Quality improvement of paediatric care in the Netherlands

The development of the quality improvement programme of the Paediatric Association of the Netherlands is described within the setting of the national programme of the Dutch government. The programme is based on four pillars: site visits by peers (visitatie), continuous medical and professional education, development of clinical (evidence based) guidelines and patient safety with complication registration. The site visits by peers play a central role in assessing the quality improvement activities in hospital based paediatric care. The self assessment approach and the confidential character of the visits are well received by the surveyed specialists. Recent inclusion of quality criteria in the legally required 5 yearly medical specialist recertification process has boosted the care for quality, which could serve as example for other countries.     

Quality indicators for paediatric palliative care

OBJECTIVES:To apply quality indicators for paediatric palliative care and evaluate performance in one service provision area.METHODS:After institutional review board approval, medical records were abstracted for well-defined and measurable quality indicators for children with chronic complex conditions (CCCs) between January 2006 and December 2011 (n=50) at a university medical centre.RESULTS:Of the 50 children with a CCC (mean age 64 months, 48% female), 39 (78%) died in hospital, 11 (22%) died at home and 13 (26%) were <1 month of age. In the final month of their life, 10 patients (20%) required an unplanned visit to the emergency department and seven (14%) were admitted. Only four patients (8%) were admitted for >14 days in their final month of life. Goals of care were addressed in a timely manner 60% of the time. An invasive procedure was performed in the final month of life in 27 (44%) patients. Bereavement follow-up was offered to 25 (50%) families. A palliative care consultant was involved with 17 (34%) patients. Palliative care was associated with less frequent invasive procedures in the final month of life and more frequent documentation of the preferred place of death.CONCLUSION:Performance on these particular quality indicators was unsatisfactory across a diverse group of children with CCCs, indicating important opportunities for improvement. Methods used to improve the quality of other aspects of paediatric care, including emphasis on efficient work systems, practical tools and interdisciplinary teamwork, should be used for ensuring delivery of high-quality palliative care.     

Calibration of the paediatric index of mortality in UK paediatric intensive care units.

AIM: To test a paediatric intensive care mortality prediction model for UK use. METHOD: Prospective collection of data from consecutive admissions to five UK paediatric intensive care units (PICUs), representing a broad cross section of paediatric intensive care activity. A total of 7253 admissions were analysed using tests of the discrimination and calibration of the logistic regression equation. RESULTS: The model discriminated and calibrated well. The area under the ROC plot was 0.84 (95% CI 0.819 to 0.853). The standardised mortality ratio was 0.87 (95% CI 0.81 to 0.94). There was remarkable concordance in the performance of the paediatric index of mortality (PIM) within each PICU, and in the performance of the PICUs as assessed by PIM. Variation in the proportion of admissions that were ventilated or transported from another hospital did not affect the results. CONCLUSION: We recommend that UK PICUs use PIM for their routine audit needs. PIM is not affected by the standard of therapy after admission to PICU, the information needed to calculate PIM is easy to collect, and the model is free.     

Intracranial tuberculosis in the Netherlands: Four paediatric cases

Abstract Since 1987 a resurgence of tuberculosis is occurring in the Netherlands in analogy to the situation in other industrialised countries. So far this has not been associated with an increased incidence of tuberculous meningitis, which is still a rare complication of the disease. Four cases of intracranial tuberculosis were recently diagnosed in our hospital. All children were from middle-class Dutch families with no identified risk for tuberculosis. An extensive contact identification search could identify a contact in two patients. Two children were in an advanced stage of disease before diagnosis. Skin tests were repeatedly negative in all cases which delayed treatment in two cases for almost 2 weeks. One patient developing a cerebral tuberculous focus during therapy responded well to a second course of corticosteroids. Three children developed severe neurological sequelae.Conclusion This report illustrates that suspicion of intracranial tuberculosis is warranted in the case of an ill-defined inflammatory neurological syndrome.     

Quality of paediatric IDDM care in Germany: a multicentre analysis. German Paediatric Diabetology Group.

Quality management has been applied in recent years to improve the care of children and adolescents with insulin dependent diabetes mellitus (IDDM). In 1995 the German Paediatric Diabetology Working Group published standards on quality control, in which relevant parameters on structure, process and outcome of care were defined. A computer software programme-developed at the University of Ulm under the auspices of the German Secretary of Health-has been used for quality control with central anonymous analysis in a nationwide survey. Data from 23 paediatric centres with 2407 patients seen between January and June 1996 were evaluated. The results showed an admission rate to hospital of 23.8 per 100 patient-years with an average duration of in-patient stay of 2.74 days/year. 80% of the patients were treated with an intensive insulin therapy regimen comprising three or more injections daily. The overall metabolic control was reasonably good with a mean HbA1c value of 7.8%. The rate of severe hypoglycaemia complicated by coma and/or convulsions was six per 100 patient-years and of ketoacidosis one per 100 patient-years. Unfortunately screening for diabetic retinopathy and nephropathy was not carried out consistently. The incidence was 44% and 33% respectively.     

Trends in paediatric care

This paper reviews reports and trends in paediatric care in Australia and overseas. In particular it looks at changes in primary care and in the management of community problems in paediatrics.     

