Realistic evaluation of Situation Awareness for Everyone (SAFE) on paediatric wards: study protocol.

INTRODUCTION: Evidence suggests that health outcomes for hospitalised children in the UK are worse than other countries in Europe, with an estimated 1500 preventable deaths in hospital each year. It is presumed that some of these deaths are due to unanticipated deterioration, which could have been prevented by earlier intervention, for example, sepsis. The Situation Awareness For Everyone (SAFE) intervention aims to redirect the 'clinical gaze' to encompass a range of prospective indicators of risk or deterioration, including clinical indicators and staff concerns, so that professionals can review relevant information for any given situation. Implementing the routine use of huddles is central to increasing situation awareness in SAFE. METHODS AND ANALYSIS: In this article, we describe the realistic evaluation framework within which we are evaluating the SAFE programme. Multiple methods and data sources are used to help provide a comprehensive understanding of what mechanisms for change are triggered by an intervention and how they have an impact on the existing social processes sustaining the behaviour or circumstances that are being targeted for change. ETHICS AND DISSEMINATION: Ethics approval was obtained from London-Dulwich Research Ethics Committee (14/LO/0875). It is anticipated that the findings will enable us to understand what the important elements of SAFE and the huddle are, the processes by which they might be effective and-given the short timeframes of the project-initial effects of the intervention on outcomes. The present research will add to the extant literature by providing the first evidence of implementation of SAFE and huddles in paediatric wards in the UK.

Summary of: A pilot improvement project in hospital-based oral healthcare: improving caries risk assessment documentation.

OBJECTIVE: To evaluate the impact of a continuous improvement project to improve completion of a caries risk assessment (CRA) and to assess its impact on delivery of dental caries prevention. DESIGN: Single centre clinical improvement project. SETTING: A paediatric dental department within a UK dental hospital over the course of 2008-2009. SUBJECTS (MATERIALS) AND METHODS: Continuous monitoring of documentation of a CRA was instigated and results fed back to clinicians. Tools were developed to structure the process of CRA. After six months of intervention, a comparison of preventive care to a pre-intervention sample was undertaken.Main outcome measures The main outcome measure was completion of a CRA. Comparison was also made with pre-intervention data on levels of preventive care received. RESULTS: Over the 12 month project the mean rate of CRA completion improved from 30% over the first 6 months to 73% in the second 6 months. Compared to the pre-intervention sample, all items of the caries prevention package had improved, with delivery of toothpaste strength advice (16% vs 60%, p = 0.001) and diet advice (32% vs 70%, p = 0.004) improving significantly. CONCLUSION: By targeting and improving CRA completion the quality of preventive care delivered has also significantly improved.

Multi-method evaluation of a paediatric ambulatory care unit (PACU): impact on families and staff.

AIM: To assess the impact of a purpose-built, short stay paediatric ambulatory care unit (PACU) on the patient journey and perceptions of parents, staff and referrers. METHODS: Multi-method evaluation, including a parent survey (n = 104), patient journey mapping (n = 10), staff interviews (n = 10), a referrer survey (n = 16), routine activity analysis, and a comparison with the A&E service (A&E parent survey: n = 41). RESULTS: Almost all parents attending PACU (94%) were satisfied with the service and significantly more likely to feel "very" satisfied than parents attending A&E (PACU: 51%, A&E: 31%; p = 0.03). Further, over three quarters (77%) of PACU parents preferred the new model to traditional A&E services. They reported receiving sufficient information (93%), reduced anxiety (55% anxious before service, 13% anxious after; p<0.001), "quick" waiting times (median: 35 min), and enhanced confidence (87%) and understanding (89%) in dealing with their ill child. The number of stages in the patient journey was reduced from six ("traditional" A&E pathway) to four (PACU pathway). Staff and referrers reported this was a "superior" model to A&E, but that improvements were required around appropriate referrals and the need for more multi-disciplinary protocols and liaison. CONCLUSION: Our study suggests that the PACU model is perceived to be an effective alternative to standard A&E services for the assessment and early management of acutely ill children and their families attending a hospital. It is highly valued by users, staff and referrers and enhances the patient journey. Lessons learnt include the need to enhance multi-disciplinary processes and clarify the role of this form of acute care provision in the wider healthcare system.

