Summary

Since November 2013, the pediatrician consultation has been an integral part of the organization of care for infants under three months of age in the pediatric emergency department of the Robert Debré University Hospital in Paris. The evolution of this consultation has made it possible to adapt both to the demands of hospital professionals and also to the needs of parents. His specific skills offer the assurance of tailored and personalized support for the family while working in multidisciplinarity and complementarity.

Context

For many years, pediatric emergency professionals have noticed a constant increase in the flow of children accompanied by their parents, whose main reason for consultation is not always emergency.

In fact, some parents regularly go to the emergency room; place open 24 hours a day where "global care" (1/P13) can be carried out without an appointment.

This frequentation of emergencies sometimes reflects “a family convenience” (1;P11), a parental concern requiring an immediate response.

Emergencies have thus become the first resort for many families; families sometimes in precariousness, even in psycho-social distress (1).

At the same time, "the opening hours of maternal and child protection centers (PMI), the scarcity of liberal pediatricians, the unavailability of city doctors" (little consultation without an appointment, "faulty on-call systems" ) lead to an extra-hospital care offer that no longer or hardly meets the needs of families (1;12).

At the Robert-Debré University Hospital, the same observation is made for pediatric emergencies : "a dysfunction between the supply of care and its use by parents" (2), in addition to this there is an increasing number of visits per year ( 90,675 in 2019 versus 81,136 in 2013).

Located in the 19th arrondissement of Paris, bordering several municipalities of the Department of Seine Saint Denis, the emergencies mainly welcome the inhabitants of the 18th, 19th and 20th arrondissement of Paris as well as those of neighboring municipalities.

A population in these districts of Paris rather underprivileged and modest , even if a social mix in certain districts is present (3).

As for Seine Saint Denis, it has become the 1st department of metropolitan France (excluding Mayotte) in terms of welcoming immigrants (30% of its population in 2015), in terms of the number of large families (18% in 2015) or single-parent families . s (up to 25% in social housing in certain territories), on the birth rate (1st rank since 1990), on the poverty rate (27.9% in 2019), on the percentage of young people under 25 years old (36% in 2015) and ranks 9th with an unemployment rate of 11% in the third quarter of 2019 where the under 25s are the most affected(4).

Thus, the population attending the pediatric emergencies of the Robert-Debré hospital comes mainly from a disadvantaged background, with socio-economic fragility (single-parent family, mother with little or no resources or totally dependent on the spouse, etc.) without a treating doctor. , most of the time. For them, the emergency room is the only accessible place that meets their expectations (immediate availability, comprehensive care), or even the emergency room represents the only doctor who follows their child. Place also where families deposit their anguish; their worry of doing wrong, of not succeeding, of not knowing, of not understanding the cries of the infant, of feeling overwhelmed by the care of their child, of no longer being able to meet their primary needs. Parenting is undermined ; lack of time, knowledge, reassuring family ties, lack of continuous accompaniment, support.

Setting up the Consultation 

In 2013, the service recorded 81,136 annual visits, including 5,592 children under 3 months (6.89%). 87.3% of these children seen in the emergency room return home (5).

Parents often come for reasons that have more to do with the child care nurse than with the emergency doctor. Sometimes, these same parents also make recurrent passages or /and medical wandering; leading on the one hand to overcrowding of emergencies, especially in winter, and on the other hand to dissatisfaction among both parents and professionals.

Following these findings, a consultation with a childcare worker was set up in November 2013 in pediatric emergencies, as part of a city-hospital project.

The main objective was to better respond to a public health need by providing individualized quality reception, care and support adapted to children under 3 months and their families.

Required Conditions

The consultation works Monday to Friday (on working days) from 10 a.m. to 5:36 p.m.

A single professional with hospital and extra-hospital experience is assigned to this position.

The construction of a box and a specific waiting room for this consultation was carried out in April 2015 (photo.1).

The attendance schedule of the child nurse is known to all emergency professionals (monthly posting in the emergency medical office and at the door beds).

