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Freedman SB, Schnadower D, Estes M, Casper TC, Goldstein SL, Grisaru S, Pavia AT, Wilfond BS, Metheney M, Kimball K, Tarr PI. Hyperhydration to Improve Kidney Outcomes in Children with Shiga Toxin-Producing E. coli Infection: a multinational embedded cluster crossover randomized trial (the HIKO STEC trial). Trials 2023; 24:359. [PMID: 37245030 DOI: 10.1186/s13063-023-07379-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Shiga toxin-producing E. coli (STEC) infections affect children and adults worldwide, and treatment remain solely supportive. Up to 15-20% of children infected by high-risk STEC (i.e., E. coli that produce Shiga toxin 2) develop hemolytic anemia, thrombocytopenia, and kidney failure (i.e., hemolytic uremic syndrome (HUS)), over half of whom require acute dialysis and 3% die. Although no therapy is widely accepted as being able to prevent the development of HUS and its complications, several observational studies suggest that intravascular volume expansion (hyperhydration) may prevent end organ damage. A randomized trial is needed to confirm or refute this hypothesis. METHODS We will conduct a pragmatic, embedded, cluster-randomized, crossover trial in 26 pediatric institutions to determine if hyperhydration, compared to conservative fluid management, improves outcomes in 1040 children with high-risk STEC infections. The primary outcome is major adverse kidney events within 30 days (MAKE30), a composite measure that includes death, initiation of new renal replacement therapy, or persistent kidney dysfunction. Secondary outcomes include life-threatening, extrarenal complications, and development of HUS. Pathway eligible children will be treated per institutional allocation to each pathway. In the hyperhydration pathway, all eligible children are hospitalized and administered 200% maintenance balanced crystalloid fluids up to targets of 10% weight gain and 20% reduction in hematocrit. Sites in the conservative fluid management pathway manage children as in- or outpatients, based on clinician preference, with the pathway focused on close laboratory monitoring, and maintenance of euvolemia. Based on historical data, we estimate that 10% of children in our conservative fluid management pathway will experience the primary outcome. With 26 clusters enrolling a mean of 40 patients each with an intraclass correlation coefficient of 0.11, we will have 90% power to detect a 5% absolute risk reduction. DISCUSSION HUS is a devastating illness with no treatment options. This pragmatic study will determine if hyperhydration can reduce morbidity associated with HUS in children with high-risk STEC infection. TRIAL REGISTRATION ClinicalTrials.gov NCT05219110 . Registered on February 1, 2022.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Childrens Hospital, Alberta Childrens Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children, s Hospital Medical Center and Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Myka Estes
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children, s Hospital Medical Center and Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Silviu Grisaru
- Section of Nephrology, Department of Pediatrics, Alberta Children, s Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Benjamin S Wilfond
- Divisions of Bioethics and Palliative Care and Pulmonary and Sleep Medicine, Department of Pediatrics and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA
| | - Melissa Metheney
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Kadyn Kimball
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Wood JN, Campbell KA, Anderst JD, Bachim AN, Berger RP, Hymel KP, Harper NS, Letson MM, Melville JD, Okunowo O, Lindberg DM. Child Abuse Pediatrics Research Network: The CAPNET Core Data Project. Acad Pediatr 2023; 23:402-409. [PMID: 35840086 PMCID: PMC9834430 DOI: 10.1016/j.acap.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network. METHODS We conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021. RESULTS Among 3667 patients with 3721 encounters, 69.4% were <3 years old; 44.3% <1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPs performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild/intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse. CONCLUSION Most children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.
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Affiliation(s)
- Joanne N Wood
- Division of General Pediatrics and PolicyLab (JN Wood), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Roberts Center for Pediatric Research, Philadelphia, Pa.
