CORRESPONDENCE: OUR EXPERIENCE
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Correspondence
was performed for 333 (69%) patients, and the rest were treated conservatively (31%). The average time to reduction was 5.6 days after the injury. However, delay up to one month for closed reduction had no correspondence to the number of reoperations or corrective surgery. Almost all (95%) primary nasal fracture reductions in adults were performed under local anaesthesia. Three-quarters (75%) of the closed reductions were performed by a resident and one-quarter (25%) by a senior doctor – with no difference in the long-term outcome.
Conflict of interest
No conflict of interests. References 1 Kelley B.P., Downey C.R. & Stal S. (2010) Evaluation and reduction of nasal trauma. Semin. Plast. Surg. 24, 339–347
2 Cil Y. & Kahraman E. (2013) An analysis of 45 patients with pure nasal fractures. Ulus. Travma Acil Cerrahi Derg. 19, 152–156 3 Runbinstein B. & Strong E.B. (2000) Management of nasal fractures. Arch. Fam. Med. 9, 738–742 4 Mondin V., Rinaldo A. & Ferlito A. (2005) Management of nasal bone fractures. Am. J. Otolaryngol. 26, 181–185 5 Fernandes S.V. (2004) Nasal fractures: the taming of the shrewd. Laryngoscope 114, 587–592 6 Cook J.A., Murrant N.J., Evans K. et al. (1992) Manipulation of the fractured nose under local anaesthesia. Clin. Otolaryngol. Allied Sci. 17, 337–340 7 Yabe T., Tsuda T., Hirose S. et al. (2012) Comparison of pediatric and adult nasal fractures. J. Craniofac. Surg. 23, 1364– 1366 8 Kim H.S., Suh H.W., Ha K.Y. et al. (2012) The usefulness of the endonasal incisional approach for the treatment of nasal bone fracture. Arch. Plast. Surg. 39, 209–215 9 Lee K., Yoo B.H., Yon J.H. et al. (2013) General anaesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture. Korean J. Anesthesiol. 65, 209–214 10 Chadha N.K., Repanos C. & Carswell A.J. (2009) Local anaesthesia for manipulation of nasal fractures: systematic review. J. Laryngol. Otol. 123, 830–836
Paediatric ENT standards in London: are we delivering a first-class service? a repeat audit Varadharajan, K.* & Narula, A.†‡ *Department of Otolaryngology, West Middlesex University Hospital, †Department of Otolaryngology, Imperial Healthcare NHS Trust, St. Mary’s Hospital, ‡Middlesex University, London, UK Accepted for publication 1 May 2015
Dear Editor, Children (aged 0–14) account for almost a third of ENT admissions,1 and ENT accounts for 25% of all paediatric admissions (aged 0–14) of surgical specalities.1 It is essential that ENT surgeons maintain a high standard of paediatric care. The Children’s Surgical Forum (CSF) of the Royal College of Surgeons of England (RCS) have set out paediatric ENT standards outlined in the following guides: ‘Surgery for Children: Delivering a First Class Service 2007’,2 ‘Ensuring
Correspondence: K. Varadharajan, Department of Otolaryngology, West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK. Fax: 0208 321 5906; e-mail: [email protected]
the provision of general paediatric surgery in the district general hospital’ (2010)3 and ‘Standards for Children’s Surgery’ (2013).4 In 2011, we conducted a regional audit of paediatric ENT standards in hospitals in London and Greater London and found that several key standards were poorly complied with.5 With recent update of guidelines by the CSF in 2013,4 we decided to repeat this audit to determine whether the standards have improved in the last 2 years. Three new standards were also assessed: the presence of at least one member of staff trained in advanced paediatric life support for emergency admissions, regular auditing of patient experiences and the presence of robust transfer arrangements for paediatric care that cannot be provided locally. In addition, we wanted to assess smaller district general hospitals affiliated with larger teaching hospitals. © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
83
Fig. 1. A comparison of % compliance with standards between the first and second cycles.
