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PubMed2001

Delegation in paediatric anaesthesia: a postal survey.

BACKGROUND: We wished to determine a consensus view from UK paediatric anaesthetic consultants of what practical skills are safe and appropriate for an anaesthetic trainee to perform during an initial 3-month module in paediatric anaesthesia. METHODS: A postal survey was sent to all UK and Ireland members of the Association of Paediatric Anaesthetists (APA). This questionnaire was designed to determine which tasks were delegated to trainee anaesthetists. Two hundred and four questionnaires were despatched, replies were received from 165 consultant anaesthetists (80% response rate). RESULTS: More than 50% of the APA respondents would always or regularly allow an anaesthetic trainee in their first 3-month module in paediatric anaesthesia to perform; an ilioinguinal block, a penile block and a caudal (but not in a neonate). CONCLUSIONS: Anaesthetic registrars undertaking an initial module in paediatric anaesthesia should learn basic airway management, ilioinguinal blocks, penile blocks and caudals (but not neonatal caudals).

Anesthesia↗

PubMed2002

Benefits and barriers for registered nurses undertaking post-graduate diplomas in paediatric nursing.

This paper presents one aspect of a larger study identifying key influences on curriculum redesign and development of a post-graduate diploma in advanced clinical nursing. The focus is on paediatric intensive care and general paediatric streams. Data presented here relate to registered nurses' perceptions of benefits and barriers when undertaking this post-graduate diploma. As well as interviews and focus group discussions with a number of nurses, data were collected through a self-administered questionnaire, A total of 885 surveys were distributed to nurses working in paediatric areas in five hospitals in Victoria, Australia. Of these, 391 were completed (response rate 44%). One hundred and thirty (33%) had post-registration or post-graduate paediatric qualifications. Perceived benefits of undertaking the post-graduate diploma mainly related to an increase in knowledge and experience and improvement of employment opportunities. Perceived barriers mainly related to financial and professional issues such as cost of the course, loss of salary, the lack of direct remuneration on completion of the course and a lack of promotional opportunities. It was of concern that several nurses expressed a belief that paediatric qualifications were unnecessary and that many believed their employers did not value the qualification. Several recommendations are suggested to address the main barriers. These include more flexibility in the provision of such courses and opportunities for financial assistance.

Attitude of Health Personnel↗

PubMed2001

Paediatric surgical reality in Germany and visions for the future.

Over the past 2 centuries paediatric surgery has developed into a well-recognised, independent surgical speciality comparable to plastic surgery or thoracic and vascular surgery. About 550 members of the GAPS (German Association of Paediatric Surgery) annually treat about 2-3% of all 0-15-year-old children of the FRG and operate 32.5% of all children who need a surgical intervention in paediatric surgical centres. There are 83 paediatric surgical centres in the FRG. Most of them perform more than 2000 operations per year. Three newer developments are likely to influence the future of paediatric surgery in Germany: 1. demographic factors, particularly the massive reduction of the reproduction rate from factor 1 to 0.59; 2. the new German National Health Care System, called "Strukturreform 2000", which will introduce the Australian DRG system and a new administrative structure permitting only a restricted care of the patients under tight economic control; and 3. the European regulations of the UEMS/EBPS which the national Landesärztekammern will be required to adopt.

Delivery of Health Care↗

PubMed2001

Quality of paediatric care: application and validation of an instrument for measuring parent satisfaction with hospital care.

OBJECTIVE: To apply and validate an adapted version of an existing adult patient questionnaire in a study of parental satisfaction with paediatric care in a university hospital. DESIGN: A cross-sectional, anonymous questionnaire study. A total of 912 questionnaires were distributed to parents by hospital staff during a 2-week period. SETTING: A university children's hospital in Stockholm, Sweden. STUDY PARTICIPANTS: Six hundred and twenty-four parents whose children were receiving care at the hospital during a 2-week period in April of 1999. MAIN OUTCOME MEASURES: The 63-item questionnaire uses eight main measurement indices and an overall quality rating to define parental satisfaction with paediatric care. Measures of the instrument's reliability and validity were established by comparison with results of a pilot study conducted 1 year earlier on the paediatric departments of two regional Swedish hospitals. All measures were compared to reliability and validity estimates in the original patient questionnaire. RESULTS: A total of 624 questionnaires were returned, a response rate of 68%. The instrument demonstrated good reliability and validity. Reliability estimates for all eight indices were greater than 0.70 and consistent over time. Inter-index correlations were generally lower than 0.60, indicating index independence. Of the nine parameters measured, parents were most satisfied with staff attitudes, care processes and medical treatment. Parents' ratings were lowest for accessibility and staff work environment. CONCLUSION: This study presents a valid and reliable questionnaire instrument for measuring parental views of paediatric hospital care. The instrument measures the quality of paediatric care from a broader perspective than previously existing parent questionnaires.

