Ian Wacogne

Handover and note-keeping: the SBAR approach

The introduction of a simple 19-point checklist, the WHO Surgical Safety checklist, led to significant reductions in surgical morbidity and mortality but other simple communication tools are urgently required to deal with other causes of avoidable harm to patients. Evidence exists that poor communication in general is of concern. Communication failures caused 11% of preventable adverse events leading to permanent disability in Australia. Communication breakdown was the leading cause of adverse events reported in the US from 1996– 2006. Organization culture was cited as a major barrier to effective communication and teamwork. Hierarchy and intimidation, failure to function as a team, and failure to follow the chain of communication were the major root causes of adverse events identified. Traditional work patterns, in which doctors worked in excess of 72 hours per week, allowed doctors to see the same patients at both day and night. Recent European health and safety legislation, known as the European Working Time Directive (EWTD) (Council Directive 93/ 104/EC, 1993), has necessitated the introduction of shift rotas in acute hospital settings. In the day, patients continue to be managed by small teams of postgraduate doctors in training, based on single organ specialties or other themes. At night, weekends, and on public holidays a small number of doctors in training and other healthcare professionals, cross-cover many different specialties. Shift systems are associated with an increased risk of adverse events. The day and night team have a clear responsibility to hand over clinical responsibility, accountability and information effectively but ineffective handover has led to delayed diagnosis, erroneous treatment, lifethreatening clinical incidents, complaints, longer length of stay and increased health expenditure. Junior doctors themselves are dissatisfied with the poor quality of clinical handover. Failure-prone communication processes, which permit omitted content and illegible or unclear notes are important risks in clinical handover. Delegation of responsibility can be unclear. The World Health Organization recommends the use of a standardized process, called SBAR, an acronym, which stipulates that the patients’ Situation and Background and the professional’s Assessment and Recommendations should form the core of the handover discussion. An example of this is shown in Figure 1, and an example of a local adaptation is shown in Figure 2. Outcomes following implementation of SBAR include improved patient safety, increased quality of care, reduced patient falls during shift change, decreased response time to nurses’ request for patient review and reduced reporting time by 70%. Introduction of SBAR also has the effect of significantly reducing interruptions to handover, and also the duration

Are follow up chest x ray examinations helpful in the management of children recovering from pneumonia

A4 year old boy with a cough and a fever is referred by his general practitioner. On auscultation of his chest there are focal signs suggestive of a lower respiratory tract infection; a chest x ray examination confirms right lower lobe collapse and consolidation. He is started on oral antibiotics and discharged home within 24 hours. He is given a follow up appointment in four weeks time in the “registrar clinic” to be reviewed after having a repeat chest x ray …

The role of Google in children's health

This month, Archives has two articles which contain the name of that most ubiquitous search engine, and which explore the use of the internet by families. In the first, patients whose symptoms had baffled doctors have had their symptoms googled by family members and have resulted in the (correct) diagnosis of lysosomal storage disease.1 In the second, the authors have tried to assess the validity of information produced by Google in response to a series of simple questions.2 They chose topical and controversial questions which might be expected to produce divergent advice. They were able to grade the reliability of advice given by the type of website, finding that those originating from official or NHS sources (URLs ending in .gov.uk or .nhs.uk) were most reliable. Sites maintained by commercial groups, universities, charities and parent support groups were less reliable. There can be few areas of medicine which have not been profoundly influenced by the development of the internet. Recently, this journal carried an article about paediatricians in Ireland regarding their near universal use of the internet as a source of information.3 Patient and parent use has grown too—although it is now more than 10 years since Gray and de Lusignan4 suggested a transition from ‘Maladie du petit papier’—used in the past to describe the challenges of a patient who appears with a list of symptoms on a bit of …

Question 1 Does anti-reflux therapy improve symptoms in infants with laryngomalacia?

