High rate of missing vital signs data at triage in a paediatric emergency department

Limitations of Blood Pressure Measurements in Pediatric Trauma Patients During Field Triage

INTRODUCTION

Recent revisions of national field triage guidelines recommend the addition of age-specific systolic blood pressure (SBP) measurement for identifying the most severely injured children requiring transport to a trauma center. The purpose of this study was to determine the frequency in which blood pressures are documented by Emergency Medical Service (EMS) providers and the role this measurement has had, among other factors, in triage decisions.

METHODS

This is an exploratory descriptive study with a retrospective review from the trauma registry database of all pediatric trauma admissions that arrived by EMS at a level II pediatric trauma center from January 1, 2019 to December 31, 2022.

RESULTS

Two hundred ninety-eight patient records of patients aged 0 to 14 were included. EMS providers documented blood pressure in 70.1% of the total sample. A significant difference in the frequency of this documentation was seen between ages zero to nine and = > 10 years (χ2(1,298) = 28.98 p <0.001). No children ages zero to nine years had SBP of < 70 mmHg + (2x age in years) documented by EMS. There were two children aged = > 10 who had a documented SBP < 90 and 12 children with documented EMS heart rate > SBP.

CONCLUSION

Many children transported by EMS in this hospital's catchment area did have a field blood pressure measurement documented, but the frequency was significantly less in younger-aged children. The blood pressure measurements of children determined to have severe injuries in the sample did not meet the inclusion criteria for high risk of serious injury by the newly established national guidelines. This suggests other prehospital criteria, such as mechanism of injury or visual cues, prompted EMS to transport these pediatric trauma patients to a regional trauma center for specialized care.

Exploring Computational Techniques in Preprocessing Neonatal Physiological Signals for Detecting Adverse Outcomes: Scoping Review

BACKGROUND

Computational signal preprocessing is a prerequisite for developing data-driven predictive models for clinical decision support. Thus, identifying the best practices that adhere to clinical principles is critical to ensure transparency and reproducibility to drive clinical adoption. It further fosters reproducible, ethical, and reliable conduct of studies. This procedure is also crucial for setting up a software quality management system to ensure regulatory compliance in developing software as a medical device aimed at early preclinical detection of clinical deterioration.

OBJECTIVE

This scoping review focuses on the neonatal intensive care unit setting and summarizes the state-of-the-art computational methods used for preprocessing neonatal clinical physiological signals; these signals are used for the development of machine learning models to predict the risk of adverse outcomes.

METHODS

Five databases (PubMed, Web of Science, Scopus, IEEE, and ACM Digital Library) were searched using a combination of keywords and MeSH (Medical Subject Headings) terms. A total of 3585 papers from 2013 to January 2023 were identified based on the defined search terms and inclusion criteria. After removing duplicates, 2994 (83.51%) papers were screened by title and abstract, and 81 (0.03%) were selected for full-text review. Of these, 52 (64%) were eligible for inclusion in the detailed analysis.

RESULTS

Of the 52 articles reviewed, 24 (46%) studies focused on diagnostic models, while the remainder (n=28, 54%) focused on prognostic models. The analysis conducted in these studies involved various physiological signals, with electrocardiograms being the most prevalent. Different programming languages were used, with MATLAB and Python being notable. The monitoring and capturing of physiological data used diverse systems, impacting data quality and introducing study heterogeneity. Outcomes of interest included sepsis, apnea, bradycardia, mortality, necrotizing enterocolitis, and hypoxic-ischemic encephalopathy, with some studies analyzing combinations of adverse outcomes. We found a partial or complete lack of transparency in reporting the setting and the methods used for signal preprocessing. This includes reporting methods to handle missing data, segment size for considered analysis, and details regarding the modification of the state-of-the-art methods for physiological signal processing to align with the clinical principles for neonates. Only 7 (13%) of the 52 reviewed studies reported all the recommended preprocessing steps, which could have impacts on the downstream analysis.