Methods
An online questionnaire was disseminated to consultants and specialist registrars in ENT working in hospitals in London and Greater London (smaller satellite hospitals were also included in this cycle). The questionnaire was formulated directly from standards from guidance from the CSF: ‘Surgery for Children: Delivering a First Class Service 2007’,2 ‘Ensuring the provision of general paediatric surgery in the district general hospital’ (2010)3 and ‘Standards for Children’s Surgery’ (2013).4 In addition, three new standards were assessed to incorporate the updated guidance.4 Some of these standards pertained specifically to ENT care, whilst others encompassed paediatric surgical care as a whole. The questionnaire consisted of three sections representing standards in administration (n = 8), clinical (n = 8) and © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
surgical/theatre practices (n = 4). The questions were posed in a binary (Yes/No) format to assess compliance with standards. The questionnaire took less than 2 min to complete (see Appendix 1 for questionnaire). The questionnaire was distributed to ENT surgeons who would have sufficient experience within the unit assessed to facilitate accurate completion of the questionnaire. In most cases, this consisted of a named contact of consultant grade; however, in some cases, this was a registrar. Results
Fifteen of 17 hospitals responded (88% response rate). Standards with high compliance in this cycle included having play specialists (100%), the presence of paediatric surgical wards with registered children’s nurses (93%), the presence of paediatric consultant anaesthetists in day-case surgery
84
Correspondence
(93%), dedicated paediatric theatre lists for elective admissions (93%) and staff being trained in child protection (93%). Compliance with 13 of 17 standards increased compared to the first cycle in 2011 (see Fig. 1). Standards that significantly improved (>10%) included all surgeons operating on children being trained in paediatric basic life support (46% to 64%), surgeons receiving structured paediatric training as per the curriculum (46% to 71%), the presence of a separate recovery area for children (62% to 86%) and staff receiving child protection training (69% to 93%). There was reduced compliance with three standards since the last audit: the presence of a child-friendly ENT department with appropriate equipment and drugs to deal with paediatric emergencies (92% to 86%), all surgeons operating on children undertaking 100 such cases per year (69% to 57%) and the acute pain services visiting children’s wards daily (54% to 43%). The three hospitals that had no inpatient paediatric services all had robust transfer arrangements to centres offering paediatric services (the distance by transport to these paediatric centres was 30 min or less in all cases). Compliance with new standards was as follows (Fig. 2): the majority of hospitals (>80%) had robust transfer arrangements for children in whom care could not be provided locally and at least one member of onsite staff trained in advanced paediatric life support for paediatric emergencies. Just over 60% of hospitals regularly audited patient experiences. Overall, 93% of hospitals complied with 60% or more of the standards, with two complying with all 20 standards. Discussion
This repeat regional audit shows a significant overall improvement in paediatric ENT standards in London. There
was increased compliance with almost all of the standards compared to the previous audit in 2011. Key areas that improved from the last audit included staff being trained in paediatric basic life support, staff receiving child protection training and structured paediatric training as per the curriculum. There is capacity for improvement particularly in acute pain services for children and ensuring surgeons operating on children do so regularly. The fall in compliance between audits in the latter standard is particularly pertinent. There are several potential reasons for this. There may be less paediatric patients in the demographic of a given ENT centre that may preclude surgeons (particularly trainee surgeons) from undertaking high volumes of operations on children. In addition, it is possible that more ENT surgeons in district general hospitals (DGH) are seeking tertiary ENT paediatric input for children. More than 80% of centres had robust transfer arrangements for children in whom care could not be provided locally. This positive finding suggests that children are being managed at centres appropriate to the complexity of their conditions. Overall, the reasons for reduced compliance with regard to ENT surgeons operating on children undertaking 100 paediatric cases per year need to be investigated in further detail in subsequent cycles. Conclusion
Overall, the results of this re-audit are encouraging and demonstrate once more that the RCS standards are pragmatic and can be achieved. We hope that ENT departments take heed of these results and aim to comply with the RCS standards. The two cycles of this regional audit suggest the need for a national audit to assess these standards in England and Wales. Keypoints
•
• • Fig. 2. Percentage of compliance with new standards in the 2nd cycle.
