Parents' and carers' impression of "quality" within a Paediatric Emergency Department.

BACKGROUND: Quality improvement systems are needed to overcome the 'Quality Gap' - difference between evidence-based guidelines and the care delivered. While there are a large array of potential quality assurance measures exists in the Paediatric Emergency Department, parent's/carer's perception of these is unknown. This study aimed to identify what 'quality of care' means to parents/carers of Paediatric Emergency Department (PED) patients, further determine which aspects of these are most important to them. Also, to identify which of the existing PED quality measures are most important to parents/carers, and their preferred method of providing feedback. METHODS: A Modified Rand-Delphi study was performed with parents/carers as the expert group and consensus was obtained from them via three web-based surveys. All parents/carers of children attending a tertiary paediatric hospital during six-week in winter were eligible- no exclusions. Quality measures scoring at least 7 on a 9-point Likert scale during the final survey were considered "very important", while those scoring at least an 8 were considered "extremely important". RESULTS: One hundred four parents/carers responded from a total of 1095 participants. Parents/carers generated 527 free text entries, to the initial survey on what 'quality of care' means. These were mapped to 48 quality measure which they ranked on subsequent surveys. Eighteen quality measures were considered very important by at least 90% of respondents. Of these, six were considered extremely important by at least 70% of respondents: 'Thorough medical assessment' (84%); 'A triage system' (84%); 'Experienced and knowledgeable staff that are skilled in paediatrics' (77%); 'Resources and equipment available to provide care' (72%); and 'Clear follow up plans and reviews that are communicated and scheduled' (72%). Parents/carers considered existing quality measures as important with 'timely treatment of a critical condition' as the most important. Most participants preferred to provide anonymous feedback (N = 69, 66%), online (N = 77, 72%) after discharge (N = 82, 70%). CONCLUSION: We have elicited what 'quality of care' means to parents/carers, and which aspects are most important to them. Parents/carers consider commonly used PED quality measure as very important. However, they are less important than outcomes generated by themselves. Further parents/carers in this study preferred to provide feedback that was anonymous and electronically distributed after they leave the ED.

Primary replacement for the management of exposed orbital implant.

Purpose: We present a series of primary orbital implant replacement for cases of implant exposure to describe our experience of this one-staged surgical approach. Methods: This study reports on a one-stage technique which involved the removal of the exposed implant or dermis fat graft (DFG) and insertion of a secondary (replacement) in the same procedure, with a variety of materials, including autologous tissue. Re-exposure in a socket where a DFG was placed was defined as a new defect in the newly epithelialized conjunctiva or dehiscence of the dermis-conjunctiva junction. All cases of primary replacement for the management of exposed orbital implant, porous and non-porous, were included, even when there were clinical signs suggestive of infection. The primary outcome was the rate of re-exposure, requiring additional surgical procedures. Infection following primary replacement was a secondary outcome. Results: Seventy-eight patients had primary replacement for the management of an exposed orbital implant. 6.4% had re-exposure at a mean follow-up of 49.7 months (9.1% for ball implants and 4.5% for DFG). The rate of exposure was higher in those with prior signs of infection than those without (8% vs. 3.6%). Re-exposure occurred in 4.5% of cases with DFG implantation, 4.3% of cases with non-porous implants and in 20% of cases with porous implants. Conclusion: Primary replacement for management of exposed orbital implant, porous and non-porous, has a high rate of successful outcome even in cases with presumed or confirmed infection.

Arousal from sleep in infants is impaired following an infection.

Numerous studies have postulated a link between recent infection and Sudden Infant Death Syndrome (SIDS). In this study we contrasted arousal responses from sleep in infants on the day of discharge from hospital following an infection with those when fully recovered and also with well age-matched control infants. Thirteen term infants comprised the infection group and nine well infants acted as age-matched controls. All infants were studied using daytime polysomnography and multiple measurements of arousal threshold (cm H(2)O) in response to air-jet stimulation applied alternately to the nares were made in both active sleep (AS) and quiet sleep (QS). All infants were studied on two occasions: firstly, immediately before discharge from the Paediatric ward, and secondly, 10-15 days later when they were completely well in the case of the infection group.Arousal thresholds in QS in the infection group were significantly elevated on the day of discharge (262 +/- 48 cm H(2)O) compared with 10-15 days later (205 +/- 31 cm H(2)O, p<0.05). Thresholds in the control group were not different between studies. This study provides evidence that arousability from QS is impaired following an infection and we postulate that this may explain the increased risk for SIDS following infection observed in previous studies.

Bilateral sectoranopia caused by bilateral geniculate body infarction in a 14-year-old boy with inflammatory bowel disease.

Bilateral lesions of the lateral geniculate bodies are rare and produce unusual field defects that can be predicted on the basis of their vascular anatomy. We report a rare case of bilateral sectoranopic visual field defects caused by bilateral infarction of the lateral geniculate nucleus in a 14-year-old boy with inflammatory bowel disease and recurrent pancreatitis.

Giant cell reparative granuloma of the orbit.

This report describes a case of an orbital giant cell reparative granuloma in an 85-year-old woman. Giant cell reparative granulomas are fibro-osseous benign proliferations typically found in the jawbones and rarely in the orbital bones. All previously described cases in the orbit have been in younger patients, classically in the third to fourth decades.