Context National statistics predict that a significant proportion of our Paediatric Outpatient Clinic patients will be overweight (BMI, body mass index, 91st-98th centile) or obese (BMI >98th centile). Height and weight is already routinely obtained from each clinic patient, and plotted on a growth chart by clinic nursing staff.
Problem Families might reasonably assume, and national guidelines would recommend, that any problem highlighted by this data would be recognised and discussed by the clinician. We suspected that only a minority of clinicians were recognising, raising and documenting the issue of increased BMI in the clinic.
Assessment of problem and analysis of its causes Height, weight, sex and identifying number for all clinic attendees (aged 2–18 years, n = 238) were recorded over 3 weeks in November 2014. Clinic staff and clinicians were blind to the audit’s purpose. 25 patients (10.5%) were overweight (BMI 91st–98th centile) and 33 (13.9%) were obese (>98th centile). Only 20.4% (11/54) of available corresponding clinic letters acknowledged the raised BMI; all of these were in the obese category, with none of the overweight children being acknowledged as such. Only 13.0% (7/54) documented any discussion or action taken (e.g. dietetic referral).
Results were presented to the department (see below). Perceived barriers to raising the issue included: 1) difficulty recognising increased BMI from only raw height/weight; 2) clinicians’ anxiety around family reaction.
Plot BMI and document alongside height/weight in medical notes, to bring to clinician’s attention.
Education/awareness raising amongst consulting clinicians.
Strategy for change Clinic nursing staff were trained to use the BMI look-up tool on the RCPCH 2012 Growth Charts (Figure 1). This involves reading off height and weight centiles, plotting one extra point on the back of the chart, then reading off a BMI centile.
A new rubber template stamp was procured, providing a space to enter BMI (alongside other core parameters including height/weight) in the medical notes (Figure 2).
BMI charts and relevant leaflets (healthy eating, local lifestyle programme) were made available in clinic rooms to facilitate consultations.
An educational meeting slot (for medics, nurses and allied professionals) was given to discussion of:
National guidance, importance of the issue
Communication tips from e-learning module
Core healthy eating/activity advice
A follow-up email was sent to all consulting clinicians containing the same points. Feedback from discussions held with the obesity service dietitians was positive. Throughout the process we agreed with staff feedback that raising the issue is not universally appropriate, depending on the nature of other discussions and existing relationships with families.
Measurement of improvement After 6 weeks, a second audit cycle gathered measurements from 186 children (70 overweight/obese, 37.6%). Of 64 eligible letters, 20 (31.3%) acknowledged increased BMI. Three were in the overweight category (previously none of these were acknowledged). 17 (26.6%) documented offer of advice or referral.
Effects of changes We have demonstrated a significant improvement in addressing raised BMI in paediatric clinic patients. The proportion of clinic letters documenting advice or referral doubled after our intervention (26.6% vs 13.0%, P = 0.034). This is a positive step forward in-line with national guidance.
Lessons learnt The extra point for BMI can be plotted very quickly. In several cases the plotting was complete but no BMI centile was written in the outpatient notes, despite the stamp being used there. Further cycles of regular education and training for clinicians and clinic staff, with feedback, will be necessary to consolidate these improvements.
Message for others Our work shows that a simple additional plot on a growth chart, supported by educational sessions, resulted in more families being offered advice on an important but sensitive health issue. Tackling the problem early on in the consultation process could potentially improve the presenting symptom as well as overall health.
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