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Re-ACT: Redesigning Allergy Care Together for Children

Sydney Children's Hospital Network
Project Added:
17 April 2015
Last updated:
22 April 2015

Redesigning Allergy Care Together for Children (Re-ACT for Kids)

Summary

This project is developing streamlined health pathways, improving operational systems, standardising diagnostic services and developing an education framework for health professionals to provide integrated care for children with diagnosed or potential food allergies. 

Poster from the Centre for Healthcare Redesign Graduation, April 2015  Poster from the Centre for Healthcare Redesign Graduation, April 2015.

Aim 

To establish an integrated system across primary, secondary and tertiary services that provides safe, evidence based, timely care for children with diagnosed or potential food allergies in Western Sydney.

Benefits

  • Improves the timeliness and equitability of access to healthcare for children with suspected food allergies and their families.
  • Strengthens the partnership between health services in Western Sydney and creates a connected food allergy service in the area.
  • Provides accessible tertiary support for local healthcare providers, to ensure the right care is delivered by the right professional at the right time.
  • Improves staff morale and satisfaction.
  • Increases awareness of current guidelines for allergy care, to reduce unwarranted variations in clinical practice.
  • Informs clinical service planning within Western Sydney Local Health District (WSLHD) and Sydney Children’s Hospital Network (SCHN) regarding the clinical and facility requirements for comprehensive food allergy care.
  • Enables cost-effective use of resources.

Project Status

Project status: Implementation - the initiative is ready for implementation, is currently being implemented, piloted or tested.

Project started:  23 July 2014.

Background

The incidence and prevalence of food allergies in Australia is rising dramatically, with a peer-reviewed study finding that one in 10 children under the age of one have a food allergy. Hospital admissions for food-related anaphylaxis have doubled over the last 10 years. According to Access Economics, in 2007 the financial cost of allergies in Australia was $7.8 billion, with $1.2 billion identified as direct health expenditure1. Food allergies significantly impact the physical and mental health of children and cause great stress for their families. 

The Australasian Society of Clinical Immunology and Allergy (ASCIA) is the peak professional body in Australia and New Zealand. ASCIA recommends that to diagnose a food allergy, an Oral Food Challenge (OFC) should be carried out under the supervision of a trained specialist, in a specialised medical centre with the necessary resources and expertise to deal with life-threatening allergic reactions. Recent evidence found that 89% of 364 OFCs conducted were negative, despite positive antibody-based tests. This means children were unnecessarily avoiding foods and could expand their dietary intake2. Unnecessary avoidance of foods may lead to nutritional deficiencies and growth concerns. According to recent evidence, it may also worsen the severity of an allergic reaction. A Melbourne study has highlighted deficits in paediatricians’ knowledge of these ASCIA anaphylaxis prescription guidelines.

In Western Sydney, the average wait time for the next available appointment with an allergy specialist at the Children’s Hospital at Westmead (CHW) was six months as of July 2007. As the only public health service providing essential challenges in this area, there were more than 900 OFCs pending, with a 15-month wait for a low-risk challenge.  Some children were therefore unnecessarily avoiding foods for up to 19 months, which is a proven risk to their safety.

Implementation 

  • Creation of a virtual Western Sydney Kids Allergy Collaborative.
  • Development of an integrated clinical service model within Western Sydney, providing a streamlined pathway for allergy care based on clinical urgency. Included the development of three clinical HealthPathways and one referral pathway.
  • Review of all CHW operational systems, including a pilot of outpatient triage, modification of food challenge request guidelines and increased OFC challenge capacity.
  • Updated skin prick testing form, triage requests by medical staff and changes to administrative processes at Mt Druitt Hospital.
  • Standardised diagnostic services in WSLHD, including the development of a business case for expanding food challenge services and introducing tertiary oversight of all patients undertaking OFCs.
  • Formalised an allergy management education framework for primary care, including: HealthPathways management for health professionals; ASCIA e-leaning module in WentWest General Practitioner (GP) training; anaphylaxis training in paediatric emergency education; and GP practice nurse training to provide anaphylaxis education for families.

Lead organisations

  • The Sydney Children’s Hospitals Network (SCHN), Westmead Campus
  • WentWest (formally Western Sydney Medicare Local)
  • Western Sydney Local Health District (WSLHD)

Implementation sites

  • The Children’s Hospital at Westmead
  • Blacktown Mt Druitt Hospital, WSLHD
  • WentWest  (HealthPathways, GP Training, GP services across Western Sydney)

Partnerships

  • Sydney Children’s Hospital Network (SCHN), Randwick
  • Allergy and Anaphylaxis Australia (consumer representative)

Results

Results 

The following results have been achieved between July 2014 and March 2015.

