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Introduction: Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs)., Methods: A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records)., Results: The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01)., Conclusions: Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Good end-of-life care planning is vital to ensure optimal care is provided for patients and their families. Two key factors are open and honest advance care planning conversations between the patient (where possible), family, and health care professionals, focusing on exploring what their future wishes are; and the development of an advance care plan document. However, in paediatric and neonatal settings, there has been little research to demonstrate how advance care planning conversations take place. This study explored health care professionals' views and experiences of paediatric advance care planning in hospitals, community settings and hospices., Methods: A qualitative methodology was employed using purposive sampling of health care professionals involved in the end-of-life care for children aged 0-18 years known to the hospital palliative care team, and had died at least three months before, but less than 18 months prior to the study. Ethics committee approval was obtained for the study. Located in the North of England, the study involved three hospitals, a children's hospice, and community services. Data were collected using semi-structured, digitally recorded, telephone interviews. All interviews were transcribed verbatim and subjected to thematic analysis., Results: Twenty-one health care professionals participated, including generalist paediatric staff as well as specialist palliative care staff. Two themes were generated from the study: The timing of planning conversations, including waiting for the relationship with the family to form; the introduction of parallel planning; avoiding a crisis situation. Secondly, supporting effective conversations around advance care planning, including where to have the conversation; introducing the conversation; and how to approach the topic encompassing the value of advance care planning and documentation for families., Conclusion: The timing of when to start the advance care planning conversations remains an issue for health care professionals. The value of doing it in stages and considering the environment where the conversations are held was noted. Timely planning was seen as vital to avoid difficult conversations at a crisis point and for co-ordination of care. Good advance care planning is to provide the best person-centred care for the child and experience for the family.

Background: The use of video cases to demonstrate key signs and symptoms in patients (patient video cases or PVCs) is a rapidly expanding field. The aims of this study were to evaluate whether the technical quality, or judgement of quality, of a video clip influences a paediatrician's judgment on acuity of the case and assess the relationship between perception of quality and the technical quality of a selection of video clips., Methods: Participants (12 senior consultant paediatricians attending an examination workshop) individually categorised 28 PVCs into one of 3 possible acuities and then described the quality of the image seen. The PVCs had been converted into four different technical qualities (differing bit rates ranging from excellent to low quality)., Results: Participants' assessment of quality and the actual industry standard of the PVC were independent (333 distinct observations, spearmans rho = 0.0410, p = 0.4564). Agreement between actual acuity and participants' judgement was generally good at higher acuities but moderate at medium/low acuities of illness (overall correlation 0.664). Perception of the quality of the clip was related to correct assignment of acuity regardless of the technical quality of the clip (number of obs = 330, z = 2.07, p = 0.038)., Conclusions: It is important to benchmark PVCs prior to use in learning resources as experts may not agree on the information within, or quality of, the clip. It appears, although PVCs may be beneficial in a pedagogical context, the perception of quality of clip may be an important determinant of an expert's decision making.

Background: There is increasing recognition of the value of advance care planning for children with life-limiting conditions. It is important that we acknowledge and reflect on the challenges that this work presents in order to optimize practice., Objective: Our aim was to review advance care planning for children with life-threatening or life-limiting conditions (LTLLCs) in our local area., Methods: We conducted a retrospective case note review. Study subjects were from two National Health Service (NHS) Trusts in Bristol in the United Kingdom. Cases were identified from Child Death Overview Panel data. Forty-two sets of case notes were reviewed in relation to 20 children. Measurements included quantitative and qualitative review of advance care planning in relation to standards set by The Association for Children's Palliative Care (ACT)., Results: In 25% of cases there was no documented discussion with families about the approach to end of life (EOL). In 25% of cases there was no evidence of an advance care plan, and the content and accessibility of those that did exist was variable. Forty-five percent of families were not offered a choice with regard to location of care (LOC) in the last months of life and 50% were not offered a choice about location of death (LOD)., Conclusions: We hope that acknowledgement of some of the challenges, alongside recognition of the clear benefits, of planning will help pediatricians to deliver this important area of care.

