tract disorders, both rare (pyelonephritic scarring) and common (urgency, frequency, dysuria, and incontinence). T L CHAMBERS. Richard Bright Renal Unit,.
Responses of principals in general practice and trainees to question asking when they would refer childreni with uninary tract infections Girls
¢ 5 years
< 5 years
¢ 5 years
14 11 1
12 12 2
26
23 3
4 2
3 1 2
5 1
5 1
Principals (n=26): First infection Second infection Subsequent infections Trainees (n= 6): First infection Second infection Subsequent infections
T L CHAMBERS
replied (table). In the practice I audited five of 606 boys aged under 16 had had a urinary tract infection. Four of the five had been referred for investigation, all after the first documented episode, and four had had a repeat urine specimen sent for culture after treatment. More of the girls (12/58 1) had had a urinary tract infection, but only five had been referred for investigation, after a median of four episodes (range three to five); only two had had a urine specimen sent for culture after treatment. The eight other children had not been referred for investigation. 'Ihese results clearly show that boys and younger children were more likely to be referred for investigation. The audit also showed a discrepancy between the intention to refer and clinical practice in the training practice. An appreciable minority of doctors would still refer a child only after more than one urinary tract infection, although it is encouraging that most of those who replied intended to refer after a second infection. Overall, responses were better than those found by Jadresic and colleagues. This may be because the sample was much smaller and limited to training practices. My findings largely confirm those of Jadresic and colleagues. Despite recommendations published in journals for family practitioners" the message bears repetition. A GENNERY
Princess Mary Maternity Hospital, Newcastle upon Tyne NE2 3BD 1 Jadresic L, Cartwright K, Cowie N, Witcombe B, Stevens D. Investigation of urinary tract infection in childhood. BAM 1993;307:761-4. (25 September.) 2 Working Group of the Research Unit, Royal College of Physicians. Guidelines for the management of acute urinary tract infection in childhood. JR Coll Physicians Lond 1991;25:36-42. 3 Potts SR, Irwin WG. Urinary tract infection in children: a survey of management. JR Coll Gen Pract 1983;33:353-5. 4 Dighe AM, Grace JF. General practice management of childhood urinary tract infection. JR Coil GetC Pract 1984;34:324-7. 5 South Bedfordshire Practitioners Group. How well do general practitioners manage urinary problems in children? Br 7 Gen Pract 1990;40:146-9.
College guidelines inaccessible to GPs EDITOR,-Lyda Jadresic and colleagues' study on investigating urinary tract infection in childhood illustrates the difficulty of disseminating guidelines.' It would have been interesting if the authors' questionnaire had asked how many of the general practitioners had had access to the issue of the Journal of the Royal College of Physicians of London in which the guidelines appeared-I suspect few had. Furthermore, although permission for the study was obtained from the medical director of the family health services authority, general practitioners were not told of the study and were not given the opportunity to play a constructive part. Moving from research to audit and producing positive change is now the challenge. This is likely to be easier if general practitioners play a part at an early stage rather than later, when they may be defensive. Consultation, perhaps through a medical audit advisory group, could have produced local standards, which could have been disseminated, used as a comparative measure, and
1142
Boys
< 5 years
question is: does it matter? To answer this we need to know whether there is a corresponding variation in community morbidity from childhood urinary tract disorders, both rare (pyelonephritic scarring) and common (urgency, frequency, dysuria, and incontinence)
built on to improve the care of children with urinary tract infection both locally and eventually nationally. A mechanism for change would then have been identified at the start. If guidelines are to become more widespread the mechanisms for putting them into practice must be addressed. The guidelines must be relevant to the everyday work of those who are expected to follow them. Measuring the care given by practitioners against standards that are not relevant to them is likely to be disappointing. ALASTAIR D SHORT
Glasgow G13 1 LU 1 Jadresic L, Cartwright K, Cowie N, Witcombe B, Stevens D. Investigation of urinary tract infection in childhood. BMJ 1993;307:761-4. (25 September.)
