Clinical audit: still an important tool for improving healthcare.

The use of data to challenge and improve healthcare has a long and distinguished history but has often failed to bring about expected improvements. It has never become fully embedded in clinical practice, probably because data alone are insufficient to drive change. There is now a greater appreciation that changing and improving healthcare requires changing behaviours. Clinical audit remains one of the important tools that can be used to facilitate such change.

Developing clinical guidelines: how much rigour is required?

Clinical guidelines that are rigorously developed play a fundamental role in improving healthcare and reducing unnecessary variations in practice. National guidelines are increasingly used by healthcare professionals, patients and commissioners; however, national bodies are unable to meet the demand for guidance on all topics. There are fewer resources available for guidance produced locally or by specialty groups, and it is necessary to achieve a balance between pragmatism and rigour while conforming to the widely accepted norms of what constitutes a good guideline. This paper introduces the key concepts around this topic with suggestions for those interested in developing their own guideline. An example of challenges encountered in generating high-quality clinical guidance is given in box 1. Box 1 Challenges in guideline development Professor Johnson runs a local developmental paediatrics service with eight other colleagues. All have different ways of managing children with PAVING syndrome. This was difficult for patients and staff and has led to disagreements on how certain patients should be managed. As a result, Professor Johnson developed a Guideline Development Group to look at the management of PAVING syndrome. The group identified 12 clinical questions (including diagnosis, exclusion of comorbidities, treatment modalities), searched the PubMed database and found some useful evidence that they used to formulate key recommendations. For one question about behavioural therapy, PubMed did not suggest any evidence so they informally arrived at a consensus among themselves and wrote up their guideline. On the back of this success, they applied for the guideline to be endorsed or supported by the Royal College of Paediatrics and Child Health (RCPCH). To their frustration, it was turned down on methodological grounds. Professor Johnson wrote to the RCPCH saying that he was "pretty peeved that the PAVING syndrome guideline had been rejected" for the College endorsement given all the work that had gone into writing it and "would the College mind being a bit more explicit in their guidance," to anyone who might consider doing this in the future?

Which urgent care services do febrile children use and why?

OBJECTIVES: To explore how parents navigate urgent and emergency care (U&EC) services when their child <5 years old has a feverish illness, their views of that experience and whether services are meeting their needs and triaging in line with national guidance. DESIGN: Parents of a febrile child <5 years old contacting any U&EC service in three localities during a 6-month period were invited to participate in a telephone questionnaire supplemented by case note review. A subset participated in an in-depth interview. RESULTS: Of 556 parents expressing an interest, 220 enrolled, making 570 contacts (median 3, range 1-13) with services during the child's illness which lasted 3 days on average. Parents' first preference for advice in hours was to see a general practitioner (GP) (67%; 93/138) and when unavailable, National Health Service Direct (46%; 38/82). 155 made more than one contact and 63% of the repeat contacts were initiated by a service provider. A range of factors influenced parents' use of services. Parents who reported receiving 'safety netting' advice (81%) were less likely to re-present to U&EC services than those who did not recall receiving such advice (35% vs 52%, p=0.01). Parents identified a need for accurate, consistent, written advice regarding fever and antipyretics. CONCLUSION: Parents know the U&EC service options available, and their first choice is the GP. Multiple contacts are being made for relatively well children, often due to repeated referrals within the system. Safety netting advice reduces re-attendances but parents want explicit and consistent advice for appropriate home management.

Interventions for improving communication with children and adolescents about their cancer.

BACKGROUND: Communication with children and adolescents with cancer about their disease and treatment and the implications of these is an important aspect of good quality care. It is often poorly performed in practice. Various interventions have been developed that aim to enhance communication involving children or adolescents with cancer. OBJECTIVES: To assess the effects of interventions for improving communication with children and/or adolescents about their cancer, its treatment and their implications, updating the 2003 version of this review. SEARCH STRATEGY: In April 2006 we updated searches of the following sources: CENTRAL (The Cochrane Library, issue 1 2006); MEDLINE (Ovid), (2003 to March week 5 2006); EMBASE (Ovid) (2003 to 2006 week 13); PsycINFO (Ovid) (2003 to March week 5 2006); CINAHL (Ovid) (2003 to March week 5 2006); ERIC (CSA) (earliest to 2006); Sociological Abstracts (CSA) (earliest to 2006); Dissertation Abstracts: (2002 to 6 April 2006).In 2003 we conducted searches of CENTRAL; MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, Sociological Abstracts and Dissertation Abstracts.For the initial (2001) publication of this review we also searched the following databases: PsycLIT; Cancerlit; Sociofile; Health Management Information Consortium; ASSIA; LISA; PAIS; Information Science Abstracts; JICST; Pascal; Linguistics and Language Behavior Abstracts; Mental Health Abstracts; AMED; MANTIS.We also searched the bibliographies of studies assessed for inclusion, and contacted experts in the field. SELECTION CRITERIA: Randomised and non-randomised controlled trials, and before and after studies, evaluating the effects of interventions for improving communication with children and/or adolescents about their cancer, treatment and related issues. DATA COLLECTION AND ANALYSIS: Data relating to the interventions, populations and outcomes studied and the design and methodological quality of included studies were extracted by one review author and checked by another review author. We present a narrative summary of the results. MAIN RESULTS: One new study met the criteria for inclusion; in total we have included ten studies involving 438 participants. Studies were diverse in terms of the interventions evaluated, study designs used, types of people who participated and the outcomes measured.One study of a computer-assisted education programme reported improvements in knowledge and understanding about blood counts and cancer symptoms. One study of a CD-ROM about leukaemia reported an improvement in children's feelings of control over their health. One study of art therapy as support for children during painful procedures reported an increase in positive, collaborative behaviour. Two out of two studies of school reintegration programs reported improvements in some aspects of psychosocial wellbeing (one in anxiety and one in depression), social wellbeing (two in social competence and one in social support) and behavioural problems; and one reported improvements in physical competence. One newly-identified study of a multifaceted interactive intervention reported a reduction in distress (as measured by heart rate) related to radiation therapy.Two studies of group therapy, one of planned play and story telling, and one of a self-care coping intervention, found no significant effects on the psychological or clinical outcomes measured. AUTHORS' CONCLUSIONS: Interventions to enhance communication involving children and adolescents with cancer have not been widely or rigorously assessed. The weak evidence that exists suggests that some children and adolescents with cancer may derive some benefit from specific information-giving programs, from support before and during particular procedures, and from interventions that aim to facilitate their reintegration into school and social activities. More research is needed to investigate the effects of these and other related interventions.