Paediatric emergency department overcrowding and adverse patient outcomes

Background

General emergency department crowding negatively impacts patient care, and increases patient morbidity.

Objectives

This study seeks to determine if markers of paediatric emergency department (PED) flow are independently associated with negative outcomes and increased health care utilization.

Methods

We conducted a retrospective cohort study of PED visits from 2008 to 2012. Data were pulled from an electronic administrative database. Using multivariate logistic regression models, we measured the association between odds of adverse outcomes (hospital/paediatric intensive care unit [PICU] admission, unscheduled return visits and mortality) with markers of PED flow (shift mean length of stay [LOS] and daily rate of patients leaving without being seen [LWBS]).

Results

We found an association between the daily LWBS proportion and the odds of being admitted to the hospital (odds ratio [OR]: 2.1; 95% confidence interval [CI]: 1.2, 3.7), as well as admission to the PICU (OR: 8.9; 95% CI: 1.1, 71.3). We found a statistically significant increase in the odds of admission if seen during shifts in the third or fourth quartile mean shift LOS. We observed lower odds of returning to the PED with increased daily LWBS proportions (OR: 0.4; 95% CI: 0.2, 0.7), but found no association between the odds of returning to the PED and mean shift LOS.

Conclusion

While we found an association between our pre-defined measures of adverse outcomes and markers of PED flow (or crowding), further studies are needed to determine whether PED overcrowding is the cause or effect of increased hospital and PICU admissions.

Advancing Concussion Assessment in Pediatrics (A-CAP): a prospective, concurrent cohort, longitudinal study of mild traumatic brain injury in children: protocol study

INTRODUCTION

Paediatric mild traumatic brain injury (mTBI) is a public health burden. Clinicians urgently need evidence-based guidance to manage mTBI, but gold standards for diagnosing and predicting the outcomes of mTBI are lacking. The objective of the Advancing Concussion Assessment in Pediatrics (A-CAP) study is to assess a broad pool of neurobiological and psychosocial markers to examine associations with postinjury outcomes in a large sample of children with either mTBI or orthopaedic injury (OI), with the goal of improving the diagnosis and prognostication of outcomes of paediatric mTBI.

METHODS AND ANALYSIS

A-CAP is a prospective, longitudinal cohort study of children aged 8.00-16.99 years with either mTBI or OI, recruited during acute emergency department (ED) visits at five sites from the Pediatric Emergency Research Canada network. Injury information is collected in the ED; follow-up assessments at 10 days and 3 and 6 months postinjury measure a variety of neurobiological and psychosocial markers, covariates/confounders and outcomes. Weekly postconcussive symptom ratings are obtained electronically. Recruitment began in September 2016 and will occur for approximately 24 months. Analyses will test the major hypotheses that neurobiological and psychosocial markers can: (1) differentiate mTBI from OI and (2) predict outcomes of mTBI. Models initially will focus within domains (eg, genes, imaging biomarkers, psychosocial markers), followed by multivariable modelling across domains. The planned sample size (700 mTBI, 300 OI) provides adequate statistical power and allows for internal cross-validation of some analyses.

ETHICS AND DISSEMINATION

The ethics boards at all participating institutions have approved the study and all participants and their parents will provide informed consent or assent. Dissemination will follow an integrated knowledge translation plan, with study findings presented at scientific conferences and in multiple manuscripts in peer-reviewed journals.

Constipation and paediatric emergency department utilization

Background

Constipation is a common condition in children. Little is known about the acute health care utilization of constipated children, including how many present to the paediatric emergency department (ED), the spectrum of presenting complaints, investigations and treatments used.

Methods

We conducted a cross-sectional chart review of all 42,875 visits to British Columbia Children's Hospital ED between August 31, 2012 and September 1, 2013. All visits were assessed for a potential diagnosis of constipation and a total of 913 patients were included. We recorded the chief complaints, tests performed and therapies administered in the ED and measures of flow/efficiency including waiting time (WT), length of stay (LOS) and disposition.

Results

Constipation-related visits comprised 2.1% of overall visits. Abdominal pain was found to be the most common presenting complaint in 65.6% of patients; however, 11.9% of patients presented with complaints unrelated to the gastrointestinal tract. Abdominal radiographs were obtained in nearly one-third of patients and almost half of the patients received a fleet enema in the ED. Only a quarter of patients were discharged home on longer-term management. Measures of ED flow were similar between groups, with no meaningful difference in WT or LOS. The vast majority of children (99.7%) were discharged home.

