We were interested to read Brogan and Raffles audit of the management
of fever and petechiae.[1] This is an important audit for many general
paediatricians in the UK. In Newcastle 36% of children with petechiae were
treated with antibiotics, only 10% had meningococcal disease (MCD). Brogan
and Raffles correctly state that more studies are required to validate
their proposed guideline. We offer two such studie...
We were interested to read Brogan and Raffles audit of the management
of fever and petechiae.[1] This is an important audit for many general
paediatricians in the UK. In Newcastle 36% of children with petechiae were
treated with antibiotics, only 10% had meningococcal disease (MCD). Brogan
and Raffles correctly state that more studies are required to validate
their proposed guideline. We offer two such studies:
(1) The ILL criteria (irritability, lethargy, low capillary refill) were applied retrospectively to a cohort of
children presenting with petechiae who were part of a multi-centre
prospective study of MCD from Merseyside, UK.[2] The ILL criteria would have
identified all except two of 66 children with MCD and petechiae. Both
those not identified presented with seizures, one had meningism, the other
a maculopapular rash. However, the ILL criteria were also present in 62 of
65 children with petechiae initially thought to have MCD, whose final
diagnosis was a viral illness. In this cohort the features that suggested
MCD were tachypnoea or signs of meningitis or septicaemia.[3] The ILL
criteria are therefore of limited use in children already suspected of
having MCD.
Local paediatricians-in-training asked for an algorithm to help
assess children with fever and petechiae. We therefore designed an
algorithm which includes risk factors from previous studies (recently
reviewed[4]), the ILL criteria, the criteria from the above Merseyside
study and a period of observation (a copy of this algorithm is available on request from the author - unfortunately eLetters do not support illustrations). We introduced this
algorithm into routine use in our hospitals this year. We are
prospectively validating its use.
(2) During the first three months 49 children presented with
petechiae. Only one child had meningococcal disease. The algorithm was
correctly followed in 34 (68%) children; this included prompt treatment
for the child with MCD. For 15 children the algorithm was not followed; 7
were given antibiotics when not indicated, 8 were not treated when the
algorithm suggested they should be.
It is obviously vitally important that antibiotics are not withheld
from children with possible MCD. When paediatricians suspects MCD they
should give prompt antibiotic treatment and then seek to confirm the
diagnosis.
Any algorithm for the management of children with fever and petechiae
must be shown to be clinically valid.[5] A large number of cases will be
needed to show our algorithm is safe and effective. This requires
collaboration between a number of centres. Any centre wishing to help
validate our algorithm would be welcome to do so: please contact one of
the authors.
Chris Richards
Ansgar Thimm
Royal Victoria Infirmary
Newcastle, UK
Julia Clark
Newcastle General Hospital
Newcastle, UK
Alistair PJ Thomson
Leighton Hospital
Crewe, UK
Tina Newton
F Andrew I Riordan
Birmingham Heartlands Hospital
Birmingham, UK
References
(1) Brogan PA, Raffles A. The management of fever and petechiae: Making sense of rash decisions. Arch Dis Child 2000;83:506-7.
(2) Riordan FAI, Thomson APJ, Sills JA, Hart CA. Who spots the spots?
The diagnosis and treatment of early meningococcal disease in children.
BMJ 1996;313:1255-6.
Following my study of publication of work presented to the Paediatric
Research Society {PRS} and the British Paediatric Association {BPA}
Plenary sessions,[1] I sought further factors, which may affect
subsequent publication.
Using the same method of searching Medline, I
identified which of the 225 studies presented to sub-speciality groups of
the BPA in 1996 were published by October 2000.
I found 1...
Following my study of publication of work presented to the Paediatric
Research Society {PRS} and the British Paediatric Association {BPA}
Plenary sessions,[1] I sought further factors, which may affect
subsequent publication.
Using the same method of searching Medline, I
identified which of the 225 studies presented to sub-speciality groups of
the BPA in 1996 were published by October 2000.
