Practical aspects of performance improvement in pediatric trauma

Pediatric trauma performance improvement programs may share some of the criteria tracked by their counterparts in the adult trauma world. However, some of the criteria must be specific to the unique diagnostic and therapeutic needs of children. Nine criteria are defined in terms of the critical issues, what information is required to evaluate the appropriateness of the care provided in regards to those issues, and acceptable thresholds for review. In addition, practical aspects of multi-disciplinary peer review in the performance improvement process is presented.     

The impact of a worker health study on working conditions

A research partnership of representatives from labor, academia, and public health enabled unionized San Francisco hotel workers to achieve important policy changes in workplace health and safety. Known as the "Housekeeping Study," the project took sixteen months to complete. A unique aspect of the project was that it utilized participatory action research methods, involving workers themselves as full participants in the study. A core group of 25 hotel room cleaners was involved in each phase of the project. The study developed health data which enabled room cleaners and their union to formulate and justify a contract proposal calling for a significant reduction in housekeeping workloads. The employer association agreed to a contract which reduced the maximum required room assignment from 15 rooms to 14 rooms per day in 14 San Francisco hotels. By lowering the maximum work assignment, these workers set a new standard which can potentially protect the health of room cleaners across the country. The project can serve as a model for worker and union participation in academic research, as well as for the application of research to improving working conditions, particularly for low-wage immigrant workers.     

Professional development for general practitioners through fellowship by assessment

BACKGROUND AND STUDY AIMS: The Royal College of General Practitioners has designed its Fellowship by Assessment (FBA) programme with the twin goals of promoting higher standards of care and offering GPs a professional challenge. By November 2000, 223 eligible doctors (2%) had opted to take FBA. This number is increasing annually. There is, however, little research to account for why GPs undertake it, or what the barriers might be. The aim of our study was to investigate GPs' experience and thinking on this issue. METHODS: A total of 13 GPs who had attained Fellowship by Assessment in the Tamar and Severn Faculties were invited to participate in a qualitative study. They were identified from the list of RCGP Fellows in the Institute of General Practice, University of Exeter, and purposefully selected to include trainers and non-trainers, men and women, rural and urban practitioners, and single-handed and large practices. Analysis of in-depth interviews was informed by grounded theory. FINDINGS: FBA served to acknowledge high standards of care. There was some variation in views about FBA, however, ranging from a perspective which prized the professional award, to the view that endorsed it as a pragmatic and useful way of structuring and monitoring improvements. Fellowship by Assessment improves the care of patients and empowers the doctors by improving their confidence. It is, however, hugely time-consuming and while our findings suggest it should be encouraged, there is a need for ways to be found whereby doctors may be supported in this form of professional development.     

Skin toxicity due to intensity-modulated radiotherapy for head-and-neck carcinoma

PURPOSE: To investigate the cause of acute skin toxicity observed in the treatment of head-and-neck cancer with extended-field intensity-modulated radiotherapy (EF-IMRT). METHODS AND MATERIALS: EF-IMRT was used to treat head-and-neck cancer, with the gross target volume receiving 70 Gy and the clinical target volume 60 Gy. A thermoplastic mask covering the head, neck, and shoulder was used for immobilization. Dosimetric studies were conducted to investigate the possible causes of the skin reactions, such as the bolus effect of the mask, the use of multiple tangential beams with IMRT plans, and the way in which the physicians contoured the lymph nodes. The dose-volume histograms of conventional opposed-lateral fields were compared with that of the multiple tangential EF-IMRT fields. IMRT plans with neck nodes contoured up to and including the skin surface were compared with plans that contoured the neck nodes 5 mm away from the skin surface. In addition, IMRT plans defining the skin as a sensitive structure were compared with plans that did not define the skin as a sensitive structure. All plans were created using an anthropomorphic Rando phantom, and the skin doses were measured with and without the mask. In each measurement, 6 thermoluminescent dosimeters (TLDs) were placed at the lateral and medial surfaces of the neck. RESULTS: For all four plans, the measured skin doses with the mask were consistently higher than those without the mask. The average dose increase was about 18% owing to the bolus effect of the mask. Multiple tangential fields used in IMRT plans contributed to an increase in skin dose by about 19% and 27%, with and without the mask, respectively. If the skin of the neck was contoured as a sensitive structure for dose optimization, the volume of skin that received >45 Gy was further reduced by about 20%. Five patients immobilized with head and shoulder masks were treated with EF-IMRT plans with the neck nodes carefully delineated away from the skin surface. The neck skin was identified as a sensitive structure for dose optimization. Grade 1 toxicity was observed in 3 patients, Grade 2 in 1 patient, and Grade 3 in 1 patient toward the end of treatment. CONCLUSION: Multiple factors contributed to the observed acute skin reaction for head-and-neck cancer patients treated with EF-IMRT. By taking into consideration the skin as a sensitive structure during inverse planning, it was possible to reduce the skin dose to a tolerable level without compromising tumor target coverage.     

Rehabilitation in severe head injury in children: outcome and provision of care

Functional outcome and provision of care to 82 children (males:females 2.7:1; age range 0 to 16 years) with severe head injury were investigated. The children were admitted to the intensive care units of the Regional Neuroscience Units of the Greater Manchester and Lancashire districts of the North West Region of the UK between 1994 and 1996. A questionnaire was devised based on 12 areas of recovery and data were collected at discharge and 6 weeks, 6 months and 12 months from discharge. Data were collected during home visits and at joint assessment at 12 months with the district consultant community paediatrician (CCP). Early involvement of the CCP enhanced the provision of needs at discharge and 6 weeks after discharge, as did a period of stay in district-level care before discharge home. CCPs received formal notification of the injured child in only 32% of cases by discharge, and 54% of cases by 6 months. Sixty-five per cent of children required early educational support but structured help reached only 55% of these children by the end of the study. Integrated planning between health and education was achieved in about half of the study population. Good physical recovery was achieved by the majority of children but parents said they did not feel prepared for the degree of help which their child still required 12 months after discharge. Children who required anticonvulsants at 12 months' follow-up scored significantly lower on cognitive potential. Psychosocial family functioning deteriorated in a substantial number of families according to parental perception. Prevalence of this perception did not diminish over the study period. Aspects of caregivers' understanding and the child's language deficits, self-care skills, fine and gross motor performance, as well as family, social, and financial consequences were assessed. A dedicated and integrated approach to assessment and provision of care across the domains of hospital, education, and community is discussed.