Conclusions

Constipation can be treated as an out-patient, rather than burdening the paediatric ED unnecessarily. This study demonstrates over utilization of radiologic tests and invasive ED treatments and an under utilization of outpatient medication and dietary counselling that may contribute to unnecessary return ED visits.

Paediatric Visits to Community Emergency Departments: Outcomes from Referrals and Unscheduled Return Visits to a Paediatric Centre

BACKGROUND: Approximately 85% of children in Canada who seek emergency care do so in a general emergency department (ED), yet also have access to a dedicated pediatric ED (PED) within reasonable range. Existing pediatric literature describing return visits to the ED for the same medical complaint – an important quality indicator of ED performance – has yet to report on patient flow patterns from general EDs to a PED.

OBJECTIVES: We sought to measure the proportion of children seen at general EDs who subsequently present to a PED for further care. We also sought to elucidate the reasons behind this pattern of revisits, and to describe the clinical management provided at the subsequent visit.

DESIGN/METHODS: A retrospective cohort study was conducted combining linked administrative databases and health records review. We reviewed all pediatric visits (<17 years of age) at 5 general EDs in Vancouver, linking visits between general EDs and the PED based on clincally compatible presentations. Our primary outcome measure was the proportion of general ED visits with a subsequent visit to a PED (within 7 days) during the 2012-13 fiscal year. Secondary outcomes included reasons for PED consultation, the clinical services accessed, and disposition at the PED.

RESULTS: During the study period, 582/17,824 (3.3%) children seen at GEDs subsequently presented to the PED within 7 days. The top 3 diagnoses among these were: fracture, viral infection, and musculoskeletal complaints. Of the 582 children with a visit to the PED, 167 (28.7%) were referred to the PED for a consultation, while the rest were family-initiated. Referred visits were more frequently associated with pediatric subspecialist consultation than family-initiated visits (41.3% versus 21.7%, p<0.01). The referred group more frequently resulted in a surgical procedure (12.0% versus 3.6%, p<0.01) or hospital admission (48.5% versus 11.6%, p<0.01).

CONCLUSION: Knowing the proportion, management, and outcomes of children that are treated in a general ED and subsequently at a PED may provide an important quality measure and opportunities to improve the management of common pediatric emergencies in the community.

Validation of Hearts-Map, A Psychosocial Assessment Tool Applied to Children and Youth with Mental Health-Related Paediatric Emergency Visits

BACKGROUND: Mental health-related pediatric emergency department (PED) visits are increasing annually, and there is a need for a validated comprehensive standardized assessment tool to better manage these patients.

OBJECTIVES: The primary objective of this study was to evaluate HEARTSS-MAP, a psychosocial assessment tool, in terms of inter-rater agreement among clinicians as well as the tool’s performance in predicting needs for acute psychiatric consultation for hospitalization.

DESIGN/METHODS: The HEARTSS-MAP evaluation was done in two phases. We retrospectively reviewed 101 cases randomly sampled from a cohort of patients who sought care at the BC Children’s Hospital (BCCH) PED for mental health complaints. Narratives pertaining to each patient’s psychosocial assessment were recorded. Clinicians, including two emergency physicians, a bedside nurse, a nurse practitioner, and two psychiatrists, were blinded to the patients' outcomes, and individually applied the HEARTSS-MAP tool to the clinical narratives. The inter-rater agreement was calculated using Cohen’s kappa statistics. We then evaluated the tool’s sensitivity and specificity in predicting admission for the retrospective cohort, as well as a prospective cohort of 62 patients assessed and managed by a PED clinician using the HEARTSS-MAP.

RESULTS: There was substantial agreement between the two pediatric emergency reviewers (κ=0.7), and moderate agreement between the pedi-atric emergency physicians and the nurse practitioner (κ=0.6), and the bedside nurse (κ=0.5). Pediatric psychiatrists had fair agreement between themselves (κ=0.3), and between psychiatrists and emergency physicians (κ=0.4). Based on retrospective data, HEARTSS-MAP had a sensitivity of 91% (95%CI: 71 to 99%), and a specificity of 41% (95%CI: 30 to 53%). When applied to prospectively collected data, the sensitivity was 100% (95%CI: 75 to 100%), and specificity was 33% (95%CI: 20 to 48%).

