Implementation of a Multidisciplinary Netcoaching Rapid Tube Wean Program at Gold Coast University Hospital

Phillipa Cordner1, Jacqui Willcox1, Rachael Fairhurst1, Cari Traicos1

1Gold Coast Hospital and Health Service, Australia

Background:

Long term tube dependency in paediatric patients has a significant physical, social and psychological impact on children and their families/ carers. There is also a significant economic cost to the health service.

The use of enteral feeding for neonates and paediatric patients within the Gold Coast Health Service over a 5 year period has increased by 170% however there was limited access to a multidisciplinary hunger provocation model which has demonstrated effectiveness within the literature and anecdotally for tube weaning in children under 2 years of age.

The establishment of the Multidisciplinary Netcoaching Rapid Tube Wean Program was initiated following the successful application by Jacqui Willcox and Rachael Fairhurst to the Gold Coast Health Improvers Program. This awarded $100 000 to plan, implement and evaluate the program over a 12 month period.

Method: Referrals for the Rapid Tube Wean Clinic are received from community and hospital based Paediatricians, and a multidisciplinary face-to-face assessment is completed to establish readiness for commencement of a tube wean. Inclusion Criteria: under 2 years of age, medically suitable, growth tracking (with weight ideally 10% greater than Ideal Body Weight) adequate oral skills for eating and drinking, stable social environment, parental engagement and awareness of mealtime strategies.

Results: Seven children have received assessment and intervention since commencement of the clinic, with 5 children weaned, and 2 children currently receiving intervention for tube weaning. One child required reinsertion of tube for hydration in the context of a viral illness. Netcoaching has been utilised with all children and families with positive feedback regarding children interacting in their usual mealtime environment (staff), as well as time and financial practicalities for parents not required to attend hospital for appointments (families).

Discussion: Enabling factors have included the support of the medical, nursing and allied health teams and preliminary cost analysis, whilst barriers to implementation have included staff recruitment and availability. The key learning is the importance for families to have greater understanding of the tube weaning journey, facilitated by support from other families.


Biography: 

Phillipa Cordner graduated from James Cook University with a Bachelor of Occupational Therapy (Hons I) in 2010. She currently works in paediatrics at the Gold Coast University Hospital in the Child Life Therapy program and a multidisciplinary feeding clinic.

Understanding Foetal Alcohol Spectrum Disorder (FASD): a Multidisciplinary Assessment Team Model of Care for those referred to a FASD Assessment clinic and the Implications for Intervention and Education about the impact of FASD on young people

Amanda Simon1, Nadishani (Nadi) Fernando1, Diana Barnett1, Ronalda Hoffman1, Tiffany Allen1

1Children’s Hospital At Westmead, WESTMEAD, AUSTRALIA

Fetal alcohol spectrum disorder (FASD) occurs in all parts of Australian society and is a permanent acquired brain injury caused by alcohol consumption during pregnancy.  The rates of FASD within the community are estimated at 2% of the population with impairments, which are lifelong. These include impairments which can affect motor skills, language skills, academic achievement, memory, attention, affect regulation and adaptive behaviour (including social skills). Therefore, given the diffuse nature of functional impairments, this is a diagnosis of relevance to all allied health professionals.

Method: At the Children’s Hospital at Westmead CICADA Centre, a multidisciplinary assessment team including an Occupational Therapist, Speech Pathologist, Clinical Psychologist and the recent addition of a Social Worker work together with a Paediatrician provide a state-wide assessment service for young people (aged 0-18) referred following concerns surrounding the impact of alcohol consumption during pregnancy.  We are in the process of assessing clinical data of patients that have presented to our service and will be using case examples to outline and illustrate the unique profiles of young people diagnosed with FASD.

Results: Between January 2018 to December 2018, ~23 young people (aged 0-17 years) received a diagnosis of FASD following a multidisciplinary diagnostic assessment.  Each child’s neurodevelopmental was assessed by a multidisciplinary team, and as part of our presentation, we will provide data of the assessments conducted through The Children’s Hospital at Westmead FASD Assessment Service during 2018.   Analysis of this data is currently being finalised, however, results will be provided at the time of presentation.  In reporting these results, we will provide information on the range of assessments used within a FASD assessment team, and recommendations for intervention to improve functional abilities.

Discussion: This presentation will provide information on the diagnostic process (including how to apply the Australian FASD Diagnostic Guidelines) and functional impacts of FASD relevant to all allied health professionals.  In addition, we aim to provide information on the rate and range of impairments seen within the FASD population, and increase understanding of intervention approaches that can be utilised when working with young people with FASD and their families.