I found 111 (49%) were published. This meant 143 (54%) of plenary and sub-
speciality studies presented to the BPA in 1996 were published within 4
years.
Sub-speciality studies were published in 61 different journals; 19
paediatric. 77 articles (54%) were in paediatric journals, 46 in Archives
of Disease in Childhood.
Publication rates varied with specialty group, type of study and the place
where the study was done. Publication rates in sub-specialty groups varied
from 100% (4/4) to 0% (0/12). Sixteen studies were randomized controlled
trials, 13 of which were published. Only 1 of 17 (6%) studies from
District General Hospitals was published, compared with 118/218 (54%) from
University departments or teaching hospitals.
Submission for publication strongly influences publication rate. However,
study design and place where the study was done also affect publication of
studies presented to scientific meetings.
F Andrew I Riordan
Birmingham Heartlands Hospital
Birmingham, UK
(1) Riordan FAI. Do presenters to paediatric meetings get their work
published? Arch Dis Child 2000;83:524-6.
I was pleased to read the letter from Richards et al proposing a
collaberative study to validate the ILL criteria. Firstly, I support this
proposal fully.
I was interested in their statement regarding the ILL criteria in
those suspected of having meningococcaemia suggesting that the ILL
criteria are of limited use. The abstract they refer to presented at the
RCPCH meeting last year[1] state...
I was pleased to read the letter from Richards et al proposing a
collaberative study to validate the ILL criteria. Firstly, I support this
proposal fully.
I was interested in their statement regarding the ILL criteria in
those suspected of having meningococcaemia suggesting that the ILL
criteria are of limited use. The abstract they refer to presented at the
RCPCH meeting last year[1] states that the presence of poor capillary
refill, meningism, altered concious level, or tachypnoea identified 28 of
32 children with culture proven meningococcal disease. 3 of the 4 children
not identified had a maculopapular rash (ie not petechial?). Moreover, 12
of 32 children with meningococcal disease had total WCC greater than 15,
but we are not told if any of the "missed" cases had abnormal total white
cell count, or elevation of serum C reactive protein.
It must be emphasised that the full "ILL criteria" included 5
components, (irritability, low capillary refill, lethargy, abnormal total
white cell count, and abnormal C reactive protein), although Richards et
al have only concentrated on the first 3 risk factors. Furthermore, they
may have applied the criteria to children who did not have petechial rash
(the 3 "missed" children with meningococcal disease with maculopapular
rash).[1]
In order not to miss any cases of invasive bacteraemia, a screening
test with high sensitivity at the expense of specificity is desirable. We
proposed that the ILL criteria, in its full form, when applied to children
with fever and petechiae, operate as a "SnNOUT" test (if a test is highly
sensitive, if that test is negative the diagnosis can be ruled out)for
invasive bacteraemia. We cannot draw the same conclusions if only part of
the risk assessment analysis is applied, or the risk factors are applied
to children who do not have fever and petechiae.
Bad news is called bad news because it is … bad news. To be told
that their child has cerebral palsy is devastating for parents and it is
naïve to expect parents to be anything other than deeply distressed.
Baird et al interviewed parents to ask their views and feelings about
how the bad news was broken to them.[1] Firstly, there are two sides to
every story. They did not interview the doctors...
Bad news is called bad news because it is … bad news. To be told
that their child has cerebral palsy is devastating for parents and it is
naïve to expect parents to be anything other than deeply distressed.
Baird et al interviewed parents to ask their views and feelings about
how the bad news was broken to them.[1] Firstly, there are two sides to
every story. They did not interview the doctors involved. As Bill
Dobyns, the eminent geneticist writes, “When parents first hear that their
child has a serious problem they are often not ready to understand or
accept it. In this situation there is no good way to give the news. I
have on several occasions heard professional friends give the most
compassionate discussion I could image only to hear later they were
‘insensitive’ and so on.”[2]
Articles about breaking bad news inevitably
do not take account of the ‘arousal gap’ – parents are in a heightened
state of arousal so that every word, gesture or silence is given a meaning
far beyond its intention.[3] Nor do the authors seem to show an
understanding of the grieving process. Very few parents are honest enough
to admit at this stage – or ever – what and who it is they are really
angry with: they are angry with the child, themselves, God, life, etc; they feel guilty about that anger.
