Is The Service ?

Accessible to people it is designed to serve  
Socially acceptable
Relevant to population needs
Consistency in its standards

Working  Definitions

Severity
50% or more wet nights in two weeks 

Initial Success
Achieving 14 consecutive dry nights within 16 week treatment period. 

Effectiveness
average number of weeks taken to reach initial criteria of success. 

Lack of Success 
Failure to meet initial criteria of success, excluding drop outs. 

Dropouts 
After initial appointment, 2 consecutive appointments are missed without notice. 
                                OR
Treatment discontinued by agreement with parents, child or doctor. 

Relapse 
More than two wet nights in two weeks 

Continued Success
No relapse in the six months after initial success 

Complete Success 
No relapse in the two years after initial success

Minimum Standard

Target Standard

Cambridge Practice

Catchment Area

Specify geographic area

Establish area in conjunction with existing services.

No geographic area specified.
Service open to all. 

64% come from local areas, within 1 or 2 postcodes, 80 % within 3 postcodes & 90 % - 4 postcodes.

Publicising the Service

To GPs, paediatricians, urologists, medical officers, psychiatrists, psychologists, school nurses, M&CHN, Continence Advisors.

Include what service is for, nature of service and referral criteria and methods.

As per minimum, but circulate annually. 

Display in public places - libraries, health centres, schools, local voluntary organisations.

Service is promoted to GPs and all Paediatric service providers in region.
Information includes service description, accessibility, referral requirements and costs involved. 

Who Will be Served

Not influenced by race, gender, culture, social class, religious back ground, nationality or care status.

State priorities in accepting referrals

Special facilities for those with English as second language.

Facilities for learning difficulties/physical disabilities

No discriminations made.
Majority % of fee rebated by Medicare.
Special needs children accommodated : Cambridge already has helped children with sensory-neural deafness, autism and developmental delay.

Appointments

Pre appointment information should be provided regarding service policies, options available and out comes which could occur.  

No one to wait greater than 1 month between referral received and appointment made.   

No one to wait greater than 3 months between referral and first appointment. 

See patient within 30 minutes of appointment time.  

Report outcome to referrers.

Not wait greater than 2 weeks.

Not greater than 1 month.

 Within 15 minutes.

Information regarding service, referral, costs and program detail given at telephone appointment and if required an initial information kit posted with further details.  

Appointments offered at time of referral (telephone)

 
Patient seen within 2 weeks (avg 2.0 weeks)

 Patients seen on time, 79% "always on time"
19% "often on time"

Close contact with referring GPs via letter at initial consultation, at discharge and any relevant events eg: relapse.

Consent to Research

Explanation, information and informed consent from parent of research undertaken or experimentation. 

No specific research at present but continual audit.Private practice - difficult to research.

Referral to Other Services

On referral to other agencies if daytime wetting or encopresis.

Treatment practitioners to have broad understanding of complimentary managements eg: homoeopathy /acupuncture.

Cambridge provides services for all continence problems both urine and bowel.
Occasionally on referral for radiology and rarely paediatric surgery.

Paediatrician has introduction to laser accupuncture

Minimum Standard

Target Standard

Cambridge Practice

Assessment

History obtained of problems, family/environment, prior treatment, prior investigation, child and family attitudes to treatment.
2 week base line assessment. 

Treatment plan agreed with child and family.

As per minimum but include options for management plan.

Detail management plan, charting progress.

Full history and examination and necessary investigations undertaken.

Full explanation to child and parents with management option discussed. 

Plan formalised and personalised manual given to parent/child for information and ongoing management / communication. 

Management

Treatments based on adequate research documenting effectiveness.  Management effectiveness should be monitored.

Treatment should be acceptable to child and parents and be described.

Range of treatments should  be discussed.

All management options discussed and based on accepted and effective practice (Cambridge current initial success 80% - intention to treat)

Explanation and Information about Methods

Treatment procedures and equipment should be explained at a level suitable to age and understanding of child and adult.

Written information, visual aids given and explain.

Complimentary to management manual full education and discussion with the child and parents.  Visual aides used.  Initial assessment / management of 1½ hrs duration.

Education re-enforced at each meeting.

All staff paediatric trained.

Alarm Based Managements

Bell and pad and mini alarm.

Comply with safety standards. 

Replace after 7 years.

Break down rate less than 1 in 5 treatments cycles.

 Replace faults within 2 weeks.