The Children’s Surgical Forum (CSF) of the Royal College of Surgeons of England (RCS) have set out key standards pertaining to paediatric ENT care, and in 2011, we conducted a pilot audit of these standards in London and found that there were several key deficiencies. Two years on we decided to re-audit these standards to assess if there has been any change. In the 15 hospitals, we audited and noted an improvement in compliance in 13 of 17 standards compared to the first cycle. Standards that improved significantly included surgeons being trained in paediatric life support, surgeons receiving structured
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
• •
paediatric training, the presence of a separate recovery area for children and staff receiving child protection training. The encouraging results of this re-audit suggest that the CSF standards are pragmatic and can be achieved. Moreover, these findings highlight the need for a national audit assessing paediatric ENT standards.
Acknowledgments
We thank all the ENT surgeons that complete the survey. Conflict of interests
The senior author (Professor Narula) was a council member of the Royal College of Surgeons of England during the audit period.
85
possible and have access to the appropriate level of care by the correct staff with appropriate skills) 2 Do ENT surgeons receive structured paediatric training in accordance with the requirements of the ENT curriculum? 3 Do all staff coming into contact with children trained in safe guarding (child protection training) 4 Are all surgeon’s operating on children trained in paediatric basic life support? 5 In paediatric emergency admissions there is always at least one member of staff onsite that is trained in APLS (Advanced Paediatric Life support)/EPLS (European Paediatric Life Support) or equivalent? 6 Do you have a dedicated clinical lead for paediatric ENT? 7 Do you a dedicated lead for paediatric surgery as a whole? 8 Are patient experience standards regularly audited? B) Clinical Standards
References 1 Department of Health (2011) Hospital episode statistics. URL http:// www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937 [accessed on 12 October 2013] 2 RCS England (2007) Surgery for Children: Delivering a First Class Service. RCSE, London. URL http://www.rcseng.ac.uk/publications/ docs/CSF.html [accessed on 10 October 2013] 3 RCS England (2010) Ensuring the Provision of General Paediatric Surgery in the District General Hospital. RCSE, London. URL http:// www.rcseng.ac.uk/ service_delivery/documents/General%20Paediatric%20Surgery%20 Guidance%20for%20commissioners% 202010.pdf [accessed on 10/10/13] 4 CSF (2013) Standards for Children’s Surgery. RCSE, London. URL http://www.rcseng.ac.uk/publications/docs/standards-in-childrenssurgery [accessed on 10 October 2013] 5 Varadharajan K., Persaud R., Al-Reefy H. et al. (2011) A pilot audit of paediatric ENT standards in London and Greater London: are we delivering a first class service? Clin. Otolaryngol. 36, 406–408
1 Does your site have both onsite and acute paediatric services to cater for paediatric ENT admissions? 2 Do you have robust transfer arrangements for transfer of unwell children in whom care cannot be provided locally? 3 Are children managed by a multidisciplinary team consisting of a paediatrician, anaesthetist, surgeon, pharmacist and registered children’s nurse? 4 Do you have dedicated childrens only ENT clinics? 5 Do you have dedicated paediatric surgical wards staffed by appropriately qualified children’s nurses? 6 Do you have an emergency department with a childfriendly environment, and appropriate drugs/equipment to cater for paediatric emergencies 7 A pre- and postoperative pain assessment takes place on every child (with a paediatric anaesthetist supervising) 8 Do you have play specialists?
Appendix 1 C) Theatre and Surgical Standards Generic Questions
1 Does your hospital provide inpatient ENT services? 2 If your hospital does not provide inpatient ENT services, where is the nearest hospital that provides inpatient ENT services? A) Administrative Standards
1 Do you have a managed clinical network in place? (that ensures children are safely treated to as close to home as
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
1 Do you have dedicated children only theatre lists for elective admissions? 2 Is there an experienced paediatric trained consultant anaesthetist present during day case surgery OR do you have a named consultant paediatric anaesthetist available for liaison and immediate cover? 3 Do you have a separate recovery area for children? 4 Do all surgeons operating on children aged less than 8 years old undertake at least 100 cases with children each year?