Secondly, Baird recommends that junior doctors are not present at the
time of disclosure. I disagree. I hold a regular ‘hand over’ clinic with
the neonatologist and a physiotherapist where these diagnoses are often
confirmed and/or disclosed. The physiotherapist is not necessarily the
one who has been or will be seeing the child, but represents her
colleagues at the clinic and is an experienced and valued member of the
team. A junior doctor from SCBU is also present. It is important that
the junior medical staff see a variety of styles of delivering bad news
and, equally importantly, a variety of responses from the parents.
Thirdly, the authors suggest that one obstacle to progress may be
senior staff believing they know how to break bad news. The implication
is that any doctor who does not go along with the guidelines recommended
in the article is being obstructive and arrogant. I admit I think I do
know how to break bad news but do not regard myself as an ‘obstacle’. I
run several joint clinics with colleagues from other paediatric and
related disciplines: these act as ongoing peer review on this and many
other aspects of our practice for both the consultants present.
Dr Charles Essex
Consultant Neurodevelopmental Paediatrician
Child Development Unit
Gulson Hospital, Coventry CV1 2HR, UK
References
(1) Baird G, McConachie H, Scrutton D. Parents’ perception of
disclosure of the diagnosis of cerebral palsy. Arch Dis Child 2000;83:475-80.
(2) Dobyns W. Lissencephaly : Frequently asked questions. http://www.lissencephaly.org/medical/doctor/index.htm
(3) Metcalfe D. Doctors and patients should be fellow travellers. BMJ 1998;316:1892-3.
This is an important area for professional discussion on a number of
fronts.
In providing quality care to children and their families it is
important that an integrated team approach is used. The authors (Ross
et al) note how 'Most errors are not a result of individual negligence,
but arise from systemic, organisational failures' (p495). In the hospital
where I currently practice a recent audi...
This is an important area for professional discussion on a number of
fronts.
In providing quality care to children and their families it is
important that an integrated team approach is used. The authors (Ross
et al) note how 'Most errors are not a result of individual negligence,
but arise from systemic, organisational failures' (p495). In the hospital
where I currently practice a recent audit of prescripition charts
indicated at least 10 unreported errors from a total of 175 patient days.
These were all due to organisational issues. As a team, we actively
encourage nursing staff to challenge prescribing behaviours which do not
endorse safe practice. Drug errors had occurred in the abouve audit
largely due to misinterpretation of the prescription, which itself was a
failing to comply with established good practice. Nursing staff are now
instructed to:
1) insist all medications are prescribed in block capitals, using the
generic meication name (unless a combination or slow release type
preparation) - if a medication is not prescribed in this manner the
prescriber is advised that they will be called to amend it.
2)That decimal points are NOT permissable - microgrammes and
nanogrammes to be written in full
3)Where possible clear guidance regarding the frequency should be
given (e.g the preffered times) (we are currently looking at removing
abbreviations, as again these are another source of error)
Regarding nurses and the reluctance to report I have this to offer.
In 18 years in health care I have seen many instances where nurses have
reported errors and yet to see a report from a medical practitioner. My
one experience where a medical practitioner administered an IV medication
to the wrong child (with the nurse who checked the medication attempting
to stop him) was that he received a token slap on the wrists from his
consultant, the nurse received a written warning.
As humans we make mistakes, but a collaborative, team approach to
minimise risk is needed to prevent error
I hope the message from this letter is not that paediatricians in
district hospitals stop doing research. The challenge is to allow an
environment in which clinical research can flourish.
