Health and safety needs in early care and education programs: what do directors, child health records, and national standards tell us?

OBJECTIVE: To identify the overlapping and unique health and safety needs and concerns identified by early care and education (ECE) directors, health records, and observed compliance with national health and safety (NHS) standards. DESIGN AND SAMPLE: Cross-sectional study. 127 ECE programs from 5 California counties participated in the study, including 118 directors and 2,498 children's health records. MEASURES: Qualitative data were collected using standardized ECE directors' interviews to identify their health and safety concerns; and objective, quantitative data were collected using child health record reviews to assess regular health care, immunizations, health insurance, special health care needs, and screening tests and an observation Checklist of 66 key NHS standards collected by research assistants. RESULTS: The overlapping health and safety needs and concerns identified by the directors and through observations were hygiene and handwashing, sanitation and disinfection, supervision, and the safety of indoor and outdoor equipment. Some of the health and safety needs identified by only one assessment method were health and safety staff training, medical plans for children with special health care needs and follow-up on positive screening tests. CONCLUSIONS: Comprehensive, multimethod assessments are useful to identify health and safety needs and develop public health nursing interventions for ECE programs.

Child care health consultation improves health and safety policies and practices.

OBJECTIVE: To evaluate the effects of county-level child care health consultation intervention programs on child care centers' health and safety policies and practices. METHODS: A 3-year experimental study was conducted in 5 California counties and 111 licensed child care centers (73 intervention, 38 comparison) participated at the baseline and postintervention times. Trained research assistants conducted objective observations with a Policies Checklist and Health and Safety Checklist, which were composed of key national health and safety standards. RESULTS: At baseline, both groups were not significantly different on the Policies Checklist and the Health and Safety Checklist. At the post-intervention time, intervention centers had significantly more and higher-quality written health and safety policies on 9 of the 10 policies rated (medication administration, care of mildly ill children, exclusion of ill children, cleaning and sanitizing, handwashing, daily health checks, inclusion of children with special needs, emergency preparedness, staff health) than comparison centers. At the postintervention time, intervention centers improved their health and safety practices in the areas of emergency preparedness and handwashing, controlling for consultation model, time in study, and director turnover. Both groups improved their indoor and outdoor facilities and overall Health and Safety Checklist means. CONCLUSIONS: Child care health consultation programs can improve the written health and safety policies and may improve practices in child care centers.

Assessing health and safety in early care and education programs: development of the CCHP health and safety checklist.

INTRODUCTION: To assess health and safety in early care and education (ECE) programs, an objective, standardized instrument was developed based on the recommended national health and safety standards. METHOD: The California Childcare Health Program Health and Safety Checklist was developed by conducting a literature review, identifying a gold standard, revising and updating the original Checklist, consulting with an advisory group, and pilot testing the Checklist. The Checklist included 66 items grouped into 10 subscales, and each item was rated on a three-point scale: meeting, partially meeting, or not meeting national standards. Face, content, and construct validity along with measures of reliability, inter-rater reliability, and internal consistency were established. RESULTS: The Checklist was completed in 127 ECE centers. The highest subscale score was for emergency preparedness and the lowest was for handwashing routines and equipment maintenance. Cronbach's alpha subscale scores ranged from moderate to strong (0.27 to 0.70). DISCUSSION: The Checklist provides valid and reliable information to assess adherence to key national health and safety standards and objective data to develop intervention programs to improve health and safety in ECE programs.

Child care health consultation programs in California: models, services, and facilitators.

OBJECTIVE: To summarize findings from a descriptive evaluation study of 20 county-level child care health consultation programs, services provided, and factors that facilitated the development of the programs. DESIGN: A 3-year intervention study of 20 county-level child care health consultation programs, selected through a competitive review process, was conducted in California. SAMPLE: Study participants were the child care health consultation program staff, lead agency administrators and health consultants, and early care and education (ECE) staff, including health advocates and directors. MEASUREMENT AND INTERVENTION: Data collection included focus groups, interviews, consultant activity logs, and surveys. Health consultation intervention services included health and safety assessments, on-site consultation, and workshops for ECE providers and parents. RESULTS: 4 child care health consultation models were established based on the type of administrative agency. Health consultants and advocates primarily provided on-site consultation and education and training on child health promotion issues. Consultation programs were facilitated by the linkages formed among agencies, community characteristics, personal relationships, lead agency support, and consultant training and knowledge. CONCLUSIONS: Child care health consultation programs can address the health and safety needs for ECE programs, but they need administrative support, trained staff, and sustainable relationships with local ECE programs.

Child care health consultants' roles and responsibilities: focus group findings.

