Pediatric Appointments Research Articles

Transition from paediatric surgery: how many patients do we need to plan for?

INTRODUCTION Transitional care is an NHS priority with newly published NICE guidance. Many paediatric surgical patients need quality care to continue into adulthood. We undertook an evaluation of our departmental activity to assess the magnitude of this issue. METHODS We identified all outpatients ≥ 15 years (potentially requiring imminent transition) seen over a 12 month period for all five general paediatric surgery consultants in our tertiary centre. Those patients requiring transition were highlighted and the appropriate adult team for referral recorded. RESULTS There were 2989 general paediatric surgery clinic appointments within the year; 289 (9.7%) were for young people aged 15 years or older; 62 patients (28% of those ≥ 15years) were deemed to require transition into adult care. Significantly more patients having colorectal surgery required follow-up (P = 0.0009 Chi-square test) compared with patients in other subspecialties. CONCLUSIONS More patients than expected required transition. This may be the case in other units. Current best practice includes time intensive preclinic planning, careful preparation of patient and family, followed by joint clinics. A joint clinic appointment takes 30 minutes, allowing for comprehensive handover and forging new relationships. In our department, we need at least ten transition clinics across 2 years. Coalition with adult colleagues is vital. These data enable us to plan services to provide quality care for our adolescent patients and highlights colorectal surgery as a priority.

Preventing Childhood Blindness and Protecting Children's Eye Health: what should we know?

Submit Manuscript | http://medcraveonline.com treatable or preventable. Knowledge of parent’s awareness and perception of eye problems are important and necessary for early detection and early age intervention. Leukocoria or white pupillary reflex is an abnormal white reflection from the retina of the eye. Leukocoria in the newborn is a medical sign for a number of conditions, including congenital cataract, persistence of the tunica vasculosa lentis, retrolental fibroplasia, coats disease and intraocular tumors. Although the prevalence of congenital cataracts is low, in developing countries up to 15/10,000 newborns have bilateral cataract [3] caused by rubella and other diseases such as toxoplasmosis, cytomegalovirus or herpes. Retinoblastoma is the most frequent eye tumor in children, with an incidence of 1/15,000 to 20,000 live births [4]. Sixty percent are unilateral: the median age at diagnosis is 2 years and most of these forms are not hereditary. Other disorders that require monitoring by an ophthalmologist from birth are prematurity (less than 1500g birth weight or 32 weeks), congenital ptosis (drooping eyelid), and although it is rare, a continuous tearing associated with photophobia, blepharospasm and increased corneal diameter must rule out a congenital glaucoma [5]. But the two leading causes of visual impairment during childhood are refractive errors and strabismus (squint). Both diseases if not detected early and corrected before 7 years of age are the mean cause of unrecoverable low vision, which is known as amblyopia. That’s why child’s eyes should be examined during regular pediatric appointments and vision testing should be conducted around age three. The prevalence of both diseases is much higher in children with special needs such as those with cerebral palsy [6].

Why children do not attend their appointments: is there a need for an interface between general practitioners and hospitals allowing for the exchange of patients' contact details?

ObjectivesA service evaluation project on the reasons why children do not attend their outpatient appointments.DesignAnalysis of paediatric clinic lists over two consecutive days. Parents of the non-attenders were identified and their reasons for not attending the appointment were elicited using a survey.SettingThe appointments were scheduled to take place in the Paediatric department at St. Mary’s Hospital, London.ParticipantsOf the 201 appointments scheduled, 49 patients did not attend their paediatric appointment. Telephone contact was successful with 35 parents.Main outcome measuresParents were asked to verify if their contact details were correct, if they were aware of the appointment and if they had received a reminder. The reasons for non-attendance were explored.ResultsOf the 49 non-attenders, correct contact details were held on file for 24 of the patients (49.0%). Of the 35 parents contacted, 18 were aware (51.4%) of their child’s appointment.ConclusionsThis project revealed that the principal reason for non-attendance is unawareness of the appointment due to incorrect contact details held by the hospital. Potential strategies for reducing non-attendance at this paediatric outpatient clinic include developing a confirmation or reminder system and improved communication with parents. The creation of a new interface between hospitals and GPs would allow hospitals to access patient contact details held by GPs. It would also ensure that hospitals hold up-to-date patient contact details and that appointment details are effectively communicated to parents. The interface would automatically feed through any updated patient details, keeping hospital records current.

