Evaluation and audit in a paediatric disability service.

Parental and professional responses to questionnaires evaluating a paediatric disability service are reported and the viability of auditing structural, process, and outcome aspects of clinical practice are discussed. Expectations of waiting time to first appointment (met for only 52% of consumers) illustrate structural issues. Process issues are reflected in consumer reactions to outreach work (for example, 94% of parents and 84% of professionals found this supportive). Outcome measures such as consumer satisfaction with the service (76% of consumers reported being ''very satisfied'' and 20% ''fairly satisfied'') suggest that service aims are being met. Good concurrence of service aims with consumer needs is indicated by parental reasons for referral (for example, 75% for diagnostic help, 73% for a better understanding of the disorder, 88% for practical help), referrers'' reasons (for example, 55% for a second diagnostic opinion, 45% due to lack of local expertise), and reports from most other professionals involved with the case that a similar service was not provided locally.     

Outcomes of a nutrition audit in a tertiary paediatric hospital: implications for service improvement

OBJECTIVE: To examine the process of anthropometric assessment of nutritional status in a tertiary paediatric hospital, to identify the barriers and to make recommendations for service improvement. METHODS: The accuracy of height and weight scales in wards was checked. Dietitians measured height and weight of a representative sample of 245 inpatients and checked whether these measurements had been recorded on bed charts. Patients were classified as overweight, obese or under-nourished. Diagnoses and procedures were obtained for each patient. Funding implications were modelled for inappropriate coding of nutritional status. RESULTS: The barriers to nutritional assessment and management of nutritional comorbidities were: (i) inaccurate height scales in seven out of 12 wards; (ii) under-recording of height and weight on patient bed charts (73% height missing, 12% both height and weight missing); (iii) under-reporting of obesity and under-nutrition in medical notes (one of eight obese patients, and none of 28 undernourished patients, reported); and (iv) low referral rate of obese or under-nourished children to dietetic services (two of 42 overweight/obese patients referred, five of 28 undernourished patients referred). Funding simulation showed that if under-nourished patients were correctly diagnosed then the potential facility reimbursement would have increased by $A52 326. CONCLUSIONS: Barriers to nutritional assessment can lead to failure to diagnose and treat both over- and under-nutrition, thereby affecting quality of patient care, and may have financial implications for hospitals. Suggestions for service improvement include provision of accurate equipment, adequate training of staff undertaking nutritional assessments and clear definitions of staff responsibilities in all aspects of the process.     

An audit of paediatric audits

An audit of audits at a children's hospital over a six year period showed that 27.8% fulfilled the criteria for a full audit and 22.2% were re-audited. It is recommended that newcomers to audit are given training on audit methodology and that all audit departments should audit their audits annually.     

An audit of paediatric audits.

An audit of audits at a children's hospital over a six year period showed that 27.8% fulfilled the criteria for a full audit and 22.2% were re-audited. It is recommended that newcomers to audit are given training on audit methodology and that all audit departments should audit their audits annually.     

An audit of paediatric epilepsy care

Basic standards for the process of paediatric epilepsy care were identified and applied in a clinical audit; findings were presented and the audit repeated. Standards agreed related to quality of correspondence, prescribing practice, appropriateness of drug monitoring, use of neuroimaging, and quality of requests for electroencephalography (EEG). Parent satisfaction with staff courtesy, doctor communication, and clinic visits were also assessed. In the second audit prescribing practice and appropriateness of drug monitoring had improved, but quality of patient correspondence and requests for EEG were unchanged. In both periods of care many parents were dissatisfied with the quality and amount of information provided about epilepsy. Standards of care for the medical management of children with epilepsy can be agreed and used to identify achievable improvements in that care.     

Microcytosis and possible early iron deficiency in paediatric inpatients: a retrospective audit

Background  

Iron deficiency anaemia is a common paediatric problem worldwide, with significant neurodevelopmental morbidity if left untreated. A decrease in the mean corpuscular volume (MCV) can be used as a surrogate marker for detecting early iron deficiency prior to definitive investigation and treatment. An audit cycle was therefore undertaken to evaluate and improve the identification, follow-up and treatment of abnormally low MCV results amongst the paediatric inpatients in an English district general hospital.     

A clinical audit of antithrombin concentrate use in a tertiary paediatric centre

Aim: The aim of this study was to investigate the clinical use of antithrombin concentrate (ATC) in children and specifically to determine the current practice of ATC administration, including dosing and indications for administration. Methods: A clinical audit was performed of patients treated with ATC during two 12‐month periods: 1 June 1999–1 June 2000 and 1 June 2009–1 June 2010. Results: Thirty‐seven patients whose age ranged from 1 day to 13.5 years (median 30 days) received a median of two doses (range 1–15) with a median dose of 40 units/kg (range 1–200 units). The majority (90%) of patients were located in the intensive care unit, and the major indication (76%) for use of the ATC was in the setting of unfractionated heparin (UFH) resistance. Post‐ATC administration, 32% of the doses given resulted in antithrombin levels reaching age‐specific normative levels. Of the patients administered ATC with the aim of optimising UFH therapy, 28% of patients had their UFH dose reduced without any measurement of UFH effect. Conclusions: This data provides the basis for future investigations of the specific biochemical changes accompanying ATC administration and the development of paediatric‐specific evidence‐based guidelines for ATC use.     

A regional paediatric rheumatology service

A paediatric rheumatology clinic has been established in Newcastle since 1974, and 160 children had been referred to it by the end of 1980. The proportion of patients in each disease category is similar to that at the national centre at Taplow although far fewer patients with a positive anti-nuclear antibody test and fewer cases of chronic uveitus are seen. The importance of combining the skills of several disciplines is stressed.     

Prospective peer-review audit of paediatric upper gastrointestinal endoscopy

AIM: To describe the findings of paediatric upper gastrointestinal endoscopy (UGE) and to reduce the rate of normal findings in children undergoing diagnostic UGE. METHODS: Upper gastrointestinal endoscopy were performed at a single tertiary referral children's hospital over a 3-year period by four endoscopists. Patients were subgrouped into diagnostic categories (recurrent abdominal pain syndrome (RAP), oesophagitis, coeliac disease and enteropathy/inflammatory bowel disease) and endoscopists recorded their clinical diagnosis as above before each procedure. Endoscopic and biopsy findings were compared with clinical diagnosis. After the first year of audit each endoscopist was appraised of their practice and strategies implemented to reduce the normal UGE. In years 2 and 3 all endoscopists were audited by their peers on a monthly basis. RESULTS: A total of 1172 UGE were performed over a 3-year period. Ninety per cent were diagnostic procedures, of which 48% were normal, 16% identified oesophagitis, 11% coeliac disease, 6% gastritis, 3%Helicobacter pylori and 1% peptic ulcer disease. Peer-review audit significantly reduced the number of normal findings in coeliac disease, RAP and overall (P < 0.01) but not in the groups with presumed oesophagitis or investigation of enteropathy/inflammatory bowel disease. CONCLUSIONS: A high proportion of patients undergoing UGE have normal procedures. Peer-review audit can reduce the number of normal procedures particularly in RAP and in the diagnosis of coeliac disease.     

Prospective audit of treatment of paediatric febrile neutropenia in Australasia

OBJECTIVES: Febrile neutropenia post-chemotherapy continues to impose a burden of morbidity and mortality on patients and families affected by childhood cancer, whereas these unplanned hospital admissions increase the financial cost of treating paediatric malignancies. There are currently no published national guidelines. This study comprises the first audit of current therapeutic practice in Australasia. METHODS: Information was sought prospectively from the 12 paediatric oncology tertiary referral centres in Australia and New Zealand regarding treatment of febrile neutropenia episodes commencing between 11 March and 10 May 2002. RESULTS: Data were returned on 127 episodes by nine centres. The median length of stay was 6 days and 18 different antibiotic regimens were implemented as first-line therapy. The median neutrophil count at the beginning and end of the febrile neutropenic episode was 0.0 x 10(9)/L (range 0.0 to 2.3 x 10(9)/L) and 0.7 x 10(9)/L (range 0.0 to 25.4 x 10(9)/L), respectively. Thirty per cent of episodes had positive blood cultures. Of these, 81% occurred in patients with tunnelled central venous catheters. The initial antimicrobial combination was changed in 61% of episodes. Outpatient antibiotics were used in 21% episodes after initial intravenous antimicrobial therapy. CONCLUSIONS: The current practice in Australasia is consistent with international guidelines, although changes are made more frequently to first-line therapy than in previous published studies. The central venous catheters are associated with a much higher risk of bacteraemia and consideration should be given to increased use of implanted port systems.     

Attitudes to psychological groups in a paediatric and adolescent diabetes service – implications for service delivery

Objective:  To explore the potential interest in psychology support groups in a paediatric and adolescent diabetes service.
Research design and methods:  A short semi-structured interview using both open and closed questions to generate quantitative and qualitative data. Sixty-four parents were interviewed on the telephone by an assistant psychologist.
Results:  The majority of parents (81%) reported an interest in participating in a psychology group if it was offered, but preferences varied between a child/young person group (33%), parents only (15%) or family groups (11%). Twenty-three percent said that they would prefer individual work rather than a group. Parents identified groups as an opportunity to acquire practical knowledge, exchange ideas in an informal setting, share a common reality with others and gain more confidence in managing diabetes together with their child. Reasons not to attend a group included parents being able to cope well at the moment, school demands, feeling uncomfortable speaking in front of a group and use of online support groups.
Conclusion:  The majority of parents identified psychological support as having a role for families living with diabetes. The audit highlighted that families have different ideas about how they would prefer this support to look and emphasized the need to consult with service users when designing psychological support for young people and families living with a chronic condition.     