Adolescent↗

PubMed1991

A prospective randomized study comparing once- versus twice-daily amikacin dosing in critically ill adult and paediatric patients.

Three hundred and forty eight critically-ill patients with a documented Gram-negative infection were randomized to receive amikacin once- (od) or twice-daily (bd). The amikacin was given by slow intravenous injection in a daily dose of 20 mg/kg in patients under the age of one year (paediatric group) and 15 mg/kg in patients over the age of one year (adult group). Paediatric and adult patients on the od regimen received a loading dose of 25 and 20 mg/kg respectively. The dosages were subsequently adjusted to achieve desirable blood levels. Patients received other antibiotics as clinically indicated. Forty-eight patients were withdrawn from the study due to death or azotaemia occurring in the first 72 h. One hundred and fifty five patients (76 paediatric) received an od dose and 145 (65 paediatric) received a bd dose. The clinical cure rate was 83% in the od group compared to 66% in the bd group (P = 0.001). The bacteriological cure rate was 81% in the od group compared to 58% in the bd group (P = 0.005). In the paediatric sub-group the cure rate was higher with the od regimen (P = 0.002) but this difference was not statistically significant in the adult patients (P = 0.1). The serum creatinine rose in 35% of patients in the bd group compared to 21% in the od group (P = 0.05). Although audiometry was not performed there was no clinical evidence of ototoxicity in any of the patients. In conclusion od amikacin dosing resulted in a higher cure and less nephrotoxicity than conventional bd dosing.

Adolescent↗

PubMed1995

Interventional catheterization in paediatric cardiology.

The primary role of interventional procedures in the management of some congenital heart diseases is established and their clinical utility broadens every day. Yesterday's relatively crude procedures have been replaced by safe and more effective techniques. Improvements and new developments in specifically designed paediatric equipment have played a significant role. In order to meet the cardiologist's drive to refine existing techniques and develop new ones, further investment into paediatric cardiac catheterization equipment is mandatory. More and more "heart operations' will be performed in cardiac catheterization laboratories in the future, and this will have clear implications on costs, as most non-surgical techniques are cheaper than surgery, and hospitalization is much shorter. New methods, tested within research protocols in specialized centres, combined with continuous critical evaluation of established techniques will ensure improved and sustained results. The primary consideration of practising paediatric cardiologists should not be whether it is possible to perform such techniques, but whether their clinical utility, morbidity and mortality justifies a non-surgical approach for their centre. Interventional catheterization, in other words has to "compete' with the results of surgery prior to new techniques being recommended for general use. Despite this "competition' it has been welcome to see a collaboration between paediatric cardiologists and paediatric cardiac surgeons in planning staged repairs of complex congenital heart disease. A typical example of this is the fenestrated Fontan procedure, in which the immediate post-operative course has dramatically improved due to the deliberate placement of a residual atrial shunt, which is then closed with an umbrella in the catheter laboratory. This type of cooperation is bound to increase further and is already contributing to a far better outcome for many of the complex congenital heart lesions.

Angioplasty, Balloon↗

PubMed2000

Assessing the appropriateness of paediatric hospital admissions in the United Kingdom.