Parental preferences for paediatric specialty follow-up care.

Objective The aim of the present study was to examine factors associated with: (1) parental preference to receive follow-up care for their child from a general practitioner (GP); and (2) a decision to seek treatment when there is a slight worsening of their child's condition. Methods Parents presenting with their child at any one of five paediatric out-patient clinics at two public hospitals in Melbourne (Vic., Australia) were surveyed. We performed frequency distributions, bivariate analyses and multivariate logistic regression to evaluate associations with the preference for a GP for follow-up care and treatment in case of a slight worsening. Results In all, 606 parents were recruited to the study, 283 being new presentations and 323 presenting for review. GPs were selected as the preference for follow-up care by 23% (n=142) of respondents, and 26% (n=160) reported they would seek treatment from a GP if the condition of their child were to worsen slightly. There was an increased likelihood to prefer a GP for follow-up care for new patients (odds ratio (OR) 3.10; 95% confidence interval (CI) 1.99-4.83), those attending general paediatrics clinic (OR 1.73; 95% CI 1.11-2.70), and parents with a lower level of education (OR 1.74; 95% CI 1.09-2.78). For review patients, if during the previous visit a paediatrician suggested follow-up with a GP, parents were more likely to prefer a GP as a follow-up provider (OR 6.70; 95% CI 3.42-13.10) and to seek treatment from a GP in case of a slight worsening (OR 1.86; 95% CI 1.03-3.37). Conclusion Most parents attending paediatric out-patient appointments prefer to return for follow-up care; however, a paediatrician's advice may have an important role in return of paediatric patients to primary care. What is known about the topic? In Australia, there has been a growing concern regarding long waiting times for specialist consultations in out-patient clinics and difficulties with access for new patients. This has occurred when the ratio of review attendees to new patients has tipped towards the review attendees. What does this paper add? Most parents of children attending paediatric out-patient clinics value follow-up care with paediatric specialists, even if the referring GP requested a return to their surgery. The advice of the consulting paediatrician in support of follow-up care with a GP contributes significantly to the willingness of parents to return to primary care and to seek treatment from their GP for a slight worsening of their child's condition. What are the implications for practitioners? The findings of the present study have significant implications for the discharge of patients from speciality care: paediatricians can have an important role in the return of paediatric patients to primary care.

The Difference a Decade Makes: Smoking Cessation Counseling and Screening at Pediatric Visits.

There has been a sharp decline in adolescents who smoke cigarettes but no national-level study evaluating the impact of smoking cessation counseling by pediatricians or other clinicians who care for children. Combined data from ambulatory portions of the National Hospital Ambulatory Care Survey and National Ambulatory Medical Care Survey from 1997-1999 and 2009-2011 were analyzed to determine changes in the frequency of pediatric visits that included clinician-reported tobacco counseling and how such counseling varied by child, family, and clinician characteristics. In 1997-1999, 1.5% of all medical visits for children aged below 19 years included tobacco counseling; this increased to 3.8% in 2009-2011 (P < .001). A marked increase from 4.1% to 11.1% was noted at well-child visits (P < .001). There were significant increases in counseling by pediatricians but not mid-level providers or general/family physicians. Provision of counseling did not result in greater visit length during either time point. During 2009-2011, visits with a diagnosis of asthma were four times as likely (OR 4.2, 95% CI 2.8-6.2) and visits for otitis media two times as likely (OR 2.1, 95% CI 1.2-3.7) to include smoking cessation counseling than sick visits for all other diagnoses. These results demonstrate a significant increase in tobacco counseling by pediatric providers within the last decade, especially at well-child visits. However, the American Academy of Pediatrics' recommendation that pediatricians counsel about the harms of tobacco use and secondhand smoke exposure has not yet been exhaustively implemented. A significant increase in smoking cessation counseling at pediatric medical appointments, especially at well-child visits, occurred from 2009-2011 compared with 1997-1999, paralleling a large decrease in smoking prevalence. These improvements in counseling rates have been predominantly noted for pediatricians but not mid-level providers or general practitioners. Counseling was not associated with increased visit lengths. Although improved counseling practices by pediatricians have been demonstrated, there is still room for improvement.