A 3-month-old infant is referred to the general paediatric clinic with stridor. You think this is likely to be due to laryngomalacia but for further reassurance you ask a colleague in ENT to assess the infant. As part of his assessment, the ENT doctor starts the infant on anti-reflux therapy, with the explanation that there is an association between reflux and laryngomalacia. You wonder if this is true, and whether anti-reflux medicine is actually helpful. In infants with stridor secondary to laryngomalacia [population] does treatment with anti-reflux therapy [intervention] lead to an improvement in symptoms [outcome]? ### Secondary sources No appropriate reviews were found in The Cochrane Library. ### Primary sources PubMed was searched in July 2011 using the search terms Gastroesophageal reflux/Gastro-oesophageal reflux/GERD/GORD/GER/GOR AND Laryngomalacia or Stridor, and combinations of the terms laryngomalacia, stridor, reflux, antireflux, proton pump inhibitor, histamine antagonists, domperidone, prokinetic and cisapride. Bibliographical searches were also undertaken. Thirteen case series or reports were identified in electronic sources, and a search of a bibliography revealed one further report of two cases.1 Five papers were excluded, four as stridor was grouped with other respiratory presentations and one as it investigated gastro-oesophageal reflux in recurrent croup. Adult papers and non-English language papers were excluded. Nine studies were included (table 1). …

Question 3 Is measurement of the lymphocyte count useful in the investigation of suspected pertussis in infants

A 3-week-old baby presents with cough and episodes of apnoea. Nasopharyngeal aspirate is negative for common respiratory viruses. You consider the diagnosis of pertussis and take a full blood count to assess the lymphocyte count. You wonder what the sensitivity and specificity of the lymphocyte count is for pertussis in infants. In an infant with clinical suspicion of pertussis [patient], how useful is a lymphocyte count [intervention] to determine the likelihood of a positive or negative diagnosis [outcome]? ### Secondary sources A search of The Cochrane Library using the search term “pertussis” yielded five reviews, none of which were relevant. ### Primary sources A Medline search was performed using the following terms: (MeSH: Lymphocytosis OR MeSH: Lymphocyte Count OR “lymphocyte” OR “lymphocytosis” OR MeSH: Leukocytosis OR MeSH: Leukocyte count OR “leucocyte” OR “leukocyte” OR “leucocytosis” OR “leukocytosis” OR “white cell count” OR “full blood count” OR “complete blood count”) AND (MeSH: Whooping Cough OR pertussis OR “whooping cough”). Limits were: “Humans” and “English Language”. The search yielded 414 individual articles. Eleven full text articles were examined, of which four were relevant; one further article was found …

QUESTION 3. Does the clinical finding of ear wax exclude the finding of otitis media

A 6-year-old boy presented with ear ache and mild fever. The assessing registrar confidently made the assertion that the diagnosis could not be otitis media as he has read that the presence of wax excludes this. You wonder if this is true. In children [population], does the clinical finding of ear wax [intervention] predict the absence of otitis media [outcome]? PubMed – advanced search criteria: otitis media, children, ear wax and/or cerumen and diagnosis. Thirty two results were found. The titles and abstracts were reviewed and two relevant studies were found.1 2 Ovid - MEDLINE/EMBASE – advanced search criteria: otitis media, children, ear wax and/or cerumen. Seventeen results were found. The titles and abstracts were reviewed and one relevant study was found (this was the same as the study found in the PubMed search).2 A further search for case reports was unsuccessful. Ovid: MEDLINE/EMBASE database – search terms: otitis media, ear …

