Referral criteria from community clinics to pediatric emergency departments.

Referral of patients to a pediatric emergency department (PED) should be medically justified and the need for referral well communicated. The objectives of this paper were (1) to create a list of criteria for referral from the community to the PED, (2) to describe how community physicians categorize their need for referral, and (3) to determine agreement between the physician's referral letter and the selected criteria. We present a descriptive study of referrals to the PED of Soroka University Medical Center, Beer-Sheva, Israel, during February to April 2003. A list of 22 criteria for referral was created, using the Delphi method for reaching consensus. One or more criteria could be selected from this list for each referral, by the referring community physicians and, independently, based on the physicians' referral letters, by two consultants, and compared. There were 140 referrals included in the study. A total of 262 criteria for referral were selected by the referring community physicians. The criteria most frequently selected were: "Need for same-day consultation/laboratory/imaging result not available in the community" (32.1%), "Suspected life- or organ-threatening infection" (16.4%), and "Need for hospitalization" (15.7%). Rates of agreement regarding criteria for referral between the referring physicians and the two consultants, and a senior community pediatrician and a senior PED pediatrician, were 57.9 and 48.6%, respectively. We conclude that the standard referral letter does not convey in full the level of need for referral to the PED. A list of criteria for referral could augment efficient utilization of emergency department services and improve communication between community physicians and the PED.

Parental attitude toward unaccompanied clinic visits of adolescents.

UNLABELLED: To describe parental attitudes regarding the age and the type of medical problems that are appropriate for adolescent unaccompanied visits to the clinic at an age younger than 18 years. METHODS: A structured interview was conducted with parents who visited two community clinics with their children. The questionnaire included: 1) At what age would you allow your child to visit the clinic alone? 2) What medical conditions are acceptable for unaccompanied visit at the age you stated (if lower than 18 years)? and 3) What medical conditions are not acceptable for unaccompanied visit at the age you stated (if lower than 18 years)? RESULTS: Two hundred and fifty three parents were interviewed. There was an agreement between parents from the two clinics regarding the mean age appropriate for an unaccompanied visit (mean 14.1 +/- 2.56 years for clinic A and 13.8 +/- 2.66 years for clinic B). Medical conditions most acceptable for unaccompanied visits were common cold (clinic A = 77.4%, clinic B = 70.5%), sore throat (A = 64.5%, B = 84.3%) and fever (A = 34.7%, B = 19.4%). Medical conditions most unacceptable for unaccompanied visit were: injury (clinic A = 68.5%, clinic B = 53.5%), fever (A = 37.1%, B = 42.6%) and severe illness (A = 19.4%, B=23.3%). CONCLUSIONS: most parents were willing to allow their adolescent children unaccompanied visits to the physician at an age below that stipulated by law. As unaccompanied visits are widely practiced and accepted by the public, it might be necessary to amend the law.

Who accompanies a child to the office of the physician?

The arrival of a minor, unaccompanied by a parent, for a clinic visit, is challenging to the physician with legal, ethical, and practical implications. This prospective study, conducted in three community pediatric clinics, examined the relationship of accompanying persons to the minors visiting the clinics. About 90% of the 1,104 visits were with an accompanying parent, mostly a mother. Over 9% of minors, especially adolescents, arrived at the clinic unaccompanied by a parent. A regression analysis demonstrated that for each increase of one month in age there was a 2% increased chance for a visit without a parent (p < .0001). Adolescents were more likely to be among the 6% of minors, who visited the clinic alone, with a rate 0.066 per 1,000 visits in the more affluent community, compared to 0.019 and 0.016 in the middle and low income communities (p < .001). Physicians as well as parents should be made aware of the regulations regarding accompaniment of minors on a visit to the clinic. Policies regarding unaccompanied visits should take into account the risk posed by the absence of a parent versus the right of adolescents for independence and privacy.

[Should a minor, unattended by a parent, be given medical services? Use of an algorithm to critique the Israel Ministry of Health regulations].

BACKGROUND: Parents are the natural custodians of their children, thus minors need parental approval to receive medical services. In February 2004, the Israel Ministry of Health issued a set of regulations titled "Visits of unaccompanied minors to primary care clinics", aimed at assisting primary care clinicians in their decision-making process on this sensitive issue. AIMS: (1) To convert the above mentioned regulations into an algorithmic format in order to facilitate their use by community clinicians, and (2) To review and critique the regulations, using the process of algorithm conversion. METHODS: The regulations were studied thoroughly. Three rounds of Delphi process for reaching consensus were used to create an algorithm, based on these regulations. The algorithm building process was used to critique the regulations. RESULTS: The Israel Ministry of Health regulations, "Visits of unaccompanied minors to primary care clinics", were found to be long and complicated. The process of building the algorithm revealed several difficulties certain concepts were not well defined, many exceptional situations were found and a large portion of the regulations was dedicated to reporting and record keeping. Converting the regulations into an algorithmic format simplified them and assisted in their CONCLUSIONS: Converting complex regulations into an algorithmic format can facilitate their daily use by community clinicians. Parts of the regulations for "Visits of unaccompanied minors to primary care clinics" are incompatible with present clinic routine and, therefore, difficult to implement.

[Evaluation of hospital admissions: admission guidelines implementation in a pediatric emergency department].

OBJECTIVES: To develop and implement locally tailored pediatric admission guidelines for use in a pediatric emergency department and evaluate the appropriateness of admissions based on these guidelines. METHODOLOGY: Our Study was based on the development of admission guidelines by senior physicians, using the Delphi Consensus Process, for use in the Pediatric Emergency Department (PED) at Soroka University Medical Center (Soroka). We evaluated the appropriateness of admissions to the pediatric departments of Soroka on 33 randomly selected days in 1999 and 2000 prior to guideline implementation and 30 randomly selected days in 2001, after guideline implementation. A total of 1037 files were evaluated. FINDINGS: A rate of 12.4% inappropriate admissions to the pediatric departments was found based on locally tailored admission guidelines. There was no change in the rate of inappropriate admissions after implementation of admission guidelines in PED. Inappropriate admissions were associated with age above 3 years, hospital stay of two days or less and the season. The main reasons for evaluating an admission as inappropriate were that the admission did not comply with the guidelines and that the case could be managed in an ambulatory setting. There were distinctive differences in the characteristics of the Bedouin and Jewish populations admitted to the pediatric departments, although no difference was found in the rate of inappropriate admissions between these populations. CONCLUSIONS: Patient management in Soroka PED is tailored to the conditions of this medical center and to the characteristics of the population it serves. The admission guidelines developed reflect these special conditions. Lack of change in the rate of inappropriate admissions following implementation of the guidelines indicates that the guidelines reflect the physicians' approach to patient management that existed in Soroka PED prior to guideline implementation. Hospital admission guidelines have a role in the health management system; however, these guidelines must be tailored to reflect local characteristics and needs.