BACKGROUND: In order to assess whether the documented rise in paediatric admissions was due to inappropriate admissions, an objective measure of the appropriateness of paediatric admissions, modified for use in the United Kingdom, was used to measure the level of inappropriate admissions. The relationship of appropriateness of admissions to age, gender, time of admission and source of referral was investigated. METHODS: A retrospective review was carried out of a sample of paediatric records in 13 NHS district general hospitals in South Eastern England between April 1990 and March 1991 using the Paediatric Appropriateness Evaluation Protocol (PAEP) modified for use in the United Kingdom. RESULTS: A total of 3,324 paediatric admissions in 13 hospitals were assessed. Eight per cent of the sampled admissions were inappropriate. Age [odds ratio (OR)=0.87], gender (OR = 1.39) and weekend admissions (OR = 1.42) were associated with inappropriate admissions. After controlling for these factors, there was no significant variation between hospitals. CONCLUSION: The low level of inappropriate admissions may be a reflection of well-developed primary care services in the United Kingdom. Alternatives to hospital admission for the assessment of minor self-limiting illness in young children may have a role in reducing inappropriate admissions.

Age Distribution↗

PubMed2004

More 'cries from the joints': assessment of the musculoskeletal system is poorly documented in routine paediatric clerking.

OBJECTIVES: The aim of this study was to describe the assessment of the musculoskeletal (MSK) system in comparison with other systems in routine paediatric medical clerking. Furthermore, to survey trainee paediatricians (SPRs, specialist registrars) about their self-rated confidence in assessing the MSK system. METHODS: Case notes of consecutive general paediatric medical patients admitted to three UK hospitals over a 4-week period were assessed using a standard pro forma. All patients had been assessed by a consultant paediatrician during their admission. A postal questionnaire was sent to all SPRs in training in each of the hospitals, regarding their confidence in assessing the MSK system compared with other systems and their exposure to MSK teaching. RESULTS: Case notes of 257 patients [117 females, median age 3 yr (range 1-18 yr)] were reviewed. The most common reason for admission was acute infection, although the spectrum of other recorded diagnoses varied between hospitals. Thirteen children (5%) had an acute problem (e.g. infection) against a background of chronic disease. The case note documentation showed that cardiovascular (CVS), respiratory (RS) and gastrointestinal (GI) systems were assessed in the vast majority (>90%) of patients, irrespective of the underlying diagnosis. However, other systems were less well recorded; the trend being the same in each hospital and in descending order, the neurological system (38%), skin (32%), eyes (10%) and musculoskeletal system (4%). Only 2.7% (7/257) patients were documented to have been asked about MSK symptoms, and only 1.6% (4/257) had any documentation of joint examination--in all cases this was limited (e.g. range of movement of the knee only), and no patients had documentation of gait being examined, even in those children presenting with 'limp'. The response rate to the postal questionnaire was 60% (67/112). The self-rated confidence in MSK assessment was markedly low in comparison with other systems, even though 61/67 recalled some teaching of the MSK system as an undergraduate (61/67) or postgraduate (50/67). Of note none could recall teaching as an undergraduate in paediatric MSK assessment and where there had been postgraduate rheumatology MSK teaching this had been delivered by paediatric rheumatologists in many cases (34/50), reflecting the centres participating in the study. CONCLUSIONS: In routine general paediatric medical in-patient clerking and throughout the admission, MSK assessment was rarely documented, and even where present was limited. This contrasts markedly with other systems which were examined in most children irrespective of the presenting complaint. Self-rated confidence in MSK assessment is low amongst SPRs compared with other systems, despite most recalling some teaching. This discrepancy between teaching and clinical practice needs to be addressed in undergraduate and postgraduate training.

Adolescent↗

PubMed1999

Paediatric intensive care in Kuala Lumpur, Malaysia: a developing subspecialty.

Paediatric intensive care in Malaysia is a developing subspecialty with an increasing number of specialists with a paediatric background being involved in the care of critically ill children. A part prospective and part retrospective review of 118 consecutive non-neonatal ventilated patients in University Hospital, Kuala Lumpur was carried out from 1 June 1995 to 31 December 1996 to study the clinical epidemiology and outcome in our paediatric intensive case unit (PICU). The mean age of the patients was 33.9 +/- 6.0 months (median 16 months). The main mode of admission was emergency (96.6 per cent) with an overall mortality rate of 42 per cent (50/118). The mean paediatric risk of mortality (PRISM) score was 20 +/- 0.98 SEM, with 53 per cent of patients having a score of over 30 per cent. Multiorgan dysfunction (MODS) was identified in 71 per cent of patients. Admission efficiency (mortality risk > 1 per cent) was 97 per cent. Standardized mortality rate using PRISM was an acceptable 1.06. The main diagnostic categories were respiratory (32 per cent), neurology (22 per cent), haematology-oncology (18 per cent); the aetiology of dysfunction was mainly infective. Non-survivors were older (29.5 vs. 13.8 months, p < 0.0001), had more severe illness (mean PRISM score 30 vs. 14, p < 0.0001), were more likely to develop MODS (96 vs. 53 per cent, p < 0.0001) and required more intervention and monitoring. Paediatric intensive care in Malaysia differs widely from that in developed countries in patient characteristics, severity of illness, and care modalities provided.