82
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Correspondence
was performed for 333 (69%) patients, and the rest were treated conservatively (31%). The average time to reduction was 5.6 days after the injury. However, delay up to one month for closed reduction had no correspondence to the number of reoperations or corrective surgery. Almost all (95%) primary nasal fracture reductions in adults were performed under local anaesthesia. Three-quarters (75%) of the closed reductions were performed by a resident and one-quarter (25%) by a senior doctor – with no difference in the long-term outcome.
Conflict of interest
No conflict of interests. References 1 Kelley B.P., Downey C.R. & Stal S. (2010) Evaluation and reduction of nasal trauma. Semin. Plast. Surg. 24, 339–347
2 Cil Y. & Kahraman E. (2013) An analysis of 45 patients with pure nasal fractures. Ulus. Travma Acil Cerrahi Derg. 19, 152–156 3 Runbinstein B. & Strong E.B. (2000) Management of nasal fractures. Arch. Fam. Med. 9, 738–742 4 Mondin V., Rinaldo A. & Ferlito A. (2005) Management of nasal bone fractures. Am. J. Otolaryngol. 26, 181–185 5 Fernandes S.V. (2004) Nasal fractures: the taming of the shrewd. Laryngoscope 114, 587–592 6 Cook J.A., Murrant N.J., Evans K. et al. (1992) Manipulation of the fractured nose under local anaesthesia. Clin. Otolaryngol. Allied Sci. 17, 337–340 7 Yabe T., Tsuda T., Hirose S. et al. (2012) Comparison of pediatric and adult nasal fractures. J. Craniofac. Surg. 23, 1364– 1366 8 Kim H.S., Suh H.W., Ha K.Y. et al. (2012) The usefulness of the endonasal incisional approach for the treatment of nasal bone fracture. Arch. Plast. Surg. 39, 209–215 9 Lee K., Yoo B.H., Yon J.H. et al. (2013) General anaesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture. Korean J. Anesthesiol. 65, 209–214 10 Chadha N.K., Repanos C. & Carswell A.J. (2009) Local anaesthesia for manipulation of nasal fractures: systematic review. J. Laryngol. Otol. 123, 830–836
Paediatric ENT standards in London: are we delivering a first-class service? a repeat audit Varadharajan, K.* & Narula, A.†‡ *Department of Otolaryngology, West Middlesex University Hospital, †Department of Otolaryngology, Imperial Healthcare NHS Trust, St. Mary’s Hospital, ‡Middlesex University, London, UK Accepted for publication 1 May 2015
Dear Editor, Children (aged 0–14) account for almost a third of ENT admissions,1 and ENT accounts for 25% of all paediatric admissions (aged 0–14) of surgical specalities.1 It is essential that ENT surgeons maintain a high standard of paediatric care. The Children’s Surgical Forum (CSF) of the Royal College of Surgeons of England (RCS) have set out paediatric ENT standards outlined in the following guides: ‘Surgery for Children: Delivering a First Class Service 2007’,2 ‘Ensuring
Correspondence: K. Varadharajan, Department of Otolaryngology, West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK. Fax: 0208 321 5906; e-mail: [email protected]
the provision of general paediatric surgery in the district general hospital’ (2010)3 and ‘Standards for Children’s Surgery’ (2013).4 In 2011, we conducted a regional audit of paediatric ENT standards in hospitals in London and Greater London and found that several key standards were poorly complied with.5 With recent update of guidelines by the CSF in 2013,4 we decided to repeat this audit to determine whether the standards have improved in the last 2 years. Three new standards were also assessed: the presence of at least one member of staff trained in advanced paediatric life support for emergency admissions, regular auditing of patient experiences and the presence of robust transfer arrangements for paediatric care that cannot be provided locally. In addition, we wanted to assess smaller district general hospitals affiliated with larger teaching hospitals. © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
83
Fig. 1. A comparison of % compliance with standards between the first and second cycles.
