Appropriate management of acute gastroenteritis in Australian children: A population-based study.

OBJECTIVES: To determine the proportion of care provided to children with acute gastroenteritis (AGE) in Australia consistent with clinical practice guidelines. METHODS: Indicators were developed from national and international clinical practice guideline (CPG) recommendations and validated by an expert panel. Medical records from children ≤15 years presenting with AGE in three healthcare settings-Emergency Department (ED), hospital admissions and General Practitioner (GP) consultations-from randomly selected health districts across three Australian States were reviewed. Records were audited against 35 indicators by trained paediatric nurses, to determine adherence to CPGs during diagnosis, treatment, and ongoing management. RESULTS: A total of 14,434 indicator assessments were performed from 854 healthcare visits for AGE by 669 children, across 75 GPs, 34 EDs and 26 hospital inpatient services. Documented adherence to guidelines across all healthcare settings was 45.5% for indicators relating to diagnosis (95% CI: 40.7-50.4), 96.1% for treatment (95% CI: 94.8-97.1) and 57.6% for ongoing management (95% CI: 51.3-63.7). Adherence varied by healthcare setting, with adherence in GPs (54.6%; 95% CI: 51.1-58.1) lower than for either ED settings (84.7%; 95% CI: 82.4-86.9) or for inpatients (84.3%; 95% CI: 80.0-87.9); p<0.0001 for both differences. The difference between settings was driven by differences in the diagnosis and ongoing management phases of care. CONCLUSIONS: Adherence to clinical guidelines for children presenting to healthcare providers with AGE varies according to phase of care and healthcare setting. Although appropriate diagnostic assessment and ongoing management phase procedures are not well documented in medical records (particularly in the GP setting), in the treatment phase children are treated in accordance with guidelines over 90% of the time.

Refractory otitis media: an unusual presentation of childhood granulomatosis with polyangiitis.

Childhood granulomatosis with polyangiitis (cGPA), previously known as Wegener's granulomatosis, is a rare, potentially fatal necrotizing vasculitis, the symptoms of which overlap with infection. We present a 16-year-old girl who, following 6 months of treatment for persistent middle ear effusion with progressive sensorineural hearing loss, developed rapidly progressing pneumonia, with pleural effusion, and multiple cavitatory lung lesions. Investigations demonstrated high titer c-ANCA and nasal septal biopsy confirmed the diagnosis of cGPA. This case highlights the difficulty in diagnosing cGPA and the potentially life-threatening consequences of failing to do so.

Go with the FLO? A novel approach to quality and safety.

In their paper "Front-Line Ownership: Generating a Cure Mindset for Patient Safety," Zimmerman and her colleagues introduce us to the novel concept of FLO - front-line ownership - within the quality and safety arena. Based on their 18-month study of nosocomial infections within five Canadian hospitals, the authors highlight the benefits of allowing front-line staff to own and manage patient safety problems as opposed to imposing programs on them that were created by leaders who did not consult them in developing appropriate solutions.Their paper highlights many of the benefits of FLO, particularly around social networking, interdisciplinary team work and clinician engagement. But how does FLO measure up in the context of other more technical methods of managing adverse events within healthcare organizations? What are the benefits and weakness of FLO? Is FLO consistent with external accreditation requirements and the drive for greater standardization? Will its necessarily longer time frame consign it to a few small-scale research projects or is there real potential to use FLO techniques for other quality and safety problems beyond nosocomial infections?

System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee.

BACKGROUND: Preventable errors are common in healthcare. Over the last decade, Root Cause Analysis (RCA) has become a key tool for healthcare services to investigate adverse events and try to prevent them from happening again. The purpose of this paper is to highlight the work of the New South Wales (NSW) RCA Review Committee. The benefits of correctly classifying, aggregating and disseminating RCA data to clinicians will be discussed. In NSW, we perform an average of 500 RCAs per year. It is estimated that each RCA takes between 20 and 90 h to perform. In 2007, the NSW Clinical Excellence Commission (CEC) and the Quality and Safety Branch at the Department of Health constituted an RCA review committee. 445 RCAs were reviewed by the committee in 14 months. 41 RCAs were related to errors in managing acute coronary syndrome. RESULTS AND DISCUSSION: The large number of RCAs has enabled the committee to identify emerging themes and to aggregate the information about underlying human (staff), patient and system factors. The committee has developed a taxonomy based on previous work done within health and aviation and assesses each RCA against this set of criteria. The effectiveness of recommendations made by RCA teams requires further review. There has been conjecture that staff do not feel empowered to articulate root causes which are beyond the capacity of the local service to address. CONCLUSION: Given the number of hours per RCA, it seems a shame that the final output of the process may not in fact achieve the desired patient safety improvements.

Paediatric prescribing of asthma drugs in the UK: are we sticking to the guideline?

BACKGROUND: Asthma guidelines should lead to improved, more rational asthma medication prescribing. The aims of this study were to assess trends in paediatric asthma drug prescribing in the UK and to assess the potential impact of the publication of the British Thoracic Society (BTS) asthma guideline. METHODS: The estimated community paediatric prescribing figures for asthma medications in the UK were studied using data from the NHS Information Centre for Health and Social Care for the years 2000-2006. RESULTS: The numbers of prescriptions for bronchodilator syrups decreased by 60% from 2000 to 2006. However, this still represents 121,000 prescriptions for bronchodilator syrups in 2006 despite minimal recommendations for their use. The percentage of steroid inhalers prescribed as combination inhalers of a steroid and a long-acting beta agonist increased from 2.6% in 2000 to 20.6% in 2006. CONCLUSIONS: Steroid-alone inhalers should be the mainstay for the vast majority of patients with asthma who require controller medications. The increase in the number of combination inhalers prescribed is not consistent with the guideline recommendations that combination inhalers should only be introduced in those patients with asthma not controlled on adequate doses of inhaled steroids. Further education of health professionals is required.