CONCLUSION: HEARTSS-MAP, the first standardized psychosocial assessment tool to be implemented at BCCH PED, demonstrates strong inter-rater reliability between emergency clinicians, with a high sensitivity in identifying patients with mental health complaints requiring hospital admission.

Trends in Pediatric Emergency Department Utilization for Mental Health-Related Visits

OBJECTIVE

To describe trends in utilization of pediatric emergency department (PED) resources by patients with mental health concerns over the past 11 [corrected] years at a tertiary care hospital.

STUDY DESIGN

We conducted a retrospective cohort study of tertiary PED visits from 2002 [corrected] to 2012. All visits with chief complaint or discharge diagnosis related to mental health were included. Variables analyzed included number and acuity of mental health-related visits, length of stay, waiting time, admission rate, and return visits, relative to non-mental health [corrected] PED visits. Descriptive statistics were used to summarize the results.

RESULTS

We observed a 47% increase in the number of mental health presentations compared with a 27.5% [corrected] increase in the number of total visits to the PED over the study period. Return visits represented a significant proportion of all mental health-related visits (32.2% [corrected] yearly). The proportion of mental health visits triaged to a high acuity level has decreased whereas the proportion of visits triaged to the mid-acuity level has increased. Length of stay for psychiatric patients was significantly longer than for visits to the PED in general. We also observed a 53.7% [corrected] increase in the number of mental health-related visits resulting in admission.

CONCLUSION

Mental health-related visits represent a significant and growing burden for the emergency department at a tertiary care PED. These results highlight the need to reassess the allocation of health resources to optimize acute management, risk assessment, and linkage to mental health services upon disposition from the PED.

Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions

AIM

The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest.

METHODS

We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate.

RESULTS

We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p<0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p<0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p<0.001).

CONCLUSION

The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis

OBJECTIVE

To determine the most accurate, noninvasive method of assessing dehydration.

STUDY DESIGN

The following data sources were searched: electronic databases, gray literature, scientific meetings, reference lists, and authors of unpublished studies. Eligible studies were comparative outpatient evaluations that used an accepted reference standard and were conducted in developed countries in children aged <18 years with gastroenteritis. Data extraction was completed independently by multiple reviewers before a consensus was made.

RESULTS

Nine studies that included 1039 participants were identified. The 4-item Clinical Dehydration Scale (CDS), the "Gorelick" score, and unstructured physician assessment were evaluated in 3, 2, and 5 studies, respectively. Bedside ultrasound, capillary digital videography, and urinary measurements were each evaluated in one study. The CDS had a positive likelihood ratio (LR) range of 1.87-11.79 and a negative LR range of 0.30-0.71 to predict 6% dehydration. When combined with the 4-item Gorelick Score, the positive LR was 1.93 (95% CI 1.07-3.49) and negative LR was of 0.40 (95% CI 0.24-0.68). Unstructured dehydration assessment had a pooled positive LR of 2.13 (95% CI 1.33-3.44) and negative LR of 0.48 (95% CI 0.28-0.82) to detect ≥ 5% dehydration.

CONCLUSIONS

Overall, the clinical scales evaluated provide some improved diagnostic accuracy. However, test characteristics indicate that their ability to identify children both with and without dehydration is suboptimal. Current evidence does not support the routine use of ultrasound or urinalysis to determine dehydration severity.

The role of physician assistants in pediatric emergency medicine: the physician's view

Objective:

To define the range of clinical conditions Canadian emergency pediatricians consider appropriate formanagement by physician assistants (PAs) and the degree of autonomy PAs should have in the pediatric emergency department (PED).

Methods:

We conducted a cross–sectional, pan-Canadian survey using electronic questionnaire technology: the Active Campaign Survey tool. We targeted PED physicians using the Pediatric Emergency Research Canada (PERC) network database (N = 297). Three outcome measures were assessed: demographic information, familiarity with PAs, and PA clinical roles in the PED. The level of PA involvement was assessed for 57 common nonemergent clinical conditions.