Child, Preschool↗

PubMed1996

Cerebral blood flow imaging in paediatrics: a review.

The ability to study regional cerebral blood flow (rCBF) is available in many institutions, especially with the spread of multi-headed gamma cameras. The use of this technique in paediatrics requires special attention to detail in the manner of data acquisition and handling the child. The interpretation of the rCBF study in a child requires knowledge of normal brain maturation. The major clinical use in paediatrics is epilepsy because of the advances in surgery and the frequency of complex partial seizures. Other indications in paediatric neurology include brain death, acute neurological loss including stroke, language disorders, cerebral palsy, hypertension due to renovascular disease, traumatic brain injury and migraine. There are paediatric psychological conditions in which rCBF assessment has been undertaken, including anorexia nervosa, autism, Gilles de la Tourette Syndrome (GTS) and attention deficit disorder-hyperactivity (ADHD). This article attempts to review all aspects of rCBF studies in paediatrics.

Adolescent↗

PubMed2007

Skin surveillance of a U.K. paediatric transplant population.

BACKGROUND: Solid organ transplant recipients are at increased risk of skin cancer. Melanoma is less common than nonmelanoma skin cancer (NMSC) although the relative proportion of melanoma among skin cancers has been shown to be higher in paediatric than adult recipients. Multiple melanocytic naevi and/or atypical naevi may be a risk factor for the development of melanoma. The relationship between naevus counts and phenotypic characteristics, disease-related variables and sun exposure has not been explored in paediatric transplant patients. OBJECTIVES: To determine the prevalence of premalignant and malignant skin lesions and to identify known risk factors associated with benign and atypical melanocytic naevi in a U.K. paediatric transplant population. METHODS: Paediatric (< or = 19 years) renal and liver transplant patients, who were 5 or more years post-transplantation, were reviewed over 12 months. Lifetime history of sun exposure, episodes of sunburn, sunny holidays, sunscreen use, sun bed use, demographic and transplantation details were collected using interview, questionnaire and case note review. A skin examination was performed for regional counts of malignant lesions, benign and atypical naevi. RESULTS: Ninety-eight patients (82 liver, 13 renal, three multiorgan) with a median follow up of 9 years (range 5-16) were reviewed. Neither skin cancer nor premalignant lesions for NMSC were detected in this group. Eighty-five patients had benign naevi (median 6, range 1-57). Clinical risk factors for increased counts of benign naevi included increasing age (P = 0.03), more episodes of sunburn (P = 0.003) and prolonged treatment with cyclosporin (P = 0.009). The presence of atypical naevi in six patients was significantly associated with more episodes of sunburn (P = 0.006) and more transplants (P = 0.04). Other variables including phenotype, skin type, sun exposure, holidays abroad, residence abroad and total duration of immunosuppression did not correlate with benign or atypical naevus counts. CONCLUSIONS: Skin cancer was not observed in paediatric solid organ transplant recipients who were 5-16 years post-transplantation. Both benign and atypical naevus counts were higher in children with frequent episodes of sunburn. As both naevi and sunburn are risk factors for melanoma, we should target fair-skinned transplant recipients with naevi for intensive sun avoidance education. A prospective, longitudinal follow-up study should determine the onset of skin cancer post-transplantation and the significance of benign and atypical naevus counts in this cohort.

Adolescent↗

PubMed1994

Teaching paediatric pharmacotherapy at colleges of pharmacy in the United States and Canada.

