The quality of published paediatric audits and their standards.

OBJECTIVE: Audit is a recognised tool for evaluating the performance and improving the quality of health services. In Ireland and the UK, clear resources are available outlining audit elements. This study was undertaken to evaluate paediatric audits published from 2007 to 2020 to determine the adherence level to the definition of audit and to assess the quality of audit standards. DESIGN: PUBMED, MEDLINE and CINAHL databases were searched to identify relevant articles published in the English language. Each was reviewed to assess whether the following criteria were met: (1) a paediatric healthcare topic was described, (2) practice was reviewed, (3) the standard was specified, (4) an intervention was made and data collection was repeated to assess improvement. The quality of the standard for each true audit was graded utilising the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS: Of 1230 published paediatric healthcare articles reviewed, 144 (11.4%) fulfilled the full criteria of an audit. Sixty-three (43.8%) true audits used the highest quality of evidence (level 1a and 1b), predominantly international or national guidelines. Fifty-six (38.9%) audits used the lowest quality of evidence (level 5), predominantly expert opinion. CONCLUSIONS: There is a mismatch between the common usage of the term audit, and the definition, despite its incorporation into training curricula and institutional support. Many articles published as audits do not adhere to the definition of audit. There are variable levels of evidence supporting the standards utilised in published true audits.

A cross-sectional survey of doctors' views on flexible postgraduate physician training in Ireland.

Recruitment and retention of doctors is a priority for the Irish healthcare service, with many leaving to work in regions with more favourable conditions. Aligning flexible training options with other jurisdictions may be an effective means of improving working conditions. We sought to assess possible improvements to the existing system and to review barriers to flexible training. We carried out a survey using 'Survey Monkey' and disseminated it to 1557 basic specialist (BST) and higher specialist trainee (HST) doctors of the Institute of Medicine, 3500 members of the Irish Medical Organisation (IMO), and across social media. There were 854 respondents; 303 (35.5%) BST, 352 (41.2%) HST, 125 (14.6%) non-training doctors, unknown, n = 74. The response rate was approximately 15-23%. Non-consultant doctors identified a preference for access to flexible training (n = 849, 99.4%), with 82.2 of doctors reporting that they would consider applying (n = 702). Most (92.4%) considered the current provision of 16 whole-time equivalent positions as inadequate (n = 789). Of doctors who would not apply for flexible training, themes identified included a perceived negative impact on their career, not meeting eligibility criteria, prolonged training, and salary implications. Suggestions for improving the system included expanding the number of places available, removing eligibility criteria, job sharing options, and the provision of regional training schemes. Access to flexible training should be a priority for the healthcare service, which may enhance recruitment and retention. A majority of our sample of non-consultant doctors identified a preference for access to flexible training options.

The early experience of doctors training in pediatrics: patient safety culture and the role and influence of the registrar.

INTRODUCTION: Postgraduate medical training incorporates education, both formal and informal, combined with clinical service. This study explored the early training experience of pediatricians in Ireland and its potential impact on patient safety. AIM: We sought to identify factors that contribute to the patient safety experience of new entrant pediatric trainees. METHODS: Trainees, or senior house officers (SHOs), in their first year of postgraduate training, participated in an interview conducted using a critical interview technique (CIT). They described an adverse event where the medical care delivered to the patient was not ideal. Thematic analysis identified themes that influenced the described event. RESULTS: Thirteen trainees participated in the interviews. This study identified influences on the relationship between the SHO and patient safety, including the SHO themselves, teamwork and communication. Colleagues within the workplace, including consultants, registrars, and nurses, also affect this relationship. The registrar is described as a central figure holding an active role in clinical care in 11 of the 13 stories told. In the participants' experience, the registrar was the senior decision-maker, teacher, team builder, and communication intermediary within the teams' hierarchical structure. The registrars' previous clinical experience, communication style, along with their ability to supervise and provide feedback shaped the SHO experience. CONCLUSIONS: Through a process designed to focus on exploring patient safety, it emerged that the registrar plays a crucial role in the working experience of their junior colleagues. The influence of the registrar needs to be recognized within clinical teams and by postgraduate training bodies.

A national physician survey of diagnostic error in paediatrics.