The childcare worker works in close collaboration with the various pediatric emergency professionals (doctors, paramedical professionals, social worker and psychologist) and since November 2015 an intra-hospital partnership with the maternity unit (doctors, midwives, health executive) has been set up. place in order to ensure continuity of care for the child and his family according to pre-established criteria.

Means Used During the Consultation

• a direct telephone line
• a job description finalized in May 2014 in order to define a working framework,
• In connection with maternity: a poster intended for midwives and pediatricians, brochures intended for mothers when making an appointment for the consultation;
• traceability for monitoring and statistical data,
• the tariff registration of the consultation (AMI 2) in order to recognize this activity (being modified),
• a hospital-city liaison form,
• A booklet: "my child is sick" for children under and over 6 months old (result of a working collaboration between pediatric emergencies, maternity and the Saint Simon Cross of the 19th arrondissement),
• a booklet specific to the consultation: "practical advice for children under 3 months", produced in February 2017 following interprofessional work between the pediatric nurse, a pediatrician and a pediatric nurse manager from the emergency department (both referents on the implementation consultation).
• A fact sheet on advice given to parents regarding nose washing, translated into three languages, created in summer 2016 (being modified),
• The child's health record as a means of information and transmission,
• various communication media (metro map, PMI listing of Paris and near suburbs),
• various professional documents on breastfeeding, infant formula, sleeping conditions, domestic accidents, sleep, crying, colic...

Four Means of Access to Consultation

• during a visit to the pediatric emergency room (figure 1: patient circuit),
• after hospitalization in a UHCD (Short-Term Hospitalization Unit),
• when leaving the maternity ward, scheduling an appointment (figure 1: patient circuit),
• call back of the family for a telephone interview, after their visit to the emergency room outside the opening hours of the consultation. 

Figure 1: Patient journey in the SAU Patient journey leaving the maternity ward Pediatric

Procedure of the Consultation

Welcoming, listening, empathy in a climate of mutual trust facilitate communication with the family. She can thus express her concerns, her questions about the behavior of their child or their discomfort as a parent.

Observation during the interview promotes highlighting of skills or difficulties of the latter.

During this consultation, the childcare worker is attentive to the psycho-socio-economic context of the parents or the single mother, the habits and customs that animate and bind them, the mother-child dyad within the family dynamics.

Each interview is unique and personalized with well-defined objectives :

• enhance the skills of parents and their child (parenting support),
• give parents tools to make them independent (health education),
• ensure the medical follow-up of their child and possibly give them addresses within the framework of the hospital-city network,
• explain if necessary the operation of the PMI (local network) with the possibility of contacting the structure, in agreement with the parents, in order to ensure a link and/or continuity of care,
• make parents understand the emergency circuit so that they can get there in an appropriate way (health education).

As a result, a standard data collection is carried out during the consultation. It addresses the family environment, the experience of pregnancy, childbirth, the stay in maternity and then the return home until the day of the emergency room. The discussion with the parents is centered on the initial reason expressed to the IAO (Infirmier d'Accueil et d'Orientation) which can evolve following the exchange with the emergency doctor then between the professional and the parents, with attentive observation of the infant until his clinical examination if necessary.

During the interview, she also discusses the housing conditions including sleeping arrangements, childcare, the notion of contagion...

During the winter period, special attention is focused on the quality of the infant's breathing (primary prevention). The childcare worker explains to the parents in simple words the psychomotor development of the young child so that they can, after a period of observation with their child, set up care or actions at home. The childcare worker checks the parents' knowledge, readjusts them if necessary and possibly shows them nose care with immediate practice from the parents in order to make them autonomous. These actions are much more understandable and assimilable for parents.

Thus, once the diagnosis has been made on the needs of the child and his family, the pediatric nurse plans a personalized care strategy, in agreement with the family.

An exchange with the emergency doctor, referent of the child, is always carried out. This exchange can lead to a short -term follow-up by the childcare worker, directly in her office; rarely to hospitalization of the child.

The four criteria (fever, difficulty breathing, vomiting, diarrhoea) which may lead to consultation in the emergency room are always discussed at the end of the consultation.

A report on the consultation is recorded in the health record, in the Urqual application (specific computer system for pediatric emergencies) or in the medical file depending on the patient's course; even a telephone link can be set up with various professionals in the extra-hospital sector (professionals from the PMI center, the liberal midwife or the attending physician).

The consultation lasts an average of one hour.

Consultation Evolution

In April 2015, at the request of emergency care professionals including doctors, a logbook was set up which is used in the absence of the childcare worker. The child's label is put there with the reason for consultation in the emergency room. After a telephone interview with the family, a written report is produced in this notebook. Depending on the situation, the childcare worker can directly suggest an appointment with the family.

Since the creation of the maternity circuit in November 2015, one of the most used criteria by the professionals of this service is the monitoring of jaundice. The impact of this organization has made it possible to avoid an extension of stay in the maternity ward, post-discharge rehospitalization, by monitoring adapted to the child's state of health, knowing that the family is expected by appointment. to consultation.

For several years, the consultation has had to adapt to the demands of emergency professionals, and also to those of parents.

Indeed, children regularly arrive at the SAU with the reason for weight loss, very often due to poor breastfeeding behavior following a combination of events after birth.

Recognition, on the part of emergency professionals on the specificity and skills of the child nurse, facilitated the non-hospitalization of these children; with all the positive consequences that this entails. The mother and the child are supported until a balance in food intake is established with a confirmed weight gain.

This care can be carried out in parallel or in connection with the PMI, the liberal midwife or the attending physician.

Moreover, as soon as one or both parents ask for help, express significant anxiety, or even psychological distress, the childcare worker has the possibility of calling on the service psychologist. Since July 2018, consultations in pairs (psychologist, childcare worker) have been set up spontaneously in order to better meet the needs of families and to establish a more efficient and adapted care strategy.

Exceptionally, the consultation welcomed children under 3 years old during the winter period 2019-2020 (mid September to mid March ) by appointment in order to ensure the injections of palivizumab (specific immunoglobulins directed against the respiratory syncytial virus) this which caused partial unavailability in the emergency and maternity departments.

Purpose of the Consultation

Implementation of a personalized health education program to promote the construction of parenthood.

Some Data on Families Between 2015 And 2019

Main Reasons for Consultation

• Parental concerns 91%
• Difficulties in establishing the mother-child bond 91%
• Breastfeeding difficulties 54%
• Breathing difficulties 54%
• Difficulties taking the bottle 32%
• Poor weight gain 20%
• Jaundice 13%
• Infant crying 13%…

The patterns can be cumulative or modified throughout the patient journey.

The consultation of a child nurse is an innovative care practice through its autonomy and its integration into the organization of pediatric emergencies where it has been able to evolve according to the needs of the population.

Its added value is without context a factor in the promotion of health education and responds well to the national health strategy, by its adaptation to the changes observed with a prioritization in "prevention, the transversality of care pathways" (6).

Parents were found to be satisfied at the end of the consultation and remotely, as well as the medical and paramedical team, with recognition of the skills specific to their position, their experience and their professional expertise.

It reduces the waiting time for complex emergencies, saving medical time, and therefore improving the care of priority children.      

The interdepartmental partnership set up with the maternity ward has made the patient journey smoother thanks to anticipated and early treatment.

This consultation is complementary to existing intra and extra hospital resources. Thus, the city-hospital partnership has contributed to better continuity of care in the care of families.

Outlook

A medium and long-term reflection must be continued on the recognition and development of this consultation of childcare workers within the hospital.

In the future, training could be offered to emergency professionals who are very keen on knowledge about young children, in order to standardize practices and give identical advice to parents. The maternity service could also participate because it has its place in this care pathway.

Finally, a reflection on pricing is underway in order to promote this advanced practice in the context of prevention and health education.

Thus, the profession of childcare worker is evolving and its field of action is anything but restricted. She has developed expertise on young children and recognition as a clinical nurse specialist is completely legitimate. The Robert Debré University Hospital is one of the first to have institutionalized this innovative practice in pediatric emergencies. This one is observed and interested by other French public establishments with which a collaboration could be envisaged in the future.