We conducted a survey of 83 colleges of pharmacy in the United States, Puerto Rico and Canada to determine the status of didactic and experiential paediatric pharmacotherapy teaching in entry-level programmes. Sixty-five completed surveys (54 from BS programmes and 11 from entry-level PharmD programmes) were received and analysed. Forty-four (81.5%) BS programmes and 11 (100%) of the entry-level PharmD programmes provide an average of 5.1 and 9.2 h of didactic paediatric teaching, respectively. While all of the entry-level PharmD programmes offered experiential rotations in paediatrics, only 38 (70%) provided BS students with an opportunity to receive paediatric experiential training. Colleges of pharmacy should re-evaluate their curricula to ensure sufficient preparation of graduates in paediatric pharmacotherapy for entry-level positions.

Canada↗

PubMed2006

Paediatric and adult computed tomography practice and patient dose in Australia.

The current practice for CT scanning of paediatric patients in Australia has been assessed through a survey sent to the site of all CT scanners licensed in New South Wales and all dedicated children's hospitals in Australia. The survey addressed demographic details, CT scanner details and scanning parameters for four imaging scenarios (brain CT, chest CT, abdomen/pelvis CT and high-resolution chest CT for three different age groups (8 weeks, 5-7 years and adult patients). The effective dose for each imaging scenario and age group was calculated and compared for 52 sites representing 53 CT scanners. For any age group and imaging scenario, there was a large spread of effective dose. For comparable CT examinations, the effective dose varied by up to 36-fold between centres. There was a clear trend for centres that frequently carry out CT scans on paediatric patients to have the lowest radiation doses. Four age group/imaging scenarios showed significantly lower effective doses for hospital-based CT than for nonhospital sites. There was also a trend for doses to be lower at dedicated paediatric centres. Effective dose was closely associated with mAs, with most centres using lower mAs for younger patients, but few centres reduced the kVp for paediatric patients. The results of the survey emphasize the need for continuing education and protocol review, particularly in paediatric CT examinations, in a complex and fast changing environment.

Adult↗

PubMed1988

Australian paediatricians and the new morbidity: a national survey of changing paediatric practice patterns.

General paediatricians across Australia were surveyed to determine whether their practice reflected the commonly held assumption that paediatrics was changing, with an increased emphasis on ambulatory and community care and involvement with conditions comprising the new morbidity. A 10 page questionnaire was mailed to every paediatrician in the Australian College of Paediatrics directory of members considered to be practising general paediatrics. Of a total of 287 questionnaires distributed, 224 were returned (response rate 80.9%). Two-thirds of respondents practised in a capital city, while the remaining third were divided equally between isolated paediatricians and those who practised in a provincial city. Only 15 paediatricians (6.8%) spent more than half their time involved in inpatient care, while 60% spent less than one-fifth of their time with inpatients. There was no correlation between inpatient involvement and length of paediatric practice, but surprisingly there was a significant trend (P = 0.007) for paediatricians practising in a capital city to do more inpatient work. Respondents were provided with a list of eight conditions held commonly to comprise the new morbidity, and there was a strong response indicating an increase in children seen with these conditions over the past 5 years, as well as a decrease in children with clearly identifiable organic disease. Furthermore, respondents indicated in absolute terms the numbers of patients seen in the past month with each of the conditions. Results confirmed the significant numbers of children seen with conditions comprising the new morbidity, their increased presentation to paediatricians in the past 5 years and the predominance of non-inpatient work in consultant paediatric practice in Australia.

Ambulatory Care↗

PubMed1994

Survey on developmental-behavioural training experiences of Australian paediatric advanced trainees.

In order to monitor whether paediatric education has adapted to meet modern practice 91 paediatric advanced trainees were surveyed to elicit their satisfaction with developmental-behavioural (DB) training. A response of 69% was obtained to a postal questionnaire. The traditional imbalance persists, with trainees considering themselves significantly better informed in the medical disciplines (P < 0.001). Satisfaction with training in the 14 developmental disciplines surveyed is less (P < 0.001) and significantly more variable compared with 11 traditional medical disciplines (P < 0.01). Formal rotations in DB disciplines had been received by all respondents by the 7th year of training. However, 46-67% consider themselves ill-informed in learning/school problems, attention-deficit hyperactivity disorder, adolescent problems, paediatric rehabilitation and language impairment. Thirty-seven per cent found formal postgraduate instruction unhelpful. Paediatric advanced training gives exposure to, but unsatisfactory formal education, in developmental and behavioural paediatrics. Current initiatives for mandatory DB training have serious implications for achieving adequate resources and standards to meet clinical and training demands.