Qualitative Study of Foster Caregivers' Views on Adherence to Pediatric Appointments

The current study is a qualitative investigation of how foster caregivers, primarily Latinos, view adherence to pediatric appointments. Our purpose was to identify how the child welfare system, pediatric clinics, and pediatric health providers serving foster children might promote appointment attendance. Participants in the study had a return appointment at an outpatient pediatric clinic that served only children in the child welfare system. Twenty-eight caregivers (13 related and 15 unrelated) participated in telephone interviews after the date of their scheduled pediatric appointment; 32% missed their return appointment. Semistructured interview guides included general questions about what promotes attending the pediatric appointment, what makes it difficult to attend the pediatric appointment, and how pediatric care affects the foster child. Analysis of qualitative data using content analysis identified three themes: (a) Multiple Methods to Attend Appointments, which included caregivers' organizational and problem-solving skills; (b) Positive Health Care Experiences, which consisted of caregivers' personal relationships with providers and staff members and clinic organization; and (c) Necessity of Pediatric Care, which included recognition of the need for health care, especially timely immunizations. All caregivers also reported that appointment reminders would be helpful. Unrelated caregivers said more often than related caregivers that appointment attendance was facilitated by clinic organization. Nonadherent caregivers more than attenders mentioned their need to solve problems to attend appointments or reschedule appointments. In summary, caregivers said they valued regular pediatric health care to treat their children's chronic conditions and prevent illnesses, but they acknowledged that their home lives were hectic and that attending scheduled appointments was sometimes difficult. Foster caregivers in this study identified the ideal pediatric clinic environment that encourages adherence to health care appointments. This environment is an organized clinic with easy access including parking, engaged pediatric health providers, ability to reschedule appointments when necessary, and an individualized and consistent appointment reminder system.

A cluster randomized trial of a transition intervention for adolescents with congenital heart disease: rationale and design of the CHAPTER 2 study.

BackgroundThe population of adolescents and young adults with congenital heart disease (CHD) is growing exponentially. These survivors are at risk of late cardiac complications and require lifelong cardiology care. However, there is a paucity of data on how to prepare adolescents to assume responsibility for their health and function within the adult health care system. Evidence-based transition strategies are required.MethodsThe Congenital Heart Adolescents Participating in Transition Evaluation Research (CHAPTER 2) Study is a two-site cluster randomized clinical trial designed to evaluate the efficacy of a nurse-led transition intervention for 16–17 year olds with moderate or complex CHD. The primary endpoint is excess time to adult CHD care, defined as the time interval between the final pediatric cardiology appointment and the first adult CHD appointment, minus the recommended time interval between these appointments. Secondary endpoints include the MyHeart score (CHD knowledge), Transition Readiness Assessment Questionnaire score, and need for catheter or surgical re-intervention. Participants are enrolled in clusters based on week of attendance in the pediatric cardiology clinic. The intervention consists of two one-hour individualized sessions between a cardiology nurse and study participant. Session One focuses on knowledge of the participant’s CHD, review of their cardiac anatomy and prior interventions, and potential late cardiac complications. Session Two focuses on self-management and communication skills through review and discussion of videos and role-play. The study will recruit 120 participants.DiscussionMany adolescents and young adults experience a gap in care predisposing them to late cardiac complications. The CHAPTER 2 Study will investigate the impact of a nurse-led transition intervention among adolescents with CHD. Fidelity of the intervention is a major focus and priority. This study will build on our experience by (i) enrolling at two tertiary care programs, (ii) including a self-management intervention component, and (iii) evaluating the impact of the intervention on time to ACHD care, a clinically relevant outcome. The results of this study will inform pediatric cardiology programs, patients and policy makers in judging whether a structured intervention program provides clinically meaningful outcomes for adolescents and young adults living with CHD.Trial registrationClinicalTrials.gov ID NCT01723332

Contágio emocional de ansiedade encarregado de educação/criança em odontopediatria

