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Transcript of 48th Annual Scientific Assembly of Family Medicine Skills ...
48th Annual Scientific Assembly Family Medicine Skills & Community
April 6-8, 2006
PEDIATRICS: ACCESS ISSUES
Dr. Cheryl R. Greenberg
The Child Health Program and the Dept of Pediatrics & Child
Health
Winnipeg Regional Health Authority
And University of Manitoba
Dec 2004
Child Health Programme- WRHA
• Vision:– Driven by a vision of a society in which all
children and their families have equal access to the full continuum of pediatric health care services. To achieve this, the Child Health programme and the Dept. of Pediatrics and Child Health will strive for highest quality, cost-effective clinical care, education, research and advocacy for children.
Child Health Programme- WRHA
• Mandate to provide excellence in care to children and youth throughout the province and in a collaborative way throughout western Canada
• To provide innovative care across the continuum through advocacy & empowerment
• Main site- Children’s Hospital of Winnipeg• Large outpatient pediatric service at St.
Boniface General Hospital• 2 level 3-4 intensive care nurseries serving
the province
Child Health Programme- WRHA
• Close linkages/services to many disciplines/programmes for children and youth: – Provincial Outreach Therapy for Children
(POTC): SMD, RCC, St. Amant Centre– Healthy Child Manitoba– Provincial Diabetes Initiative– Children’s Asthma Education Programme – Children’s Hospital Foundation of MB, Inc and
Manitoba Institute of Child Health (MICH)– MB Telehealth
History• 1909: 3 story home on Beaconsfield– 15 cots, 1 nurse,
volunteer doctors and surgeons
• Almost 100 years later– State –of –the –art
127 bed facility– Treats greater than
130,000 patients a year
• Committed to excellence in 3 pillars– Service, teaching
and research
Children’s Hospital Winnipeg• "Most paediatricians in
Canada and the United States wore bow ties. There were said to be two reasons which justified its use by paediatricians - (1) it prevented strangulation of the paediatrician by an aggressive 2 1/2 year old who caught hold of the four-in-hand [tie] and pulled with all his might and main; and (2) it kept the tie out of the diaper area."
Winnipeg Children’s Hospital• Only tertiary care facility for children
and youth in this province• Serves a much larger catchment area
in providing general and subspecialty care to children and youth also in– Northwest Ontario– Portions of NU
• Serves as a referral “regional”centre for tertiary care for an increasing number of subspecialties
Children’s Hospital • Long history of innovation and excellence• Patterns are changing in how health care is
delivered, who is delivering it and to whom– Inpatient to outpatient focus– Patient focussed to family-centred and
culturally effective care• Health care providers truly cross the
continuum and have a regional, provincial and national focus
• Improvement in health outcomes for children and their families depend on effecting change
• Interventions must be based on evidence –based quality data and strategies to implementing valid findings
Dept. of Pediatrics & Child Health- Univ. of Manitoba
• Mission to teach and train current and future generations of doctors and other health care professionals
• Mandate for excellence in research• Currently 84 Geographical Full Time
(GFT) and 58 “part-time” pediatricians with University appointments
• 18 Sections encompassing all (sub)specialties
• The same doctors (GFTs and PTs) that teach and do research are the ones providing the care
Mission and Vision• Fundamental belief in 3 pillars of Excellence
– Excellence in clinical care– Excellence in research– Excellence in teaching
• Closely related and totally interdependent• Child Health research is synonymous with
excellence in care for children and youth• Child Health research and clinical care is
fundamental to better health in adulthood• Research opportunities drive recruitment
Section of Allergy & Clinical Immunology
OUTPATIENTS• Last complete year
› 2555 out patients seen in consultation
• Current waiting list › 1 year or more- asthma and
allergy are increasingly exponentially!