| | - Kristine A Campbell
- Department of Pediatrics (KA Campbell), University of Utah, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, Utah
| | - James D Anderst
- Children's Mercy Kansas City (JD Anderst), University of Missouri Kansas City School of Medicine, Kansas City, Mo
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics (AN Bachim), Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Rachel P Berger
- Department of Pediatrics (RP Berger), UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pa
| | - Kent P Hymel
- Penn State Health Children's Hospital, Penn State College of Medicine (KP Hymel), Hershey, Pa
| | - Nancy S Harper
- University of Minnesota School of Medicine, Center for Safe and Healthy Children (NS Harper), Minneapolis, Minn
| | - Megan M Letson
- Nationwide Children's Hospital (M Letson), The Ohio State University College of Medicine, Columbus, Ohio
| | - John D Melville
- Division of Child Abuse Pediatrics (JD Melville), Medical University of South Carolina, Charleston, SC
| | - Oluwatimilehin Okunowo
- Data Science & Biostatistics Unit, Department of Biomedical and Health Informatics (O Okunowo), Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, Pa
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect (DM Lindberg), University of Colorado School of Medicine, Aurora, Colo
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3
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Wismer AC, Rakic M, Kuehni CE, Jaboyedoff M, Romano F, Kopp MV, Brandenberger J, Staubli G, Keitel K. Consensus Minimal Dataset for Pediatric Emergency Medicine in Switzerland. Pediatr Emerg Care 2022; 38:511-516. [PMID: 36099537 PMCID: PMC9555753 DOI: 10.1097/pec.0000000000002841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Standardized, harmonized data sets generated through routine clinical and administrative documentation can greatly accelerate the generation of evidence to improve patient care. The objective of this study was to define a pediatric emergency medicine (PEM) minimal dataset for Switzerland (Swiss PEM minimal dataset) and to contribute a subspecialty module to a national pediatric data harmonization process (SwissPedData). METHODS We completed a modified Delphi survey, inviting experts from all major Swiss pediatric emergency departments (PEDs). RESULTS Twelve experts from 10 Swiss PEDs, through 3 Delphi survey rounds and a moderated e-mail discussion, suggested a subspecialty module for PEM to complement the newly developed SwissPedData main common data model (CDM). The PEM subspecialty CDM contains 28 common data elements (CDEs) specific to PEM. Additional CDEs cover PEM-specific admission processes (type of arrival), timestamps (time of death), greater details on investigations and treatments received at the PED, and PEM procedures (eg, procedural sedation). In addition to the 28 CDEs specific to PEM, 43 items from the SwissPedData main CDM were selected to create a Swiss PEM minimal dataset. The final Swiss PEM minimal dataset was similar in scope and content to the registry of the Pediatric Emergency Care Applied Research Network. CONCLUSIONS A practical minimal dataset for PEM in Switzerland was developed through recognized consensus methodology. The Swiss PEM minimal dataset developed by Swiss PEM experts will facilitate international data sharing for PEM research and quality improvement projects.
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Affiliation(s)
- Alice C. Wismer
- From the Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Milenko Rakic
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Claudia E. Kuehni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Manon Jaboyedoff
- Service of Pediatrics, Department Women-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabrizio Romano
- From the Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Matthias V. Kopp
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Julia Brandenberger
- From the Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Georg Staubli
- Department of Pediatric Emergency Medicine, Childrens' University Hospital Zurich, Zurich, Switzerland
| | - Kristina Keitel
- From the Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
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4
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Kratchman DM, Vaughn P, Silverman LB, Campbell KA, Lindberg DM, Anderst JD, Bachim AN, Berger RP, Hymel KP, Letson M, Melville JD, Wood JN. The CAPNET multi-center data set for child physical abuse: Rationale, methods and scope. CHILD ABUSE & NEGLECT 2022; 131:105653. [PMID: 35779985 PMCID: PMC9332134 DOI: 10.1016/j.chiabu.2022.105653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND The pediatric subspecialty of Child Abuse Pediatrics (CAP) was certified by the American Board of Medical Subspecialties in 2006. Relative to its impact on pediatric health, CAP-focused research has been relatively under-funded. Multi-center networks related to CAP-focused research have made important advances, but have been limited in scope and duration. CAPNET is multi-center network whose mission is to support CAP-focused research. OBJECTIVE To describe the rationale, development, and scope of the CAPNET research network infrastructure, the CAPNET data registry and associated data resources. METHODS Based on existing priorities for CAP-focused research, we used consensus building and iterative testing to establish inclusion criteria, common data elements, data quality assurance, and data sharing processes for children with concerns of physical abuse. RESULTS We describe the rationale, methods and intended scope for the development of the CAPNET research network and data registry. CAPNET is currently abstracting data for children <10 years (120 months) old who undergo sub-specialty evaluation for physical abuse at 10 US pediatric centers (approximately 4000 evaluations/year total) using an online data capture form. Data domains include: demographics; visit timing and providers, medical/social history, presentation, examination findings, laboratory and radiographic testing, diagnoses, outcomes, and data for contact children. We describe the methods and criteria for collecting and validating data which are broadly available to CAP investigators. CONCLUSIONS CAPNET represents a new data resource for the CAP research community and will increase the quantity and quality of CAP-focused research.