Methods
An online questionnaire was disseminated to consultants and specialist registrars in ENT working in hospitals in London and Greater London (smaller satellite hospitals were also included in this cycle). The questionnaire was formulated directly from standards from guidance from the CSF: ‘Surgery for Children: Delivering a First Class Service 2007’,2 ‘Ensuring the provision of general paediatric surgery in the district general hospital’ (2010)3 and ‘Standards for Children’s Surgery’ (2013).4 In addition, three new standards were assessed to incorporate the updated guidance.4 Some of these standards pertained specifically to ENT care, whilst others encompassed paediatric surgical care as a whole. The questionnaire consisted of three sections representing standards in administration (n = 8), clinical (n = 8) and © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
surgical/theatre practices (n = 4). The questions were posed in a binary (Yes/No) format to assess compliance with standards. The questionnaire took less than 2 min to complete (see Appendix 1 for questionnaire). The questionnaire was distributed to ENT surgeons who would have sufficient experience within the unit assessed to facilitate accurate completion of the questionnaire. In most cases, this consisted of a named contact of consultant grade; however, in some cases, this was a registrar. Results
Fifteen of 17 hospitals responded (88% response rate). Standards with high compliance in this cycle included having play specialists (100%), the presence of paediatric surgical wards with registered children’s nurses (93%), the presence of paediatric consultant anaesthetists in day-case surgery
84
Correspondence
(93%), dedicated paediatric theatre lists for elective admissions (93%) and staff being trained in child protection (93%). Compliance with 13 of 17 standards increased compared to the first cycle in 2011 (see Fig. 1). Standards that significantly improved (>10%) included all surgeons operating on children being trained in paediatric basic life support (46% to 64%), surgeons receiving structured paediatric training as per the curriculum (46% to 71%), the presence of a separate recovery area for children (62% to 86%) and staff receiving child protection training (69% to 93%). There was reduced compliance with three standards since the last audit: the presence of a child-friendly ENT department with appropriate equipment and drugs to deal with paediatric emergencies (92% to 86%), all surgeons operating on children undertaking 100 such cases per year (69% to 57%) and the acute pain services visiting children’s wards daily (54% to 43%). The three hospitals that had no inpatient paediatric services all had robust transfer arrangements to centres offering paediatric services (the distance by transport to these paediatric centres was 30 min or less in all cases). Compliance with new standards was as follows (Fig. 2): the majority of hospitals (>80%) had robust transfer arrangements for children in whom care could not be provided locally and at least one member of onsite staff trained in advanced paediatric life support for paediatric emergencies. Just over 60% of hospitals regularly audited patient experiences. Overall, 93% of hospitals complied with 60% or more of the standards, with two complying with all 20 standards. Discussion
This repeat regional audit shows a significant overall improvement in paediatric ENT standards in London. There
was increased compliance with almost all of the standards compared to the previous audit in 2011. Key areas that improved from the last audit included staff being trained in paediatric basic life support, staff receiving child protection training and structured paediatric training as per the curriculum. There is capacity for improvement particularly in acute pain services for children and ensuring surgeons operating on children do so regularly. The fall in compliance between audits in the latter standard is particularly pertinent. There are several potential reasons for this. There may be less paediatric patients in the demographic of a given ENT centre that may preclude surgeons (particularly trainee surgeons) from undertaking high volumes of operations on children. In addition, it is possible that more ENT surgeons in district general hospitals (DGH) are seeking tertiary ENT paediatric input for children. More than 80% of centres had robust transfer arrangements for children in whom care could not be provided locally. This positive finding suggests that children are being managed at centres appropriate to the complexity of their conditions. Overall, the reasons for reduced compliance with regard to ENT surgeons operating on children undertaking 100 paediatric cases per year need to be investigated in further detail in subsequent cycles. Conclusion
Overall, the results of this re-audit are encouraging and demonstrate once more that the RCS standards are pragmatic and can be achieved. We hope that ENT departments take heed of these results and aim to comply with the RCS standards. The two cycles of this regional audit suggest the need for a national audit to assess these standards in England and Wales. Keypoints
•
• • Fig. 2. Percentage of compliance with new standards in the 2nd cycle.
