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Evaluation of fast track admission policy for children with sickle cell crises: questionnaire survey of parents' preferences

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7109.650 (Published 13 September 1997) Cite this as: BMJ 1997;315:650
  1. Caroline R Fertleman, paediatric registrar (c.fertleman{at}ucl.ac.uk)a,
  2. Angela Gallagher, paediatric nursing managera,
  3. Mary A Rossiter, consultant paediatriciana
  1. a North Middlesex Hospital, London N18 1QX
  1. Correspondence to: Dr Fertleman Department of Paediatrics, University College London Medical School, Rayne Institute, London WC1N 6JJ
  • Accepted 14 March 1997

Introduction

In Britain most people with painful sickle cell crises are admitted to hospital through an accident and emergency department. Interviews with patients have shown that this is unsatisfactory because the staff are often inexperienced in dealing with pain from sickle cell crises.1 Patients want immediate and effective pain relief and not to be asked irrelevant questions.2 An audit in our department in early 1994 showed that many children with painful sickle cell crises waited over an hour to receive analgesia. In October 1994 we therefore set up a fast track system whereby children with severe pain from sickle cell crises are admitted directly to the ward after a telephone call from a parent. All 112 children with sickle cell disease have preprescribed doses of pethidine and naloxone written on a prescription chart that is kept on the children's ward. A nurse assesses the child immediately on arrival and gives intramuscular pethidine if appropriate. A doctor is then able to assess and admit a calmer child.

Subjects, methods, and results

We evaluated the efficacy of this innovation by asking: do children receive intramuscular pethidine faster under the fast track policy, do parents prefer the new system, and do other hospitals in London operate similar systems? The time a child waited before receiving an intramuscular injection of pethidine was compared before and after implementation of the fast track policy (January to August 1994 v January to August 1995). For those seen in 1994 the time to pethidine was determined from record cards in the accident and emergency department and for those seen in 1995 from a form completed by the nurses. The time to pethidine was compared using a Mann-Whitney U test.

All 25 parents whose children had used both systems by March 1996 completed questionnaires about the two systems. They were asked to mark on a visual analogue scale (0=very good, 50=very bad) how they rated each admission system3 and for their comments about the two systems. We also conducted a telephone survey of hospitals with local populations of patients with sickle cell disease to find out how the admission of children with painful crises was managed.

Fig 1
Fig 1

Parental satisfaction with admission policies (0=very good, 50=very bad)

The median time to pethidine for the 37 children (15 boys) admitted through the accident and emergency department (age 7 months to 15 years) was 38 minutes compared with 5 minutes for the 35 children (18 boys) admitted directly to the ward (age 8 months to 14 years) (P<0.001). A total of 21 of the 25 questionnaires that were distributed were returned. All parents preferred the fast track admission system and the median improvement in the satisfaction rating on the Likert scale was 36 (95% confidence interval 11.5 to 58.3) (figure). Most parents commented that they preferred the new system because it was much faster and their children did not have to wait for transfer to the ward; they also added that the ward staff knew more about sickle cell disease, knew their children, and did not ask irrelevant questions before giving pethidine. Our telephone survey showed that most hospitals (13/15) had special arrangements for paediatric assessment of children with sickle cell crisis so that they were seen as soon as possible after arrival, which was almost always in the accident and emergency department; however, in all cases children had to be assessed by a doctor before any analgesia was prescribed or given.

Comment

Our results show that with a fast track admission policy children receive pethidine faster and that this policy is preferred by parents. The three elements of fast track admission (direct access to the ward, preprescribed analgesia, and assessment and administration of pethidine on arrival by a nurse) are not practised together in any other hospital in London to our knowledge. Fast track admission could be implemented in other hospitals with local populations with sickle cell disease.

Acknowledgments

We thank all the families of those affected by sickle cell disease at the North Middlesex Hospital. These data were presented in the haematology and oncology forum at the annual meeting of the British Paediatric Association in April 1996 in York.

Funding: None

Conflict of interest: None.

References

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