Wheeze detection: recordings vs. assessment of physician and parent.

BACKGROUND: Parental and professional agreement as to the presence of wheezing in infants and preschool children has been shown to be poor. Agreement on the absence or presence of physical signs on chest examination in these populations is far from perfect, even among experienced physicians. OBJECTIVES: We sought to compare the assessment of a parent, nurse, and physician with the "gold standard" of acoustic analysis for the presence of wheezing in infants and preschool children attending a hospital clinic. SETTING AND SUBJECTS: Urban district general hospital in North London, England. Wheezy children under 6 years old attending a "walk-in" emergency pediatric ambulatory care unit. RESULTS: Comparisions were completed on 31 children (age range 4-62 months). The severity of wheeze was independently evaluated by a parent, nurse, and experienced pediatrician, and these were compared with breath sounds recorded and analyzed by acoustic techniques for the presence and severity of wheezing. In only 10 of 31 (32%) children did the parent and the physician agree on the wheeze severity score. In 13 infants, the parent scored higher than the doctor and in 8 the parent scored lower. In 16 (52%) of the children, there was complete agreement as to the severity of wheezing by the nurse and the physician. In 24 of the 31 children (77%), the acoustic wheeze score agreed with the physician wheeze score; in 6 children the acoustic score was lower and in 1 it was higher. CONCLUSIONS: The physician was able reliably to judge the severity of wheeze measured objectively, whereas nurses and parents were not. This study has important implications for the interpretation of parental questionnaire studies of asthma prevalence and severity.

Intravenous salbutamol bolus compared with an aminophylline infusion in children with severe asthma: a randomised controlled trial.

BACKGROUND: The relative efficacies of aminophylline and salbutamol in severe acute childhood asthma are currently unclear. A single bolus of salbutamol was compared with a continuous aminophylline infusion in children with severe asthma in a randomised double blind study. METHODS: Children aged 1-16 years with acute severe asthma were enrolled if they showed little improvement with three nebulisers (combined salbutamol and ipratropium) administered over an hour and systemic steroids. Subjects were randomised to receive either a short intravenous bolus of salbutamol (15 micro g/kg over 20 minutes) followed by a saline infusion or an aminophylline infusion (5 mg/kg over 20 minutes) followed by 0.9 mg/kg/h. RESULTS: Forty four subjects were enrolled, with 18 randomly allocated to receive salbutamol and 26 to receive aminophylline. The groups were well matched at baseline. An intention to treat analysis showed that there was no statistically significant difference in the asthma severity score (ASS) at 2 hours between the two groups (median (IQR) 6 (6, 8) and 6.5 (5, 8) for salbutamol and aminophylline respectively, p=0.93). A similar improvement in ASS to 2 hours was seen in the two groups (mean difference -0.08, 95% CI -0.97 to 0.80), there was a trend (p=0.07) towards a longer duration of oxygen therapy in the salbutamol group (17.8 hours (95% CI 8.5 to 37.5) v 7.0 hours (95% CI 3.4 to 14.2)), and a significantly (p=0.02) longer length of hospital stay in the salbutamol group (85.4 (95% CI 66.1 to 110.2) hours v 57.3 hours (95% CI 45.6 to 72.0)). There was no significant difference in adverse events between the two groups. CONCLUSIONS: This study suggests that, in severe childhood asthma, there is no significant difference in the effectiveness of a bolus of salbutamol and an aminophylline infusion in the first 2 hours of treatment. Overall, the aminophylline infusion was superior as it significantly reduced the length of stay in hospital.

Issues in the identification of comorbidity of mental retardation and psychopathology in a multicultural context.

Identification of the comorbidity of mental retardation and psychopathology in a multicultural setting raises manifold difficulties. The present study explored the sampling and identification issues implicated in estimating the prevalence of this dual diagnosis in a South African clinic sample. The relations between the prevalence of dual diagnosis and socioeconomic status, gender, and severity level of retardation were investigated. The detection rate of 4.36% was significantly lower than that of other studies. Prevalence was found to be greater in areas of high socioeconomic status, among males, and among less severely retarded individuals. Implications of these findings for cross-cultural studies and for allocation of service resources for patients with dual diagnosis are considered.

Association between the diagnosis of mental retardation and socioeconomic factors.