ObjectiveTo evaluate the Emotional Contagion of Anxiety existance between carers and their children. Methods41 children (ages from 3 to 6) that were present in Paediatric Dentistry appointments at Clínica Dentária Universitária Egas Moniz and their respective carers were surveyed, using a demographic questionnaire and two instruments to measure the anxiety suffered in dental appointment settings; Modified Venham Picture Test (children) and the Portuguese Version of Modified Dental Anxiety Scale (carers). The data obtained were submitted to analysis with the 21st version of Statistical package for the Social Sciences, specifically recurring to, Spearman's Roh, Shapiro‐Wilk e Mann‐Whitney Tests, being considered a 0.05 level of significance. ResultsNo significant correlation was found between the anxiety suffered by the children and the anxiety suffered by the carers with most of the children in the study (56.1%) considered free of anxiety and most of the carers in the study considered as moderately anxious (56.1%). On the same record we point the fact that children manifest slightly more anxious in follow‐up appointments. ConclusionEven though no Emotional Anxiety Contagion was found on the studied sample, it is undeniable that the anxiety exists, especially in a Dentistry appointment setting.

The economic burden of outpatient appointments following paediatric fractures

IntroductionPaediatric fractures are common and frequently followed-up. The aim of this study is to quantify the private costs for the affected families, as well as the costs for society due to paediatric fracture clinic follow-up appointments. Patients and methods295 paired parent and surgeon questionnaire regarding the cost related to a scheduled follow-up appointment for an upper limb fracture in children aged 6–13 years were collected prospectively over 7 months. In addition, the medical appropriateness of the appointment and whether or not the control changed the management of the fracture was investigated. ResultsThe direct cost of attending a paediatric upper limb fracture clinic was estimated to €48.5 while the cost for society due to productivity loss was €78.4 per consultation. In 89.2% of the cases the surgeons found the appointment necessary, it was deemed unnecessary or inconclusive in 10.6%. The treatment plan was altered in 6.8%, and an extra follow up was scheduled in 5.8%. Fractures of the clavicle were most often regarded as unnecessary to follow up clinically or radiologically by the surgeons. DiscussionThe direct cost for the affected families and the costs for society due to productivity loss of paediatric fracture follow-up appointments are noticeable. Although most patients and surgeons deem these controls as valuable, they lead to a change in treatment plan in only 12.6% of the cases. A stringent management protocol can safely reduce the number of clinical and radiographical follow-ups.

Trends in paediatric rheumatology referral times and disease activity indices over a ten-year period among children and young people with Juvenile Idiopathic Arthritis: results from the childhood arthritis prospective Study.

Objectives. The medical management of JIA has advanced significantly over the past 10 years. It is not known whether these changes have impacted on outcomes. The aim of this analysis was to identify and describe trends in referral times, treatment times and 1-year outcomes over a 10-year period among children with JIA enrolled in the Childhood Arthritis Prospective Study.Methods. The Childhood Arthritis Prospective Study is a prospective inception cohort of children with new-onset inflammatory arthritis. Analysis included all children recruited in 2001–11 with at least 1 year of follow-up, divided into four groups by year of diagnosis. Median referral time, baseline disease pattern (oligoarticular, polyarticular or systemic onset) and time to first definitive treatment were compared between groups. Where possible, clinical juvenile arthritis disease activity score (cJADAS) cut-offs were applied at 1 year.Results. One thousand and sixty-six children were included in the analysis. The median time from symptom onset and referral to first paediatric rheumatology appointment (22.7–24.7 and 3.4–4.7 weeks, respectively) did not vary significantly (∼20% seen within 10 weeks of onset and ∼50% within 4 weeks of referral). For oligoarticular and polyarticular disease, 33.8–47 and 25.4–34.9%, respectively, achieved inactive disease by 1 year, with ∼30% in high disease activity at 1 year. A positive trend towards earlier definitive treatment reached significance in oligoarticular and polyarticular pattern disease.Conclusion. Children with new-onset JIA have a persistent delay in access to paediatric rheumatology care, with one-third in high disease activity at 1 year and no significant improvement over the past 10 years. Contributing factors may include service pressures and poor awareness. Further research is necessary to gain a better understanding and improve important clinical outcomes.

Private general paediatric care availability in Melbourne.