We welcome the coverage given to the major, and potentially fatal, problem
of medication errors within managed health care.[1] We disagree however
with the key message that MEDICATION ERRORS ARE UNCOMMON. They are
endemic, extremely common, overlooked and often ignored.
Observational studies of medicine administration within hospitals in
the United Kingdom report an error rate of 3% to 8%.[2] In
co...
We welcome the coverage given to the major, and potentially fatal, problem
of medication errors within managed health care.[1] We disagree however
with the key message that MEDICATION ERRORS ARE UNCOMMON. They are
endemic, extremely common, overlooked and often ignored.
Observational studies of medicine administration within hospitals in
the United Kingdom report an error rate of 3% to 8%.[2] In
contrast Ross et al report 195 errors, collated from a mandatory error
reporting policy, in 65 months.[1] While mandatory reporting is a
commendable principle, the reality remains that the majority of healthcare
professionals will not report errors, and the majority of medication
errors, will not be reported.
Reasons for lack of reporting among nursing
staff include confusion regarding the definition of drug errors and the
appropriate action to take when they occurred, fear of disciplinary
action, loss of clinical confidence and variation in managerial response.[3]
Voluntary, non-punitive error reporting programmes have been
advocated as the most effective way to promote candid disclosure of
medical error.[4]
Unless we are aware of what errors occur, we cannot expect to implement an
appropriate system fix.
We would suggest that the occurrence of 3 errors/month, represents a
tremendous under-reporting of the extent of medication error.[1] If
patient through put totalled 335,835 patient bed-days, and we assume that
each day the average patient received 6 doses of medicine, an error rate
of 5%, suggests that a more realistic interpretation of the extent
of the error iceberg is an incidence of greater than 100,000.
The conclusion therefore that medication errors are uncommon is
unfortunately not true. The reality is that REPORTED MEDICATION ERRORS ARE
UNCOMMON.
Neil A Caldwell
Principal Pharmacist/Lecturer
Wirral Hospital NHS Trust/Liverpool John Moores University
Don K Hughes
Principal Pharmacist Clinical Services/Honorary Lecturer
Wirral Hospital NHS Trust/Liverpool John Moores University
References
(1) Ross LM, Wallace J, Paton JY. Medication errors in a paediatric
teaching hospital in the UK: five years operational experience. Arch Dis Child 2000;83:492-7.
(2) Barber N, Dean B. The incidence of medication errors and ways to reduce
them. Clinical Risk 1998;4:103-6.
(3) Gladstone J. Drug administration errors: a study into the factors
underlying the occurrence and reporting of drug errors in a district
general hospital. Journal of Advanced Nursing 1995;22:628-37.
(4) Cohen MR. Why error reporting systems should be voluntary. BMJ 2000;320:728-9.
West Kent Community Paediatricians unreservedly approved the paper by
Wynne and Speight.[1] Paediatricians leading District Child Protection
Services do not recognise the protected professional described by Dame
Barbara Hale viz a viz the social worker.[2] Child protection work is lonely
and stressful. It carries a significant vulnerability to malicious
complaints for political reasons and media witch-hu...
West Kent Community Paediatricians unreservedly approved the paper by
Wynne and Speight.[1] Paediatricians leading District Child Protection
Services do not recognise the protected professional described by Dame
Barbara Hale viz a viz the social worker.[2] Child protection work is lonely
and stressful. It carries a significant vulnerability to malicious
complaints for political reasons and media witch-hunts.
Hale refers to the Local Authority’s need to take reasonable steps to
protect children from abuse. What does reasonable mean? Work within the
Children Act Child Protection framework is hampered by a lack of resources
from local authorities to fund this work. The limited professional
training social workers receive in child health and development, which
assists a proper understanding of Abuse presentations, compounds this.
Suspicious bruising is therefore not recognised. Front line Health
Visitors' and Paediatricians' concerns may be met with a courteous ignorance
or more worrying a cynical disregard at senior managerial level.