Dipstick testing a useful screening tool EDITOR,-Lyda Jadresic and colleagues' study of the management of suspected urinary tract infection in children is unlikely to improve routine practice.' Many general practitioners are likely to react with hostility to a survey of practice in primary care conducted entirely from a secondary care setting. Though the authors lament the lack of "appropriate" investigation of suspected urinary tract infection by general practitioners at weekends and during bank holidays, there is no useful discussion of practical strategies that can be used in primary care. Most surprising is the lack of reference to the use of dipsticks that detect both leucocyte esterase and nitrite as a screening tool. Shaw et al showed that the combined dipstick test is as successful as microscopic examination in detecting urinary tract infection but that the false positive rate is lower.2 Because of the likelihood of false positive bacteriological results being obtained from collection bag samples in children under 2 years old' the low false positive rate of dipstick testing makes it an attractive screening investigation. This is particularly important if antibiotic treatment is started before confirmatory culture of catheter or suprapubic specimens. The authors also do not mention dipslide inoculation: I presume that this service was not offered in Gloucester. PHILIP M J WILSON
Glasgow G42 9JT 1 Jadresic L, Cartwright K, Cowie N, Witcombe B, Stevens D. Investigation of urinary tract infection in childhood. BAJ 1993;307:761-4. (25 September.) 2 Shaw KN, Hexter D, McGowan KL, Schwartz JS. Clinical evaluation of a rapid screening test for urinary tract infections in children. J Pcdiatr 1990;118:733-6. 3 Crain EF, Gershel JC. Urinary tract infection in febrile infants younger than 8 weeks of age. Pediatncs 1990 ;86:363-7.
Is underinvestigation linked to morbidity? EDITOR,-Lyda Jadresic and colleagues show distinct variations in the investigation, by culture or urine specimens and imaging of the renal tract, of children with urinary tract infection in Gloucestershire.' They conclude "that urinary tract infection is underdiagnosed and underinvestigated." That may be so, but the important
Richard Bright Renal Unit, Southmead Hospital, Bristol BS 10 5NB 1 Jadresic L, Cartwright K, Cowie N, Witcombe B, Stevens D. Investigation of urinary tract infection in childhood. BM7 1993;307:761-4. (25 September.)
Giving intravenous drugs Students should be trained and tested EDirOR,-K Teahon and D N Bateman suggested that preregistration house officers are poor at giving intravenous drugs.' As part of the new curriculum at the Medical College of St Bartholomew's Hospital the clinical course has been expanded to emphasise training in clinical skills for medical students. This training occurs in the first clinical year. Each student learns eight specific clinical procedures in a purpose built skills centre, a unique facility developed in conjunction with St Bartholomew's College of Nursing and Midwifery and the Barts NHS group. The development of the skills centre was inspired by the Maastricht Skills Lab in response to the recent changes in the provision of health care in London and advances in medical education. Our skills training programme goes beyond the basic clinical skills required by the General Medical Council's consultation document2 and includes intravenous injection and phlebotomy. We have assessed the efficacy of training in giving intravenous drugs by means of an objective structured clinical examination.3 Results show a 14% increase in the mean score after the introduction of specific training. Students are aware that these skills will be formally assessed as part of their end of year examination. This is known to be a powerful factor in determining what students actually learn.4 JANE DACRE BRIAN JOLLY SIAN GRIFFITH GEORGE NOBLE Medical College of St Bartholomew's Hospital, Charterhouse Square, London EC1M 6BQ I Teahon K, Bateman DN. A survey of intravenous drug adminis-
tration by preregistration house officers. BMJ 1993;307:605. (4 September.) 2 General Medical Council. 1993 Recommendations on undergraduate medical education. London: GMC, 1993. 3 Harden RM, Gleeson FM. Assessment of clinical competence using an objective structured clinical examination. Med Educ 1 983;22:40. 4 Jolly B, Newble D, Chinner T. Leaming effect of reusing stations in an objective structured clinical examination. Teachitng and Learninig in Medicine 1993;2:66.
Preprepared drugs save time EDITOR,-We share K Teahon and D N Bateman's concern about the administration of intravenous drugs by preregistration house officers.' In 1985 a prospective study was carried out in two surgical wards at Hope Hospital, during which every episode of the reconstitution and administration of parenteral drugs was observed by a work study engineer.2 Eighty three intravenous reconstiutions were observed; all were performed by junior doctors. The total error rate for intravenous drugs was 13% (11 reconstitutions), and this included errors in the selection of drug, dosage, diluent, and route. In addition, aseptic technique was incorrect on 18 occasions and there was considerable
BMJ VOLUME 307
30 OCTOBER 1993
