BRITISH MEDICAL JOURNAL VOLUME 284 27 MARCH 1982

ABC of 1 to 7 H B VALMAN

SERVICES FOR CHILDREN :

OUTPATIENT CLINICS AND DAY CARE

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If children are to receive appropriate health care they need a spectrum ofconnected services: primary care from general practice and the schoolhealth service and secondary care mainly through the hospital. Thehospital provides accident and emergency, outpatient, day, and inpatientservices. To use resources most efficiently the district services for acutelyill children should be centralised in one department in the main hospital;ideally facilities for inpatient, outpatient, and day care should be closetogether.

Outpatient consultationAn average-sized unit cannot manage more than about 1000 new

outpatients and 5000 return visits a year. Ideally all children should be seenwithin a week of referral, but in many units urgent cases are seen within aweek and others in two or three weeks. The referral letter should describethe doctor's worries, current medication, investigations performed, and thefamily or social background. Referral letters are read by the consultant, whodetermines the date of the appointment according to the probablediagnosis. If the letter is illegible or vital information is missing a dangerousdelay may occur before the child is seen. Packing the clinic with spuriouslyurgent cases may prevent any child from having an adequate consultation.New patients are usually seen by a consultant or by a registrar who

discusses the children with the consultant. Parents need to know that notevery child can see the consultant, or fewer patients would be seen. Mostparents prefer to see the same doctor each time. Considerable paediatricexperience is needed before outpatient care can be provided competentlyand ideally a doctor with less than a year's experience in paediatricsshould not do this work alone.

Indications for referral

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.:..: :. :..:.pecial expertigtose:............. .. . .. ...................... ......................

Families may pressurise a family doctor to seek a second opinion eventhough he does not consider it necessary. Most family doctors willanticipate the parents' feelings and arrange a consultation at a suitable stage.There is usually no hesitation in referring children when the diagnosis isobscure, a particular consultant has special expertise in that problem, thedisease is likely to cause long-term handicap, special investigations arenecessary, or the advice of a large team is appropriate. The decision isharder when the consultant is unlikely to be able to provide additionaltreatment but the parents may be helped to accept their doctor'sexplanation and management after being seen in hospital. For example, theparents of a child with recurrent upper respiratory infections may imaginethat he has a serious disease and be reassured by an independent opminon.

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Second opinion.......................................... ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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BRITISH MEDICAL JOURNAL VOLUME 284 27 MARCH 1982

Type of problems seen

Inappropriate referrals

Neonatal follow-up clinics

Appointment systems and acc

The commonest problems in new patients include recurrent respiratorytract infections, bronchial asthma, behaviour problems, enuresis, failure tothrive, recurrent abdominal pain, and convulsions. Children with systolicmurmurs are referred after the murmur has been detected at routineexaminations, and children with suspected urinary tract infections areoften sent for further investigations.Some chronic conditions are followed up in hospital clinics because their

management demands special skill. Joint clinics may be held withspecialists in diabetes, leukaemia, orthopaedics, or plastic surgery, and theremay be special clinics for cystic fibrosis, gastroenterology, fits, or chronichandicaps. Children with severe asthma tend to be seen in generalpaediatric clinics since they form the largest single group of children with arecurring or persisting disability.

Children with suspected diabetes mellitus or with features suggestingnon-accidental injury should be admitted immediately; in thesecircumstances an outpatient referral is dangerous. Similarly children with anacute illness of unknown cause may well have recovered by the time of theappointment.

Most special care baby units arrange to follow up selected patients untilthey are 18 months or 2 years old. Most were born weighing under 2000 gand a few have had birth asphyxia or less common problems such asneonatal convulsions. These infants are usually seen at a separate clinic,where enough time is available for developmental assessment.

ommodationThere are several problems with appointment systems: ensuring that

new patients are given enough time for their consultation and that there isan allowance for patients who arrive late or default or for those withcomplex problems that take a long time to deal with. Children becomeirritable and hungry if they have to wait too long and their mothers mayforget their main problems when they finally enter the consulting room.The outpatient departmnent for children should be designed especially for

them, but in most hospitals it still has to be shared with other specialties.There should at least be a separate waiting area with furniture of theappropriate size and no stairs, lifts, or heavy doors, which could causeaccidents. Rooms are needed for measuring, changing, breast feeding, andurine collection, and the consulting room needs a small table and chair fora toddler, toys and books, and pictures on the walls and ceiling.

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Communication

A letter sent promptly to the family doctor should contain the probablediagnosis, prognosis, and management. The history and physical findingsshould be noted briefly. The results of investigations can be included in asecond letter to the family doctor and in another to the parents.An efficient receptionist is the pivot of the clinic. She should like

children and have sympathy with their mothers. She will be the first personto meet the family when they arrive and her kindness will affect theirfeelings about the unit. A paediatric nurse measures and weighs thechildren and collects urine specimens. In most cases the doctor canexamine the child with only the mother present and no nurse.

Indications for day care.....................

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pivesu:op............. ~~~~~Day care is the best method of providing certain services, and though the

.~~~~~~X cost needs to be considered it should no't be the mhain reason for..n.dicati.ons.t. advocating day care. Day patients are those who attend for observation,. . ...... ........