The 2001 Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 stated that there must be standards for hospitals as a whole and that hospitals, which do not meet these standards, should not be able to offer services within the National Health Service (NHS). In 2013, agreed standards for pediatric neurosurgery were produced. Between 2001 and 2013 several key documents were published, which formed the background to the review that produced these standards:, the 'Safe and Sustainable' review. The process had the mission statement, 'Safe, sustainable and world class. Not ordinary, OK or just good enough.' In April 2013, the new commissioning structure of NHS England came into being. Clinical Reference Groups (reporting directly into the new structure) and pediatric neurosurgical operational delivery networks are taking the Safe and Sustainable pediatric neurosurgery standards and models of care into practice in England. Effective outcome data collection will allow us to assess whether these networks will improve equity of access for English children to world-class pediatric neurosurgical care and reduce the variation in outcomes seen at the present time., (© 2014 John Wiley & Sons Ltd.)

Objectives: ENT has a high paediatric workload. National recommendations for provision of paediatric surgical services are provided by three key documents produced by the Department of Health and Royal Colleges of Surgeons and Anaesthetists. This second cycle audit assesses the current state of paediatric services in ENT departments in England and Wales based on these recommendations and whether progress has been made since the first audit in 2003., Methods: A hyperlinked web-based questionnaire was e-mailed to ENT consultants in 164 ENT departments. The questionnaire addressed key areas recommended in the guidelines - theatre and anaesthetic provisions, inpatient/outpatients facilities and staff training. The responses were categorised according to hospital type - teaching hospitals, large or small district general hospitals and specialist stand-alone hospitals., Results: An overall response rate of 56% was achieved. Children's ward facilities remained high across all types of hospitals, with most having dedicated paediatric medical cover and specialised staff. There was an improvement in the number of staff qualified to provide paediatric life support. The level of anaesthetic supervision and expertise in theatres improved, as did the overall level of post-operative management. However, the provision of acute pain services remained relatively low., Conclusions: Overall there has been an improvement in the provision of paediatric surgical services in accordance with the guidelines but there remains variability in some aspects relating to the size of the hospital., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Introduction: The use of simulation-based assessments for high-stakes physician examinations remains controversial. The Managing Emergencies in Paediatric Anaesthesia course uses simulation to teach evidence-based management of anesthesia crises to trainee anesthetists in the United Kingdom (UK) and Canada. In this study, we investigated the feasibility and reliability of custom-designed scenario-specific performance checklists and a global rating scale (GRS) assessing readiness for independent practice., Methods: After research ethics board approval, subjects were videoed managing simulated pediatric anesthesia crises in a single Canadian teaching hospital. Each subject was randomized to two of six different scenarios. All 60 scenarios were subsequently rated by four blinded raters (two in the UK, two in Canada) using the checklists and GRS. The actual and predicted reliability of the tools was calculated for different numbers of raters using the intraclass correlation coefficient (ICC) and the Spearman-Brown prophecy formula., Results: Average measures ICCs ranged from 'substantial' to 'near perfect' (P ≤ 0.001). The reliability of the checklists and the GRS was similar. Single measures ICCs showed more variability than average measures ICC. At least two raters would be required to achieve acceptable reliability., Conclusions: We have established the reliability of a GRS to assess the management of simulated crisis scenarios in pediatric anesthesia, and this tool is feasible within the setting of a research study. The global rating scale allows raters to make a judgement regarding a participant's readiness for independent practice. These tools may be used in the future research examining simulation-based assessment., (© 2013 John Wiley & Sons Ltd.)