Development and satisfaction with individual programme planning in a disability service.

A consumer survey of a preschool disability service identified parents who did not feel their concerns were fully understood by professionals, nor felt involved or in agreement with treatment decisions, nor that services were provided in a coordinated way. A system of individual programme planning (IPP) was introduced in order to address these issues and other shortfalls of the existing service. Information was obtained from 96% of parents and 87% of professionals who attended IPP meetings over a four month period. Overall satisfaction was high (92% of parents: 96% of professionals). Parents now felt fully involved in decision making, 80% felt their views were understood and 100% agreed with treatment goals. Dissatisfaction was expressed with meeting attendance, the marginalisation of parents, and the timing and chairing of meetings. Consumer satisfaction surveys are recommended for use in highlighting areas of service shortfall, to direct and evaluate service change, and to monitor quality.     

Referral to a specialist paediatric palliative care service in oncology patients

A 19-month-old male with Chediak-Higashi syndrome developed Epstein-Barr virus (EBV)-associated accelerated phase. Real-time polymerase chain reaction showed high EBV-DNA levels in plasma and peripheral blood mononuclear cells. His condition was refractory to conventional treatments for hemophagocytic lymphohistiocytosis, including corticosteroids, cyclosporine, and etoposide. In situ hybridization revealed higher proportion of EBER-1-positive cells in CD19+ cell fraction than in CD8+ cell fraction. Complete remission was achieved by combination therapy with rituximab and cyclosporine; subsequent bone marrow transplantation was successful. Combination therapy with rituximab and cyclosporine could be effective in patients with EBV-infected T and B cells.     

Monitoring height and weight: Findings from a developmental paediatric service

Aim: To assess the recording of weight and height in children with disabilities and identify subgroups at risk of being either underweight or overweight. Methods: A retrospective clinical audit was undertaken within the Department of Developmental Medicine at The Royal Children's Hospital, Melbourne. Most recent weight and height measurements and data about the child's underlying condition were collected from the medical records of children attending a clinical appointment over a 3‐month period. Primary medical diagnosis, age, gender, mode of feeding and ability to ambulate were recorded. Body mass index was calculated and corrected for age and gender. Results: Study sample size was 583 (356 males), mean age was 8.25 years (range 2.8–17.4 years). Body mass index could be calculated for 48%. Height was less commonly measured in those with severe physical impairments. A survey of barriers to weight and height measurement showed that the main barrier to measuring height was practical difficulties. The percentage of children classified as overweight/obese was 26.6% and this was associated with intellectual disabilities, moderately impaired ambulation, older age and female gender; 13.5% of the study group was underweight, the majority of whom were non‐ambulant. Conclusions: Although significant rates of underweight and overweight were identified in children with a range of disabilities within our service, monitoring of weight status was suboptimal. Despite this, data indicate that specific subgroups of children with disability appear at risk of being either overweight or underweight. Where height cannot be measured, other anthropometric measures such as waist circumference may be useful in the assessment of children with disabilities.     

A prospective audit of paediatric colonoscopy under general anaesthesia

Colonoscopy in children is frequently performed using intravenous sedation. Traditionally, there have been few advocates of general anaesthesia and some have regarded colonoscopy conducted in this way as potentially more hazardous. The aim of this study was to undertake a prospective audit of paediatric colonoscopy carried out under general anaesthesia. The details of all children referred for colonoscopy during a 3.5-y period were collected prospectively and the safety and efficacy of performing colonoscopy under general anaesthesia were analysed. A total of 250 colonoscopies was performed in 215 children of median age 10.7 y (range 5 months to 16 y) and ileoscopy was carried out in 164 of these cases. An increasing proportion of patients was investigated as day-cases, including most of the 56 who had additional procedures carried out under the same anaesthetic. There were no complications from the colonoscopy (including the 18 patients who underwent polypectomy). Only one procedure-related complication occurred and this was avoidable. These results confirm the safety of paediatric colonoscopy under general anaesthesia and demonstrate the advantages and feasibility of such an approach.     

Setting up a clinical audit of paediatric morbidity in Hong Kong: some early experiences

A method of clinical audit was devised to document paediatric morbidity patterns at the Prince of Wales Hospital, a new 1428 bed general hospital serving the eastern part of the Hong Kong New Territories (with a current population of about 750,000). The applicability of the method is illustrated by considering morbidity in 1654 children aged from 1 month to 12 years admitted to the hospital over a 13 month period in 1984-85.