Biography:

Amanda Simon is a speech pathologist at Children’s Hospital at Westmead in Sydney NSW.

She has over 25 years’ experience in almost all areas of paediatric speech pathology practice including clinical work with children in out of home care, infants and children with communication and feeding difficulties, children with literacy difficulties, children with craniofacial anomalies including cleft palate and adolescents with mental health issues.

She has a particular interest in the interface between communication development and psychosocial difficulties in children and adolescents.

Amanda currently works as a speech pathologist in the Fetal Alcohol spectrum Disorder assessment clinic at Children’s Hospital at Westmead amongst her other roles at the hospital.

 

The journey of a paediatric patient with Child Life Therapy (CLT) at Gold Coast University Hospital- a case study

Mrs Phillipa Cordner1,2,3,4, Mrs Mary Scannell1,2,3,4

1Gold Coast Hospital And Health Service, Gold Coast, Australia, 2Gold Coast Hospital Foundation, 3Children’s Hospital Foundation,  4Greater Charitable Foundation,

Background: Ben* was booked for a dental procedure under general anaesthetic due to sensory preferences and behaviours limiting his participation in an examination in the dental clinic environment. Ben and his family were identified by the Child Life Therapist during preadmission screening, and prioritised for support prior to and throughout his day surgery admission.

Method: The Child Life Therapist liaised with nursing and anaesthetic staff to support a delayed presentation to the hospital, as preadmission screening had identified that wait periods, unfamiliar environments and unfamiliar routines increased Ben’s anxiety, usually resulting in self harming and physical aggression towards others. The CLT  conducted assessment to determine Ben’s sensory preferences, behaviours and usual leisure and play occupations prior to admission, and utilised this information to set up the environment prior to Ben’s arrival to support his sensory preferences and minimise harm in the environment.

CLT liaised with medical and nursing staff regarding Ben’s sensory preferences, behaviours and leisure occupations, co-ordinating a multidisciplinary approach to facilitating Ben’s care. This including adaptation to usual preadmission routines and environments to support Ben, use of therapeutic distraction and strategies during wait periods and transitions and supporting Ben’s parents throughout admission and recovery.

Results: Ben was able to remain in the waitroom and transition to the anaesthetic bay prior to theatre without the use of sedative medication, utilising therapeutic intervention to support Ben’s sensory preferences and behaviours within an unfamiliar medical environment and routine.  His mother reported that the experience was much better than she had anticipated, and staff reported that without the Child Life Therapy input there would have been a lower threshold for use of a sedative medication to support admission.

Discussion: The collaboration between Ben, his family, CLT, nursing and anaesthetic staff was integral to the co-ordination of safe, child and family centred care.

*Name changed for confidentiality


Biography:

Phillipa Cordner graduated from James Cook University with a Bachelor of Occupational Therapy (Hons I) in 2010. She currently works in paediatrics at the Gold Coast University Hospital in the Child Life Therapy program and a multidisciplinary feeding clinic.

Who is responsible for assessing children’s weight?: views from health care professionals

Mrs Kamila Davidson1, Dr Helen  Vidgen1, Professor  Elizabeth Denney-Wilson2

1Queensland University Of Technology, Brisbane, Australia, 2The University of Sydney, Sydney, Australia

Background: Routine assessment of children’s weight status is the first step in identification of overweight and obesity yet currently in Australia there is a lack of clarity with regard to responsibility for the undertaking of this health check.  While the National Health and Medical Research Council “Obesity Guidelines” recommend for primary health care professionals to assess weight status during consultations this does not routinely occur in practice.

This study aimed to determine primary health care professionals’ views on responsibility for routine weight status assessment in primary school aged children.

Methods: Using the case study of a regional town, Rockhampton, purposeful sampling was used to represent the key primary health care settings and professional groups. Interviews were conducted with 31 health professionals. Data were collected and analysed guided by the COM-B framework.

Results: General practitioners and nurses were seen as having a role in weight status assessment.  A number of barriers to assessing and raising weight related concerns were identified and these led to inconsistent raising of the issue with families.  Increasing awareness about the importance of weight status assessment, a systems approach and appropriate referral options were seen as essential for any change to occur.

Discussion: There is a need for long-term commitment from Governments, primary health care settings, professional groups and health professionals to implement the “Obesity Guidelines” if progress is to be made in addressing this important public health problem.