Attitude of Health Personnel↗

PubMed2004

Development and use of a portable paediatric resuscitation card.

OBJECTIVES: Inaccuracy and delay in decision making in paediatric resuscitation has been previously demonstrated and may result in preventable death. We assessed several domains of paediatric resuscitation knowledge amongst a sample of tertiary hospital paediatric doctors, developed a portable aide-memoire reference card containing reference normal values, including an algorithm for recognition and management of the seriously ill/arrested child, and assessed the ability of medical staff to use this card to obtain accurate information. METHODS: A convenience sample of 46 members of the Royal Children's Hospital medical staff completed a questionnaire. Knowledge deficits identified were used to create a 9 x 6 cm, name tag sized, laminated card providing physiological parameters and information required for paediatric resuscitation. The card was then distributed to all medical staff. A sample of 18 doctors completed an identical questionnaire 4 months after introduction of the card. Pre- and post-card results were analysed across a range of knowledge domains. RESULTS: Basic calculations were incorrect in over 40% of all pre-card responses. Seniority did not predict more correct answers. The post-card group obtained significantly more correct answers than the pre-card group. CONCLUSION: Medical staff wore, and were able to use the card to provide the correct values for paediatric resuscitation parameters. The use of a card significantly improved knowledge of the correct values for resuscitation data. This project has resulted in the card being issued to all medical and nursing staff and is now accessible via the Royal Children's Hospital internet at http://perseus.rch.unimelb.edu.au/genmed/resuscardontheweb.htm

Education, Medical, Continuing↗

PubMed2004

Dr James George Beaney (1828-1891): a pioneer Australian paediatrician and paediatric surgeon.

Dr James George Beaney (1828-1891) was a flamboyant and controversial Melbourne surgeon and paediatrician. He was the first in Australia, in 1859, to publish a medical textbook; and the first, in 1873, to publish a paediatric text, Children: their treatment in health and disease. An analysis of four of his published works relating to paediatrics and paediatric surgery establishes his place as a true pioneer in the chronology of children's medicine and welfare in his adopted land. He undertook heroic yet conservative surgery on children, was the first to write in detail about paediatric anaesthesia, and was the pioneer of family planning in Australia. In Children: their treatment in health and disease, he described in detail the supreme importance of breastfeeding, detailed clear practical concepts for the weaning of infants and discussed the diagnosis and management of diseases of the mouth, ears, eyes and teeth of infants. Beaney was shunned by much of the established medical profession because of his self-promoting flamboyance and his egotism. However, an audit of surviving archives and of his published works affords him a place as another, hitherto unacknowledged true pioneer of Australian paediatrics.

Australia↗

PubMed2006

Training in paediatric trauma: the problem of safer societies.

BACKGROUND: Trauma remains the most common cause of child death worldwide but the incidence of major trauma is declining in many developed countries: this has implications for training. METHODS: A survey of paediatric surgeons and paediatric surgical trainees was undertaken to evaluate perceptions of the relative importance of various forms of trauma training. A questionnaire was e-mailed to Australasian paediatric surgeons and trainees to determine trauma courses they had undertaken, operative and non-operative paediatric trauma experience and attitudes towards trauma training. RESULTS: The overall response rate was 49% (40 of 83 consultants and 11 of 22 trainees). The Early Management of Severe Trauma course had been undertaken by 82% of consultants and all trainees. The Definitive Surgical Trauma Care course had been undertaken by 22% of consultants and one trainee. The number of trauma laparotomies carried out in the previous year was in the one to five range for 71% of responders. Greater emphasis was placed on the value of adult trauma experience by consultants who had a general surgical fellowship. CONCLUSION: In societies where major trauma in children is relatively rare (fortunately) and the opportunities for training are limited, it is important to ensure that advanced trainees in paediatric surgery gain sufficient skills from a variety of sources to enable them to treat competently the severely injured child with multiple injuries.

Adult↗