Clinic data from the regional hospital in Cape Town, South Africa, over 4 years for 538 children with a diagnosis of mental retardation were examined in order to establish whether differences in mental retardation referral patterns existed between low and high socioeconomic areas. Results indicate that mild mental retardation referrals were underrepresented in low socioeconomic areas and that paramedical agencies were the primary referral source in these areas. Differences in mild mental retardation referral patterns by area over time may stem from service difficulties or variations in referral thresholds. Cross-cultural implications of the findings were discussed with relevance to the development of culturally sensitive community-based intervention programs.

The aetiology of learning disability in preschool children with special reference to preventability.

The aims of the study were to determine the aetiology of moderate and severe learning disability in preschool children in Cape Town, to consider the causes by race and to assess the degree of preventability. All children under the age of 6 years who presented to the Developmental Assessment Clinics at the Red Cross Children's Hospital with a developmental quotient of less than 50 over a 1-year period were included. The Development Assessment Clinics form a regional multidisciplinary service for the evaluation of preschool children with development disabilities. Over the 12-month period, 232 children were identified, of whom 65% were Coloured, 32% African and the remaining 3% white. This roughly corresponds with teh breakdown of births by race in the region. Regarding the aetiology, in 45% the disability was prenatal in origin, in 17% perinatal, in 9% postnatal and in a quarter it was idiopathic. In the Coloured and white children, the cause in over a half arose prenatally and in 8.3% postnatally. In contrast, the cause in less than a third of the African cases arose in the prenatal period, but 36% resulted from perinatal complications. More of the African children had multiple disabilities and additional disabilities were more common in the perinatal and postnatal categories. Forty per cent of all cases were considered to be preventable, 16% with existing knowledge and current practice. There was no significant difference in preventability between the races.

Child abuse services at a children's hospital in Cape Town, South Africa.

UNLABELLED: Since the establishment of a Child Abuse Management Service at the Red Cross War Memorial Children's Hospital in the early 1980s, there has been a steady increase in patient numbers. In order to assess the profile of patients, and also the allocation of staff to the service, all child abuse related patients seen at the Red Cross War Memorial Children's Hospital in Cape Town over the period of June 1989 through July 1990 were reviewed. Five hundred and three children with a median age of less than 7 years were seen. Abuse was confirmed in 389 (160 physical abuse and 229 sexual abuse). Abuse was suspected and not confirmed in 114 (41 physical and 73 sexual). Half of the patients presented to the hospital outside of normal working hours. Eighty-one percent of children less than 5 years of age were seen in the Trauma Unit by surgical residents with minimal pediatric training. One hundred and thirty four of the patients were Xhosa speaking while only one social worker and no medical staff could speak Xhosa. Pediatric residents were involved in the care of less than 2% of cases. CONCLUSION: Management of child abuse constitutes a significant commitment and appropriate staff allocation is essential. Although it is not possible for each child in whom abuse is suspected to be seen by a specialist, they should be seen by those staff with the most expertise. Staff allocation must take into account the needs for education, training, and audit as well as service provision.

Sexually transmitted diseases in children and evidence of sexual abuse.

During the period June 1989 to March 1991, laboratory evidence of sexually transmitted diseases (STDs) was found in 107 patients at the Red Cross War Memorial Children's Hospital in Cape Town. Data was available on 96 patients aged 23 months to 14 years (mean 75.9 months). Vaginal discharge was the most frequent presenting symptom (76%), particularly in those less than 5 years of age (90%). Although a history of abuse was not given on presentation in 62%, evidence of abuse was subsequently elicited in 67% of patients. Neisseria gonorrhoeae was the most common sexual pathogen (61 isolates, 8 penicillin resistant), followed by G vaginalis (17 isolates), Trichomonas vaginalis (7 infections), and T pallidum (9 TPHA positive, 5 with VDRL 1:4 or higher). Chlamydia trachomatis was demonstrated by immunofluorescence in 14 children. Multiple STDs were demonstrated in 10 patients. Although evidence of CSA was not found in all patients with STDs it was likely that the vast majority of patients had acquired these infections by CSA. Symptomatic prepubertal children with G vaginalis isolates should be investigated for CSA. Chlamydial immunofluorescence tests did not assist the diagnosis of CSA in children and should not be used, as they have no medicolegal significance.