CONCLUSIONS

The review found heterogeneity in the techniques used and inconsistent reporting of parameters and procedures used for preprocessing neonatal physiological signals, which is necessary to confirm adherence to clinical and software quality management system practices, usefulness, and choice of best practices. Enhancing transparency in reporting and standardizing procedures will boost study interpretation and reproducibility and expedite clinical adoption, instilling confidence in the research findings and streamlining the translation of research outcomes into clinical practice, ultimately contributing to the advancement of neonatal care and patient outcomes.

Feasibility study of the Utstein Style For Drowning to aid data collection on the resuscitation of drowning victims

Aim

The revised Utstein Style For Drowning (USFD) was published in 2015. Core data were considered feasible to be reported in most health systems worldwide. We aimed to determine the suitability of the USFD as a template for reporting data from drowning research.

Method

Clinical records of 437 consecutive drowning presentations to the Sunshine Coast Hospital and Health Service Emergency Departments (ED) between 1/1/2015 and 31/12/2021 were examined for data availability to complete the USFD. The proportions of patients with each variable documented is reported. Time taken to record core and supplementary variables was recorded for 120 consecutive patients with severity of drowning Grade 1 or higher.

Results

There were 437 patients, including 227 (51.9%) aged less than 16 years. There were 253 (57.9%) males and 184 (42.1%) females. Sixty-one patients (13.9%) received cardiopulmonary resuscitation (CPR). There were nine (2.1%) deaths after presentation to the ED. Median time for data entry was 17 minutes for core variables and 6 min for supplementary. This increased to 29 + 6 minutes for patients in cardiac arrest. Sixteen (32.7%) of 49 core variables and four (13.3%) of 30 supplementary variables were documented 100% of the time. One (2.0%) core and seven (23.3%) supplementary variables were never documented. Duration of submersion was documented in 100 (22.9%) patients.

Conclusion

USFD is time consuming to complete. Data availability to enable completion of the USFD varies widely, even in a resource rich health system. These results should be considered in future revisions of the USFD.

Vital signs-based deterioration prediction model assumptions can lead to losses in prediction performance

OBJECTIVE

Vital signs-based models are complicated by repeated measures per patient and frequently missing data. This paper investigated the impacts of common vital signs modeling assumptions during clinical deterioration prediction model development.

STUDY DESIGN AND SETTING

Electronic medical record (EMR) data from five Australian hospitals (1 January 2019-31 December 2020) were used. Summary statistics for each observation's prior vital signs were created. Missing data patterns were investigated using boosted decision trees, then imputed with common methods. Two example models predicting in-hospital mortality were developed, as follows: logistic regression and eXtreme Gradient Boosting. Model discrimination and calibration were assessed using the C-statistic and nonparametric calibration plots.

RESULTS

The data contained 5,620,641 observations from 342,149 admissions. Missing vitals were associated with observation frequency, vital sign variability, and patient consciousness. Summary statistics improved discrimination slightly for logistic regression and markedly for eXtreme Gradient Boosting. Imputation method led to notable differences in model discrimination and calibration. Model calibration was generally poor.

CONCLUSION

Summary statistics and imputation methods can improve model discrimination and reduce bias during model development, but it is questionable whether these differences are clinically significant. Researchers should consider why data are missing during model development and how this may impact clinical utility.

Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents

INTRODUCTION

Prehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale.

METHODS

We used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores.

RESULTS

The odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04).

CONCLUSIONS

Missing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.

Time is tissue: Barriers to timely transfusion after pediatric injury

ABSTRACT

Strategies to improve outcomes among children and adolescents in hemorrhagic shock have primarily focused on component resuscitation, pharmaceutical coagulation adjuncts, and hemorrhage control techniques. Many of these strategies have been associated with better outcomes in children, but the barriers to their use and the impact of timely use on morbidity and mortality have received little attention. Because transfusion is uncommon in injured children, few studies have identified and described barriers to the processes of using these interventions in bleeding patients, processes that move from the decision to transfuse, to obtaining the necessary blood products and adjuncts, and to delivering them to the patient. In this review, we identify and describe the steps needed to ensure timely blood transfusion and propose practices to minimize barriers in this process. Given the potential impact of time on hemorrhage associated outcomes, ensuring timely intervention may have a similar or greater impact than the interventions themselves.