Results:

Of 297 physicians, 152 completed the survey, for a response rate of 51.2%. None of the 57 clinical categories achieved at least 85% agreement regarding PA management without direct physician involvement. Twenty-four clinical conditions had ≥ 15% agreement that any PA involvement would be inappropriate. For the remaining 33 clinical conditions, more than 85% of respondents felt that PA could appropriately manage but were divided between requiring direct and only indirect physician supervision. Respondents' selection of the number of conditions felt to be appropriate for PA involvement varied between the size of the emergency department (ED) in which they work (larger EDs 87.7–89.1% v. smaller EDs 74.2%) and familiarity with the clinical work of PAs in the ED (90.5–91.5% v. 82.2–84.7%).

Conclusion:

This national survey of Canadian PED physicians suggests that they feel PAs could help care for a large number of nonemergent clinical cases coming to the PED, but these clinical encounters would have to be directly supervised by a physician.

Trends in use in a Canadian pediatric emergency department

Introduction:

Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.

Methods:

A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).

Results:

Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.

Conclusions:

Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.

Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial

IMPORTANCE

The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines.

OBJECTIVE

To determine whether "just-in-time" (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA.

DESIGN, SETTING, AND PARTICIPANTS

Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams).

INTERVENTIONS

Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA.

MAIN OUTCOMES AND MEASURES

The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA.

RESULTS

The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P < .001) and rate compliance by 12.0% (95% CI, 0.8%-23.2%; P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P < .001). Neither intervention had a statistically significant effect on CC fraction, which was excellent (>89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation.

CONCLUSIONS AND RELEVANCE

The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02075450.

Paediatric patient family engagement with clinical research at a tertiary care paediatric hospital

BACKGROUND

Subject recruitment is essential for conducting clinical research; however, there are very few studies evaluating research uptake by families in a paediatric setting.

OBJECTIVES

To determine how frequently paediatric patients and their families receiving care at a tertiary paediatric hospital participated in research. The secondary objectives were to explore factors that influence patient families' decisions to participate in research and how they perceived their experiences.

METHODS

A cross-sectional study surveying families of children receiving care in a sample of clinical areas at a tertiary care paediatric hospital in British Columbia was conducted. A self-administered questionnaire was used, and was facilitated by trained interviewers. Descriptive statistics were used to report the proportion of patient families that have previously been invited to participate in research and, among these, the proportion who had agreed to participate. Patient families' perceptions of research and their past experiences therein were also reported.

RESULTS

A total of 657 families were approached, of which 543 were enrolled (82.6% response rate). Among the 439 families that had visited the hospital previously, 114 (26.0%) had been invited to participate in research and 99 (87%) had consented to participate. Of these 99 families, only one had a negative experience, and 84 (85%) of these participant families were at least somewhat likely to participate in research again in the future.

CONCLUSIONS

Only one-quarter of families that had previously visited the hospital had been invited to participate in a research project. Of the families approached previously, there was a high rate of participation and willingness to participate in future research.

Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department

BACKGROUND

Pediatric acute respiratory infections (ARIs) represent a significant burden on pediatric Emergency Departments (EDs) and families. Most of these illnesses are due to viruses. However, investigations (radiography, blood, and urine testing) to rule out bacterial infections and antibiotics are often ordered because of diagnostic uncertainties. This results in prolonged ED visits and unnecessary antibiotic use. The risk of concurrent bacterial infection has been reported to be negligible in children over three months of age with a confirmed viral infection. Rapid viral testing in the ED may alleviate the need for precautionary testing and antibiotic use.

OBJECTIVES

To determine if the use of a rapid viral detection test for children with an acute respiratory infection (ARI) in Emergency Departments (EDs) changes patient management and resource use in the ED, compared to not using a rapid viral detection test. We hypothesized that rapid viral testing reduces antibiotic use in the ED as well as reduces the rate of ancillary testing and length of ED visits.

SEARCH METHODS

We searched CENTRAL (2014, Issue 6), MEDLINE (1950 to July week 1, 2014), MEDLINE In-Process & Other Non-Indexed Citations (15 July 2014), EMBASE.com (1988 to July 2014), HealthStar (1966 to 2009), BIOSIS Previews (1969 to July 2014), CAB Abstracts (1973 to July 2014), CBCA Reference (1970 to 2007) and ProQuest Dissertations and Theses (1861 to 2009).