Biography:

Ms Kamila Davidson is an Accredited Practicing Dietitian (APD) and a PhD Candidate with the School of Exercise and Nutrition Sciences.  Her PhD research is exploring the responsibility for assessing weight status of primary school aged children, and how to improve early identification of overweight and obesity.  Kamila previously worked with the PEACHTM project, the largest State trial of a healthy lifestyle program for primary school aged children and with The Health Impact Project, which aimed to improve the health and wellbeing of children aged 0-5 years and their parents. Currently, Kamila is involved with the Nourish: Early Childhood Education project as a research assistant and works as a sessional academic

Are we doing what they’re doing? Tube weaning at The Canberra Hospital and internationally

Kathryn  Rodda1

1The Canberra Hospital , Chifley, Australia

AIMS: Tube dependence can be an expensive and detrimental side effect of managing medically complex children.  Evidence from international sites shows that hunger provocation tube weaning is effective at increasing successful return to oral feeding (Hartdorff et al, 2015).  Research shows that 90% of hunger provocation tube weans are successful, with a 75% success rate on the first attempt and the majority of children weaned on the second attempt (Wilken et al, 2013).  However, there are only anecdotal reports on the use and success of hunger provocation tube weaning in hospitals in Australia (Gardiner et al, 2016).

This retrospective review examines success rates of hunger provocation tube weaning at The Canberra Hospital’s (TCH) Children’s Feeding Clinic (CFC), and a thematic review of the factors contributing to unsuccessful tube weans.

METHODS: Retrospective review of outcomes since commencing hunger provocation tube weaning at TCH (2015 – 2018 inclusive). Review of patient, carer and environmental characteristics of successful and unsuccessful tube weans

RESULTS

  • 42 tube weans managed by TCH CFC 2015 – 2018.
  • 30/42 (71%) successful first time, 9 of the remaining successful second attempt (total successful = 39/42 = 93%).
  • 3/42 unsuccessful in first 2 attempts (7%).

Reasons for unsuccessful tube weans can be grouped into three main areas – patient specific, parent/carer expectations and stress, and environmental factors.  Parent factors are most likely to result in a second unsuccessful tube wean attempt.

CONCLUSION: Hunger provocation tube weaning managed by TCH Children’s Feeding Clinic has similar success rates to published international data.

CLINICAL SIGNIFICANCE: Hunger provocation tube weaning is generally effective and should be considered for all medically appropriate children.

REFERENCES: Gardiner, Vuillermin and Fuller (2016).  A descriptive comparison of approaches to paediatric tube weaning across five countries.  International Journal of Speech Language Pathology


Biography:

Kathryn is a speech pathologist working in the area of acute neonatal and paediatric feeding.  Her clinical work includes establishing feeding in sick and premature neonates, feeding and dysphagia support and management for children with complex feeding and medical presentations, and tracheostomy management.

Tube-feed weaning: Connecting to disconnect

Marina Keating1, Olivia Naylor1, Linda Correia1

1Perth Children’s Hospital, Nedlands, Australia

Feeding a baby or child is a major aspect of parenting. For parents of children with feeding difficulties who require tube feeding, feeding their child is anything but ‘natural’ or easy. The number of children receiving tube feeds at home has increased over the past 20 years, involving a significant shift in care and responsibility from hospital, to home and family. This shift has emotional, physical and psychosocial implications for the caregiver and their family. Tube dependency is a condition with negative impacts on a child’s growth, health and typical development. It is highly stressful & anxiety provoking for the child & their family and is an economic burden to the Australian healthcare system.

Prior to 2014, there was no formalised tube-weaning program or associated clinical guideline at Perth Children’s Hospital (PCH). Funding supported the development of an evidenced-based clinical guideline for tube-weaning and external training for the multi-disciplinary team. An internal audit of 40 PCH patients was used to examine the impact of implementing the guideline on reducing tube dependency between 2014-2017. The audit also compared the number of Emergency Department (ED) presentations, inpatient admissions and length of stay pre and post tube-wean.

The audit indicated that 98% of patients undergoing a tube-feed wean at PCH had a successful wean (i.e. successful transition to full oral feeding). The audit also indicated that post tube-wean there was an 82% reduction in ED visits, a 94% reduction in inpatient admissions and a 98% reduction in inpatient length of stay.

These outcomes translated to reduced cost for PCH and less distress for patients and families. The results of this audit have implications for the management of tube dependency in an acute hospital setting, and will be of interest to clinicians involved in tube weaning or considering implementing a tube weaning service.


Biography:

Marina Keating (APD) is a Paediatric Dietitian at PCH who has worked as a clinical paediatric senior dietitian and dietitian for 23 years specialising predominantly in feeding difficulties and infant, neonatal, surgical and critical care tertiary nutrition.