Factors associated with the frequency of respiratory rate measurement by hospital nurses: a multicentre cross-sectional study

BACKGROUND

Although the respiratory rate (RR) is a sensitive predictor of patient deterioration, it is often neglected. Moreover, only a few studies have investigated the factors that cause health professionals to disregard RR.

AIMS

This cross-sectional study aimed to elucidate the factors affecting the frequency of RR measurement by the nurses.

METHODS

An original questionnaire, comprising 18 factors extracted from previous studies, was administered to nurses from nine hospitals.

FINDINGS

Of the 644 eligible nurses, 592 (92%) completed the questionnaire. The adjusted odds ratios and 95% confidence intervals of the factors of importance, educational experiences, shortened-count method use, negative experiences, and inconvenience were 2.24 (1.13-4.45), 2.26 (1.20-4.26), 0.61 (0.42-0.91), 0.45 (0.29-0.70), and 0.41 (0.26-0.65), respectively.

CONCLUSION

Education, feedback systems, and automation are the primary issues that need attention. Prioritising these factors could provide a practical guide for optimising the frequency of RR measurement.

Documentation of paediatric head injuries in a mixed metropolitan emergency department

OBJECTIVE

Head injuries are a common presentation of children to Australian EDs. Healthcare documentation is an important tool for enhancing patient care. In our study, we aimed to assess the adequacy of paediatric head injury documentation in a mixed ED.

METHODS

A retrospective analysis of presentations to a mixed ED between 2017 and 2018. Children aged <16 years old with a primary diagnosis of head injury were included. Documentation items based on local head injury guidelines were assessed in both medical and nursing documentation. We compared cases aged <1 and ≥1 year.

RESULTS

There were 427 presentations that met the case definition. Medical documentation was present in 422 cases and nursing documentation in 310 cases. In combined medical and nursing documentation, items poorly documented include blood pressure (BP; 21.3%) and secondary survey (16.9%). In solely medical documentation, least commonly documented items are high-risk bony injuries (22.5%), high-risk soft tissue injuries (22.3%), seizure (22.0%) and non-accidental injury (3.6%). Glasgow Coma Scale (GCS) was poorly documented in cases aged <1 year (10.9%, P < 0.001).

CONCLUSIONS

The largest gaps in the documentation of paediatric head injuries were BP and paediatric GCS in infants. Future audits and educational strategies should focus on targeting clinically relevant items that are predictive of serious outcomes.

Improving the prioritization of children at the emergency department: Updating the Manchester Triage System using vital signs

Background

Vital signs are used in emergency care settings in the first assessment of children to identify those that need immediate attention. We aimed to develop and validate vital sign based Manchester Triage System (MTS) discriminators to improve triage of children at the emergency department.

Methods and findings

The TrIAGE project is a prospective observational study based on electronic health record data from five European EDs (Netherlands (n = 2), United Kingdom, Austria, and Portugal). In the current study, we included 117,438 consecutive children <16 years presenting to the ED during the study period (2012–2015). We derived new discriminators based on heart rate, respiratory rate, and/or capillary refill time for specific subgroups of MTS flowcharts. Moreover, we determined the optimal cut-off value for each vital sign. The main outcome measure was a previously developed 3-category reference standard (high, intermediate, low urgency) for the required urgency of care, based on mortality at the ED, immediate lifesaving interventions, disposition and resource use. We determined six new discriminators for children <1 year and ≥1 year: “Very abnormal respiratory rate”, “Abnormal heart rate”, and “Abnormal respiratory rate”, with optimal cut-offs, and specific subgroups of flowcharts. Application of the modified MTS reclassified 744 patients (2.5%). Sensitivity increased from 0.66 (95%CI 0.60–0.72) to 0.71 (0.66–0.75) for high urgency patients and from 0.67 (0.54–0.76) to 0.70 (0.58–0.80) for high and intermediate urgency patients. Specificity decreased from 0.90 (0.86–0.93) to 0.89 (0.85–0.92) for high and 0.66 (0.52–0.78) to 0.63 (0.50–0.75) for high and intermediate urgency patients. These differences were statistically significant. Overall performance improved (R² 0.199 versus 0.204).