Objective The aims of the present study were to determine the actual availability of private general paediatric appointments in the Melbourne metropolitan region for children with non-urgent chronic illnesses and the cost of such care. Methods A 'secret shopper' method was used. Telephone calls were made to a random sample of 47 private paediatric clinics. A trained research assistant posed as a parent, requesting the first available appointment with a specific paediatrician. Data regarding appointment availability, total potential charges and net charges after the Medicare rebate were collected. Results Appointments were available in 79% (n=37) of clinics, with 72% (n=34) able to offer an appointment with the requested general paediatrician. The number of days until available appointments varied from same day appointments to a wait of 124 days, with an average wait of 33 days. Of practices that provided information about the appointment cost (n=42), five bulk-billed for the consultation, whereas the remainder (n=37) were fee-paying clinics. The potential maximum charge for an initial consultation in the fee-paying clinics ranged from A$177 to A$430, with an average cost of A$279. The potential maximum out-of-pocket cost for patients ranged from A$40 to A$222, with an average out-of-pocket cost of A$128. Conclusions Private paediatric care in the Melbourne metropolitan region is generally available. The out-of-pocket cost of private paediatric out-patient care may present a potential economic barrier for some families. What is known about the topic? In Australia, out-of-pocket expenses for private specialist care are not covered by private health insurance. There are no data available on the actual cost of private paediatric consultations that are based on real-time assessments. Data collected in 1998 suggested that the average waiting time for a first standard consultation with a general paediatrician in a private room was 14.1 days. There are no recent empirical data on appointment availability and waiting time for appointments with general paediatricians in Australia. What does this paper add? There is high availability of paediatric consultations in the private sector. Waiting times for an appointment vary considerably from same day appointments to a wait of 124 days, with an average wait of 33 days. The cost of a private paediatric consultation in Australia to the patient is considerable, with an average potential maximum up-front charge for an initial consultation of A$279 and an average potential maximum out-of-pocket cost of A$128. What are the implications for practitioners? Data on the availability and cost of private paediatric consultations are imperative to formulate evidence-informed policy and better understand variations in the availability of public and private care.

P-034 Brief Behavioral Intervention for Sleep Disturbance for Adolescents and Young Adults with Crohnʼs Disease

Sleep disturbance is common in patients with Crohn's disease (CD) and has been associated with fatigue and increased disease activity. Behavioral interventions for insomnia have improved sleep and associated fatigue in other populations but have not been tested in young adults with IBD. This study presents results of an open trial over 3 months of Brief Behavioral Therapy for Sleep in IBD (BBTS-I) in adolescents and young adults with CD to evaluate feasibility and effects on insomnia and fatigue. Over 18 months, we screened all CD subjects ages 15 to 30 using the Pittsburgh Sleep Quality Index (PSQI) and Multidimensional Fatigue Inventory (MFI) at pediatric or adult GI clinic appointments. Participants scoring ≥7 on PSQI and ≥45 on MFI completed a further assessment which included further probes of sleep using subjective (questionnaires) and objective (actigraphy) measures, a structured psychiatric interview for DSM-IV (SCID). The BBTS-I consisted of 2 to 4 sessions consisting of sleep hygiene, behavioral strategies, and hypnosis delivered in either face-to-face or phone sessions. Primary outcomes were PSQI and MFI; secondary outcomes were anxiety and depression severity (Hamilton Rating Scale; HRSA and HRSD), CD activity (Harvey Bradshaw [HB]), and quality of life (Short Inflammatory Bowel Disease Questionnaire; SIBDQ. Paired t-test was used to evaluate pre-post differences in outcomes. The relationship between change in sleep, fatigue, and CD activity over time was also explored. Over 18 months, 224 CD subjects were approached, 193 screened; 93 screened positive and 51 completed a more comprehensive assessment; and 48 participated in the BBTS-I intervention. Subjects receiving the intervention were predominantly Caucasian, 63% female, with mean age of 23.5 and mild mean CD activity. Baseline mean PSQI was 10.8 (SD 3.2) and MFI was 64.6 (SD 11.2). Anxiety disorders and depression was common and mean HRSA of 13.1 (SD 7.2); mean HRSD of 13.1 (SD 4.8), and mean SIBDQ of 45.7 (SD 9.4) at baseline. 72% of the sample participated in the intervention. After BBTS-I, there was a significant reduction in PSQI (mean change, 4.036; P < 0.001; η2 = 0.57) and MFI (mean change, 11.97; P < 0.001; η2 = 0.53) over time. There were also significant pre-post increase in SIBDQ (P < 0.001; η2 = 0.61) and reduction of HRSD (P = 0.001; η2 = 0.42), HB (P = 0.001; η2 = 0.34), and HRSA (P = 0.04; η2 = 0.25). Improvement of PSQI over time was not significantly correlated with changes in MFI, HB, HRSA, or HRSD. Improvement in MFI over time was significantly correlated with improvements in HRSA (r = 0.75; P < 0.001) and HRSD (r = 0.47; P = 0.007) but not improved PSQI or HB over time. Using a brief behavioral intervention for sleep disturbance in young adults with CD is feasible and has promising effects in improving sleep, fatigue, quality of life, anxiety, depression and CD activity. Improvement in sleep over time after the intervention does not appear related to changes in disease activity or mood symptoms while improvement in fatigue is related to improvements in anxiety and depression. Randomized trials with larger samples will be needed to show that behavioral intervention for sleep is efficacious in patients with IBD.

