain