Performance of clinical clerks doing paediatric rotations in a community hospital versus a university hospital

INTRODUCTION

Most clinical clerks (third-year medical students) do their paediatric rotation at the IWK Health Centre, the Dalhousie University-affiliated tertiary care paediatric institution in Halifax, Nova Scotia. Due to limited space, some clerks are sent to community hospitals in the provinces of New Brunswick and Prince Edward Island. These community hospitals are different in terms of the academic environment and the availability of paediatric subspecialty services.

OBJECTIVE

To compare performance of clinical clerks doing paediatric rotations in community hospitals (group I) with those in a university hospital (group II).

METHODS

The end-of-rotation test scores on the 45 single correct answer multiple choice questions and the three 15 min objective structured clinical examinations in group I (n=54) and group II (n=124) for two consecutive academic years were studied. The end-of-rotation comments by the clerks in group I were examined to assess the quality of their experience.

RESULTS

For the two academic years, the cumulative mean ± SD scores for multiple choice questions and objective structured clinical examinations were 82.82±7.47 and 70.82±11.37, respectively, in group I compared with 83.03±7.74 and 69.02±11.23 in group II. There were no significant differences in the results between the two groups. No difference in results was seen when the scores were analyzed separately for each of the academic years. The clerks in group I rated their experience as positive.

CONCLUSIONS

Clerks doing paediatric rotations in community hospitals perform as well and receive similar educational benefits as those at university hospitals. Community hospitals can provide a quality experience for paediatric clerkship training.     

Improving child survival: Malnutrition Task Force and the paediatrician's responsibility

Malnutrition (underweight) contributes to approximately 60% of all child deaths, yet health professionals, policy makers, and donor agencies often fail to recognise its relevance to child survival. There is a need for the paediatric community to champion the importance of adequate nutrition for normal growth and development, and of placing sufficient emphasis on the prevention and treatment of malnutrition. Many severely malnourished children die from inappropriate treatment. Case fatality rates of 25-30% are commonly found and in some hospitals as many as 50-70% will die. Many of these deaths are avoidable. Weaknesses in health systems, inappropriate training of doctors and nurses, inadequate supervision, and lack of support for staff all contribute to compromised quality of care. The International Union of Nutritional Sciences, with support from the International Pediatric Association, Launched a global Malnutrition Task Force in 2005. The main objective is to ensure that an integrated system of prevention and treatment of malnutrition is actively supported as a fundamental aspect of care, and becomes an integral part of all training programmes.     

Uninsured immigrant and refugee children presenting to Canadian paediatric emergency departments: Disparities in help-seeking and service delivery

INTRODUCTION:

Access to health care for medically uninsured immigrant and refugee children is a public health concern due to the consequences of delayed or substandard care for child development and health.

OBJECTIVE:

To explore possible differences in help-seeking and service delivery across migratory statuses, institutions and provinces.

METHODS:

A review was undertaken of 2035 emergency files of immigrant, refugee and undocumented children without provincial health care coverage who sought care at three major paediatric hospitals in Montreal (Quebec) and Toronto (Ontario) during 2008 and 2009.

RESULTS:

Refugee claimant children with Interim Federal Health Program benefits consulted for less urgent problems than the overall hospital population, except in one hospital that had a multicultural paediatric ambulatory clinic. Undocumented children and new permanent resident immigrant children within the three-month waiting period for provincial health care coverage were over-represented in the very urgent triage category and presented more often for injuries, trauma and mental health problems than did refugee claimant children.

DISCUSSION/CONCLUSIONS:

Wide interhospital differences suggest that the predicament of limited access to health care of these groups of vulnerable medically uninsured children needs to be addressed through further research to inform policies and develop training.     

Innovative programmes of medical education: I. Case studies

This paper discusses five innovative programmes in medical education with the view of giving a glimpse of the new approaches to the education of physicians. Each one of them has unique features and provides useful lessons. The School of Medicine, McMaster University, Hamilton (Canada), pioneered the use of interdisciplinary problem based learning. The programme obliterates the basic science and clinical science dichotomy, and involves self-directed, small group (tutorial) learning as the principal educational method. Faculty of Medicine, University of Sherbrooke (Canada) shows the way for introduction of innovative problem-based curriculum in a traditional medical school. The University Centre for Health Sciences, Ben Gurion University of the Negev, Beersheva (Israel), serves as the nodal point of the health care system in the region. Merging of the service and the educational systems has not only succeeded in better community orientation of graduates, but also in improving the health care availability in the region. The University of Philippines, College of Medicine, Institute of Health Sciences, Tacloban (Philippines), trains grassroot workers as well as physicians. Through a ladder-type curriculum, a health worker can rise to become a doctor of medicine. The Chulalongkorn University Medical School, Bangkok, Thailand, has successfully run a parallel innovative track for students of rural background. The students are identified from the underserved areas, and are given a large part of their clinical training at the provincial/district hospitals. The programme has succeeded in inculcating favourable attitudes towards working in rural areas, and in improving the care at provincial/district hospitals. These innovative programmes have emerged as role-models for bold experimentation in medical education. MESRAP is a success story of a heavily community-oriented parallel curriculuar track in an established medical school in a developing country.     

Ontario and the enhanced 18-month well-baby visit: Trying new approaches

In Ontario, the 18-month well-baby visit is the last scheduled primary care visit before school entry. Recognizing the importance of this visit and the role that primary care plays in developmental surveillance, an Ontario expert panel recommended enhancing the 18-month visit. Their recommendations are based on evidence from multiple disciplines, which underscore the reality that the quality of the early years experience establishes trajectories of health and well-being for children. An underlying premise of the recommendations is that when there are collaborations among parents, primary care, community health and child development services, the outcomes for children will be improved. The present article focuses on two Ontario pilot projects that were funded to discover how, in real life primary care settings, the recommendations could be implemented and outcomes measured. Findings and insights were significant, and future directions are clear, as the strategy for an enhanced 18-month well-baby visit is implemented in the future for Ontario.     

Concept of health care counseling for pediatricians

Health care counseling (HCC) is a relatively new concept that amalgamates human biology, human psychology and medical sociology principles, and applies the same in real-time clinical situations. In India, there is a real paucity of trained mental health personnel, and hence counseling services are restricted to few departments. HCC is especially important for the child population, as the pediatricians need to partner the parenting responsibilities in different illness care settings covering the period from newborn to adolescence. This paper proposes steps for further development of the concept, expertise and systematic training program for health personnel, as an activity of Centre for Health Care Counseling Studies under Kerala University of Health Sciences. Once the process is documented, we hope that the same would be made available to other states in India.     

Global initiatives for improving hospital care for children: state of the art and future prospects

Deficiencies in the quality of health care are major limiting factors to the achievement of the Millennium Development Goals for child and maternal health. Quality of patient care in hospitals is firmly on the agendas of Western countries but has been slower to gain traction in developing countries, despite evidence that there is substantial scope for improvement, that hospitals have a major role in child survival, and that inequities in quality may be as important as inequities in access. There is now substantial global experience of strategies and interventions that improve the quality of care for children in hospitals with limited resources. The World Health Organization has developed a toolkit that contains adaptable instruments, including a framework for quality improvement, evidence-based clinical guidelines in the form of the Pocket Book of Hospital Care for Children, teaching material, assessment, and mortality audit tools. These tools have been field-tested by doctors, nurses, and other child health workers in many developing countries. This collective experience was brought together in a global World Health Organization meeting in Bali in 2007. This article describes how many countries are achieving improvements in quality of pediatric care, despite limited resources and other major obstacles, and how the evidence has progressed in recent years from documenting the nature and scope of the problems to describing the effectiveness of innovative interventions. The challenges remain to bring these and other strategies to scale and to support research into their use, impact, and sustainability in different environments.     

Simulation in paediatrics: An educational revolution

Recent changes in the culture of medical education have highlighted deficiencies in the traditional apprenticeship model of education, and emphasized the need for more experiential modalities of learning. Simulations, which are scenarios or environments designed to closely approximate real-world situations, have recently found their way into the medical training of health care providers. High-fidelity simulators are life-like mannequins connected to computer systems that control the physiological and physical responses of the mannequin. These simulators are able to provide direct feedback to learners in safe, risk-free environments. This technology has been used to teach all aspects of medical care, including medical knowledge, technical skills, and behavioural training or communication skills. The present article provides a general overview of simulation that will hopefully help to generate interest in paediatric simulation across Canada. Several tertiary care paediatric hospitals in Canada are already using simulation to teach health care providers; continued growth and interest is expected in this exciting area of medical education.     

Treatment of children with cystic fibrosis: central,local or both?

Owing to a lack of longitudinal studies, the effect of centralization of care on pulmonary function and survival remains unclear. Three different levels of involvement of centralized care in the treatment of paediatric cystic fibrosis patients were compared with regard to longitudinal pulmonary function and nutritional and microbiological status in a 3-y period, and the literature was reviewed on the possible advantages and disadvantages of centralized care. The study included 105 paediatric patients attending the Cystic Fibrosis Centre between January 1997 and January 2001. Twenty-three patients were treated by local paediatricians according to the protocol of the Centre and were seen only once a year at the Centre, for an annual check-up (local care). Forty-one patients were treated at the Centre only (centralized care). The remaining 41 patients were treated in close cooperation between the Centre and local hospitals, with patients visiting the doctors alternately (shared care). The mean annual changes in pulmonary function and body mass index from all patients, as well as a microbiological survey, were reviewed. No significant differences were found between the three groups for annual changes in FEV1, FVC and body mass index, nor did the review of microbial colonization show any significant differences between the groups. Because the groups in this study were relatively small, the results might have been influenced by lack of power.

Conclusion: In this relatively small group, no differences in pulmonary function, nutritional status or microbiological colonization between the three levels of involvement of centralized care could be found. This could signify that local paediatricians have a special role in the care for patients with cystic fibrosis, in close cooperation with the specialists at the Centre.     

Developments in paediatric palliative care

This article tracks the development of paediatric palliative care from the appreciation of children’s entitlement to high quality palliative care in the 1970s through to the formal recognition of paediatric palliative medicine as a subspecialty by the RCPCH in 2009. It summarizes recommendations from recent key documents with respect to the development of equitable and sustainable paediatric palliative care services and it also outlines opportunities for training in this evolving specialty. We then describe best practice in three areas of paediatric palliative care that are topical at present; advance care planning, transitional care and extubation within a palliative care framework. The principles of practice in each of these areas can be applied to much of paediatrics and it remains the case that much of palliative medicine in children can and should be provided by generalists. However, it is hoped that increased awareness of how paediatric palliative care services are evolving and the specialist care that is available, will enable enhanced collaboration with specialist services when required.     

The evolution of freestanding children��s hospitals in Canada

OBJECTIVE

The purpose of the present article is to examine the evolution of freestanding children’s hospitals in Canada over the past century. The results include documentation of the number of freestanding children’s hospitals in Canada that have since closed, merged with other institutions or remained freestanding. Similar data are presented for the United States (US). Also included is an analysis of factors in the internal and external environment that contributed to the changing structure of children’s hospitals.

METHODS

Sources of information included a review of the literature, publicly available data and statistics on children’s hospitals in Canada and the US.

RESULTS

Nine of the 16 children’s hospitals in Canada were freestanding at one time. Today, only two remain freestanding. Three formerly freestanding children’s hospitals have merged with maternal health facilities and four formerly freestanding children’s hospitals have merged with adult institutions. Similar trends are seen in the US.

CONCLUSIONS

The structure of children’s hospitals in North America has changed significantly over the past century. This can be attributed to a number of factors, including the evolution of the health status of children due to medical advances, as well as external forces such as demographics and the rising cost of health care. The impact on the health of children and the mission of children’s hospitals in terms of patient care, teaching and research remains to be seen.     

Where should paediatric surgery be performed?

We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals. There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre. Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in are than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK. There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists. The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that "Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient 'critical mass' for clinical effectiveness." Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results. The same seems to be true in the fields of oncology, radiology, pathology, and intensive care. The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states "that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management." The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England, the British Association of Paediatric Surgeons, the Senate of Surgery of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, the Audit     

Comprehensive health assessment for newly arrived refugee children in Australia

Providing appropriate and responsive care to refugees from diverse backgrounds and with unique health needs is challenging. Refugee children may present with a wide range of conditions, which may be unfamiliar to health professionals in developed countries. Additionally, refugees may experience unfamiliarity with the Australian health system and distrust of authority figures and/or medical practitioners. This article provides an overview of the priority areas in health and health management for paediatric refugee patients for paediatricians as well as other relevant health care providers caring for this group. Specific issues covered include general health assessment, infectious diseases, immunization, growth and nutrition, oral health, development and disability, mental health and child protection. Comprehensive health assessment can assist in identifying children at risk of poor health and to provide them with timely and effective care, advocacy and appropriate referral.     

Young people with spina bifida: Transfer from paediatric to adult health care

An expectation of health care for young people with disability is that quality coordinated care continues to be available as they pass from the paediatric to the adult health care system. While individual clinicians provide this service well, the widespread absence of coordinated multidisciplinary care for young people with spina bifida in the adult health care system is a major deficiency. This paper describes the planning and implementation that underpinned the transfer of 10 young people with spina bifida from a paediatric to an adult service. The range of structural, financial and ‘cultural’ barriers that need to be overcome before patients can be successfully transferred is highlighted; lessons learned from this model may serve to facilitate the development of other transfer services.     

Advance care planning for paediatric patients

Medical and technological advances have increased survival rates and enhanced the quality of life for infants, children and youths with chronic life-threatening conditions. Advance care planning includes the process of discussing life-sustaining treatments and establishing long-term care goals. Paediatric health care practitioners have an ethical obligation to educate themselves about this aspect of medical care. The present statement aims to assist health care practitioners to discuss advance care planning for paediatric patients in varied settings. Advance care planning requires effective communication to clarify the goals of care and establish agreement on what treatments may or may not be appropriate to achieve these goals, including resuscitative and palliative measures.     