Conclusions

Six new discriminators based on vital signs lead to a small but relevant increase in performance and should be implemented in the MTS.

Management of children visiting the emergency department during out-of-office hours: an observational study

BACKGROUND

The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours.

METHODS

We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital.

RESULTS

Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining.

CONCLUSIONS

Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.

Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre study

BACKGROUND

Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS.

METHODS

The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece).

FINDINGS

Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82-0·90) for high-urgency patients and 0·67 (0·61-0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87-0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81-0·85).

INTERPRETATION

The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs.

FUNDING

Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.

Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up

Background

The rapid identification of deterioration in the pediatric population is complex, particularly in the emergency department (ED). A comprehensive multi-faceted Pediatric Early Warning System (PEWS) might maximize early recognition of clinical deterioration and provide a structured process for the reassessment and escalation of care. The objective of the study was to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS implemented in the ED of an urban public general hospital in British Columbia, Canada, and to guide provincial scale up.

Methods

We used a before-and-after design to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS (pediatric assessment flowsheet, PEWS score, situational awareness, escalation aid, and communication framework). Sources of data included patient medical records, surveys of direct care staff, and key-informant interviews. Data were analyzed using mixed-methods approaches.

Results

The majority of medical records had documented PEWS scores at triage (80%) and first bedside assessment (81%), indicating that the intervention was implemented with high fidelity. The intervention was effective in increasing vital signs documentation, both at first beside assessment (84% increase) and throughout the ED stay (> 100% increase), in improving staff’s self-perceived knowledge and confidence in providing pediatric care, and self-reported communication between staff. Satisfaction levels were high with the PEWS scoring system, flowsheet, escalation aid, and to a lesser extent with the situational awareness tool and communication framework. Reasons for dissatisfaction included increased paperwork and incidence of false-positives. Overall, the majority of providers indicated that implementation of PEWS and completing a PEWS score at triage alongside the Canadian Triage and Acuity Scale (CTAS) added value to pediatric care in the ED. Results also suggest that the intervention is aligned with current practice in the ED.

Conclusion

Our study shows that high-fidelity implementation of PEWS in the ED is feasible. We also show that a multi-component PEWS can be effective in improving pediatric care and be well-accepted by staff. Results and lessons learned from this pilot study are being used to scale up implementation of PEWS in ED settings across the province of British Columbia.

Aging is independently associated with an increasing normal respiratory rate among an older adult population in a clinical setting: A cross-sectional study

AIM

Clinical prediction scores for older patients are inaccurate, partially because they do not account for the effects of aging on the respiratory rate. The principal aim of the present study was to assess the effects of aging on the normal respiratory rate in older patients in a clinical setting.

METHODS

We recruited 634 participants aged >59 years to <100 years who presented to our hospital (Iwakuni Municipal Miwa Hospital, for regular appointments without any new symptoms. We assessed the relationship between age and respiratory rate using Pearson's correlation coefficient and the Jonckheere-Terpstra test. We carried out multiple linear regression analysis, with sex, age, blood pressure, heart rate and 14 comorbidities as dependent variables, and respiratory rate as the independent variable.

RESULTS

The mean ± standard deviation respiratory rate for all for all participants was 16.1 ± 4.28. The mean ± standard deviation respiratory rates for individuals aged in their 60s, 70s, 80s and 90s were 14.8 ± 4.28, 15.5 ± 3.62, 16.37 ± 4.48 and 17.1 ± 4.45, respectively. Pearson's correlation coefficient between age and respiratory rate was 0.17 (95% confidence interval 0.10-0.25). The Jonckheere-Terpstra test and multiple linear regression analysis showed a significant positive trend between age group and respiratory rate (P < 0.001).

CONCLUSIONS

Although the correlation coefficient between age and respiratory rate was low (R = 0.17), aging was a statistically significant factor in determining the normal respiratory rate in older patients. Furthermore, the respiratory rate increased with age. Geriatr Gerontol Int 2019; 19: 1179-1183.

Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway

BACKGROUND

Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template.

METHODS

The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties.

RESULTS

All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method.