PIP: This study examines the nature and extent of sexually transmitted diseases related to sexual abuse among patients seeking treatment during June 1989-March 1991 at the Red Cross War Memorial Children's Hospital in Rondebosch, Cape Town, South Africa. 107 patients aged 23-174 months (about 2-15 years of age) were identified by laboratory testing as having a sexually transmitted disease. Analysis pertained to 96 patients. 10 children had multiple infections. 60 patients were assessed after 2-3 months, of whom 20% (12 cases) indicated evidence of child sexual abuse. 47% of the 36 patients who were not followed-up had evidence of child sexual abuse. Age was unrelated to follow-up or sexual abuse. Genital symptoms were evident at the initial visit among 87 patients (91%), of whom 65% had no prior history of abuse. 26% had a history of sexual abuse. 8 patients had a history of sexual abuse but no genital symptoms. 79% had genital symptoms of vaginal discharge. 39 patients aged under 5 years had a vaginal discharge, and 10 had a history of sexual abuse. 29 cases were determined not to be related to sexual abuse. There were 61 children infected with Neisseria gonorrhoea, 17 children with Gardnerella vaginalis, 14 children with Chlamydia trachomatis, 9 children with Trichomonas vaginalis, and 9 children with Treponema pallidum (positive cultures for syphilis, but without clinical features). Sexual child abuse was found to be higher than previously reported at this center. The approach in this study was to deny sexual abuse until confirmation of a sexually transmitted disease. Almost 33% of children in this study had no physical evidence of sexual abuse. The hospital policy is to teach children and caregivers safety skills and awareness and to develop a rapport with parents. Ceftriaxone was administered as therapy, since most children had gonorrhea, and there was resistance to penicillin and poor follow-up. The authors find that all children with Gardnerella vaginalis should be investigated for child sexual abuse. There was an express need for follow-up of patients due to the almost 10% with multiple infections.

Rarity of fistulas in Crohn's disease of the jejunum.

: To compare the fistulizing tendency of Crohn's disease of the jejunum versus the ileum, we reviewed the records of 1,920 patients with Crohn's disease admitted to the Mount Sinai Hospital between 1960 and 1994. Fifty-eight of the cases (3%) had jejunal involvement. Of these 58 patients, six (10%) had fistulas originating from the jejunum. Four of the cases of jejunal fistulas came from a subgroup of 41 patients who had both jejunum and distal ileum involvement (10%); by contrast, there were 12 cases of ileal fistulas in the same subgroup (29%, p = 0.05). As another measure of the relative rarity of jejunal versus ileal fistulization, there were 252 cases of ileal fistulas in our overall series among 723 patients with distal ileal Crohn's disease (34%), compared with the 10% (six of 60) incidence of jejunal fistulization (p = 0.001). Only 50% (316) of our cases of jejunal fistulization were spontaneous, compared with 86% of a random sample (43 of 50) from our 252 cases of fistulas with ileitis. The development of jejunal fistulas did not appear to depend upon the presence of stricturing; they were nearly as common among nonstricturing cases (two of 27, 7%) as among stricturing cases (four of 31, 13%; p = NS). The inherent proclivity of Crohn's disease to fistulize thus appears to increase with a progressively distal location in the gastrointestinal tract.

Breaking bad news to parents with disabled children--a cross-cultural study.

This cross-cultural retrospective study investigates the problems parents experience when told that their child is physically and/or mentally disabled. The authors try to compare, where relevant, some of the responses of the parents from different ethnic groups. The parents of 40 randomly selected coloured, 26 white and 24 black pre-school children who were first seen at the Developmental Assessment Clinic at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa between January 1989 and December 1990 were asked to participate in this study. The final sample comprised 65 children. Except for the Xhosa speaking parents, the majority of parents received the diagnosis in their own language (English or Afrikaans). Most Xhosa speaking parents denied having received an explanation of the diagnosis, or having had an opportunity to ask questions. Only a few black parents reported being asked as to their understanding of the diagnosis. White parents tended to deny the diagnosis of mental handicap more often than the other groups despite reporting that explanations were given. The majority of parents would have liked a written report after the first consultation. Despite these findings, most parents felt satisfied with the way the news were given to them, reported good progress in their children and some of them expected their children to go to a normal school. Use of a language other than the parent's tongue tends to have a negative influence on the communication between doctors and parents. A diagnosis of mild mental handicap, a 'perception' of good progress and an absence of visible signs of the disability contribute to parental denial of the reality of the child's developmental delay and its scholastic consequences. The process of 'breaking the news' can be facilitated by the introduction of a few simple measures as described in the recommendations.