Validation of the Behavioral Health Checklist in Diverse Pediatric Primary Care Settings.

Examine the validity and clinical utility of the Behavioral Health Checklist (BHCL), a screening tool with 2 forms (4-7, 8-12 years) developed for use with children of diverse backgrounds. At pediatric primary care appointments, the parents of 1274 children completed a demographic form, the BHCL, and the Child Behavior Checklist (CBCL). Concurrent validity was examined by conducting correlations between the BHCL and the diagnostic scales of the CBCL. Diagnostic prediction was examined by conducting logistic regression analyses and plotting receiver operating characteristics (ROC) curves. Clinical utility was investigated by examining sensitivity, specificity, and kappa corrections for total predictive power. The pattern of correlations with the CBCL provided evidence of convergent and discriminant validity for both versions of the BHCL. ROC curve plots provided clear evidence of predictive validity (area under curve values ranged from .84 to .96 across factors and both age-determined versions). Cut-points achieving sensitivity and specificity values of at least .70 were identified for each BHCL factor for each version. The BHCL was demonstrated to have strong construct and predictive validity. The predictive validity of each version was demonstrated across genders, socioeconomic status, and racial groups (black or African American and white). The BHCL has promise as a developmentally and culturally effective behavioral health screener for use in pediatric primary care practices.

Pediatric Return Appointment Adherence for Child Welfare-Involved Children in Los Angeles California

This study of primarily Latino caregivers and Latino child welfare-involved children had the following aims: (1) explore the return appointment adherence patterns at a pediatric medical clinic; and (2) determine the relationship of adherence to return appointments and caregiver, child, and clinic variables. The sample consisted of caregivers of child welfare-involved children who were asked to make a pediatric outpatient clinic return appointment (N = 87). Predictors included caregiver demographics, child medical diagnoses and age, and clinic/convenience factors including distance from the clinic to caregiver's home, days until the return appointment, reminder telephone call, Latino provider, and additional specialty appointment. Predictors were examined using χ(2) and t tests of significance. Thirty-nine percent of all caregivers were nonadherent in returning for pediatric appointments. When return appointments were scheduled longer after the initial appointment, caregivers were less likely to bring children back for medical care. The 39 % missed return appointment rate in this study is higher than other similar pediatric populations. Better coordination between pediatricians and caregivers in partnership with child welfare case workers is needed to ensure consistent follow-up regarding health problems, especially when appointments are not scheduled soon after the initial appointment.