Olivia Naylor is a Senior Occupational Therapist and Clinical Coordinator (Early Intervention and KKIND- Keeping Kids in No Distress) at PCH. Her current clinical role includes working with infants & their families as well as in the NICU.

Linda Correia is a Senior Speech Pathologist at PCH working with tertiary complex neonates, infants and young children and their families who are experiencing feeding difficulties.

Imagining the impossible: Perspectives from young people with Duchenne Muscular Dystrophy, parents/caregivers and health professionals when preparing for the transition to adulthood

Mrs Tegan Pinese1, Dr Merrill Turpin Merrill Turpin2, Dr Jodie Copley Jodie Copley2

1 School of Health and Rehabilitation Sciences, Graduate School, University Of Queensland, Brisbane, Australia, 2Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Queensland, , Brisbane, Australia

Introduction: The transition to adulthood for young people with Duchenne Muscular Dystrophy (DMD) is complex, given they are entering a time when independence is societally expected, yet physical dependence is increasing for them.

Objective: The aim of this study is to explore the perspectives of young people with DMD, parents/caregivers and health professionals when imagining and planning for adulthood, as well as identifying the current processes involved within transition planning.

Methods: An Action Research Approach was used to investigate the perspectives of participants about making the transition to adulthood with DMD. Data was obtained through semi-structured interviews and focus groups. Interviews and focus groups were transcribed verbatim and data analysed using inductive thematic analysis.

Results: Fifty-five participants were included in this research study, with the following key themes identified; 1) working as a team: 2) the transition process: 3) imagining what is possible: 4) the need for information and support: 5) defining a successful transition.

Conclusion: The results of this study highlight the current nature of transition planning for young people with DMD. Imagining what is possible for adulthood and identifying ways in which to achieve desired meaningful outcomes can be challenging for these young people. The challenge for health professionals is learning how best to engage young people with DMD and their parents/caregivers in transition planning discussions in a manner that respects the difficulties with planning for an unknown future. Typical approaches to goal setting within transition planning is likely to not be helpful for these young people, with alternative strategies and approaches required.


Biography:

Tegan Pinese is an occupational therapist and has been working within the field of paediatrics since graduating in 2008. Tegan is currently completing a PhD through the University of Queensland, supervised by Dr Merrill Turpin and Dr Jodie Copley. This research project focuses on the perspectives of young people with Duchenne Muscular Dystrophy (DMD) parents and caregivers and health professionals regarding the transition from adolescence to adulthood for these young people.

Self-management for children and young people with chronic conditions: An international consensus

Ms Nicole Saxby1,2, Dr Karen Ford1, A/Prof Sean Beggs1, Prof Malcolm Battersby2, Prof Sharon Lawn2

1Royal Hobart Hospital, Hobart, Australia, 2Flinders University Human Behaviour and Health Research Unit, Adelaide, Australia

Objectives: To define ‘supported self-management’ for children and young people with chronic conditions. To create a consensus list of developmentally appropriate self-management tasks that can be completed by the child/young person, and self-management support practices for clinicians.

Study design: This study used a Delphi technique . Based on research output, international experts (including doctors, nurses, allied-health professionals, and teachers) were invited to participate in three survey rounds. Round one contained open-ended and multiple-choice questions eliciting general opinions about children’s and young people’s self-management. Thematic analysis elicited qualitative themes and defined endpoints. For round two, results were provided to the interdisciplinary expert panel as statements for rating their agreement using a 7-point Likert scale, with consensus predefined as moderately or extremely satisfied by >70% of participants. Statements not meeting consensus were re-presented in round three, with group feedback incorporated. Statements were considered finalised when: 1) expert consensus was reached; and, 2) the research team agreed with expert consensus. Finalised statements informed creation of the ‘Children and Young People as Partners in Health Consensus-based Tool’.

Results: Sixteen experts participated: 12 completed round one; 14 completed round two; and 12 completed round three. Of 99 statements, 90 reached consensus, with statements separated into five developmentally appropriate groups. Statements covered broad self-management and self-management support domains including knowledge, involvement, monitoring/responding to symptoms, transition, impact, lifestyle, and support.  Division of responsibility and autonomy were distinct themes.

Conclusions: This research provides consensus-based guidance for paediatric clinicians providing self-management support to children and young people with chronic conditions.


