Care of children in UK emergency departments

In June 1999 an intercollegiate working party was established to review emergency services for children and to make recommendations for future provision of these services. The subsequent report—Accident and Emergency Services for Children (AESC)—made 32 recommendations (representing minimum levels of care), to be implemented by  2004.

The authors of this article sent questionnaires to lead emergency doctors in the UK. Although currently 41 departments have separate paediatric emergency departments, 92% of children attend general departments; these show the largest shortfall from recommendations of the AESC report. In 1997, 10% of hospitals did not have inpatient services onsite now only 1.9% do not (minor injury units excluded).

Assessing the severity of illness is essential, but a quarter of departments seeing more than 18 000 children a year do not have separate triage facilities, and 23% do not triage children with an appropriately trained nurse. Level 2 care, while awaiting a paediatric retrieval team (children's mobile intensive care unit), is delivered in 85% of departments, often at cost to emergency, paediatric, and intensive care services. The current trend of centralisation means that emergency staff must deliver this care, so there must be the appropriate mix of skills on duty.

The National Service Framework expects emergency professionals to do courses in paediatric life support and to regularly update; currently, 47% of nurses do not attend such courses.

One in four patients presenting at emergency departments is a child. Child centred good quality care which is accessible at the right time is required, however there is considerable room for improvement in the care of children in emergency departments. This government has recognised unacceptable variations nationwide in the quality of care for children and wants to eliminate these differences (the National Service Framework). The framework allows adult nurses to care for children only within the limits of their knowledge and should be under direct supervision of a children's trained nurse.

The AESC recommends that hospitals seeing more than 18,000 children should have a consultant in paediatric emergency medicine by 2004 and in all emergency departments by 2010. This, along with many of the other AESC recommendations made five years ago, has not been met and without future investment in staffing and facilities a child centred service will be hard to achieve.

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Finding type 2 diabetes in primary care

A concern about the obesity epidemic is the increased numbers of people with adult-onset diabetes. Chance finding of frank diabetes or pre-diabetic hyperglycaemia is often a major trigger for lifestyle changes of less but better food, more exercise, and lost weight.

This smacks of screening. Screening is a word fraught with danger, because in any set of circumstances there are three camps: the small numbers of enthusiasts who are either for it or against it, and the great mass of normal professionals whose main reaction is profound cynicism about another target. A study that shows that real-world targeted screening can work and might make sense  is a welcome relief.

The study was conducted in 16 practices in Somerset and Devon. Trained practice nurses ran the screening clinics. Patients were sent a provisional clinic appointment, followed up by telephone reminder. Weight, height and age were recorded, and a fasting venous blood sample taken for plasma glucose measurement.

Those with fasting plasma glucose over 6 mmol/L were invited for repeat testing. Diabetes was defined as plasma glucose of 7 mmol/L or more on both occasions. Impaired fasting glycaemia was defined as levels of 6.1-6.9 mmol/L on both tests.

The response rate to invitation to attend the screening clinic was 61%. Of the 1,287 who attended for screening 199 (15%) had an abnormal first test. All of these attended a second time. Overall the findings were:

· 148 (12%) had an abnormal second test

· 55 (4.3%) had type 2 diabetes

· 93 (7.2%) had impaired fasting

These screening strategies discovered substantial numbers of people with previously undiagnosed type 2 diabetes. Undiagnosed diabetes rates were about 20% of those already diagnosed. For those with impaired fasting glycaemia, a glucose tolerance test might have been appropriate.

Lower age and BMI criteria should identify people early enough for lifestyle changes to be effective, especially in those with impaired glycaemia.

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London hospital mortality data for individual surgeons

Another UK hospital has started publishing mortality data for operations performed by individual cardiothoracic surgeons. At least two other hospitals have taken this step, but St George’s hospital is the first in London to do so.

St George’s Hospital published raw data on mortality after coronary artery bypass graft, mitral valve replacement, and aortic valve replacement for the years 2002, 2003, and 2004. These data were pooled, and not attributed to individual surgeons.

Risk adjusted mortality after coronary artery bypass graft was also published for the same period. Complication rates for all cardiac surgery and for coronary artery bypass graft were released.

Risk adjusted mortality for all procedures was presented in a graph for the St George’s Healthcare NHS Trust’s five cardiac surgeons, named as individuals. All surgeons performed well, with no significant difference between them.

The hospital’s chief executive, Peter Homa, said: "We think we can go further. Cardiac surgery is on the leading edge of this debate, but surgeons from other specialties want to get involved too.

There is no reason in principle why we shouldn’t be publishing similar information right across all areas of surgery."

A BMA spokesperson said the BMA would oppose the use of crude mortality data.

"Evidence from other countries shows that some surgeons are deterred from taking on very complex and therefore high risk procedures because published simplistic leagues tables count against them." 

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