This review will attempt to put the various systems that allow clinicians to assess errors, omissions, or avoidable incidents into context and where possible, look for areas that deserve more or less attention and resource specifically for those of us who practice pediatric anesthesia. Different approaches will be contrasted with respect to their outputs in terms of positive impact on the practice of anesthesia. These approaches include audits by governmental organizations, national representative bodies, specialist societies, commissioned boards of inquiry, medicolegal sources, and police force investigations. Implementation strategies are considered alongside the reports as the reports cannot be considered end points themselves. Specific areas where pediatric anesthetics has failed to address recurring risk through any currently available tools will be highlighted., (© 2011 Blackwell Publishing Ltd.)

Objectives: In 1997 a review of paramedic practice upon adult patients in the UK found many inconsistencies and deficiencies in basic care. A follow up review in 2002 identified widespread improvement in provision of equipment and skills to provide basic and advanced life support.Paediatric care was not assessed in either review. The authors conducted this study to identify current standards of care in paediatric paramedic practice and areas of potential improvement., Method: A questionnaire designed to determine what equipment and skills were available to paramedics for the management of common or serious paediatric emergencies was sent to chief executives of the 32 NHS Ambulance Trusts in England and Wales., Results: The trend of expanding and standardising practice among adult patients has not extended to paediatric practice despite national guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Furthermore there are some serious failings in the provision of care and skills. Many Trusts have not adopted JRCALC guidelines for the management of life threatening paediatric emergencies such as asthma, meningitis, and fluid replacement in hypovolaemia., Conclusions: Ambulance Trusts not meeting standards set out in the JRCALC guidelines must address their areas of deficiency. Failure to do so endangers children's lives and leaves Trusts open to criticism.

The image of United Bristol Healthcare trust is changing; its rating has risen from zero stars to two. The new management team is struggling with tight finances, but the trust must break even. UBHT managers are aiming to develop a more corporate culture.

Introduction: In 1997 the Royal College of Paediatrics and Child Health introduced portfolios to guide and monitor the learning of specialist registrars. We studied their value for assessment., Methods: Using Bigg's SOLO criteria we devised a marking scheme based on 6 domains of competence: clinical, communication, teaching and learning, ethics and attitudes, management and evaluation, and creation of evidence. We rated portfolios according to quality of evidence presented and expectations by year of training. We similarly assessed trainee performance in the annual record of in-training assessment (RITA) interview. Specific advice based on the results of the first portfolio assessments was circulated to all trainees, instructing them to increase the structure and decrease the bulk of portfolios. A second sample of portfolios was reviewed a year later, using similar evaluations, to determine the effects., Results: A total of 76 portfolios were assessed in year 1 by a single rater; 30 portfolios were assessed in year 2 by 2 independent raters. The quality of documentation improved from year 1 to year 2 but there was no significant increase in portfolio scores. The inter-rater correlation coefficient of the portfolio assessment method was 0.52 (Cohen's kappa 0.35). The inter-rater correlation coefficient of the RITA interview was 0.71 (Cohen's kappa 0.38). There was moderate inter-assessment correlation between portfolios and RITA interviews (kappa 0.26 in year 1 and 0.29 in year 2). Generalisability analysis suggested that 5 successive ratings by a single observer or independent ratings by 4 observers on the same occasion would be needed to yield a generalisability coefficient > 0.8 for overall portfolio rating., Conclusions: This method of portfolio assessment is insufficiently reliable as a sole method for high stakes, single-instance assessment, but has a place as part of a triangulation process. Repeated portfolio assessment by paired observers would increase reliability. Longer term studies are required to establish whether portfolio assessment positively influences learner behaviour.

The inquiry into the services provided by the paediatric cardiac surgical team at Bristol Royal Infirmary between 1984 and 1995 marks a watershed in the development of health and social care services in the UK. There was an organisational failure of foresight based on a series of systemic and communication failures which contributed to oversight of an 'incubating' hazard which ultimately led to disaster. The recommendations of the Bristol inquiry have provided a major stimulus to the modernisation programme and especially of governance in health and social care which aims to restore public confidence and create 'high-trust' organisations. While it is premature to evaluate the impact of the changes, there is little evidence at present to indicate that they will improve the quality of professional decision making and the safety of users or enhance user and public confidence in the NHS and other public services.