G287 Impact of telephone reminders on attendance rate at paediatric clinics

Background Non-attendance in clinics has a major economic impact in the National Health Service. Literature review indicates that the major reason for non-attendance is patients or parents forgetting their appointment and reminders before clinic appointment reduces the “did not attend” (DNA) rate. Telephone call reminders were introduced for all paediatric outpatient appointments from February 2014 in our District General Hospital setting. Aim We aimed to evaluate the DNA rate at the paediatric outpatients after implementation of telephone reminders. Methods Using our hospital outpatient database, DNA rates were reviewed for 6 months (Feb–July 2013) and compared with the DNA rates for similar duration in 2014 (before and after the introduction of reminders). For Feb–July 2014 period, comparison was also made for patients who confirmed attendance during reminders versus those left a voice message and those who didn’t receive a call or did not answer. Results Total number of patients in 6 months (2013) were 4156 [2674 follow-up (F/U), 1482 New] and 4732 (3100 F/U, 1632 New) in 2014 (Figure 1). Overall DNA rate for both F/U and New appointments in 2014 was 11.4% (post intervention), which was 5.1% (p value DNA rate was lowest at 3.4% in the patients who answered and confirmed the appointment. Patients confirming attendance were less likely to DNA compared to those patients who had voice messages (10.98% DNA, p value 0.0041) or not answering phone/not called (13.65% DNA, p value 0.0001). Conclusion Our results endorse the usefulness of telephone reminders and validates that confirmation of clinic appointment plays a significant role in reducing the DNA rate in the Paediatric outpatient setting. Telephone reminders and text messaging are extremely cost effective interventions, and hence routine reminders with confirmation of appointment should become standard NHS practice.

G587(P) Improving understanding of children attending paediatric outpatients

<h3>Context</h3> A busy paediatric outpatient department in a UK district general hospital <h3>Problem</h3> There is currently no information provided to children by the trust. This may have been adversely affecting our paediatric outpatients. By providing an information leaflet to children we hoped to improve their understanding and patient experience. <h3>Assessment of problem and analysis of its causes</h3> Children are often overlooked in relation to patient information. Paediatric leaflets are usually written for parents. We surmised that children would benefit from understanding why they were coming to outpatients and what they could expect to happen while they were there. When children are more informed they may be more relaxed and therefore more cooperative with the physical examination. Children who have a positive experience of their first outpatient appointment may be more comfortable with future appointments. <h3>Intervention</h3> A trust patient information leaflet that parents could go through with their children prior to attending their first paediatric outpatient appointment. <h3>Study design and strategy for change</h3> Send out information leaflet with all new appointments for children aged 2–12 years (over an 8 month period) with a request that parents go through it with their child before attending the appointment. Leaflet designed with assistance of senior paediatric speech and language therapist to ensure that age-appropriate language used. Pictures were included to illustrate components of outpatient appointment, such as being weighed by nurse. Leaflet approved by in-hospital communications department. <h3>Measurement of improvement</h3> A questionnaire given to parents in outpatient reception. Parents were asked whether they received leaflet, whether they went through it with their child and whether they felt it was helpful. If they didn’t receive it they were asked whether they thought it may have been helpful. We also asked our clinicians to ask the children pre-defined questions prior to beginning the consultation to try and capture the children’s views verbatim. Most clinicians did not complete these questions. This may reflect time pressure during appointments. We collated the questionnaire responses and analysed the data. We also obtained further suggestions for improvement from parents. Key findings: 42% of parents who had not received the leaflet reported that it would have been helpful. However 78% of parents who received the leaflet prior to the appointment reported that it was useful (Figure 1). When asked to explain what their child understood about why they were coming to clinic and what would happen 24% left the question blank, possibly due to a language barrier. Some comments from parents who had not received leaflet prior to appointment included ‘I wish we could have received this beforehand to go through with my child’ and <b>‘</b>it’s always important to communicate with children and explain to them everything in advance. This will help to keep them calm and happy.’ A parent who had received leaflet commented ‘perhaps a child-friendly version - in colour and larger font would be helpful’. <h3>Effects of changes</h3> Our work demonstrated that most parents in our population valued the provision of this information to their children. We used parents’ views as a proxy for their children’s which may not be accurate. Over time, as more leaflets are distributed, it may be possible to investigate whether children who received the leaflet had a more positive experience of outpatients than those who didn’t. <h3>Lessons learnt</h3> Designing an information leaflet requiring trust approval took much longer than we anticipated. Our leaflet needs to be translated into other languages to better serve the local population. Work is needed to make our leaflet more user-friendly for younger children. <h3>Message for others</h3> Give consideration to children’s views and understanding of what coming to hospital means for them. Seek to inform them and make their experience a positive one.