CONCLUSIONS

We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Posterior Reversible Encephalopathy Syndrome: A Rare Childhood Case with Unconsciousness

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by seizures, altered consciousness, visual disturbances, and headache. Characteristic findings on neuroimaging include cerebral edema, typically involving the parieto-occipital white matter. PRES has been associated with hypertension, autoimmune disease, and Henoch-Schölein purpura (HSP), but few cases have been reported, and fewer cases of PRES have been reported in children.

CASE REPORT

We report the case of a 4-year-old girl who presented with blindness and semi-consciousness. The patient had no significant medical history and no abnormalities on physical examination or laboratory testing, although she had slightly elevated blood pressure. After hospitalization, the patient showed some characteristic signs of HSP and cranial magnetic resonance imaging revealed PRES as the cause of semi-consciousness. In our discussion, we examine the clinical features of PRES and remarkable points for the clinical diagnosis and management of this rare but important disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although reports of PRES in children are rare, PRES should be considered in the differential diagnosis of children presenting with disturbance of consciousness. Emergency physicians should consult with pediatric physicians to confirm diagnoses of PRES and determine an appropriate treatment plan, given its variable etiology. Measurements of blood pressure, which are often missing in pediatric cases, can help physicians to arrive at a correct diagnosis.

Reducing Clinical Noise for Body Mass Index Measures Due to Unit and Transcription Errors in the Electronic Health Record

Body mass index (BMI) is an important outcome and covariate adjustment for many clinical association studies. Accurate assessment of BMI, therefore, is a critical part of many study designs. Electronic health records (EHRs) are a growing source of clinical data for research purposes, and have proven useful for identifying and replicating genetic associations. EHR-based data collected for clinical and billing purposes have several unique properties, including a high degree of heterogeneity or "clinical noise." In this work, we propose a new method for reducing the problems of transcription and recording error for height and weight and apply these methods to a subset of the Vanderbilt University Medical Center biorepository known as EAGLE BioVU (n=15,863). After processing, we show that the distribution of BMI from EAGLE BioVU closely matches population-based estimates from the National Health and Nutrition Examination Surveys (NHANES), and that our approach retains far more data points than traditional outlier detection methods.

Explaining transgression in respiratory rate observation methods in the emergency department: A classic grounded theory analysis

BACKGROUND

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often inaccurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs.

OBJECTIVE

To develop a substantive theory explaining ED registered nurses' reasoning when they miss or misreport respiratory rate observations.

DESIGN

This research project employed a classic grounded theory analysis of qualitative data.

PARTICIPANTS

Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed responses from individual interviews and open-ended responses from an online questionnaire.

METHODS

Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were employed to code data. This approach facilitated the identification of the main concern of the participants and aided in the generation of theory explaining how the participants processed this issue.

RESULTS

The main concern identified is that ED registered nurses do not believe that collecting an accurate respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational requirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The theory 'Rationalising Transgression', explains how participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing strategies that adjust the significance of the organisational requirement. These strategies include; Compensating, when nurses believe they are compensating for errant behaviour by enhancing the patient's outcome; Minimalizing, when nurses believe that the patient's outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy that sanctions negligent behaviour and occurs when nurses 'cut corners' to get the job done. Nurses' use these strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising transgression CONCLUSION: This research reveals that despite continuing education regarding gold standard guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses' understanding of acceptable practice methods. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes.

Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study

STUDY OBJECTIVE

We evaluate the association between discharge tachycardia and (1) emergency department (ED) and urgent care revisit and (2) receipt of clinically important intervention at the revisit.

METHODS

The study included a nonconcurrent cohort of children aged 0 to younger than 19 years, discharged from 2 pediatric EDs and 4 pediatric urgent care centers in 2013. The primary exposure was discharge tachycardia (last recorded pulse rate ≥99th percentile for age). The main outcome was ED or urgent care revisit within 72 hours of discharge. Additional outcomes included interventions received and disposition at the revisit, prevalence of discharge tachycardia at the index visit, and associations of pain, fever, and medications with discharge tachycardia. Multivariable logistic regression determined relative risk ratios for revisit and receipt of clinically important intervention at the revisit.