Biography: 

Nicole is an Advanced Practicing Dietitian based in Hobart, Tasmania. She currently works as the State-wide Paediatric Coordinator for the Tasmanian Cystic Fibrosis Service. She has a strong background in paediatric healthcare and has almost completed a Doctor pf Philosophy focused in Paediatric Chronic Condition Self-Management from Flinders University (submitting in the next few weeks). Other interests of Nicole’s are interdisciplinary practice, knowledge translation and implementation science. To date, Nicole’s biggest professional achievement has been leading the Nutrition Guidelines for Cystic Fibrosis in Australia and New Zealand project involving over 40 dietitian and 20 interdisciplinary colleagues

High Intensity Users: A chart audit of multiple presentations to a paediatric emergency department

Ms Jaime Odonovan1

1Lady Cilento Children’s Hospital, South Brisbane, Australia

Background:

High intensity users impact waiting times and the efficacy of Emergency Departments (ED) and have a flow on effect on the functioning and resource use of the entire hospital. There is an absence in the literature regarding the causes as to why there are multiple and avoidable presentations to a paediatric tertiary hospital.  Literature in the wider ED research demonstrates that there are identifiable reasons on the impact of these presentations. This innovative study is the first known study to identify populations and causes for these presentations and level of social worker (SW) intervention.

Methods:

461 patients were coded, based on their triage notes, into ten categories.  A retrospective chart audit was completed for patients who met the inclusion criteria to identify triggers for presentation and the SW interventions that were provided. 10% of the charts were peer reviewed.

Results:

37 patients charts were reviewed, which resulted in 415 presentations to the ED. Despite the high indicators of psychosocial dysfunction/concerns only 6% of presentations resulted in a referral to SW. The primary reason SW were referred was for discharge planning/youth homelessness. SW were rarely engaged for significantly distressed or anxious parents even though this is a key indicator for representation.

Conclusions:

There are four identified themes that require further examination in the ED that potentially could change presentations and reduction of resources in the ED.  Medical processes/procedures, vulnerable populations, mental health issues and parental coping and anxiety were the themes contributing to high intensity users presenting to the ED.


Biography:

Jaime O’donovan is a Senior Social Worker at the Lady Cilento Children’s Hospital

A retrospective study of the low FODMAP diet in children with a functional gastrointestinal disorder

Mrs Stephanie Brown1, Professor Andrew  Day2, Professor Richard Gearry2, Professor Kevin Whelan3

1University of Otago, Christchurch, New Zealand, 2University of Otago, Christchurch, New Zealand, 3King’s College, Nutritioal sciences division, London, United Kingdom

Background: Functional gastrointestinal disorders (FGID) such as Irritable bowel syndrome (IBS) are increasingly more common in children (1) and affect 20% of children worldwide (2). The aetiology  combines genetic, environmental and psychological factors, with no clear organic cause (3). Symptoms are recurrent,  including abdominal pain, diarrhoea, constipation, alternating stool patterns, excessive gas production and abdominal distension (4). FGIDs are associated with a reduced quality of life, school absences and psychological challenges (5). Treatment options are variable due to the heterogeneity of FGIDs.

In adults with diagnosed IBS, a low FODMAP diet is an effective dietary strategy to alleviate symptoms (6). FODMAPs are short-chained carbohydrates, poorly absorbed by the gastrointestinal tract due to their increased osmotic activity and excess gas production from the bacterial fermentation process. Currently, there is a paucity of data examining dietary interventions that restrict carbohydrates in children with IBS. The aim of this study was to assess the efficacy of the low FODMAP diet in children with a FGID.

Methods: A retrospective cohort study of children with a FGID managed with FODMAP-free diet was undertaken. Subjective measures and a survey were used to assess diet efficacy.

Results: Of the 29 children included in this study, 16 subjects (55%) experienced complete resolution of symptoms by the end of the four-week diet. Twenty-eight percent of subjects had partial resolution and 13% experienced no symptom relief. Complete resolution of gastrointestinal symptoms were observed for 75% of those with distention, 62.5% of those with diarrhoea and 58% of those with abdominal pain. Fructans were the most common symptom-causing fermentable sugar.

Conclusion: The low FODMAP diet is an efficacious dietary treatment strategy for children with FGIDs. This  study adds to the small body of evidence supporting FODMAP dietary interventions in children with FGID. Further prospective studies are required.


Biography:

Stephanie Brown is a paediatric gastroenterology dietitian at Christchurch Hospital. She is part of a MDT responsible for the nutritional management of children who require dietetic input. Stephanie is completing her PhD with a focus on Nutrition and paediatric IBD. She is married with two young children and loves the outdoors.

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