PURPOSE: To describe the roles and responsibilities of newly trained health professionals, primarily nurses called Child Care Health Consultants. METHOD: Health professionals hired by county agencies to become Child Care Health Consultants enrolled in the California Training Institute (CTI) for Child Care Health Consultants, a 9-day educational training program divided into three modules. They participated in one focus group during each module. Research staff led the focus groups and the participants were asked, "What are your roles and responsibilities?" Qualitative analyses were conducted and common themes were identified. FINDINGS: The nine focus groups included 44 participants, 95% were nurses with an average of 20 years of work experience. The roles and responsibilities of the Child Care Health Consultants were described by five themes: network, education, sustainability, on-site service, and administration. CONCLUSION: These findings contribute to the new field of child care health consultation by defining the common roles and responsibilities of Consultants.

Management and outcomes of care of fever in early infancy.

CONTEXT: Fever in infants challenges clinicians in distinguishing between serious conditions, such as bacteremia or bacterial meningitis, and minor illnesses. To date, the practice patterns of office-based pediatricians in treating febrile infants and the clinical outcomes resulting from their care have not been systematically studied. OBJECTIVES: To characterize the management and clinical outcomes of fever in infants, develop a clinical prediction model for the identification of bacteremia/bacterial meningitis, and compare the accuracy of various strategies. DESIGN: Prospective cohort study. SETTING: Offices of 573 practitioners from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, the District of Columbia, and Puerto Rico. PATIENTS: Consecutive sample of 3066 infants aged 3 months or younger with temperatures of at least 38 degrees C seen by PROS practitioners from February 28, 1995, through April 25, 1998. MAIN OUTCOME MEASURES: Management strategies, illness frequency, and rates and accuracy of treating bacteremia/bacterial meningitis. RESULTS: The PROS clinicians hospitalized 36% of the infants, performed laboratory testing in 75%, and initially treated 57% with antibiotics. The majority (64%) were treated exclusively outside of the hospital. Bacteremia was detected in 1.8% of infants (2.4% of those tested) and bacterial meningitis in 0.5%. Well-appearing infants aged 25 days or older with fever of less than 38.6 degrees C had a rate of 0.4% for bacteremia/bacterial meningitis. Frequency of other illnesses included urinary tract infection, 5.4%; otitis media, 12.2%; upper respiratory tract infection, 25.6%; bronchiolitis, 7.8%; and gastroenteritis, 7.2%. Practitioners followed current guidelines in 42% of episodes. However, in the initial visit, they treated 61 of the 63 cases of bacteremia/bacterial meningitis with antibiotics. Neither current guidelines nor the model developed in this study performed with greater accuracy than observed practitioner management. CONCLUSIONS: Pediatric clinicians in the United States use individualized clinical judgment in treating febrile infants. In this study, relying on current clinical guidelines would not have improved care but would have resulted in more hospitalizations and laboratory testing.

Urine testing and urinary tract infections in febrile infants seen in office settings: the Pediatric Research in Office Settings' Febrile Infant Study.

OBJECTIVE: To determine the predictors and results of urine testing of young febrile infants seen in office settings. DESIGN: Prospective cohort study. SETTING: Offices of 573 pediatric practitioners from 219 practices in the American Academy of Pediatrics Pediatric Research in Office Settings' research network. SUBJECTS: A total of 3066 infants 3 months or younger with temperatures of 38 degrees C or higher were evaluated and treated according to the judgment of their practitioners. MAIN OUTCOME MEASURES: Urine testing results, early and late urinary tract infections (UTIs), and UTIs with bacteremia. RESULTS: Fifty-four percent of the infants initially had urine tested, of whom 10% had a UTI. The height of the fever was associated with urine testing and a UTI among those tested (adjusted odds ratio per degree Celsius, 2.2 for both). Younger age, ill appearance, and lack of a fever source were associated with urine testing but not with a UTI, whereas lack of circumcision (adjusted odds ratio, 11.6), female sex (adjusted odds ratio, 5.4), and longer duration of fever (adjusted odds ratio, 1.8 for fever lasting > or = 24 hours) were not associated with urine testing but were associated with a UTI. Bacteremia accompanied the UTI in 10% of the patients, including 17% of those younger than 1 month. Among 807 infants not initially tested or treated with antibiotics, only 2 had a subsequent documented UTI; both did well. CONCLUSIONS: Practitioners order urine tests selectively, focusing on younger and more ill-appearing infants and on those without an apparent fever source. Such selective urine testing, with close follow-up, was associated with few late UTIs in this large study. Urine testing should focus particularly on uncircumcised boys, girls, the youngest and sickest infants, and those with persistent fever.