4. ~ ~ ~ ~ 4~investigation, surgery., or other treatment and who need some form ofH.rna.supervision, or period of recovery. The child is not separated from his

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eiri~~umctsion parents, he sleeps at home at night, and the life of the family is less

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.2.W . . . .. disrupted than during admission. Parents will usually prefer to bring theirchildren to a day centre, if necessaymr hnoc,ta aeteadmitted. In some busy departments day care may be the only way of

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,4.r.>^**.-zi.s>b*^+**K*X* investigatioensuringthat'there are enough beds and nurses for all the children for

Abo t a third of all, elective general sur children can be carried outin a day unit. Suitable surgical problems inclueaprtoofhemdlear and grommet insertion, hernia operations, circumcision, andsigmoidoscopy. There is also a place for preventive and restorative dental::;:::;:::: . ;: care, particularly in physically and mentally handicapped children. If the

~~~~ ~~~~~~ ~~mother has satisfactory postoperative analgesics to give her child at home,.....fQ.UfrC;U these procedures are as safe in a day unit as in an inpatient ward.

Postoperative visits or phone calls to the home by doctors or nurses are;>*o ^ > ,, btt=,- ,> rarely necessary. The anaesthetic given must be suitable for day care, and

S: ::":::- ze;+::thesurgery should not be delegated to a junior doctor.Swouf Indications for medical day care are less well defined, and the pcatients

t ~ ~ being seen need to be reviewed regularly to avoid overwhelming the service.~ ~ .% ~. s> The main indications are nvestigations, treatment of specific problemst W Em sigmoidoscopy.T such as a severe attack of bronchial asthma or repeated chemotherapy for

1icare,patin cuaYO rlyin leukaemia, and referral from the family doctor for an opinion onadmission. Children with failure to thrive or developmental delay, whowere previously admitted for long periods, can be investigated completelyin a day care unit.

____________________________________ Day care can complement an outpatient visit, especially with necessaryrr .' @ ~ but difficult investigations. Taking blood for measuring anticonvulsant

j t concentrations from a kicking, fat toddler can be an ordeal for everyone in

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1. a hectic outpatient clinic; in the day care unit it may be much easier. Some~~ .*~~~~~ ~tests, such as sweat tests or sugar tolerance tests, take a long time but the

.l... RR?'|**~.~ ~day care unit's playroom reduces the ordeal. Toddlers are often distressed....X g 1 1by an intravenous pyelogram and even more by a micturating cystogram,

ACfhi 1 but preliminary sedation in the day care unit and a bed to sleep in|-| afterwards may reduce the anxiety and discomfort.

BRITISH MEDICAL JOURNAL VOLUME 284 27 MARCH 1982 965

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BRITISH MEDICAL JOURNAL VOLUME 284 27 MARCH 1982

Walk-in day cases| _ E _M Family doctors may be encouraged to refer particular groups of patients

to the unit on a "phone and walk in" basis. These may include patientswith suspected urinary tract infections, where a properly collectedspecimen is crucial, or those with bronchial asthma, in whom earlytreatment may abort an acute attack. Pressure from parents may persuade a

family doctor to send a child to the unit rather than wait for anoutpatient appointment. This is an abuse of the system and will not lead tothe satisfactory management of a child with a chronic problem.Some paediatric units in inner city areas have taken this idea a stage

further and provided an open clinic for a few hours each day where familydoctors can send patients without appointment for a second opinion.Among other advantages, such a clinic may prevent children being broughtto the accident and emergency department at any time of the day or nightand seeing a doctor who has not had paediatric experience. These clinicsmust be managed by doctors with considerable experience and avoidbecoming another way of fragmenting primary care.

Staffing and accommodationErtdronce

A senior house officer supervised by a registrar can be responsible for a

Day ro\om r bed/cotwo\rd day unit on a part-time basis; and it is also particularly suitable for part-Receptior \ \ \ \ time paediatric nurses. Both the staff and the accommodation need to beRle on |separated from those of the inpatient unit, since the pace and type of work

e \\\\\ 1are different and cannot be mixed without loss of efficiency.l\\to\\e\ l |In district hospitals the day care unit for children can be a four-bedded

NtSu\\\\\\\ ward separated from the main unit by doors. There are many advantages\ Single bed in having an operating theatre nearby. Ideally there should be a quiet area,

a section for procedures, and a play area, where observation is easy butsound is not readily transmitted.

iftso Dirty and \ X B ward| utilitytrootment \XW \\\\g\ Dr H B Valman, MD, FRCP, is consultant paediatrician, Northwick Park Hospital

and Clinical Research Centre, Harrow.Two bed The illustration of a Nucleus children's nursing section is reproduced by

sNtuatrse permission of the DHSS.

VulvovaginitisVulvovaginitis may cause dysuria, vulval irritation, or a yellow stain onthe pants, but the only abnormality to be seen may be a thin yellowish-grey vaginal discharge. The symptoms and even the results of a urineexamination may be wrongly attributed to a urinary infection. Swabs(moistened with 0 9% sodium chloride solution) of the secretions aresent to the laboratory for microscopy and culture and the mother istaught how to collect a specimen for threadworm ova. When the childwakes in the morning, Sellotape is applied several times to the stretchedperineal skin, and ova will adhere to it. Alternatively, ova can be collectedfrom the perianal skin with a moist swab.The only pathogens needing specific antimicrobial treatment are rare

infections due to gonococci, monilia, or trichomonas. Antibiotic treatmentof other organisms may result in fungal overgrowth causing iatrogenicdisease. If no pathogens are detected the symptoms may be due to poorperineal hygiene and may resolve after twice daily baths. Detergents inpoorly rinsed pants or "bubble baths" may cause a chemical vulvovaginitis.The remaining cases are usually related to a thin unstimulated vaginalmucosa. If the problem needs more than reassurance dienoestrol creamcan be applied daily for three days and once a week for a month. Thistiny dose thickens the mucosa. Longer treatment may cause withdrawalbleeding. A profuse purulent blood-streaked offensive discharge orsymptoms which recur despite these measures are indications forexamination under general anaesthesia to exclude a foreign bodyin thevagina.

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