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.     

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.     

Patterns of reporting by health care and nonhealth care professionals to child protection services in Canada

BACKGROUND:

All Canadian jurisdictions require certain professionals to report suspected or observed child maltreatment. The present study examined the types of maltreatment, level of harm and child functioning issues (controlling for family socioeconomic status, age and sex of the child) reported by health care and nonhealth care professionals.

METHODS:

χ² analyses and logistic regression were conducted on a national child welfare sample from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003), and the differences in professional reporting were compared with its previous cycle (CIS-1998) using Bonferroni-corrected CIs.

RESULTS:

Analysis of the CIS-2003 data revealed that the majority of substantiated child maltreatment was reported to service agencies by nonhealth care professionals (57%), followed by other informants (33%) and health care professionals (10%). The number of professional reports increased 2.5 times between CIS-1998 and CIS-2003, while nonprofessional reports increased 1.7 times. Of the total investigations, professional reports represented 59% in CIS-1998 and 67% in CIS-2003 (P<0.001). Compared with nonhealth care professionals, health care professionals more often reported younger children, children who experienced neglect and emotional maltreatment, and those assessed as suffering harm and child functioning issues, but less often reported exposure to domestic violence.

CONCLUSION:

The results indicate that health care professionals play an important role in identifying children in need of protection, considering harm and other child functioning issues. The authors discuss the reasons why under-reporting is likely to remain an issue.     

The 18-month well-child visit in primary care: Clinical strategies for early intervention

Family physicians, paediatricians, nurse practitioners and all primary health care providers are well-positioned in the health care system to provide identification and intervention for developmental delay in early childhood. This can be accomplished through the promotion of healthy child development by supporting children and their parents, paying special attention to issues of attachment and parent-child interactions. Early recognition and intervention is critical for addressing all developmental, social and behavioural problems in young children. A familiarity with local community resources and services is crucial; it will assist primary health care providers in supporting families by providing extra assistance and assessment for families at risk. The present article reports on the evidence-based interventions at the 18-month visit including screening tools, resources and a case example. The importance of interdisciplinary coordination to provide a comprehensive approach to screening, assessment and intervention for developmental delays in infants and young children is highlighted.     

Priorities for early childhood development in low-income countries

The remarkable progress in reducing child mortality in low-income countries is now accompanied with a rapidly expanding population of child survivors and increased life expectancy. However, many have special health care needs in the early foundational years for optimal health and educational and vocational status. Investment in early childhood development (ECD) is therefore crucial but likely to be constrained by lack of adequate resources making priority-setting inevitable. A review of current ECD approaches in sub-Saharan Africa and South Asia shows that concerted multidisciplinary and cross-sectoral initiatives targeted at children with developmental disabilities across all crucial domains of ECD and guided by available evidence on optimal timing for interventions are urgently required. This focus would necessitate appropriate national ECD policies, modifications to the current global ECD programs in the developing world, and a more active collaboration between pediatricians and other related service providers.     

Health of Australian children in out-of-home care: needs and carer recognition

Aim: Following research highlighting high levels of health need in New South Wales children in out‐of‐home care, this study aimed to quantify health need in a sample of Queensland children in care based on multidisciplinary child health assessments. The study also sought to examine the concordance between foster carers' health concerns for children for whom they are providing care and health need as established through referrals made as a result of health assessment. Methods: Children entering out‐of‐home care in the north Brisbane area within the previous month were referred for baseline child health assessment. Child health was assessed by paediatricians and clinical nurses utilising a pro forma‐based methodology. Analysis of initial carer concerns, health referrals and immunisation status in the sample was undertaken. Results: Of the 63 children assessed, 70% were found to require multiple referrals to various health services. The most frequently made referrals included paediatrician follow‐up (41% of children), counselling services (30%) and audiology (26%). Only 68% of the sample was found to be fully immunised. A discrepancy was noted between foster carers' child health concerns and level of referral need established during assessment. Conclusions: Queensland children in care have high health needs similar to those evidenced by children in care in other areas of Australia. Foster carers appear to underestimate the health needs of children in their care, demonstrating the necessity of multidisciplinary health screens and foster carer training in order to detect child health problems in this population.     

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by a county level of urban influence.