The intensive care unit in paediatric oncology.

There were 70 admissions from a regional paediatric oncology centre to the intensive care unit over a six and a half year period. Patients were divided into those with systemic infections (n = 19), respiratory infections (n = 15), metabolic effects (n = 9), tumour mass effects (n = 10), neurological complications (n = 8), and others (n = 9). The overall survival was 51%. Patients admitted with metabolic or tumour mass related effects had the best prognosis with a survival of 84%. If dialysis is required in this group of patients then continuous arteriovenous haemofiltration is recommended. Patients with systemic or respiratory infections comprised the main poor prognosis group with a survival of 26%. For patients with a systemic infection who required ventilation, the mortality was 100%. The outlook for patients with a generalised encephalopathy was also poor, with no neurologically intact survivors. The median APACHE-II (acute physiology and chronic health evaluation) score for patients who died was 27 and for survivors was 16. There is a need for close cooperation between staff of intensive care and paediatric oncology units. Alternative treatments should be considered for patients with systemic infections who require ventilation.     

Calculation of the need for paediatric intensive care beds.

A study of paediatric intensive care usage and need was undertaken in the former English Northern region to define appropriate local provision in the light of apparently conflicting published evidence. It was hypothesised that daily bed need would follow a Poisson distribution. All admissions of children aged less than 15 years who required intensive care in the region were recorded retrospectively for the financial year 1993/4. The mean number of beds occupied was 11.7 per day, which is equivalent to 20.7 beds per million children per day. The distribution of numbers of beds used mirrored a Poisson distribution closely, and the predicted bed requirement to cover 95% of days in the year was in agreement with that observed. Review of recommendations for paediatric intensive care provision from other studies suggests that apparent differences arise largely from the effect of different sizes of population served, and that, when allowance is made for this, underlying rates of bed requirement are strikingly similar, with a mean of around 20 per million children per day. A formula is given for the application of this model to local populations.     

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.     

Bronchoscopy in paediatric intensive care

Bronchoscopy is a highly versatile technique in the context of intensive care and has many potentially valuable indications. Safety is of paramount importance and the risks in critically unstable patients are correspondingly greater than in more stable children. The main contraindication to bronchoscopy is if it will provide no useful information. The procedure is obviously more risky in children with severe hypoxia, uncontrolled bleeding diathesis, cardiac failure or severe pulmonary hypertension. Monitoring should include at least oxygen saturation, blood pressure (ideally by continuous, invasive monitoring) and preferably capnography. Indications for bronchoscopy in paediatric intensive care include endobronchial toilet, sometimes instilling recombinant human DNAase even in children who do not have cystic fibrosis; checking tube patency and position; assisting in a difficult intubation or tube change; achieving the selective intubation of a main bronchus; the diagnosis and management of ventilator-associated pneumonia or the ventilated, immunocompromised host; the assessment of lobar collapse or focal hyperinflation; airway stent assessment; assessment of stridor on extubation and the diagnosis of any associated disease. New iatrogenic complications are also likely to be discovered. The procedure is very safe if performed by experienced operators with back-up from doctors skilled in airway management and the monitoring of sick children.     

Evaluation of paediatric intensive care in a regional centre.

All 162 consecutive admissions to a multidisciplinary paediatric intensive care unit in the UK have been prospectively evaluated in terms of therapeutic intention, sickness levels, age, utilisation of resources, and outcome. For 101 (62.3%) of the children admitted the aim of treatment was to cure the condition but for 30 (18.5%) ultimately only a palliative option was available. Five children were admitted to avail of specialised monitoring facilities. One half of the children admitted were physiologically unstable. The majority (102, 62.9%) were age 12 months or less. Resource utilisation, which was not affected by therapeutic intention, was greatest for the sickest patients, those age 1 month or less and non-survivors. Mortality rate overall was 17.9%. Mortality was unaffected by age and therapeutic intention and was inversely related to level of sickness. The information provided by this study forms a basis for medical audit within the unit and is essential for meaningful comparisons of standards of care and outcome with other units.     

Calibration of the paediatric index of mortality in UK paediatric intensive care units

AIM—To test a paediatric intensive care mortality prediction model for UK use.
METHOD—Prospective collection of data from consecutive admissions to five UK paediatric intensive care units (PICUs), representing a broad cross section of paediatric intensive care activity. A total of 7253 admissions were analysed using tests of the discrimination and calibration of the logistic regression equation.
RESULTS—The model discriminated and calibrated well. The area under the ROC plot was 0.84 (95% CI 0.819 to 0.853). The standardised mortality ratio was 0.87 (95% CI 0.81 to 0.94). There was remarkable concordance in the performance of the paediatric index of mortality (PIM) within each PICU, and in the performance of the PICUs as assessed by PIM. Variation in the proportion of admissions that were ventilated or transported from another hospital did not affect the results.
CONCLUSION—We recommend that UK PICUs use PIM for their routine audit needs. PIM is not affected by the standard of therapy after admission to PICU, the information needed to calculate PIM is easy to collect, and the model is free.