Question 3 What is the efficacy of duct tape as a treatment for verruca vulgaris

An 8-year-old girl attends a general paediatric outpatient clinic for medical review and it is noted that she has duct tape on her finger. When asked about it, her mother states that duct tape was recommended by a dermatologist for the treatment of verrucas on the girls fingers and toes. You wonder what the evidence base is for this treatment. In children with verrucas [population] does treatment with duct tape [intervention] bring about resolution of verrucas [outcome]? ### Secondary sources A Cochrane review on the subject of verrucas was published in 2006; this revealed only one relevant paper, which was also identified in the primary search. ### Primary sources We searched the PubMed, Ovid MEDLINE, EMBASE and CINAHL databases, using the search criteria ‘warts’, ‘verrucas’, ‘duct tape’ and ‘children’. A search of PubMed produced six results, two of which were randomised controlled trials (RCTs) and are included in this review. The other results were comments or letters and are not included. The same search of Ovid MEDLINE, EMBASE and CINAHL produced the same two RCTs. Due to the paucity of results specific to the paediatric population, we extended our search to include adults, which generated just one further RCT. We also carried out a broader search using …

Question 3 In patients with spontaneous pneumothorax, does treatment with oxygen increase resolution rate?

A 15-year-old boy is admitted with sudden onset chest pain and breathlessness. Chest x-ray shows a small pneumothorax. He has no background health problems. He is treated conservatively with high-flow oxygen, as the registrar has been taught this can improve the resolution rate of pneumothoraces. The consultant questions the biological plausibility of this treatment. In patients with spontaneous pneumothorax (population), does treatment with oxygen (intervention) increase resolution rate (outcome)? ### Primary sources Medline (1950 to present) was searched via the Ovid interface on 6 July 2009. ‘Pneumothorax’ [MeSH] and ‘oxygen inhalation therapy’ [MeSH] with no limits produced 113 results, two of which were relevant. ### Secondary sources EMBASE (Ovid) was searched using the headings ‘spontaneous pneumothorax’ [MeSH] and ‘oxygen therapy’ [MeSH] with no limits producing 23 results, none of which were relevant. The reference list of …

Spending an additional 40 min outdoors each day reduces the incidence of myopia among primary school children in China.

ed from: He M, Xiang F, Zeng Y, et al. Effect of time spent outdoors at school on the development of myopia among children in China: A randomized clinical trial. JAMA 2015;314:1142. Myopia or short-sightedness, can be corrected. However, it imposes a socioeconomic burden through life-long eye examinations and the purchase of glasses. Highly myopic patients report a lower quality of life. Furthermore, progression to ‘high myopia’ above 6.0 D is associated with serious vision loss from retinal detachment or macular disease. Aetiology is multifactorial. Risk factors include family history, ethnicity, excessive near work or indoor pastimes, lack of vitamin D, lack of ultraviolet (UV) radiation and urban living. One in five teenagers are myopic in the UK. Interventions shown to reduce myopia include atropine eye-drops, glasses (bifocal, varifocal, peripherally defocused) and lifestyle interventions such as increased exercise and time outdoors. In this large interventional study, a school-based outdoor exercise programme reduced myopia by 9.5% and prevented 78 children from requiring glasses. The annual cost of refractive correction is £140–£360 per person in the UK, allowing for inflation. This study predicts in their cohort a cost saving of £32 000– £84 000 over three years. It is unknown whether this observed benefit is transient or will be sustained into adulthood. It is widely accepted that children with a sedentary lifestyle are at increased risk of obesity, heart disease and diabetes. Increasing the childhood time spent engaging in outdoor activity is low cost and low risk and with multiple benefits, including the potential to reduce myopia. Robert J Barry, Ian Wacogne, Joe Abbott Birmingham Children’s Hospital, Birmingham, West Midlands, UK Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, Centre for Translational Inflammation Research, University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, Birmingham, UK Correspondence to Dr Robert J Barry; r.j.barry@bham.ac.uk Provenance and peer review Not commissioned; internally peer reviewed. To cite Barry RJ, Wacogne I, Abbott J. Arch Dis Child Educ Pract Ed 2016;101:219. Received 26 April 2016 Accepted 2 May 2016 Published Online First 31 May 2016

Unusual chest radiographic findings in children

A 9-year-old British Asian girl with asthma was referred by her general practitioner to outpatients with a 12-month history of dry cough and an abnormal chest radiograph. There was no history of recent …