SELECTION CRITERIA

Randomized controlled trials (RCTs) of rapid viral testing for children with ARIs in the ED.

DATA COLLECTION AND ANALYSIS

Two review authors used the inclusion criteria to select trials, evaluate their quality, and extract data. We obtained missing data from trial authors. We expressed differences in rate of investigations and antibiotic use as risk ratios (RRs), and expressed difference in ED length of visits as mean differences (MDs), with 95% confidence intervals (CIs).

MAIN RESULTS

No new trials were identified in this 2014 update. We included four trials (three RCTs and one quazi-RCT), with 759 children in the rapid viral testing group and 829 in the control group. Three out of the four studies were comparable in terms of young age of participants, with one study increasing the age of inclusion up to five years of age. All studies included either fever or respiratory symptoms as inclusion criteria (two required both, one required fever or respiratory symptoms, and one required only fever). All studies were comparable in terms of exclusion criteria, intervention, and outcome data. In terms of risk of bias, one study failed to utilize a random sequence generator, one study did not comment on completeness of outcome data, and only one of four studies included allocation concealment as part of the study design. None of the studies definitively blinded participants.Rapid viral testing resulted in a trend toward decreased antibiotic use in the ED, but this was not statistically significant. We found lower rates of chest radiography (RR 0.77, 95% CI 0.65 to 0.91) in the rapid viral testing group, but no effect on length of ED visits, or blood or urine testing in the ED. No study made mention of any adverse effects related to viral testing.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support routine rapid viral testing to reduce antibiotic use in pediatric EDs. Rapid viral testing may or may not reduce rates of antibiotic use, and other investigations (urine and blood testing); these studies do not provide enough power to resolve this question. However, rapid viral testing does reduce the rate of chest X-rays in the ED. An adequately powered trial with antibiotic use as an outcome is needed.

Bone fractures in children: is there an association with obesity?

OBJECTIVE

To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children.

STUDY DESIGN

This was a prospective cross-sectional study conducted at 2 tertiary care pediatric emergency departments. A convenience sample of children 2-17 years of age with a nonpenetrating extremity injury was enrolled. Demographics, activity level, mechanism of injury, participant BMI, and presence of a fracture were recorded. The main outcome was the odds of an extremity bone fracture based on BMI category; logistic regression was used to estimate the odds of fracture by BMI category.

RESULTS

We enrolled 2213 children, of whom 1078 (48.7%) sustained a fracture and 316 (14.3%) were classified as obese. The mean (SD) age was 9.5 (4.2) years, and percentage of male children was 56.8%. Compared with children with a normal BMI, the adjusted odds of fracture among obese, overweight, and underweight children were 0.75 (0.58, 0.97), 1.15 (0.89, 1.48), and 1.44 (1.00, 2.07) respectively.

CONCLUSIONS

Obese children had a minor but statistically significant decreased odds of fracture relative to children with a normal BMI, but no association was observed in overweight children. However, underweight children were found to be at an increased odds of fracture. This study suggests that overweight and obese children do not have increased odds of extremity fracture.

Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department

OBJECTIVES

To determine whether there is an association between childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined.

METHODS

The present study was a retrospective, cross-sectional study conducted at a tertiary care children's emergency department. Eligible cases for review were children (two to 17 years of age) with an extremity fracture. Severe extremity fractures were defined as those requiring manipulation under anesthesia, open operative repair and/or admission to hospital. The primary outcome was the proportion of severe extremity fractures and the secondary outcome was the proportion of complications.

RESULTS

A total of 1340 charts of children who presented with extremity fracture from January 2008 to December 2010 were reviewed. The mean (± SD) age of the study population was 9.1±4.0 years and 62.1% were male. Overall, 19.9% (95% CI 17.8% to 22.0%) were obese and 39.6% (95% CI 36.7% to 39.1%) sustained a severe extremity fracture. The OR of severe extremity fractures among obese versus nonobese children was 1.00 (95% CI 0.76 to 1.32), adjusted for age, sex and mechanism of injury. In addition, the OR of experiencing complications among obese relative to nonobese children was 1.12 (95% CI 0.68 to 1.85).