OBJECTIVE: To examine child and hospital demographics and children's health care coverage, use, expenditures, and quality by a county-level measure of urban influence. METHODS: Two national health care databases serve as the sources of data for this report: the 2002 Medical Expenditure Panel Survey (MEPS) and the 2002 Nationwide Inpatient Sample (NIS) and State Inpatient Databases (SID) from the Healthcare Cost and Utilization Project (HCUP). In both data sets, county urbanicity is defined by use of a collapsed version of the 2003 Urban Influence Codes, to distinguish among children residing in and hospitals located in large metropolitan (metro) counties, small metro counties, micropolitan counties, and noncore counties. RESULTS: Demographics. In large metro counties, greater percentages of the child population are Hispanic or black non-Hispanic than in small metro, micropolitan, and noncore counties; in micropolitan and noncore counties, higher proportions of children are below 200% of the federal poverty level than in large metro and small metro counties. Noncore areas have a greater percentage of children in fair or poor health compared with those in small metro and micropolitan counties. Most hospitals are located in large and small metro areas, and large metro areas have a higher proportion of teaching hospitals compared with other areas. Health care. In general, there were no overall differences by place of residence in the proportion of children with and without insurance, although differences emerged in subpopulations within Urban Influence Code types. Hispanic children residing in large metro counties were more likely to be uninsured than those in small metro counties. Overall, the proportion of children with at least one dental visit was larger in small metro areas compared with both large metro and noncore areas. The proportion of children with medicines prescribed was generally lower in large metro areas compared with all other areas both overall and among subpopulations of children. Children in noncore areas were more likely to have a hospital inpatient stay and any emergency department use compared with children in large metro areas. Children in large metro counties had longer average inpatient stays and a higher hospital inpatient charge per day compared with children in all other counties. Although most hospitalizations for children from large metro areas occurred in large metro areas, over half of hospitalizations for noncore children occurred outside of noncore counties. Further, children from noncore counties appear to be hospitalized for ambulatory sensitive conditions more than children from all other areas. CONCLUSIONS: County-level data analyses performed using a collapsed version of the Urban Influence Codes with MEPS and HCUP data shed additional light on the health care patterns for children that were not previously evident when only the dichotomous metropolitan/nonmetropolitan geographic schema was used.     

Differences in health care quality for children and adults under managed care: justification for separate quality assessments?

OBJECTIVE: To assess reported results of health care quality for children and adults in managed systems of care and to determine if variations exist between reported quality results for adults and children within the same plan. METHODS: We utilized Consumer Assessment of Health Plan Survey results reported from 424 managed care plans to the National Committee for Quality Assurance in 1999. Responses from 218 530 adults (515 per plan, 424 plans) and 55 081 parents of children 0-12 years of age (304 per plan, 181 plans) were available. Restricting analyses to the 178 plans reporting both adult and child results, we performed matched-pairs analyses to test the hypothesis that child results would be the same as their adult counterparts within the same plan. Regression methods were employed to test for potential demographic differences explaining observed differences. RESULTS: Within the same plan, reported results for care provided by specialists and primary care physicians to adults and children in the same plan revealed marked variation, including rating of doctor (Spearman correlation coefficient, r(S) =.504) and rating of specialist (r(S) =.326). Conversely, assessments of activities related directly to health plan activities showed little variation, including rating of health plan (r(S) =.850) and claims processing (r(S) =.857). Differences in demographic characteristics between adults and child survey respondents do not appear to explain observed variations. CONCLUSIONS: Separate quality of care assessments for adults and children within the same managed care system identify significant differences in reported quality. Having health plan quality information about adult care does not serve as a proxy for needed information on children, particularly the care related to primary care and specialist providers. Areas of health plan assessment common to both adults and children (eg, claims processing) could be replaced with more targeted assessments of importance to parents and purchasers (eg, children with chronic conditions).     

Parent caregiver-related predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid.