Paediatric use of intensive care

OBJECTIVES--To determine the number of children from a defined population who use intensive care facilities, to analyse bed occupancy data for those children, and to estimate the number of intensive care beds required to satisfy this demand throughout the year. DESIGN--Examination of admission data books from intensive care units within the four Birmingham health authorities and the neighbouring health authorities. RESULTS--Two hundred and ninety seven children resident within the four Birmingham health authorities used intensive care facilities in a calendar year. One hundred and forty one (47%) of these were admitted for specialist paediatric services. Of the remaining 156, 106 (68%) were cared for in adult intensive care units, 46 (29%) in a paediatric intensive care unit and four (3%) in a special care baby unit. Use of intensive care varied from none to 11 patients each day, and was lowest in the summer and highest during the winter months. During periods of peak demand, one in 19,000 (5.3/100,000) children were using intensive care facilities. CONCLUSIONS--These data provide a population based minimum need for paediatric intensive care beds. They are higher than previous estimates and do not include provision for children from outside Birmingham, or for those denied intensive care due to bed shortages. These factors and the marked seasonal variation in demand need to be considered when planning intensive care services for children if bed shortages are to be avoided.     

Paediatric use of intensive care.

OBJECTIVES--To determine the number of children from a defined population who use intensive care facilities, to analyse bed occupancy data for those children, and to estimate the number of intensive care beds required to satisfy this demand throughout the year. DESIGN--Examination of admission data books from intensive care units within the four Birmingham health authorities and the neighbouring health authorities. RESULTS--Two hundred and ninety seven children resident within the four Birmingham health authorities used intensive care facilities in a calendar year. One hundred and forty one (47%) of these were admitted for specialist paediatric services. Of the remaining 156, 106 (68%) were cared for in adult intensive care units, 46 (29%) in a paediatric intensive care unit and four (3%) in a special care baby unit. Use of intensive care varied from none to 11 patients each day, and was lowest in the summer and highest during the winter months. During periods of peak demand, one in 19,000 (5.3/100,000) children were using intensive care facilities. CONCLUSIONS--These data provide a population based minimum need for paediatric intensive care beds. They are higher than previous estimates and do not include provision for children from outside Birmingham, or for those denied intensive care due to bed shortages. These factors and the marked seasonal variation in demand need to be considered when planning intensive care services for children if bed shortages are to be avoided.     

Improving child survival: Malnutrition Task Force and the paediatrician's responsibility.

Malnutrition (underweight) contributes to approximately 60% of all child deaths, yet health professionals, policy makers, and donor agencies often fail to recognise its relevance to child survival. There is a need for the paediatric community to champion the importance of adequate nutrition for normal growth and development, and of placing sufficient emphasis on the prevention and treatment of malnutrition. Many severely malnourished children die from inappropriate treatment. Case fatality rates of 25-30% are commonly found and in some hospitals as many as 50-70% will die. Many of these deaths are avoidable. Weaknesses in health systems, inappropriate training of doctors and nurses, inadequate supervision, and lack of support for staff all contribute to compromised quality of care. The International Union of Nutritional Sciences, with support from the International Pediatric Association, Launched a global Malnutrition Task Force in 2005. The main objective is to ensure that an integrated system of prevention and treatment of malnutrition is actively supported as a fundamental aspect of care, and becomes an integral part of all training programmes.     

Hospital services for children in the Solomon Islands: rebuilding after the civil conflict

AIMS: The Solomon Islands health service, infrastructure and economy were severely affected by the civil conflict that occurred between 1998 and 2003. In 2002 plans to rebuild health services for children, especially those provided in provincial hospitals, were developed by paediatricians, in collaboration with the World Health Organization. We aimed to inform this process by an assessment of the strengths and weaknesses of the child health service, particularly in provincial hospitals. METHODS: A systematic assessment of the quality of hospital care for children in Solomon Islands was conducted in November 2003. The study used a WHO assessment tool, modified for use in the Asia-Pacific region. RESULTS: The assessment highlighted several problems in clinical care, human resources, health financing, referral systems, and training, and has been used as a basis for several interventions for improving the quality of paediatric care. CONCLUSION: This study and the initiatives that have followed it demonstrate the link between such assessments, child health policy and quality improvement activities. Such programs can be implemented even where resources are very limited. Sustaining initiatives based on this assessment will be important for the Solomon Islands if it is to achieve the Millennium Development Goals for child survival by 2015.