CONCLUSIONS

The results of the present study demonstrated that in children with extremity fractures, obese children were not at increased risk for sustaining more severe extremity fractures or subsequent complications compared with nonobese children.

Parents' willingness to have their child receive care by physician assistants in a pediatric emergency department

OBJECTIVE

To determine the willingness of parents of children visiting a pediatric emergency department to have a physician assistant (PA) assess and treat their child and the waiting time reduction sufficient for them to choose to receive treatment by a PA rather than wait for a physician.

METHOD

After describing the training and scope of practice of PAs, we asked caregivers of children triaged as urgent to nonurgent if they would be willing to have their child assessed and treated by a PA on that visit: definitely, maybe, or never. We also asked the minimum amount of waiting time reduction they would want to see before choosing to receive treatment by a PA rather than wait for a physician.

RESULT

We approached 320 eligible subjects, and 273 (85.3%) consented to participate. Regarding whether they would be willing to have their child receive treatment by a PA, 140 (51.3%) respondents answered definitely, 107 (39.2%) said maybe, and 26 (9.2%) said never. Most respondents (64.1%) would choose to have their child seen by a PA instead of waiting for a physician if the waiting time reduction were at least 60 minutes (median 60 minutes [interquartile range 60 minutes]). Respondents' perception of the severity of their child's condition was associated with unwillingness to receive treatment by a PA, whereas child's age, presenting complaint, and actual waiting time were not.

CONCLUSION

Only a small minority of parents of children visiting a pediatric emergency department for urgent to nonurgent issues are unwilling to have their child treated by PAs.

The effect of medical trainees on pediatric emergency department flow: a discrete event simulation modeling study

BACKGROUND

Providing patient care and medical education are both important missions of teaching hospital emergency departments (EDs). With medical school enrollment rising, and ED crowding becoming an increasing prevalent issue, it is important for both pediatric EDs (PEDs) and general EDs to find a balance between these two potentially competing goals.

OBJECTIVES

The objective was to determine how the number of trainees in a PED affects patient wait time, total ED length of stay (LOS), and rates of patients leaving without being seen (LWBS) for PED patients overall and stratified by acuity level as defined by the Pediatric Canadian Triage and Acuity Scale (CTAS) using discrete event simulation (DES) modeling.

METHODS

A DES model of an urban tertiary care PED, which receives approximately 40,000 visits annually, was created and validated. Thirteen different trainee schedules, which ranged from averaging zero to six trainees per shift, were input into the DES model and the outcome measures were determined using the combined output of five model iterations.

RESULTS

An increase in LOS of approximately 7 minutes was noted to be associated with each additional trainee per attending emergency physician working in the PED. The relationship between the number of trainees and wait time varied with patients' level of acuity and with the degree of PED utilization. Patient wait time decreased as the number of trainees increased for low-acuity visits and when the PED was not operating at full capacity. With rising numbers of trainees, the PED LWBS rate decreased in the whole department and in the CTAS 4 and 5 patient groups, but it rose in patients triaged CTAS 3 or higher. A rising numbers of trainees was not associated with any change to flow outcomes for CTAS 1 patients.

CONCLUSIONS

The results of this study demonstrate that trainees in PEDs have an impact mainly on patient LOS and that the effect on wait time differs between patients presenting with varying degrees of acuity. These findings will assist PEDs in finding a balance between providing high-quality medical education and timely patient care.

Novel Conserved Genotypes Correspond to Antibiotic Resistance Phenotypes of E. coli Clinical Isolates