Social factors associated with tuberculous meningitis. A study of children and their families in the western Cape.

A descriptive study was conducted in order to assess some of the social factors associated with the long-term effects of tuberculous meningitis on children and their families. The specific areas examined were the socio-economic status of the children, maternal employment, the utilisation of health services and the scholastic progress of the children. Recommendations are made. The sample was drawn from a register of children with tuberculous meningitis in the Western Cape Health Region for the period 1985-1987. All the available survivors (16 black and 91 coloured children) were included in the study and the care-giver was interviewed by a researcher. Forty-six subjects lived in an urban area and 61 in a rural area. All the children came from socially deprived families and lived in over-crowded conditions; a significant number of families had incomes below the household subsistence level. Of the mothers previously employed, 35% had stopped working and 19% of the families experienced a financial loss as a result of the child's illness. The majority of urban children utilised public health services and the majority of rural children were dependent on the private sector for health care. School-going children had a high failure rate (53%).

Missed opportunities for measles immunisation in selected western Cape hospitals.

Measles is still a major cause of childhood mortality and morbidity in South Africa. The World Health Organisation (WHO) has recently recommended that greater attention be paid to opportunities for immunisation in the curative sector. This study quantified the extent of missed opportunities for measles immunisation in children attending primary, secondary and tertiary level curative hospitals in the western Cape. Exit interviews of 1,068 carers of children aged between 6 and 59 months inclusive showed that 2.4-40.7% of carers had been requested to produce a Road-to-Health card, and that 4.8-43.1% of carers had a card available. The proportion of children with documented evidence of measles immunisation available ranged from 4.8% to 40.0% between facilities. The study demonstrated that a considerable number of potential opportunities to immunise children against measles are currently being missed in children attending hospitals and day hospitals in the western Cape. The study documents the effect of a fragmented approach to health care, and indicates a need for rapid integration of preventive and curative components of health care into a metropolitan-based primary health care service.

The referral letter--a problem of communication.

This cross-sectional descriptive study assesses the letters sent with referred patients to Red Cross War Memorial Children's Hospital, Cape Town, and makes appropriate recommendations. During the 6-month period 1 July-31 December 1987, 9,288 letters were photocopied at the admissions offices of the hospital. A sample of the letters collected, systematically stratified to represent the available days during the study, was analyzed. Detailed analysis of 1,143 (12.3%) letters was undertaken. The private sector, i.e. general practitioners, was the largest referral agency, followed by community-based day hospitals. The quality of information in referral letters was comparable to that found in other studies. The quality of letters influenced the writing of replies by hospital staff. There is a need to develop ways of improving communication between hospital staff and referral agents.

Patterns of referral to Red Cross War Memorial Children's Hospital, Cape Town.

Patterns of referral to Red Cross War Memorial Children's Hospital were studied to assess the appropriateness of referrals. From 1 July to 31 December 1987 all 9,288 referral letters presented to the hospital were collected and a sample (4,662 letters) analysed. It emerged that the patients were similar to those attending the outpatient department without referral, except that relatively fewer referred patients were black. The private sector, i.e. general practitioners, was the largest referral agency, followed by day hospitals. Most patients were referred to the outpatient department without an appointment. Of the specialist clinics, the surgical clinics (i.e. ophthalmology and ear, nose and throat) had the highest number of referrals. The majority of patients (84.9%) were not admitted. Only in 30.3% of referred cases did the hospital make contact with referral agents. Referral rates were highest from the predominantly coloured areas of the Cape Peninsula. The hospital cannot isolate itself from the community it serves and needs to support and guide referral agents in order to improve the utilisation of the hospital. Training of health professionals in order to increase expertise is a priority. A study of the total patient population would facilitate the understanding of hospital utilisation. Similar studies could be beneficial at other hospitals.