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Affiliation(s)
- Devon M Kratchman
- Safe Place: The Center for Child Protection and Health, PolicyLab, Center for Pediatric Effectiveness and Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Porcia Vaughn
- Department of Pediatrics, Division of Child Protection and Family Health, University of Utah, Salt Lake City, UT 84115, United States; The Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT 84115, United States
| | - Ligia Batista Silverman
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, 12631 E. 17(th) Ave - C326, Aurora, CO, United States
| | - Kristine A Campbell
- Department of Pediatrics, Division of Child Protection and Family Health, University of Utah, Salt Lake City, UT 84115, United States; The Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT 84115, United States
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, 12631 E. 17(th) Ave - C326, Aurora, CO, United States
| | - James D Anderst
- Children's Mercy Kansas City, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, TX, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, United States
| | - Kent P Hymel
- Penn State College of Medicine, Hershey, PA, United States
| | - Megan Letson
- Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John D Melville
- Division of Child Abuse Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Joanne N Wood
- Safe Place: The Center for Child Protection and Health, PolicyLab, Center for Pediatric Effectiveness and Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
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5
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Klassen TP, Dalziel SR, Babl FE, Benito J, Bressan S, Chamberlain J, Chang TP, Freedman SB, Kohn Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Oostenbrink R, Plint AC, Rino P, Roland D, Van de Mosselaer G, Kuppermann N. The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care. Emerg Med Australas 2021; 33:900-910. [PMID: 34218513 DOI: 10.1111/1742-6723.13801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks. METHODS PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic. CONCLUSIONS Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.
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Affiliation(s)
- Terry P Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,Pediatric Emergency Research Canada (PERC)
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Paediatric Research in Emergency Departments International Collaborative (PREDICT)
| | - Franz E Babl
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain.,Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG)
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy.,Research in European Pediatric Emergency Medicine (REPEM)
| | - James Chamberlain
- Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Pediatric Emergency Care Applied Research Network (PECARN)
| | - Todd P Chang
- Pediatric Emergency Care Applied Research Network (PECARN).,Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California, USA.,Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC)
| | - Stephen B Freedman
- Pediatric Emergency Research Canada (PERC).,Departments of Pediatrics and Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Guillermo Kohn Loncarica
- Latin American Pediatric Emergency Medicine Society, University of Buenos Aires, Buenos Aires, Argentina.,Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI)
| | - Santiago Mintegi
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG).,Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Rakesh D Mistry
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC).,Department of Paediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Lise E Nigrovic
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC).,Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rianne Oostenbrink
- Research in European Pediatric Emergency Medicine (REPEM).,General Pediatrics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Amy C Plint
- Pediatric Emergency Research Canada (PERC).,Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pedro Rino
- Latin American Pediatric Emergency Medicine Society, University of Buenos Aires, Buenos Aires, Argentina.,Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Damian Roland
- Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI).,Children's Emergency Department, University of Leicester, Leicestershire, UK
| | - Greg Van de Mosselaer
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Translating Emergency Knowledge for Kids, Winnipeg, Manitoba, Canada
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network (PECARN).,Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
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6
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Klassen T, Dalziel SR, Babl FE, Benito J, Bressan S, Chamberlain J, Chang TP, Freedman SB, Kohn-Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Oostenbrink R, Plint AC, Rino P, Roland D, Van De Mosselaer G, Kuppermann N. The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care. Pediatr Emerg Care 2021; 37:389-396. [PMID: 34091572 PMCID: PMC8244934 DOI: 10.1097/pec.0000000000002466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks. METHODS The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings. CONCLUSIONS The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.