Objective: to determine whether any differences in maternal satisfaction with the examination of a newborn baby between midwives and junior paediatricians are maintained over a three-month period., Design, Setting and Participants: randomised controlled trial. Eight hundred and twenty-six mother and baby pairs in a district general hospital in South East England were randomised to a junior paediatrician or a midwife for the routine examination. Four hundred and eighty-six mothers completed a maternal satisfaction questionnaire on day-one and again three-months later. Maternal satisfaction with the examination was analysed in relation to randomised group, process and background variables., Findings: high satisfaction with the examination was reported by most mothers (day-one: 82%; three-months: 79%). At day-one, mothers whose babies were examined by a midwife were more satisfied with the examination (crude odds ratio (OR) for the lowest tertile of satisfaction 0.49, 95% CI 0.32-0.73). However, after controlling for provision of health education during the examination (e.g. discussing feeding, sleeping and skin care) and continuity of care provided, maternal satisfaction was no longer related to status of examiner (adjusted OR 0.83, 95% CI 0.52-1.33). Three months later, there was no significant difference in maternal satisfaction with midwife and junior paediatrician examinations of the newborn baby (crude OR 0.89, 95% CI 0.58-1.37). Discussion of health-care issues by the examiner during the examination was significantly related to increased satisfaction even at three-months. Three month ratings of low satisfaction with the examination were most strongly predicted by current maternal depressive mood, even when other factors were adjusted for (adjusted OR 2.58, 95% CI 1.19-5.59)., Key Conclusions: from the mother's perspective, the quality of midwife examination is at least as satisfactory as that of junior paediatricians and this perception is maintained over a three-month period. Satisfaction can be significantly enhanced if the examiner provides information on behavioural and health-care issues. The examination of the newborn baby provides an important window of opportunity for sharing information on newborn behaviour and care issues., (Copyright 2002 Elsevier Science Ltd.)

The report of the 'National Coordinating Group on Paediatric Intensive Care' (NHS Executive 1997) recommended that general (adult) intensive care units in district general hospitals should no longer continue to care for critically ill children apart from providing resuscitation prior to transfer to a specialist centre. This recommendation was made despite a lack of outcome data in the UK to support this conclusion. We wish to report our outcome data from one such unit. Over a four-year period, we have prospectively used Paediatric Risk of Mortality scoring to estimate the risk of death for 95 children cared for in our adult unit in a district general hospital (DGH) and have compared this with the observed outcome. The observed mortality of 2 deaths was less than the predicted mortality of 2.32 deaths. Our results suggest that an adult unit can provide a paediatric intensive care service that is associated with an acceptable outcome in terms of mortality. These data suggest that the role of such units with regard to the provision of paediatric intensive care should be considered further.

This article demonstrates the Queen's Medical Centre approach to assessing and addressing risk in terms of Health and Safety within a busy children's unit. This article focuses on compartmentalising a large clinical area on two floors of a busy teaching hospital which become manageable sized subunits; each has a health, safety and risk management link person who attends the regular meetings to discuss key issues. These link people, with experience and training observe clinical areas within the zone, for hazards and potential hazards (risk inspection) and then calculate the hazard on a risk score. This is then risk assessed and all risk prioritised within the Children's Services Directorate Team. The author describes how a proactive approach to health, safety and risk management has brought about significant improvements, enhanced quality of care and improved morale and motivation of the nursing team.