INTRODUCTION: This study examined the associations between characteristics of the parent caregiver and health care service utilization by children with cerebral palsy enrolled in Medicaid. METHODS: A questionnaire was administered to the parents of children with cerebral palsy being treated in a North Carolina hospital, and the responses were linked with health services claims data from Medicaid. Data were available for 93 patients who maintained 1 year of continuous enrollment. The impact of selected demographic variables (race, years the child had the condition, employment, transportation) and behavioral variables (belief the child was receiving appropriate care, willingness to use home nursing and respite services, self-assessment of the severity of the child's condition, and use of orthopedic aids) on the frequency and costs of health care services was explored with use of multiple regression analysis. RESULTS: Parents who were willing to use home nursing and respite services were more likely to utilize these services, as well as inpatient facilities and orthopedic care, for their children (P <.05). However, parents who perceived that their child was receiving adequate care were less likely to utilize orthopedic care and home nursing for their children (P <.05). DISCUSSION: The belief of the parents in the adequacy of care received by their child, as well as their willingness to utilize supplemental health care services, were major predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid. Parents who believed that their children receive enough care may need to be targeted for care management and disease management programs to ensure the continuum of treatment and care for these children.     

Management of the child with a learning disorder

The label "learning disabilities" is all-embracing; it describes a syndrome, not a specific child with specific problems. Parent involvement in and collaboration with pediatricians and schools in navigating service systems, accessing appropriate services, and case management are particularly relevant for children with LD. Comprehensive service delivery in school settings requires the interface of other service sectors, such as primary care, mental health,and other community agencies that also recognize and address children's problems. To date, marked differences exist among the assessment, classification and diagnostic, and treatment practices of these service systems, despite the fact that they address the same patient population--school-aged youth. Additionally, many of these agencies and systems operate in isolation with limited cross-sector communication or service collaboration. Parent involvement and advocacy, with assistance from pediatricians and knowledgeable school personnel, is necessary to ensure that appropriate resources available from these sectors are well coordinated and provided for children with an LD to improve their school performance and ongoing educational experience.     

Paediatric emergency and acute care in resource poor settings

Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co‐morbidities, treatment, monitoring and supportive care, discharge planning and follow‐up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under‐graduate courses and continuing professional development. Quality processes combine evidence‐based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.     

Ability of hospitals to care for pediatric emergency patients.

CONTEXT: The needs of children in emergency situations differ from those of adults and require special attention, yet there has been no study of the ability of U.S. hospitals to care for emergently or critically ill children. OBJECTIVE: To estimate the distribution of pediatric services available at U.S. hospitals with emergency departments (EDs). DESIGN: Self-report survey of 101 hospital EDs. PARTICIPANTS: Stratified probability sample of all U.S. hospitals operating EDs. RESULTS: The majority of hospitals that usually admit pediatric patients do not have separate pediatric facilities. Hospitals without a pediatric department, ward, or trauma service usually transfer critically injured pediatric trauma patients; however, nearly 10% of hospitals without pediatric intensive care facilities admit critically injured children to their own facilities. Likewise, 7% of hospitals routinely admit pediatric patients known to require intensive care to their adult intensive care units rather than transferring the patient to a facility with pediatric intensive care facilities. Few hospitals have protocols for obtaining pediatric consultation on pediatric emergencies. Appropriately sized equipment for successful care of infants and children in an emergency situation was more likely to be missing than adult-sized equipment, and significant numbers of hospitals did not have adequate equipment to care for newborn emergencies. CONCLUSION: Emergent and critical care of infants and children may not be well integrated and regionalized within our health care system, suggesting that there is room for improvement in the quality of care for children encountering emergent illness and trauma.     

Improving detection and quality of assessment of child abuse and partner abuse is achievable with a formal organisational change approach

Aim:   To improve detection and quality of assessment of child and partner abuse within a health service.
Methods:   A formal organisational change approach was used to implement the New Zealand Family Violence Intervention Guidelines in a mid-sized regional health service. The approach includes obtaining senior management support, community collaboration, developing resources to support practice, research, evaluation and training. Formal pre–post evaluations were conducted of the training. Barriers and enablers of practice change were assessed through 85 interviews with 60 staff. More than 6000 clinical records were audited to assess rates of questioning for partner abuse. Identifications of partner abuse and referrals made were counted through the Family Violence Accessory File. Referrals to the Department of Child, Youth and Family Services (CYFS) were recorded routinely by the CYFS. Audits assessed quality of assessment of child and partner abuse, when identified.
Results:   More than 700 staff were trained in dual assessment for child and partner abuse. Evaluations demonstrate improved confidence following training, though staff still need support. Barriers and enablers to asking about partner abuse were identified. Referrals from the health service to the CYFS increased from 10 per quarter to 70 per quarter. Identification of partner abuse increased from 30 to 80 per 6-month period. Routine questioning rates for partner abuse vary between services.
Conclusion:   Achieving and sustaining improved rates of identification and quality of assessment of child and partner abuse is possible with a formal organisational change approach.     

Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries

Background: Little is known about the treated prevalence and services received by children and adolescents in low‐ and middle‐income countries (LAMICs). The purpose of this study is to describe the characteristics and capacity of mental health services for children and adolescents in 42 LAMICs. Methods: The World Health Organization Assessment Instrument for Mental Health Systems (WHO‐AIMS), a 155‐indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower‐middle, and 5 upper‐middle‐income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO‐AIMS instrument. Results: The median one‐year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health. Conclusions: Mental health services for children and adolescents in low‐ and middle‐income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.     

Integrated Management of Childhood Illness (IMCI) : A robust strategy

Integrated Management of Childhood Illness (IMCI), a strategy fostering holistic approach to child health and development, is built upon successful experiences gained from effective child health interventions like immunization, oral rehydration therapy, management of acute respiratory infections and improved infant feeding. The core intervention of IMCI is integrated management of the five most important causes of childhood deaths-acute respiratory infections, diarrheal diseases, measles, malaria and malnutrition. Using a set of interventions for the integrated treatment and prevention of major childhood illnesses, the IMCI strategy aims to reduce death as well as the frequency and severity of illness and disability, thus contributing to improved growth and development. In health facilities, the IMCI strategy promotes the accurate identification of childhood illness (es) in the outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers and the provision of preventive services, and speeds up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. It also creates a scientifically sound link between the management guidelines at the community level and the management approach in a referral centre. The strategy also envisages actual situations when referral is not possible and offers the best possible options in such circumstances. In the home setting, it promotes appropriate early home care and care-seeking, improved nutrition and prevention, and the correct implementation of prescribed care. In addition to its focus on treatment of illness in the health facility as well as at home, it also provides an opportunity for important preventive interventions such as immunization and improved infant and child nutrition including breastfeeding. The IMCI strategy reduces wastage of resources and avoids duplication of efforts that may occur in a series of separate disease control programs. The essential pillars include improvement in the case management skills of health personnel, improvement in health systems, and improvement in family and community practices. IMCI has been introduced in more than 80 countries and 19 of them have already scaled up IMCI implimentation Even though it is too early to relate the decrease in childhood mortality with the introduction of IMCI inthese countries, there are several indirect indicators which endorse its validity as a comprehensive and effective strategy. IMCI has helped countries to revise and update their child health policies, streamline the essential drug lists for children, increase service utilization, improve quality of care and nutritional counselling, improve health systems and improved family and community practices.     

Palliative care situation in Palestinian Authority

Palliative care is a very new concept in Palestine. In fact, it is still not applicable or provided within the Palestinian health care system. However, Al-Sadeel Society had organized a one day workshop in Bethlehem on November 2008 for the health professionals from the governmental and non-governmental sectors to initiate and introduce the idea of palliative care for the first time in Palestine. The general population of Palestine is approximately 2.4 millions (2007), with a life expectancy of 74.3 years of age, the death rate is 3.7 per 1000 population, having 8,910 deaths a year. Deaths due to cancer were 2,305 in five years (1999-2003), where 5,542 new cases were newly diagnosed in the same period. Health services available for cancer patients are hospital units either in patient or day care units. According to the ministry of health (MOH) statistics there are 75 beds in oncology departments in MOH hospitals; represent 2.7% of the total number of beds available, and 60 beds in daily care departments with an occupancy rate at 231.8%. There is no hospice or bereavement follow up care available for patients or their families. Despite the fact that the Palestinian culture is one of the cultures that respect and care for the elderly, but at the end of life, when the load of symptoms is high, most of the patient are care for at hospitals, and usually dye there, because the families are not able to care for their patients, and as there is no system for home care available for the Palestinian patients, and if it is available it is available in limited places and on private bases that are expensive and not affordable to the majority of patients, gross domestic product (GPD) per capita= 1,100 as 2007 estimates). We conducted a needs assessment survey within the only four facilities that provide care for the oncology patients in the West Bank and were filled by the direct health care providers. The results were expressing the fact that there is no palliative care service available for cancer patients or their families, absence of organizations strategic planning for palliative care, No presence of educational resources for palliative care, No presence of communication or consultation to the clergy man, Absence of bereavement support group, no active follow up for the patient and the family, no standards for palliative care service or training programs in palliative care, no home care service for palliative care, absence of community awareness for palliative care And Absence of national standard for palliative care. The recommendations that we can conclude, depending on the needs assessment that we did, and according to the recommendations that come up through the workshop that was organized by Al-Sadeel Society and was attended by key personnel from the Palestinian MOH who summarized the conclusion, are as follows: 1.?The need for better quality care for the cancer patient.2.?The need for training of health professionals in palliative care.3.?The importance of networking and cooperation between the national NGO's and the MOH.4.?The need for public awareness regarding the early detection for cancer especially breast cancer.5.?The need for national policy and standards for palliative care and opioids legislations.6.?The importance of base line data and research. 7.?The need for interdisciplinary team work in the issue of cancer. 8.?To involve palliative care education within the curriculum of schools of health professions.     

Annotation: Pathways to care for children with mental health problems

BACKGROUND: Although many children with mental health problems are in contact with primary health care services, few receive appropriate help. METHODS: Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services. RESULTS: Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services. CONCLUSIONS: As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.     

Health status of children with special health care needs: measurement issues and instruments.

The methods for measuring health care outcomes and monitoring the health status of the child with a chronic health condition must be available, accessible, and meaningful. This review was evoked by this need to identify reliable and valid instruments for measuring the health status of children with special health care needs. The objectives are as follows: (1) to review the methodologic and substantive issues related to the selection of instruments and (2) to identify those instruments available currently for collecting data regarding health status of children with special health care needs. A Medline search of the literature published since 1966 through 1998 and restricted to human subjects and the English language was conducted. Indexing terms included health status, quality of life, outcome assessment, functional status, and patient satisfaction. Multiple reviewers selected instruments based on their usefulness in clinical settings as generic, disease nonspecific, child health status instruments. Few instruments were identified that can be used by pediatricians for tracking and monitoring the health status of children with special health care needs. In conclusion, to progress in the field of outcomes measurement of children with special health care needs, it will be necessary to develop new measurement tools. These instruments must (1) provide valid and reliable information on health status; (2) be useful in guiding the management of patients; and (3) not be a burden for physicians, patients, or patient's families.     

Which children need to be transferred to the paediatric intensive care unit?

A paediatric intensive care service provides the necessary support, interventions and treatment for children who have critical illness or injury. The critically ill child has special medical needs and therefore requires care from medical and nursing staff trained in both paediatrics and intensive care. This is best provided in a service that conforms to agreed guidelines and standards. This review discusses the guidelines for admission to a paediatric intensive care unit (PICU), which must be modified and adapted to each hospital's policy. They are not meant to be all-inclusive, and it is recommended that professionals discuss each case with the tertiary centre as some hospitals have both PICU and high-dependency unit beds and can offer different types of service for the critically ill child.     

A 'chronic disorder' health-care model for children with complex developmental disorders

OBJECTIVES: To conceptualize, develop and evaluate a 'chronic disorder' clinical model of health services for children with 'low-severity' developmental disorders assessed and treated within a public Child Development Unit. METHODOLOGY: Concepts of family empowerment, child resiliency and the management of clinical complexity were explicitly incorporated into the service model and the clinical strategies in order to address long-term goals of prevention and health promotion. To explore the efficacy of this model, a telephone audit survey was conducted of parents of 42 children seen sequentially through this modified service. RESULTS: Parent data indicate a high level of satisfaction with the integrated, individualized assessment processes and effective transmission of information through both written reports and dedicated discussion visits. A treatment methodology based on parent chosen treatment goals for short and long time-frames was experienced as achievable and successful. CONCLUSIONS: These data suggest that the service goals of an integrated team process, parent empowerment and effective clinical collaborations may be achievable from a health care setting. A change in emphasis from remedial treatment to adaptation, health promotion and tertiary prevention is integral to these strategies. The concepts, clinical model and evaluation are presented to stimulate discussion around the question of what child health services are attempting to achieve for children with complex developmental disorders.