G443(P) Evaluating user experience in community paediatrics using the friends and family test (fft)

Aims The FFT survey is only due to be rolled out nationally to all community and mental health trusts in 2015 by DOH. Our aim was to proactively use the FFT to evaluate child and young person (CYP) and carer’s experience about community paediatric clinic appointments, in a variety of settings. This would be helpful towards obtaining timely feedback from CYP and parents, about the quality of care offered by community paediatricians and identify areas for improvement. Method The Friend and Family Test (FFT) is a single question survey which asks patients and carers whether they would recommend the NHS service they have received, to friends and family who need similar treatment or care. The survey was conducted prospectively on all patients seen by community paediatricians during a 6-week period from 1st July until 15th August 2014. At the end of each clinic consultation, the form was handed to eligible CYP and carers for completion. CYP aged 8 years and over were included and those with moderate to severe learning difficulty were excluded. Carers of CYP from 0–19 years’ age range were included. A marked box was kept for them to drop the completed form in at the reception, before leaving the clinic. All the completed forms were sent to the audit department for further evaluation. Results In total 348 forms (106 by CYP and 242 by carers) were completed over the 6 weeks period. The responses across individual questions were highly correlated. See Figures 1 and 2. Conclusion The total number of responses collected is a good representative sample of our caseload. Both CYP and carers report high satisfaction score about their experience with the doctor at clinic appointments. 97% of carers and 85% of CYP were either extremely likely or very likely to recommend our service to friends and families. Using a validated tool asking a single question in a busy outpatient setting, we have been able to collect robust evidence about the quality of our service. We plan to use this survey to positively influence commissioners for service development.

G586(P) Phototherapy management in jaundiced babies: jaundice management tool

G586(P) Phototherapy management in jaundiced babies: jaundice management tool

G293(P) Does every child referred to paediatric out patients need to be seen?

Aims In the UK, the referral rate from primary care to General Paediatrics has drastically increased from from 15.5 to 25.7/1000 children per annum1. A Cochrane review identified that ‘local educational interventions involving secondary care specialists and structured referral guidelines are the only interventions shown to negatively impact referral rates’2. This study investigated whether written dialogue with GPs could empower them to appropriately manage potential General Paediatric out patient referrals in the community. Method A retrospective case note review of 300 referrals which were managed with individualised advice letters rather than outpatient appointments between October 2012 and March 2014 was conducted. Results All children under the age of 1 were offered outpatient appointments. The distribution of age groups is illustrated in Figure 1. The system based referrals are demonstrated in Table 1. 84% (n = 253) of referrals were managed by a single advice letter. Within this group, only 26% (n = 66) were re directed to more appropriate services. Of the remaining 47 referrals, 38% (n = 18) were offered outpatient appointments after further telephone discussion with the GP; 57% (n = 27) were re referred after the GP received the advice letter. Of the patients offered out patient appointments, 40% (n = 19) were discharged after the initial consultation and 4% (n = 2) did not attend. No adverse outcomes were noted. Conclusion This study demonstrates that through supporting GP colleagues, selected outpatient referrals can be appropriately managed in the community. In our trust 253 new General Paediatric appointments would represent 41 General Paediatric clinics. However the ‘Payment by Result’ offers perverse financial incentive to manage more patients in secondary care. If adopted regionally this approach would improve patient care in the community and free up Consultant time towards consultant delivered acute care.

Attitudes toward Human Papilloma Virus Vaccination and Head and Neck Cancer Prevention in a Diverse, Urban Population.

(1) To understand if awareness of the human papilloma virus (HPV) vaccination's potential to prevent head and neck cancer improves acceptability of the vaccine in a large urban population and (2) to identify characteristics of those in whom such discussions would have the greatest impact. In-person, anonymous survey. Academic public hospital between March 2014 and June 2014. Patients aged 12 to 24 years and their parents or guardians awaiting scheduled outpatient pediatric appointments. Demographics and modified Carolina HPV Immunization Attitudes and Beliefs Scales data were cross-analyzed, followed by univariate binomial logistic regression to identify predictors for major outcomes of interest. More than 78% of those surveyed indicated they would be more receptive to the HPV vaccine if given strong evidence that it prevented head and neck cancer. Respondents were more likely to increase receptivity to HPV vaccination if they held the belief that they did not have enough information about the vaccine or indicated they preferred to wait because the vaccine was too new. Increasing public awareness of head and neck cancer prevention with HPV vaccination could increase HPV vaccination acceptance.