  • Reduction in wait time for low-risk OFCs from up to 18 months to up to 13 months.
  • Alterations to the model of care for food challenges and subsequent reduction in challenges requested, from 68 to 45 per month.
  • Increased capacity from 780 to more than 1000 challenges per year at CHW.
  • Five patients commenced home food challenge pilot.
  • HealthPathways published on draft site for consultation.
  • Final draft review of anaphylaxis policy, within network emergency management.
  • Electronic OFC request form to be live on Powerchart in April 2015. This will provide real time, accessible wait list details at CHW, with a goal of reducing wait times for OFCs to less than six months for all children.

Expected long term outcomes

  • Development of a formalised service agreement for Western Sydney Kids Allergy Collaborative.
  • HealthPathways developed and available to healthcare practitioners on live site.
  • Improved health professional knowledge and engagement around anaphylaxis and allergy management.
  • Formalised education framework for health professionals involved in paediatric allergy care.
  • Improved patient experience of allergy services within Western Sydney through repeat patient interviews.
  • Use of scheduling system to regularly audit the timeframes of ‘next available appointment’ and ‘new appointment wait time versus triage category’.
  • Reduction in proportion of review patients versus new patients.
  • WSLHD allergy service in line with ASCIA recommendations and best practice.
  • Increased communication between health professionals, with minimum data set audits sent from tertiary service to GPs and paediatricians.
  • Increased annual maintenance care at the primary care level, with tertiary guidance.
  • Consumer satisfaction with experience of integrated food challenge model.
  • Presentation accepted on ‘Paediatrics and Partnerships’ at HealthPathways Conference in April 2015.
  • Presentation accepted on project for Lean Symposium in May 2015.

Lessons Learnt

  • Sponsorship and governance are critical for success.
  • The principles of the Centre for Healthcare Redesign framework is a strong process to follow.
  • It is important to understand the data and its source.
  • It is important to understand and manage the expectations of all stakeholders.
  • More can be achieved when working in partnership with other services.

References 

  1. Mullins RJ, et al. The economic impact of allergy disease in Australia: not to be sneezed at. ASCIA/Access Economics Report; November 2007.
  2. Fleischer DM, Bock SA, Spears GC, Wilson CG, Miyazawa NK, Gleason MC, et al. Oral food challenges in children with a diagnosis of food allergy. Journal of Pediatrics 2011; 158: 578-83.

Further reading

  • ASCIA. A submission for allergic diseases to be recognised as a National Health Priority. Allergy in Australia 2014.
  • Dunn Galvin A, Cullinane, Daly DA, Flokstra-de Blok BMJ, Dubois AEJ, Hourihane JO’B. Longitudinal validity and responsiveness of the food allergy quality of life questionnaire—parent form in children 0-12 years following positive and negative food challenges. Clinical and Experimental Allergy 2010; 40: 476-85.
  • Leiw WK, et al. Anaphylaxis fatalities and admission in Australia. Journal of Allergy and Clinical Immunology 2009; 123(2): 434-42.
  • Morawetz DY, et al. Management of food allergy: a survey of Australian paediatricians. Journal of Paediatrics and Child Health 2014; 50(6): 432-7. DOI: 10.1111/jpc.12498. Epub 2014 Feb 26.
  • Osborne, et al. Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. Journal of Allergy and Clinical Immunology 2011; 127: 668-76.
  • Perry TT, Matsui EC, Kay Conover-Walker M, Wood RA. The relationship of allergen-specific IgE levels and oral food challenge outcome. Journal of Allergy and Clinical Immunology. 2004; 114: 144-149.
  • Peters RL, Allen KJ, Dharmage SC, et al. HealthNuts Study: Skin prick test responses and allergen-specific IgE levels as predictors of peanut, egg, and sesame allergy in infants. Journal of Allergy and Clinical Immunology 2013; 132(4): 874-80. DOI: 10.1016/j.jaci.2013.05.038. Epub 2013 Jul 24.
  • Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment. Journal of Allergy and Clinical Immunology 2014; 133(2): 291-307. DOI: 10.1016/j.jaci.2013.11.020. 

Contact

Christie Graham
Food Allergy Project Officer
Sydney Children’s Hospitals Network
Phone: 02 9845 2645
Email: christie.graham@health.nsw.gov.au

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