The Children Act industry of lawyers and doctors who specialise in
defence work has lengthened Court hearings. The defence process now
ensures that in Care proceedings, paediatricians DO have to prove beyond
reasonable doubt that the child has suffered significant harm. Hale
should review the Kent County Court Care proceedings for the past three
years.
The medico–legal role bears closer scrutiny. The Department of Health and RCPCH
need to clarify the role of the medical expert in cases of Child Abuse.
Why are some doctors highly visible as peripatetic defence experts for
common Abuse presentations? Why do these doctors seldom agree with the
findings of the experienced district paediatrician? There is an overdue
need of a proper process of accreditation for this work. This should
include a rigorous audit of the defence expert’s findings in the context
of the district paediatrician’s grave concerns. The integrity of the
medical profession should be above reproach.
Dr G A Evans FRCPCH DCCH, Retired
Formerly Clincal Director Children’s Service
Thamesgateway NHS Trust
Dartford, Kent, UK
References
(1) Speight N, Wynne J. Is the Children Act failing severely abused and neglected children? Arch Dis Child 2000;82:192-6.
(2) Hale B. In defence of the Children Act. Arch Dis Child 2000;83:463-7.
Dargan et al state that the girl with lead poisoning "was not given DMSA (meso-2,3 dimercaptopropanesulphonate)..."
DMSA is dimercaptosuccinic acid. The antidote they refer to is usually abbreviated to DMPS.
We were interested to read Brogan and Raffles audit of the management of fever and petechiae.[1] This is an important audit for many general paediatricians in the UK. In Newcastle 36% of children with petechiae were treated with antibiotics, only 10% had meningococcal disease (MCD). Brogan and Raffles correctly state that more studies are required to validate their proposed guideline. We offer two such studie...
Following my study of publication of work presented to the Paediatric Research Society {PRS} and the British Paediatric Association {BPA} Plenary sessions,[1] I sought further factors, which may affect subsequent publication.
Using the same method of searching Medline, I identified which of the 225 studies presented to sub-speciality groups of the BPA in 1996 were published by October 2000. I found 1...
Dear Editor:
I was pleased to read the letter from Richards et al proposing a collaberative study to validate the ILL criteria. Firstly, I support this proposal fully.
I was interested in their statement regarding the ILL criteria in those suspected of having meningococcaemia suggesting that the ILL criteria are of limited use. The abstract they refer to presented at the RCPCH meeting last year[1] state...
Bad news is called bad news because it is … bad news. To be told that their child has cerebral palsy is devastating for parents and it is naïve to expect parents to be anything other than deeply distressed.
Baird et al interviewed parents to ask their views and feelings about how the bad news was broken to them.[1] Firstly, there are two sides to every story. They did not interview the doctors...
Dear Editor
This is an important area for professional discussion on a number of fronts.
In providing quality care to children and their families it is important that an integrated team approach is used. The authors (Ross et al) note how 'Most errors are not a result of individual negligence, but arise from systemic, organisational failures' (p495). In the hospital where I currently practice a recent audi...
I hope the message from this letter is not that paediatricians in district hospitals stop doing research. The challenge is to allow an environment in which clinical research can flourish.
We welcome the coverage given to the major, and potentially fatal, problem of medication errors within managed health care.[1] We disagree however with the key message that MEDICATION ERRORS ARE UNCOMMON. They are endemic, extremely common, overlooked and often ignored.
Observational studies of medicine administration within hospitals in the United Kingdom report an error rate of 3% to 8%.[2] In co...
West Kent Community Paediatricians unreservedly approved the paper by Wynne and Speight.[1] Paediatricians leading District Child Protection Services do not recognise the protected professional described by Dame Barbara Hale viz a viz the social worker.[2] Child protection work is lonely and stressful. It carries a significant vulnerability to malicious complaints for political reasons and media witch-hu...
Dear Editor
Can the scrotal temperature be measured with a conventional thermometer?
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