 
Logging system re alarm use and return.

Other booster types or alternative alarms available.

New detector for each new patient, service each 2 years.

 
Replace after 5 years.

Break down rate less than 10%.

 
Replace fault within 1 week.

  
Alarm loss rate less than 10%.

Bell and pad and body worn alarms used.  Some vibratory alarms for hearing impaired.

All comply with Australian safety standards. 
 

All checked and maintained after each use and during treatment as necessary. 

Break down rate for body worn alarm 17% (complete break down). 

Immediate replacement of any problem alarms / battery replacement.   

All alarms logged for use by hirer, return date, returned, non returns noted.  One lost to date.

Medications

Treatment used appropriate and review 1 weeks after use.  Monthly review if children

Medications only used on consultation with parents primarily as interval management until success achieved with alarms (eg school camps).
Rarely for daytime wetting.
Reviewed by telephone 2-3 days, then in 2 weeks and each 2-3 weeks.

Minimum Standard

Target Standard

Cambridge Practice

Follow Up

Within 1 week of start of treatment

Follow up every 3 weeks.

 Offer 1 appointment for each failed to attend. (FTA)

A facility to seek and receive advice between appointments.

Within 1 weeks of starting treatment

Follow up maintained at 2 weekly intervals.

 Facility within 24 hours.

Follow-up in clinic each 2 - 3 weeks.  Telephone contact on day after first night.

Telephone, letters or   E-mail each week. 

FTA's offered further appts up to 2 FTA's.

FTA Rate 2.7% of consultations.

Alarms replaced / repaired in working hours, some delivered after hours to parents home.
After hours number given with usually immediate contact. 

Drop Outs

Not greater than 25% of starting treatment. 

Apply follow up system to avoid losing contact with patients.

Not greater than 15%

Drop out rate 2.0
Fail to attend  2.7% 

All current patients on running sheet kept by Continence Nurse Advisors.  All Files remain in "Active" file system until discharge, reviewed monthly.

Relapses

Successful treatment followed up by telephone/letter at a minimum 6 months and offer treatment if relapse.

Follow up to 12 months.

All patients follow up at 6 months and 24 months by letter and telephone.

All offered appointments if relapse.

Monitoring and Evaluation

Performance of Individual child. 

All treatment monitored to record wet/dry nights. 

Feed back from users.

 Routine evaluation of degree of satisfaction of treatment and actions taken to improve.

Record kept of all complaints and action taken appropriately. 

Also monitor progress indicators, frequency, size of wet patch, time alarm goes off.

 Regular sharing with parents / child.

Analyse data annually and summary of data provided to referrers.

Progress monitored by wets per nights, patch size, self awakening, time of wetting/alarm, and dry and wet nights. 

Bowel problems / soiling also monitored as appropriate.   

 
Client satisfaction surveys sent to all.

Date collated each month and trends followed.

Data available to referring practitioners and public via Internet site and to referring practitioners yearly via mail. 

Minimum Standard

Target Standard

Cambridge Practice

Effectiveness of Service

Outcome Data 

Based on Butler's working definitions.

Process Data

Gathering data on performance indicators.  Based on service delivery.

Clinical performance Indicator 

Best is
Single Effectiveness Ratio. 

(initial success as % of all entering treatment).

Action taken if Service in decline.

Data available to referral sources, child and family, esp. success and relapse rates

Devise clinical plan to improve results

 Single effectiveness ratio at least 50%.

Outcome data collected / collated / analysed each month.

Results published on Internet, to child and parent in manual, and to referring practitioners each year. 

Performance indicator data collated and analysed monthly and published as above.

Single effectiveness ratio by Butler criteria 80%. (ie intention to treat)

Standards being maintained.

Staff Training, Supervision and Support

All staff trained in treatment methods used.

Staff have regular performance appraisal.

Staff to have access to regular sources of updating and support from colleagues.

Staff meetings - informal/ad hock, formal each 3 months.

Training programs yearly to second yearly. 

Discussion re recent literature.

Paediatrician attends public hospital continence clinic as visiting paediatrician

Termination of Treatment

No termination on any grounds other than decision of child and parent.

Valued clinical appraisal of lack of effectiveness or unsuitability for child/adult.

Other circumstances outside control of advisors.

Not terminated after an arbitrary time limit, through shortage of resources or need for other patients.

No patient has had treatment terminated other than by patient's wishes and discussion with advisors.