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Affiliation(s)
- Terry Klassen
- From the Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba
- The Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Pediatric Emergency Research Canada
| | - Stuart R. Dalziel
- Departments of Surgery
- Paediatrics: Child and Youth Health, University of Auckland
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative
| | - Franz E. Babl
- Paediatric Research in Emergency Departments International Collaborative
- Departments of Paediatrics
- Critical Care, University of Melbourne, Australia
- Emergency Research, Murdoch Children's Research Institute, Melbourne
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo
- University of the Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group
| | - Silvia Bressan
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Research in European Pediatric Emergency Medicine
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
- Pediatric Emergency Care Applied Research Network
| | - Todd P. Chang
- Pediatric Emergency Care Applied Research Network
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Calgary, AB, Canada
- Division of Pediatric Emergency Medicine, Pediatric Emergency Care Applied Research Network (PECARN), Los Angeles, CA
| | - Stephen B. Freedman
- Pediatric Emergency Research Canada
- Section of Pediatric Emergency Medicine, Department of Pediatrics
- Section of Gastroenterology, Department of Emergency Medicine, Cumming School of Medicine, University of Calgary
- Division of Pediatric Emergency Medicine, Pediatric Emergency Research Canada (PERC), Calgary, AB, Canada
| | - Guillermo Kohn-Loncarica
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica
| | - Mark D. Lyttle
- Emergency Department, Bristol Royal Hospital for Children
- Faculty of Health and Applied Sciences, University of the West of England
- Paediatric Emergency Research in the United Kingdom and Ireland, Bristol, United Kingdom
| | - Santiago Mintegi
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo
- University of the Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
| | - Rakesh D. Mistry
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine
- Division of Pediatric Emergency Medicine, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Denver, CO
| | - Lise E. Nigrovic
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Emergency Medicine, Boston Children's Hospital
- Department of Emergency Medicine, Harvard Medical School
- Division of Pediatric Emergency Medicine, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Boston, MA
| | - Rianne Oostenbrink
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Department of General Pediatrics, ErasmusMC–Sophia
- Division of Pediatric Emergency Medicine, Research in European Pediatric Emergency Medicine, Rotterdam, the Netherlands
| | - Amy C. Plint
- Pediatric Emergency Research Canada
- Children's Hospital of Eastern Ontario
- Pediatrics
- Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Pedro Rino
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica
| | - Damian Roland
- Faculty of Health and Applied Sciences, University of the West of England
- Paediatric Emergency Medicine Leicester Academic Group
- Children's Emergency Department, Leicester Royal Infirmary
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, United Kingdom
| | - Gregory Van De Mosselaer
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Translating Emergency Knowledge for Kids
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network
- Departments of Emergency Medicine
- Pediatrics, University of California Davis School of Medicine, Sacramento, CA
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7
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Bennett TD, Callahan TJ, Feinstein JA, Ghosh D, Lakhani SA, Spaeder MC, Szefler SJ, Kahn MG. Data Science for Child Health. J Pediatr 2019; 208:12-22. [PMID: 30686480 PMCID: PMC6486872 DOI: 10.1016/j.jpeds.2018.12.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Tellen D Bennett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; CU Data Science to Patient Value (D2V), University of Colorado School of Medicine, Aurora, CO; Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Computational Bioscience Program, University of Colorado Denver Anschutz Medical Campus, Aurora, CO.
| | - Tiffany J Callahan
- Computational Bioscience Program, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - James A Feinstein
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Debashis Ghosh
- CU Data Science to Patient Value (D2V), University of Colorado School of Medicine, Aurora, CO; Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO; Computational Bioscience Program, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - Saquib A Lakhani
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Michael C Spaeder
- Pediatric Critical Care, University of Virginia School of Medicine, Charlottesville, VA
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Michael G Kahn
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Computational Bioscience Program, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
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Deakyne Davies SJ, Grundmeier RW, Campos DA, Hayes KL, Bell J, Alessandrini EA, Bajaj L, Chamberlain JM, Gorelick MH, Enriquez R, Casper TC, Scheid B, Kittick M, Dean JM, Alpern ER. The Pediatric Emergency Care Applied Research Network Registry: A Multicenter Electronic Health Record Registry of Pediatric Emergency Care. Appl Clin Inform 2018; 9:366-376. [PMID: 29791930 DOI: 10.1055/s-0038-1651496] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes. METHODS A data dictionary, and subsequent data model, were developed describing EHR data sources to include all processes of care within the emergency department (ED). ED visit data were deidentified and XML files were created and submitted to a central data coordinating center for inclusion in the registry. Automated data quality control occurred prior to submission through an application created for this project. Data quality reports were created for manual data quality review. RESULTS The Pediatric Emergency Care Applied Research Network (PECARN) Registry, representing four hospital systems and seven EDs, demonstrates that ED data from disparate health systems and EHR vendors can be harmonized for use in a single registry with a common data model. The current PECARN Registry represents data from 2,019,461 pediatric ED visits, 894,503 distinct patients, more than 12.5 million narrative reports, and 12,469,754 laboratory tests and continues to accrue data monthly. CONCLUSION The Registry is a robust harmonized clinical registry that includes data from diverse patients, sites, and EHR vendors derived via data extraction, deidentification, and secure submission to a central data coordinating center. The data provided may be used for benchmarking, clinical quality improvement, and comparative effectiveness research.