The practice of general paediatricians in the initial evaluation of congenital hypothyroidism (CHT) was assessed. This was performed by a questionnaire survey of paediatricians in East Anglia of whom 84% responded. Nineteen of 25 clinicians based in seven district hospitals managed children with CHT. The median number of children in the care of each clinician was 4 (range 1-17) and the median number of children attending each hospital was 12 (range 5-23). All except one clinician arranged to confirm the diagnosis with a serum thyroid stimulating hormone concentration and free or total thyroxine. There was variation of opinion on the value of serum triiodothyronine and free triiodothyronine measurements, antibody screening, knee radiographs, and thyroid isotope scans. One clinician sought advice when notified of new children and two expressed the need for an investigation protocol. These findings indicate that most general paediatricians in East Anglia manage only a few children with CHT; the initial diagnosis is appropriately confirmed but they are uncertain about the value of other investigations.

Objective: To investigate the relationship between clinic provision, consultant and nursing caseload, and processes and outcomes of diabetes care in children., Design: Retrospective audit in the South Western region of England of 801 children and young people with diabetes; 701 were seen in a designated clinic. Seven of 21 consultants fulfilled the British Paediatric Association (BPA) criteria for a specialist in childhood diabetes. Seventeen nurses provided specialist care., Main Outcome Measures: Glycated haemoglobin, admissions to hospital clinic attendance rates, contacts with a dietitian, measurements of height and weight, and screening rates for hypertension, microalbuminuria, and retinopathy., Results: Children under the care of 'non-specialists' had higher admission rates to hospital with all diabetes related problems and for hypoglycaemia and lower screening rates for microalbuminuria than those under 'specialists'. Children under the care of the two tertiary hospital consultants and lowest glycated haemoglobin results, spent least time in hospital at diagnosis, were most likely to have their heights and weights plotted, and to be screened for microalbuminuria and retinopathy, had higher admission rates, lower clinic attendance rates, and fewer dietitian consultations. Higher nursing caseloads were associated with longer periods of admission at diagnosis, better clinic attendance rates, reduced rates of admission after diagnosis, and less likelihood of having blood pressure measured and being screened for microalbuminuria. Children attending general paediatric clinics were less likely to be seen by a dietitian and to have their height and weight plotted., Conclusions: The results are consistent with the recommendation of a BPA working party in 1990 that children with diabetes should be cared for by specialist paediatricians with a caseload of more than 40 children, and that children should be seen in a designated diabetic clinic.

An appraisal system for Community Child Health Doctors in Nottingham is described and evaluated. All staff are invited to an annual meeting with their consultant, preparation documents having been filled in by both appraisee and appraiser beforehand. These form the basis of the session, which is predominantly a self-assessment. A written report of the appraisal is produced, with sections on current performance (kept by appraiser and appraise only), training needs, and objectives (copies sent to the academic team and the medical manager). The system was assessed by questionnaires to both appraisers and appraisees. There was general agreement that the system had been adequately explained, and that the preparation documents and the appraisal time were useful. The written report was generally accepted as being a reliable record of the appraisal. Three of the fifteen appraisees were unhappy with the system, feeling it was a negative experience which concentrated on weaknesses. Others made positive comments. It was not always possible to achieve protected time. Some of the reports were delayed. The appraisal system described was found to be acceptable and workable by most people involved. The need for adequate administrative and clerical support was noted.

Primary care teams should state the aims of a preventive service and, through performance review, assess whether these aims have been achieved. The paediatric surveillance scheme in one practice is described, and the results of certain intermediate outcome measures are given.

More than half the general practitioners in the north of England, and all the health visitors, were sent questionnaires about the primary health care of children. Eighty per cent of general practitioners responded. Their qualifications and experience in paediatrics were poor, although this was less true for younger practitioners. The doctors differed widely in their management of hypothetical clinical problems, possibly owing to this lack of training. Health visitors were thought to have an important role in developmental screening within the primary health care team, but the teamwork itself seemed weak. Although 83% of general practitioners considered developmental screening should be primarily the responsibility of the primary health care team, 31% of practices did not do it and had no plans to start. Rather more than half of the doctors in these non-screening practices would accept a clinical medical officer to screen their patients on their premises. Suggestions are made for ways of encouraging general practitioners to carry out developmental screening.