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Editor,—The only conclusion to be drawn from MacFaul et al’s article on parental and professional perception of need for emergency admission to hospital1 is the need for more studies in this area.
The study was retrospective and sampled a biased population—that is, parents of children who had been told their child needed hospital admission. Parents’ anxiety levels are highest at the time of admission and their perceived need for admission at this time tends to be based on emotion rather than information about their child’s illness. When a doctor has said the child is being admitted, most parents are not going to say that admission is unnecessary. When there is only moderate correlation between severity of illness score and need for admission score, it is an issue of parental education and the answer to this should not be automatic admission to hospital.
In the discussion, MacFaul et al acknowledge the limitations of their data collection methods but then draw rather dogmatic conclusions ignoring these limitations. They make only scant reference to models of successful alternatives to admission to hospital with assessment units and experienced home care teams.2 ,3Further studies are needed: to address consultant assessment of severity of the child’s condition and a need for admission at presentation; and to ascertain the views of parents and general practitioners with experience of both home care and acute admission to hospital as to which is the preferred option. Until these studies are performed, MacFaul et al’s conclusions are potentially harmful to the development of paediatric services in the next millennium.
Editor,—The article by MacFaulet al states that a prospective questionnaire was used to study emergency paediatric admissions. However, this was only prospective to assess parents’ perception of the severity of their child’s illness and the need for admission. A retrospective questionnaire was used to assess consultants’, general practitioners’, and parents’ views regarding the need for admission and alternative services.
The study failed to clarify the term “admission”. This may be attendance with an ill child for observation to seek a second opinion or for an overnight stay.
It is not surprising that the parents and general practitioners scored highly the need for admission. However, it is interesting that the parents have given the severity of their child’s illness a much lower score. This merits interpretation in light of the definition of admission. Once the child has been assessed, parents should be given a clear choice of the alternatives at the time of admission if the child does not need an overnight stay.
When consultants’ views regarding the need for admission was assessed retrospectively, 71% were in favour of admission. However, on the score of the severity of illness only 10% exceeded 6. It is obviously and always difficult to assess illnesses retrospectively. The need for admission is a clinical judgment that has to be made on the spot at the time of admission by an experienced member of staff.
The decision to discharge some children should be taken jointly by an experienced paediatrician, the senior nurse looking after the child, and the parents. Unfortunately this study, perhaps unintentionally, has ignored the views of the nurses.
Dr MacFaul et al comment:
We are pleased that Drs Goodyear and Mulik support our views that further studies into admission are needed. Despite being based only on inpatients, our study, which collected data concurrently, provides information that assists understanding of the factors influencing admission. There is little published information about the views and needs of parents or general practitioners on provision of alternatives to traditional paediatric care, and we emphasised the need to take these into account. Their views give some insight into recent rises in demand for admission, especially at night. Support from skilled nurses at home can help parents to cope but this will require additional resources not yet likely to be released from hospital.
Our findings generally served to strengthen arguments for the development of new style paediatric services1-1 rather than being potentially harmful to them. We argue that provision of same day paediatric consultation supported by outreach nursing could bring peak evening demand forward into daytime and prevent overnight admission, which may otherwise become the only option. But alternatives to admission, like any new process, should be evaluated and their roles questioned. The ambulatory services referred to both by us and your correspondents report reduction in overnight stay but not in overall admissions.
Dr Madlom raises important issues. An admission included children managed acutely as inpatients by the paediatric team for however short a period.1-2 Future studies should include assessment of illness severity for general paediatrics and views of nurses, usually involved in discharge but not so often in the admission decision.
Most agree that children should only be admitted to hospital when it is necessary—but if admission is needed it should be achieved easily and speedily and be as short as possible.1-2 Other means of managing acute illnesses should be considered and we need to refine our criteria for specialist intervention in acute childhood illnesses. If more children are seen by specialist services, even if only a small proportion is admitted, more children might end up in hospital. The trend for parents to attend accident and emergency (A&E) departments rather than their general practitioner compounds the problem as a higher proportion of A&E attendances may be admitted, although data on this are limited. The CESDI report of 19981-3 identified deficiencies in the management of acute illness both in hospital and in primary care. Improved support to general practice may encourage parents to seek consultation from services better geared to deliver care at home.