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Affiliation(s)
- Sara J Deakyne Davies
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Robert W Grundmeier
- Department of Pediatrics and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Diego A Campos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Katie L Hayes
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, United States
| | - Jamie Bell
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Evaline A Alessandrini
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, United States
| | - James M Chamberlain
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee Wisconsin, United States
| | - Rene Enriquez
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Beth Scheid
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Marlena Kittick
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
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Quality Improvement in Pediatric Head Trauma with PECARN Rules Implementation as Computerized Decision Support. Pediatr Qual Saf 2017; 2:e019. [PMID: 30229157 PMCID: PMC6132459 DOI: 10.1097/pq9.0000000000000019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/28/2017] [Indexed: 01/30/2023] Open
Abstract
Supplemental Digital Content is available in the text. Background: For the 1.4 million emergency department (ED) visits for traumatic brain injury (TBI) annually in the United States, computed tomography (CT) may be over utilized. The Pediatric Emergency Care Applied Research Network developed 2 prediction rules to identify children at very low risk of clinically important TBI. We implemented these prediction rules as decision support within our electronic health record (EHR) to reduce CT. Objective: To test EHR decision support implementation in reducing CT rates for head trauma at 2 pediatric EDs. Methods: We compared monthly CT rates 1 year before [preimplementation (PRE)] and 1 year after [postimplementation (POST)] decision support implementation. The primary outcome was change in CT use rate over time, measured using statistical process control charts. Secondary analyses included multivariate comparisons of PRE to POST. Balancing measures included ED length of stay and returns within 7 days after ED release. Results: There were 2,878 patients with head trauma (1,329 PRE and 1,549 POST) included. Statistical process control charts confirmed decreased CT rates over time POST that was not present PRE. Secondary statistical analyses confirmed that CT scan utilization rates decreased from 26.8% to 18.9% (unadjusted Odds Ratio [OR], 0.64; 95% Confidence Interval [CI], 0.53 -0.76; adjusted OR, 0.71; 95% CI, 0.58 -0.86). Length of stay was unchanged. There was no increase in returns within 7 days and no significant missed diagnoses. Conclusions: Implementation of EHR-integrated decision support for children with head trauma presenting to the ED is associated with a decrease in CT utilization and no increase in significant safety events.
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Abstract
OBJECTIVE To identify publishing trends within the field of pediatric emergency medicine between 2004 and 2013. METHODS We conducted a MEDLINE search of pediatric emergency medicine articles, filtered by clinical trial, published between 2004 and 2013 in ten journals from the fields of pediatrics, emergency medicine, general medicine, and pediatric emergency medicine. Each article was classified by journal type, study design, results (positive or negative/equivocal), age/type of subjects, and major topic (based on the objective of the study). Articles were stratified by publication period (2004-2008 or 2009-2013) to analyze trends. RESULTS A total of 464 articles were analyzed. The majority of articles were described as randomized-controlled trials (47%) with negative/equivocal findings (70%). The most common major topics were pain management, asthma, sedation, bronchiolitis, resuscitation, simulation, and ultrasound. Over time, the percentage of articles published in pediatrics and pediatric emergency medicine journals increased (P = 0.0499) and the percentage for all study designs increased except for randomized controlled trials (P = 0.0089). There were no differences between the 2 publication periods when stratified by results, age/type of subjects, and major topic. CONCLUSIONS By identifying these trends, we hope to encourage researchers to perform studies in the field of pediatric emergency medicine where deficiencies lie and to guide pediatric health care professionals to where published, evidence-based studies can be found in the medical literature.