› urgent consults prioritizedINPATIENTS• Hospital consultations seen
immediately
Section Resources
• 3 consultant allergists + 1 community ped
• 1 nurse practitioner• 1 clinic nurse• 4 part-time asthma educators• 2 full time secretaries• Excluding research support staff
Children's Hospital Asthma Admissions
1993-2003
0
100
200
300
400
500
600
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year of Admissions*Children's Asthma Education Project Began **CAEC Offically Launched
Nu
mb
er o
f A
dm
issi
on
s
Totals
*
517
22
Section of Allergy & Clinical Immunology
– “Made in Manitoba” research• Leaders in the translation between research and
practice –ie “BEST PRACTICE” based on locally gathered evidence-based quality data– Eg. MB Health supported a 4 yr Demonstration
Project which showed the impact of education on decreasing health services utilization and enhanced quality of life of children and youth with asthma
– Simultaneously supported by Industry (Merck Frosst; AZ)to allow the project to move forward- $200,000 p.a for all research costs (Research nurses; data analysis; laboratory measurements)
– Programme has ongoing continuous evaluation and since 2002 in a province-wide programme (CAEC), total operating budget $120,000 pa
Asthma Educator Intervention
0
100
200
300
400
500
600
1:1 Education Class Participants
Num
ber o
f Par
ticip
ants
Totals
CAEC WebsiteApril 2003 to March 2004
www.asthma-education.com
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
12 Month Period From Launch April 2003 to March 2004
Hits
/Mon
th
Totals
Section of Allergy- Impact of Research
• Top quality research goes hand in hand with top quality care- current research $ > $3 million pa operating costs not medical remuneration
• Industry supports research now• Active fellowship programme
– 2 members are co-mentors in the CIHR- funded National Training programme in Allergy and Clinical Immunology
• Clinical load continues to grow- needs unmet– 3 GFTs supplemented by community ped but
clinical and research commitments not being met
The Child Health Program and the Dept of Pediatrics & Child
Health• Our deliverables are care, research & teaching
excellence• The only reason we have excellent tertiary care
here is because people chose to come here because of the research potential
• Only have excellent care if there is excellent research
• Current system is leading to crisis in all Sections– Increasingly difficult to fulfill its committment
to clinical and academic missions
Al Aynsley-Green
National Clinical Director for Children for England
Bridging the gap between politics, policy and practice!
Children should be our nation’s most precious asset!
• Nothing matters more to families than the health and welfare of their children
• They are a living message to a time we will not see• They are vital for our national economic survival• Healthy mothers produce healthy children who
become healthy adults• Much adult ill health has its roots in childhood
‘Children’s services were described in the 1970s as a Cinderella service. Cinderella has never been to the ball. It’s still a Cinderella service after 25 years. This can’t be right.’
Ian Kennedy on the Bristol Inquiry.BMJ 2001;323:183
The systems failures exposed by Kennedy and Laming:
• care always subordinated to demands of adults
• lack of concern for vulnerable individuals
• failure to listen to patients and caregivers
• quality of care less than it should be
• lack of effective planning
• fragmentation and lack of responsibility
• lack of effective leadership
• (Ability to admit a sick child is a major success!)
Map of Manitoba's Regional Health Authorities
• • •
• MANITOBA CHILD HEALTH ATLAS 2004• • Inequalities in Child Health: • Assessing the Roles of Family, Community, Education and Health CareMarni Brownell, PhD
Noralou Roos, PhDRandy Fransoo, MScAnne Guevremont, BSc, MEdNorman Frohlich, PhDAnita Kozyrskyj, BScPhm, PhDRuth Bond, MAJennifer Bodnarchuk, MA Shelley Derksen, MScLeonard MacWilliam, MSc, MNRMMatt Dahl, BScNatalia Dik, MScBogdan Bogdanovic, BComm, BAMonica Sirski, MMathHeather Prior, MSc
• Acknowledgements• This is the website for The Manitoba Child Health Atlas 2004, published solely on the World Wide Web. The Atlas comes out of
a 3-year project funded by the Canadian Population Health Initiative focusing on factors that contribute to inequalities in child health and well-being. The Atlas provides descriptive, population-based analyses of the health and educational outcomes of Manitoba children, at the level of health regions and sub-regions.
• Graphs and maps of variations in child health and educational achievement at various stages of development and by family circumstances and community characteristics are provided on this website. Excel files with the data used to develop these graphs and maps are also provided so users can develop their own output.
• • Winnipeg Report
(20-page pdf) Figures from Report * SummaryNon-Winnipeg Rural and Northern Health Care Meeting Presentation * * PowerPoint file can be downloaded for notes.