UNLABELLED: This cross-sectional survey explored paediatric physician perspectives regarding diagnostic errors. All paediatric consultants and specialist registrars in Ireland were invited to participate in this anonymous online survey. The response rate for the study was 54 % (n = 127). Respondents had a median of 9-year clinical experience (interquartile range (IQR) 4-20 years). A diagnostic error was reported at least monthly by 19 (15.0 %) respondents. Consultants reported significantly less diagnostic errors compared to trainees (p value = 0.01). Cognitive error was the top-ranked contributing factor to diagnostic error, with incomplete history and examination considered to be the principal cognitive error. Seeking a second opinion and close follow-up of patients to ensure that the diagnosis is correct were the highest-ranked, clinician-based solutions to diagnostic error. Inadequate staffing levels and excessive workload were the most highly ranked system-related and situational factors. Increased access to and availability of consultants and experts was the most highly ranked system-based solution to diagnostic error. CONCLUSION: We found a low level of self-perceived diagnostic error in an experienced group of paediatricians, at variance with the literature and warranting further clarification. The results identify perceptions on the major cognitive, system-related and situational factors contributing to diagnostic error and also key preventative strategies. WHAT IS KNOWN: • Diagnostic errors are an important source of preventable patient harm and have an estimated incidence of 10-15 %. • They are multifactorial in origin and include cognitive, system-related and situational factors. What is New: • We identified a low rate of self-perceived diagnostic error in contrast to the existing literature. • Incomplete history and examination, inadequate staffing levels and excessive workload are cited as the principal contributing factors to diagnostic error in this study.

Field testing the utility of procalcitonin and the acute infantile observation score in febrile infants 6 to 36 months old presenting to the pediatric emergency department with no obvious focus of infection.

BACKGROUND: Serious bacterial illness (SBI) presents a diagnostic challenge in febrile infants. History, clinical signs, and laboratory information combined with experiential knowledge affects decisions to admit and treat. AIM: To assess the utility of serum procalcitonin and the Acute Infantile Observation Score (AIOS) performed at emergency department presentation in predicting (a) confirmed serious bacterial illness and (b) illness severity. METHODS: Sensitivity, specificity, and likelihood ratios were calculated for C-reactive protein, white cell count, serum procalcitonin, and AIOS. RESULTS: Forty-six infants were recruited. Seven had a diagnosis of SBI, 28 were moderately ill with length of stay >24 hours, and 12 were severely ill with length of stay >96 hours. The positive likelihood ratios for confirmed SBI were C-reactive protein = 5.3, procalcitonin = 0.43, white cell count = 1.9, and AIOS = 1.5. CONCLUSION: Procalcitonin and the AIOS do not modify the diagnostic uncertainty of the ED physician assessing the febrile infant with respect to admission or antibiotic treatment above standard laboratory investigations.

Considering statins for cholesterol-reduction in children if lifestyle and diet changes do not improve their health: a review of the risks and benefits.

Children who appear healthy, even if they have one or more recognized cardiovascular risk factors, do not generally have outcomes of cardiovascular or other vascular disease during childhood. Historically, pediatric medicine has not aggressively screened for or treated cardiovascular risk factors in otherwise healthy children. However, studies such as the P-Day Study (Pathobiological Determinants of Atherosclerosis in Youth), and the Bogalusa Heart Study, indicate that healthy children at remarkably young ages can have evidence of significant atherosclerosis. With the increasing prevalence of pediatric obesity, can we expect more health problems related to the consequences of pediatric dyslipidemia, hypertriglyceridemia, and atherosclerosis in the future? For many years, medications have been available and used in adult populations to treat dyslipidemia. In recent years, reports of short-term safety of some of these medications in children have been published. However, none of these studies have detailed long-term follow-up, and therefore none have described potential late side-effects of early cholesterol-lowering therapy, or potential benefits in terms of reduction of or delay in cardiovascular or other vascular end-points. In 2007, the American Heart Association published a scientific statement on the use of cholesterol-lowering therapy in pediatric patients. In this review paper, we discuss some of the current literature on cholesterol-lowering therapy in children, including the statins that are currently available for use in children, and some of the cautions with using these and other cholesterol-lowering medications. A central tenet of this review is that medications are not a substitute for dietary and lifestyle interventions, and that even in children on cholesterol-lowering medications, physicians should take every opportunity to encourage children and their parents to make healthy diet and lifestyle choices.

Systematic review and metaanalysis of statins for heterozygous familial hypercholesterolemia in children: evaluation of cholesterol changes and side effects.

Heterozygous familial hypercholesterolemia (heFH) affects 1 in 500 individuals. Evidence supports the low-density lipoprotein (LDL)-lowering effect of statins for adults with heFH. However, there are concerns regarding the treatment children with heFH. By performing a systematic review and metaanalysis of the published literature, this study aimed to evaluate the efficacy and safety of statins used for children with heFH. A systematic review was performed by searching multiple medical databases and citations to identify reports of randomized controlled trials of statins used to treat children with heFH. The trials were retrieved, reviewed, and subjected to metaanalysis. The search yielded 2,174 titles. Of the 63 studies retrieved and reviewed, 56 were excluded, 7 were included in the systematic review, and 4 were included in the metaanalysis. Significant heterogeneity was detected. The metaanalysis showed significant LDL lowering, high-density lipoprotein (HDL) cholesterol elevation, and increases in height and weight with statins. The metaanalysis could not be performed for many side effects of statins, but individual trials showed no significant side effects. Quality assessment showed methodologic concerns, with potential for bias. For example, six trials analyzed statin effects without intention to treat despite such a stated intention. Metaanalysis shows significant LDL lowering with statin treatment. Further studies, including epidemiologic and multicenter studies, are required.