RESULTS

Of eligible visits, 126,774 were included, of which 10,470 patients (8.3%) had discharge tachycardia. Discharge tachycardia was associated with an increased risk of revisit (adjusted RR 1.3; 95% confidence interval 1.2 to 1.5), increased risk of tachycardia at the revisit (relative risk 3.1; 95% confidence interval 2.6 to 3.7), and of the receipt of certain clinically important interventions (supplemental oxygen, respiratory medications and admission, antibiotics and admission, and peripheral intravenous line placement and admission). However, there was no increased risk for the composite outcome of receipt of any clinically important intervention or admission on revisit.

CONCLUSION

Discharge tachycardia is associated with an increased risk of revisit. It is likely that tachycardia at discharge is not a critical factor associated with impending physiologic deterioration.

Accurate respiratory rates count: So should you!

It is well documented that the respiratory rate is the least accurately recorded vital sign. Despite nurses consistently confirming that they understand the physiological importance of the respiratory rate, more often than not, they estimate a value rather than count for an entire minute. Until recently, little has been known about why this phenomenon perpetuates. However, it has now been established that many emergency department registered nurses believe they are enhancing patients' outcomes by performing tasks other than counting a patient's respiratory rate. This discussion highlights the significance of recording accurate respiratory rates, as opposed to estimating a rate; emphasizing that just four breaths either side of the normal range could be indicative of impending clinical deterioration.

Scoring systems in paediatric emergency care: Panacea or paper exercise?

Scoring systems to recognise the most ill patients, or those at risk of deterioration, are increasingly utilised in hospitals that look after paediatric inpatients. There have been efforts to implement these systems in emergency and urgent care settings, but they have yet unproven value. This is because the child or young person presenting acutely is a different cohort than the 'treated' ward-based group. The majority of children presenting to emergency and urgent care settings are discharged home, and so, scoring systems need to recognise the most unwell but also assist in safe and appropriate discharge as well as highlighting those patients in need of more senior review. This article explores this conundrum, suggesting how cognitive factors have a role to play, and how scoring systems can have wider effects than just individual patient care.

Improving the Manchester Triage System for pediatric emergency care: an international multicenter study

Objectives

This multicenter study examines the performance of the Manchester Triage System (MTS) after changing discriminators, and with the addition use of abnormal vital sign in patients presenting to pediatric emergency departments (EDs).

Design

International multicenter study

Settings

EDs of two hospitals in The Netherlands (2006–2009), one in Portugal (November–December 2010), and one in UK (June–November 2010).

Patients

Children (<16years) triaged with the MTS who presented at the ED.

Methods

Changes to discriminators (MTS 1) and the value of including abnormal vital signs (MTS 2) were studied to test if this would decrease the number of incorrect assignment. Admission to hospital using the new MTS was compared with those in the original MTS. Likelihood ratios, diagnostic odds ratios (DORs), and c-statistics were calculated as measures for performance and compared with the original MTS. To calculate likelihood ratios and DORs, the MTS had to be dichotomized in low urgent and high urgent.

Results

60,375 patients were included, of whom 13% were admitted. When MTS 1 was used, admission to hospital increased from 25% to 29% for MTS ‘very urgent’ patients and remained similar in lower MTS urgency levels. The diagnostic odds ratio improved from 4.8 (95%CI 4.5–5.1) to 6.2 (95%CI 5.9–6.6) and the c-statistic remained 0.74. MTS 2 did not improve the performance of the MTS.

Conclusions

MTS 1 performed slightly better than the original MTS. The use of vital signs (MTS 2) did not improve the MTS performance.