The Children’s Surgical Forum (CSF) of the Royal College of Surgeons of England (RCS) have set out key standards pertaining to paediatric ENT care, and in 2011, we conducted a pilot audit of these standards in London and found that there were several key deficiencies. Two years on we decided to re-audit these standards to assess if there has been any change. In the 15 hospitals, we audited and noted an improvement in compliance in 13 of 17 standards compared to the first cycle. Standards that improved significantly included surgeons being trained in paediatric life support, surgeons receiving structured
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
• •
paediatric training, the presence of a separate recovery area for children and staff receiving child protection training. The encouraging results of this re-audit suggest that the CSF standards are pragmatic and can be achieved. Moreover, these findings highlight the need for a national audit assessing paediatric ENT standards.
Acknowledgments
We thank all the ENT surgeons that complete the survey. Conflict of interests
The senior author (Professor Narula) was a council member of the Royal College of Surgeons of England during the audit period.
85
possible and have access to the appropriate level of care by the correct staff with appropriate skills) 2 Do ENT surgeons receive structured paediatric training in accordance with the requirements of the ENT curriculum? 3 Do all staff coming into contact with children trained in safe guarding (child protection training) 4 Are all surgeon’s operating on children trained in paediatric basic life support? 5 In paediatric emergency admissions there is always at least one member of staff onsite that is trained in APLS (Advanced Paediatric Life support)/EPLS (European Paediatric Life Support) or equivalent? 6 Do you have a dedicated clinical lead for paediatric ENT? 7 Do you a dedicated lead for paediatric surgery as a whole? 8 Are patient experience standards regularly audited? B) Clinical Standards
References 1 Department of Health (2011) Hospital episode statistics. URL http:// www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937 [accessed on 12 October 2013] 2 RCS England (2007) Surgery for Children: Delivering a First Class Service. RCSE, London. URL http://www.rcseng.ac.uk/publications/ docs/CSF.html [accessed on 10 October 2013] 3 RCS England (2010) Ensuring the Provision of General Paediatric Surgery in the District General Hospital. RCSE, London. URL http:// www.rcseng.ac.uk/ service_delivery/documents/General%20Paediatric%20Surgery%20 Guidance%20for%20commissioners% 202010.pdf [accessed on 10/10/13] 4 CSF (2013) Standards for Children’s Surgery. RCSE, London. URL http://www.rcseng.ac.uk/publications/docs/standards-in-childrenssurgery [accessed on 10 October 2013] 5 Varadharajan K., Persaud R., Al-Reefy H. et al. (2011) A pilot audit of paediatric ENT standards in London and Greater London: are we delivering a first class service? Clin. Otolaryngol. 36, 406–408
1 Does your site have both onsite and acute paediatric services to cater for paediatric ENT admissions? 2 Do you have robust transfer arrangements for transfer of unwell children in whom care cannot be provided locally? 3 Are children managed by a multidisciplinary team consisting of a paediatrician, anaesthetist, surgeon, pharmacist and registered children’s nurse? 4 Do you have dedicated childrens only ENT clinics? 5 Do you have dedicated paediatric surgical wards staffed by appropriately qualified children’s nurses? 6 Do you have an emergency department with a childfriendly environment, and appropriate drugs/equipment to cater for paediatric emergencies 7 A pre- and postoperative pain assessment takes place on every child (with a paediatric anaesthetist supervising) 8 Do you have play specialists?
Appendix 1 C) Theatre and Surgical Standards Generic Questions
1 Does your hospital provide inpatient ENT services? 2 If your hospital does not provide inpatient ENT services, where is the nearest hospital that provides inpatient ENT services? A) Administrative Standards
1 Do you have a managed clinical network in place? (that ensures children are safely treated to as close to home as
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
1 Do you have dedicated children only theatre lists for elective admissions? 2 Is there an experienced paediatric trained consultant anaesthetist present during day case surgery OR do you have a named consultant paediatric anaesthetist available for liaison and immediate cover? 3 Do you have a separate recovery area for children? 4 Do all surgeons operating on children aged less than 8 years old undertake at least 100 cases with children each year?