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Schenk E, Edgerton EA. A tale of two populations: addressing pediatric needs in the continuum of emergency care. Ann Emerg Med 2014; 65:673-8. [PMID: 25441766 DOI: 10.1016/j.annemergmed.2014.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 08/08/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
Nearly 27% of all annual emergency department (ED) visits are pediatric related, a relatively small percentage in comparison to the number of visits from the adult population. The majority of the 31 million children and adolescents access care in nonpediatric facilities and have different clinical presentations and needs than adults. Administered by the Health Resources and Services Administration within the Department of Health and Human Services, the Emergency Medical Services for Children (EMSC) program is a federal entity that aims to ensure that pediatric care is well integrated into the entire emergency medical services system so that no matter where a child lives or travels, he or she can receive appropriate and timely care. The objective of this article is to describe the role of the EMSC program in the development of the pediatric emergency care system. The program is striving to improve pediatric emergency care in a number of ways: EMSC State Partnership grant performance measures address the ability of the out-of-hospital and hospital settings to care for children; the National Pediatric Readiness project works with EDs to ensure that essential resources are present to care for children; regionalization grants focus on the challenges of geographic isolation, access to specialty care, and limited resources; and the targeted issue grants focus on the care of the child in the out-of-hospital setting in which there is a paucity of evidence-based knowledge.
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Affiliation(s)
- Ellen Schenk
- Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD
| | - Elizabeth A Edgerton
- Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD.
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Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. J Trauma Acute Care Surg 2014; 77:427-32. [PMID: 25159246 DOI: 10.1097/ta.0000000000000296] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the variability of clinician-performed Focused Assessment with Sonography for Trauma (FAST) examinations and its impact on abdominal computed tomography (AbCT) use in hemodynamically stable children with blunt torso trauma (BTT). The FAST is used with variable frequency in children with BTT. METHODS We performed a planned secondary analysis of children (<18 years) with BTT. Patients with a Glasgow Coma Scale (GCS) score of less than 9, those with hypotension, and those taken directly to the operating suite were excluded. Clinicians documented their suspicion for intra-abdominal injury (IAI) as very low, less than 1%; low, 1% to 5%; moderate, 6% to 10%; high, 11% to 50%; or very high, greater than 50%. We determined the relative risk (RR) for AbCT use based on undergoing a FAST examination in each of these clinical suspicion strata. RESULTS Of 6,468 (median age, 11.8 years; interquartile range, 6.3-15.5 years) children who met eligibility, 887 (13.7%) underwent FAST examination before CT scan. A total of 3,015 (46.6%) underwent AbCT scanning, and 373 (5.8%) were diagnosed with IAI. Use of the FAST increased as clinician suspicion for IAI increased, 11.0% with less than 1% suspicion for IAI, 13.5% with 1% to 5% suspicion, 20.5% with 6% to 10% suspicion, 23.2% with 11% to 50% suspicion, and 30.7% with greater than 50% suspicion. The patients in whom the clinicians had a suspicion of IAI of 1% to 5% or 6% to 10% were significantly less likely to undergo a CT scan if a FAST examination was performed: RR, 0.83 (0.67-1.03); RR, 0.81 (0.72-0.91); RR, 0.85 (0.78-0.94); RR, 0.99 (0.94-1.05); and RR, 0.97 (0.91-1.05) for patients with clinician suspicion of IAI of less than 1%, 1% to 5%, 6% to 10%, 11% to 50%, and greater than 50%, respectively. CONCLUSION The FAST examination is used in a relatively small percentage of children with BTT. Use increases as clinician suspicion for IAI increases. Patients with a low or moderate clinician suspicion of IAI are less likely to undergo AbCT if they receive a FAST examination. A randomized controlled trial is required to more precisely determine the benefits and drawbacks of the FAST examination in the evaluation of children with BTT. LEVEL OF EVIDENCE Prognostic and epidemiologic study, II.
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Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160-70. [PMID: 19758692 DOI: 10.1016/s0140-6736(09)61558-0] [Citation(s) in RCA: 1039] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.
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Affiliation(s)
- Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA, USA.