Benefit of BP Measurement in Pediatric ED Patients

Introduction. Obtaining blood pressures in pediatric emergency department patients is the standard of care; however, there is little evidence to support its utility. This prospective study assesses the benefit of BP acquisition in patients ≤5 years. Methods. Data were collected by the ED triage nurses on 649 patients in two community hospital EDs. Relationships between abnormal blood pressures and the patients' age, acuity, and calm versus not-calm emotional state were analyzed. Results. There were significant differences in the rate of elevated BPs in the calm and not-calm groups of patients. Overall, one- and two-year-old patients were more likely to have elevated BPs than those in other age groups. Very few patients in the sample had hypotension (1%). There was no relationship between Emergency Severity Index (ESI) acuity level and an abnormal BP. Nineteen percent of calm patients had elevated BPs, with 3.6% of patients in the stage two class of hypertension. Conclusions. There is limited benefit in obtaining BPs in children age of five or less regardless of whether the child is calm or not in ESI acuity levels 3 and 4.

Improving vital sign documentation at triage: an emergency department quality improvement project

BACKGROUND

Improving the quality and safety of patients seen in an emergency department (ED) has become a priority in Italy. The Tuscan Regional Health Ministry has supported quality improvement projects in several Tuscan EDs in cooperation with Harvard Medical International and Harvard Medical School.

OBJECTIVE

To improve the triage process, we assessed the completeness of documenting the vital signs of patients seen at triage in the ED of the University Hospital Santa Chiara, Pisa, Italy. At the University Hospital of Pisa's ED, triage is based on 5 categories, each identified by a color: white (lowest priority), blue, green, yellow, and red (highest priority). For patients triaged as "yellow," blood pressure, heart rate, and oxygen saturation are considered mandatory vital signs and important components of a complete patient record. The aims of this project were as follows: 1) to assess the percentage of patients seen during ED triage in whom vital signs were recorded in the clinical record, 2) to analyze the reasons for missing vital sign data, and 3) to design and implement a strategy to improve the percentage of patients in whom vital signs were recorded.

METHODS

This project began in November 2005 with the identification of a multidisciplinary ED Quality Team. Faculty from Harvard Medical School provided a 2-day training course on the methods and tools of clinical quality improvement. After the training, the team defined their improvement project. The clinical quality improvement project followed a Plan-Do-Study-Act cycle. Preintervention and postintervention data collection consisted of a retrospective analysis of one-third of all patients triaged in the "yellow" category who were admitted to the ED during 1 month, randomly selected using a computer-generated list.

RESULTS

A total of 245 clinical records in the preintervention (March 2006) and 251 (April-May 2007) during the postintervention were included. We found that in 77.9% (191/245) of these records, vital signs were correctly recorded during the preintervention period. Patients with limb trauma and those with abdominal complaints represented the vast majority of patients in whom vital sign data were missing. The postintervention data revealed an improvement in the documentation of mandatory vital signs from 77.9% to 87.9%.

CONCLUSIONS

Creating a multidisciplinary team and implementing a formal quality improvement project improved vital sign documentation at triage for a group of patients seen during ED triage in 1 Italian hospital.

Importance of vital signs to the early diagnosis and severity of sepsis: association between vital signs and sequential organ failure assessment score in patients with sepsis

OBJECTIVE

While much attention is given to the fifth vital sign, the utility of the 4 classic vital signs (blood pressure, respiratory rate, body temperature, and heart rate) has been neglected. The aim of this study was to assess a possible association between vital signs and the Sequential Organ Failure Assessment (SOFA) score in patients with sepsis.

METHODS

We performed a prospective, observational study of 206 patients with sepsis. Blood pressure, respiratory rate, body temperature, and heart rate were measured on arrival at the hospital. The SOFA score was also determined on the day of admission.

RESULTS

Bivariate correlation analysis showed that all of the vital signs were correlated with the SOFA score. Multiple regression analysis indicated that decreased values of systolic blood pressure (multivariate regression coefficient [Coef] = -0.030, 95% confidence interval [CI] = -0.046 to -0.013) and diastolic blood pressure (Coef = -0.045, 95% CI = -0.070 to -0.019), increased respiratory rate (Coef = 0.176, 95% CI = 0.112 to 0.240), and increased shock index (Coef = 4.232, 95% CI = 2.401 to 6.062) significantly influenced the SOFA score.

CONCLUSION

Increased respiratory rate and shock index were significantly correlated with disease severity in patients with sepsis. Evaluation of these signs may therefore improve early identification of severely ill patients at triage, allowing more aggressive and timely interventions to improve the prognosis of these patients.