Send letter to journal:
Re: Care network for managing cardiac problems in children in district general hospital

Dear Editor,

We read with interest the article of Pushparajah et al 1 reviewing the impact of a managed care network for the assessment of cardiac problems in children in a District General Hospital (DGH). We agree that there is increasing demand for paediatric cardiology services in DGH’s, which of course increases the workload on specialist paediatric cardiologists. The model described in this study works very effectively in a DGH.

We have been running this type of service in Cambridge from 1996. Two consultant paediatricians, with special expertise in paediatric cardiology (PsePC), co-ordinate the investigations and subsequent care of all children referred to the department with suspected congenital heart disease. With the agreement of the Paediatric Department all children, with suspected heart disease, were referred to these two paediatricians who reviewed children in a one-stop paediatric echocardiography clinic. The impact of this new service has been carefully audited. Patients were examined and echocardiography was performed as the first line investigation. Children who were known to have congenital heart disease, which had been diagnosed, either prenatally, or postnatally before hospital discharge were excluded from this study. Between December 1996 and December 2000, 479 children attended the clinic. One hundred and thirty five children were excluded (45 with known congenital heart disease and 90 referred for the assessment of chest pain, palpitations or oncology cardiac follow-up). Three hundred and forty four children were investigated for a newly diagnosed heart murmur. The age, at clinic attendance, was a median of 4.6 years (range 10 days to 17.5 years). Three hundred and 15 children (91.6%) had structurally normal hearts and were discharged from the clinic at that first consultation. Twenty-nine children (8.4%) had a cardiac anomaly. Of these, only six children (1.7%) required either a cardiac surgical or catheter intervention.

Like Pushparajah et al1, we feel that there is a significant role for appropriately trained paediatricians in District General Hospitals. Where PsePC’s work closely with paediatric cardiologists a high efficient service can be developed. This close collaboration is critical to maintain training and governance standards. In our own hospital, where a large proportion of children are diagnosed antenatally or early prenatally with congenital heart disease, the vast majority of referrals thereafter are for innocent heart murmurs. If these children can be appropriately identified and discharged from clinics by the paediatricians, it means the paediatric cardiologists can give their specialist attention to children with significant pathology. Like Pushparajah, we believe that this model of care should be developed in more DGH’s across the country.

Abbreviations: DGH(district general hospital),PsePC (paediatrician with special expertise in paediatric cardiology)

References:

1. Pushparajah K,Garvie D,Hickey A et al – Managed care network for the assessment of cardiac problems in children in a district general hospital. Arch Dis Child 2006; 91:892-895

Yours sincerely