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Meert KL, Donaldson A, Nadkarni V, Tieves KS, Schleien CL, Brilli RJ, Clark RSB, Shaffner DH, Levy F, Statler K, Dalton H, van der Jagt EW, Hackbarth R, Pretzlaff R, Hernan L, Dean JM, Moler FW. Multicenter cohort study of in-hospital pediatric cardiac arrest. Pediatr Crit Care Med 2009; 10:544-53. [PMID: 19451846 PMCID: PMC2741542 DOI: 10.1097/pcc.0b013e3181a7045c] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) To describe clinical characteristics, hospital courses, and outcomes of a cohort of children cared for within the Pediatric Emergency Care Applied Research Network who experienced in-hospital cardiac arrest with sustained return of circulation between July 1, 2003 and December 31, 2004, and 2) to identify factors associated with hospital mortality in this population. These data are required to prepare a randomized trial of therapeutic hypothermia on neurobehavioral outcomes in children after in-hospital cardiac arrest. DESIGN Retrospective cohort study. SETTING Fifteen children's hospitals associated with Pediatric Emergency Care Applied Research Network. PATIENTS Patients between 1 day and 18 years of age who had cardiopulmonary resuscitation and received chest compressions for >1 min, and had a return of circulation for >20 mins. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 353 patients met entry criteria; 172 (48.7%) survived to hospital discharge. Among survivors, 132 (76.7%) had good neurologic outcome documented by Pediatric Cerebral Performance Category scores. After adjustment for age, gender, and first documented cardiac arrest rhythm, variables available before and during the arrest that were independently associated with increased mortality included pre-existing hematologic, oncologic, or immunologic disorders, genetic or metabolic disorders, presence of an endotracheal tube before the arrest, and use of sodium bicarbonate during the arrest. Variables associated with decreased mortality included postoperative cardiopulmonary resuscitation. Extending the time frame to include variables available before, during, and within 12 hours following arrest, variables independently associated with increased mortality included the use of calcium during the arrest. Variables associated with decreased mortality included higher minimum blood pH and pupillary responsiveness. CONCLUSIONS Many factors are associated with hospital mortality among children after in-hospital cardiac arrest and return of circulation. Such factors must be considered when designing a trial of therapeutic hypothermia after cardiac arrest in pediatric patients.
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Corneli HM, Zorc JJ, Mahajan P, Majahan P, Shaw KN, Holubkov R, Reeves SD, Ruddy RM, Malik B, Nelson KA, Bregstein JS, Brown KM, Denenberg MN, Lillis KA, Cimpello LB, Tsung JW, Borgialli DA, Baskin MN, Teshome G, Goldstein MA, Monroe D, Dean JM, Kuppermann N. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007; 357:331-9. [PMID: 17652648 DOI: 10.1056/nejmoa071255] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. METHODS We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. RESULTS Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes. CONCLUSIONS In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002 [ClinicalTrials.gov].).
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MacLean S, Désy P, Juarez A, Perhats C, Gacki-Smith J. Research education needs of pediatric emergency nurses. J Emerg Nurs 2006; 32:17-22. [PMID: 16439282 DOI: 10.1016/j.jen.2005.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Evidence-based practice in the emergency care of children is critical. The Pediatric Emergency Care Applied Research Network (PECARN) was developed to increase pediatric research; however, participation by emergency nurses has been limited. To identify research needs in order to increase research involvement, the Emergency Nurses Association (ENA) conducted a research needs assessment with nurses in PECARN emergency departments. METHODS A self-administered needs assessment questionnaire was completed by 216 ED managers and nurses in 26 PECARN emergency departments between August and November of 2004. The questionnaires included items about research education, knowledge, and experience, as well as barriers to and resources for conducting research. Descriptive statistics were used to analyze the data. RESULTS The primary barriers to nurses' research involvement included limited research knowledge and experience, limited awareness and availability of research resources, lack of dedicated time, and limited recognition for research contributions. However, the nurses reported moderate to extensive interest in research continuing education and desired moderate to extensive involvement in pediatric research. DISCUSSION The nurses worked in research institutions with increased access to subjects and collaborative opportunities, indicating strong potential for nurses' research involvement. However, few institutions had practice models that included research recognition and dedicated research time. Furthermore, limited knowledge, experience, and awareness of research resources added to the barriers that reduced research involvement. To begin addressing the barriers, ENA developed a research curriculum based on the continuing education needs and interests identified by the nurses.
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Affiliation(s)
- Susan MacLean
- Emergency Nurses Association, Des Plaines, IL 60016-6569, USA
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