Hoskote Aparna, Wray Jo, Banks Victoria, Brown Katherine, Lakhanpaul Monica
Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.
BMJ Paediatr Open. 2020 Apr 21;4(1):e000587. doi: 10.1136/bmjpo-2019-000587. eCollection 2020.
Children with congenital heart disease have complex medical and neurodevelopmental needs. We aimed to develop a multi-professional consensus-based referral pathway applicable to action the results of the brief developmental assessment (BDA), a validated early recognition tool, that categorises the neurodevelopmental status as green (appropriate for age), amber (equivocal) or red (delayed) in children aged between 4 months and 5 years.
A Delphi consensus survey detailing two scenarios-a child categorised as delayed (red) and another as equivocal (amber) on administration of the BDA at the time of discharge from the tertiary centre-was sent to 80 expert professionals from primary, secondary and tertiary care seeking agreement on next steps and referral pathways. An iterative process was proposed with a pre-defined rule of 75% for consensus.
The survey was completed by 77 Delphi panel experts in Round 1, 73 in Round 2 and 70 in Round 3. Consensus was achieved (1) for the child with amber or red BDA, the child should be under the care of a paediatrician with expertise in cardiology (PEC) (or general paediatrician if no PEC) based at their local hospital, (2) for the child with red BDA, the PEC should initiate referral to community services at first assessment, (3) for child with amber BDA, a re-assessment by the health visitor should occur within 1-2 months, with referral to community services and notification to the PEC if on-going concerns.
The Delphi process enabled a consensus to be reached between health professionals on referral pathways for specialist neurodevelopmental assessment/treatment for children with heart disease, in response to amber or red BDA results. The agreed referral pathway, if implemented, could underpin a national guideline to address and intervene on the neurodevelopmental difficulties in children with heart disease.
患有先天性心脏病的儿童有复杂的医疗和神经发育需求。我们旨在制定一种基于多专业共识的转诊途径，以应用简短发育评估（BDA）的结果。BDA是一种经过验证的早期识别工具，可将4个月至5岁儿童的神经发育状况分为绿色（发育与年龄相符）、黄色（不明确）或红色（发育迟缓）。
向来自初级、二级和三级医疗保健机构的80名专家专业人员发送了一份德尔菲共识调查，详细描述了两种情况——一名儿童在三级中心出院时进行BDA评估被分类为发育迟缓（红色），另一名被分类为不明确（黄色）——以寻求就后续步骤和转诊途径达成一致。提出了一个迭代过程，预先设定的共识规则为75%。
第一轮有77名德尔菲小组专家完成了调查，第二轮有73名，第三轮有70名。达成了以下共识：（1）对于BDA评估为黄色或红色的儿童，应由当地医院具有心脏病学专业知识的儿科医生（或在没有心脏病学专业儿科医生的情况下由普通儿科医生）进行护理；（2）对于BDA评估为红色的儿童，心脏病学专业儿科医生应在首次评估时启动向社区服务机构的转诊；（3）对于BDA评估为黄色的儿童，健康访视员应在1至2个月内进行重新评估，如果仍有担忧，则转诊至社区服务机构并通知心脏病学专业儿科医生。
德尔菲过程使卫生专业人员就心脏病儿童的专科神经发育评估/治疗转诊途径达成了共识，以应对BDA评估为黄色或红色的结果。如果实施商定的转诊途径，可为解决和干预心脏病儿童的神经发育困难的国家指南提供支持。