• © 2004 University of ManitobaLast modified on Tuesday, 05-Jul-2005 22:37:17 CDT
Figure 3.3.3a: Age Profile of Brandon, 2000Population: 47,337
7% 6% 5% 4% 3% 2% 1% 0% 1% 2% 3% 4% 5% 6% 7%
0-4
10-14
20-24
30-34
40-44
50-54
60-64
70-74
80-84
90 +Brandon 2000
Manitoba 2000
Males Females
Figure 3.3.9a: Age Profile of Burntwood, 2000Population: 45,051
7% 6% 5% 4% 3% 2% 1% 0% 1% 2% 3% 4% 5% 6% 7%
0-4
10-14
20-24
30-34
40-44
50-54
60-64
70-74
80-84
90 +Burntwood 2000
Manitoba 2000
Male Female
Infant Mortality Rates for Liveborn Infants Under 1 Year of Ageby Manitoba RHA, 1997-2001
0 2 4 6 8 10 12
South Eastman
Central
Brandon
Assiniboine
Winnipeg
Interlake
North Eastman (1)
Parkland
Churchill (s)
Nor-Man
Burntwood (1)
Manitoba
Rate per 1000
Manitoba RHA
Manitoba Average
'1' indicates rate signifi cantly diff erent f rom the Manitoba mean
's' indicates data suppressed due to small numbers
Child Mortality Rates for Children Aged 1-19 Years by Manitoba RHA, 1997-2001
0 2 4 6 8 10 12
South Eastman
Central
Brandon
Assiniboine
Winnipeg (1)
Interlake
North Eastman (1)
Parkland
Churchill (s)
Nor-Man (1)
Burntwood (1)
Manitoba
Adjusted Rate per 10000
Manitoba RHA
Manitoba Average
'1' indicates rate signifi cantly diff erent f rom the Manitoba mean
's' indicates data suppressed due to small numbers
Low Birth Weight Rates by Manitoba RHA, 1997-2001
0 10 20 30 40 50 60 70 80
South Eastman
Central
Brandon
Assiniboine
Winnipeg (1)
Interlake
North Eastman
Parkland
Churchill
Nor-Man
Burntwood
Manitoba
Rate per 1000
Manitoba RHA
Manitoba Average
'1' indicates rate signifi cantly diff erent f rom the Manitoba mean
Aboriginal People
• First Nations (Indian); Inuit; Metis• 10% of Winnipeg is aboriginal- children 17-18%• Much poorer health status
– 52% of teen pregnancy aboriginal
– 83% of children in care are aboriginal
– Severe trauma overrepresented• “Eagle’s Eye View”, United Way Wpg
• MCHP/Centres/Reports
• Statistics Canada, Aboriginal People’s Survey 2001
Canadian Hospitals that Specialize in Pediatric Care
Hospital No. of BedsMost Recent Annual
Budget Budget/Bed
Winnipeg Children's Hospital 120 $46.0 million $0.38
Montreal Children's Hospital 180 $77.3 million $0.43
McMaster Children's Hospital, Hamilton 117 $55.0 million $0.47
Children's Hospital of Western Ontario, London 70 $45.0 million $0.64
Children's Hospital of Eastern Ontario, Ottawa 150 $130.0 million $0.87
Alberta Children's Hospital, Calgary 107 $130.0 million $1.21
Source: The Medical Post/Special Report: Pediatric Hospitals/March 7, 2006
Context now:• Population base with every circumstance, condition and
disease affecting children• Best opportunity to improve children’s lives and health
for 50 years!• The way we think about things and do them need to
change• Outstanding opportunities for staff - esprit de corps,
pride, valued; training, teaching, evidence & research• Innovative approaches to care to improve the patient’s
experience• We must see ourselves as co-drivers in the driving seat!
Guiding Principles- organized integrated approach
• Ownership /Commitment/Will– Shared between community/clinicians/leadership
• Data and Scope– Listing and Coordination of existing services
– Preventative vs crisis care
• Communication• Knowledge translation
– Monitor outcomes
Clinical Scenarios- Refer or Not?
• 1 month old below birth weight and respiratory difficulties
• 5 year old with abdominal pain
• 2 year old with buckle fracture
• ADHD?• Learning problems
If Refer, to whom , how, when?
• To consultant pediatrician or subspecialist?– Pediatrician – refer to community pediatrician in Wpg
• ? “private clinic” or St Boniface ambulatory group• Ambulatory clinic group at Children’s• Consultant pediatricians in Portage, Brandon, Thompson
– Subspecialist• Most common- cardiology, allergy, neurology, GI, ped surgery
( and subspec surgery), plastics, ortho, diabetes, respirology, neonatology, child development, CADEC, Hemat/oncol
• Phone? Every service has on call physician 24/7 204-787-2071• FAX 787-4807
If Refer, to whom , how, when?
• Develop core group of consultant general pediatricians to triage consults, offer rapid feedback as required
• 24 hour “Hot Line”
• Increase use of TeleHealth
• Outreach clinics
Provincial Child Health Strategy
• Regional networks of family physicians with designated individuals with enhanced skills in pediatrics– To achieve this: implement enhanced skills training for 3rd year
now, CME/ upgrade for current family physicians- rotations in Winnipeg; Telehealth case conferences; PALS; NALS, ACORN; CLIPP ( www.dartmouth.edu/~clipp); Healthy ABC’s ; Can. Ped. Soc. website
• Consultant general pediatricians available 24/7– Onsite +/- off –site
• Enhance recruitment to Family Medicine and General Pediatrics
Every Child Matters 5 key objectives:
• Being healthy• Staying safe• Enjoying and achieving• Making a positive contribution• Securing economic well-being
delivered by:
- Supporting parents and carers
- Early interventions and effective protection
- Accountability and integration
- Workforce reform