Current efforts to understand antibiotic resistance on the whole genome scale tend to focus on known genes even as high throughput sequencing strategies uncover novel mechanisms. To identify genomic variations associated with antibiotic resistance, we employed a modified genome-wide association study; we sequenced genomic DNA from pools of E. coli clinical isolates with similar antibiotic resistance phenotypes using SOLiD technology to uncover single nucleotide polymorphisms (SNPs) unanimously conserved in each pool. The multidrug-resistant pools were genotypically similar to SMS-3-5, a previously sequenced multidrug-resistant isolate from a polluted environment. The similarity was evenly spread across the entire genome and not limited to plasmid or pathogenicity island loci. Among the pools of clinical isolates, genomic variation was concentrated adjacent to previously reported inversion and duplication differences between the SMS-3-5 isolate and the drug-susceptible laboratory strain, DH10B. SNPs that result in non-synonymous changes in gyrA (encoding the well-known S83L allele associated with fluoroquinolone resistance), mutM, ligB, and recG were unanimously conserved in every fluoroquinolone-resistant pool. Alleles of the latter three genes are tightly linked among most sequenced E. coli genomes, and had not been implicated in antibiotic resistance previously. The changes in these genes map to amino acid positions in alpha helices that are involved in DNA binding. Plasmid-encoded complementation of null strains with either allelic variant of mutM or ligB resulted in variable responses to ultraviolet light or hydrogen peroxide treatment as markers of induced DNA damage, indicating their importance in DNA metabolism and revealing a potential mechanism for fluoroquinolone resistance. Our approach uncovered evidence that additional DNA binding enzymes may contribute to fluoroquinolone resistance and further implicate environmental bacteria as a reservoir for antibiotic resistance.

Canadians' willingness to receive care from physician assistants

OBJECTIVE

To determine the willingness of Canadians to accept treatment from physician assistants (PAs).

DESIGN

Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients' preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours.

SETTING

Vancouver, BC.

PARTICIPANTS

Two hundred twenty-nine mothers attending a hospital with their children.

MAIN OUTCOME MEASURES

The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied.

RESULTS

Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively).

CONCLUSION

These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.

Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department

BACKGROUND

Pediatric acute respiratory infections (ARIs) represent a significant burden on pediatric Emergency Departments (EDs) and families. Most of these illnesses are due to viruses. However, investigations (radiography, blood, and urine testing) to rule out bacterial infections and antibiotics are often ordered because of diagnostic uncertainties. This results in prolonged ED visits and unnecessary antibiotic use. The risk of concurrent bacterial infection has been reported to be negligible in children over three months of age with a confirmed viral infection. Rapid viral testing in the ED may alleviate the need for precautionary testing and antibiotic use.

OBJECTIVES

To determine the effect of rapid viral testing in the ED on the rate of precautionary testing, antibiotic use, and length of ED visit.

SEARCH METHODS

We searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); EMBASE (1988 to December 2011); MEDLINE Ovid (1950 to November week 4, 2011); MEDLINE In-Process & Other Non-Indexed Citations (8 December 2011); HealthStar (1966 to 2009); BIOSIS Previews (1969 to December 2011); CAB Abstracts (1973 to December 2011); CBCA Reference (1970 to 2007); and Proquest Dissertations and Theses (1861 to 2009).

SELECTION CRITERIA

Randomized controlled trials (RCTs) of rapid viral testing for children with ARIs in the ED.

DATA COLLECTION AND ANALYSIS

Two review authors used the inclusion criteria to select trials, evaluate their quality and extract data. We obtained missing data from trial authors. We expressed differences in rate of investigations and antibiotic use as risk ratios (RRs), and expressed difference in ED length of visits as mean differences (MDs), with 95% confidence intervals (CIs).

MAIN RESULTS

We included four trials (three RCTs and one quazi-RCT), with 759 children in the rapid viral testing group and 829 in the control group. Three out of the four studies were comparable in terms of young age of participants, with one study increasing the age of inclusion up to five years of age. All studies included either fever or respiratory symptoms as inclusion criteria (two required both, one required fever or respiratory symptoms, and one required only fever). All studies were comparable in terms of exclusion criteria, intervention, and outcome data. In terms of risk of bias, one study failed to utilize a random sequence generator, one study did not comment on completeness of outcome data, and only one of four studies included allocation concealment as part of the study design. None of the studies definitively blinded participants.Rapid viral testing did not reduce antibiotic use in the ED significantly, neither clinically nor statistically. We found lower rates of chest radiography (RR 0.77, 95% CI 0.65 to 0.91) in the rapid viral testing group, but no effect on length of ED visits, or blood or urine testing in the ED. No study made mention of any adverse effects related to viral testing.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to support routine rapid viral testing as a means to reduce antibiotic use in pediatric EDs. Results suggest that rapid viral testing may be beneficial in terms of reducing rates of antibiotic usage, urine investigations and blood investigations, but are not statistically significant due to lack of power. Rapid viral testing does reduce the rate of chest X-rays in the ED. A large trial addressing the effect on antibiotic usage is needed.