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Singu BS, Verbeeck RK, Pieper CH, Ette EI. Confirming the Suitability of a Gentamicin Dosing Strategy in Neonates Using the Population Pharmacokinetic Approach with Truncated Sampling Duration. CHILDREN (BASEL, SWITZERLAND) 2024; 11:898. [PMID: 39201833 PMCID: PMC11352679 DOI: 10.3390/children11080898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/15/2024] [Accepted: 05/17/2024] [Indexed: 09/03/2024]
Abstract
(1) Background: Gentamicin is known to be nephrotoxic and ototoxic. Although gentamicin dosage guidelines have been established for preterm and term neonates, reports do show attainment of recommended peak concentrations but toxic gentamicin concentrations are common in this age group. (2) Methods: This was a prospective, observational study conducted in Namibia with 52 neonates. A dose of 5 mg/kg gentamicin was administered over 3-5 s every 24 h in combination with benzylpenicillin 100,000 IU/kg/12 h or ampicillin 50 mg/kg/8 h. Two blood samples were collected from each participant using a truncated pharmacokinetic sampling schedule. (3) Results: The one-compartment linear pharmacokinetic model best described the data. Birthweight, postnatal age, and white blood cell count were predictive of clearance (CL), while birthweight was predictive of volume (V). For the typical neonate (median weight 1.57 kg, median postnatal age 4 days (0.011 years), median log-transformed WBC of 2.39), predicted CL and V were 0.069 L/h and 0.417 L, respectively-similar to literature values. Simulated gentamicin concentrations varied with respect to postnatal age and bodyweight. (4) Conclusions: A 5 mg/kg/24 h dosage regimen yielded simulated gentamicin concentrations with respect to age and birthweight similar to those previously reported in the literature to be safe and efficacious, confirming its appropriateness.
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Affiliation(s)
- Bonifasius Siyuka Singu
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia; (R.K.V.); (E.I.E.)
| | - Roger Karel Verbeeck
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia; (R.K.V.); (E.I.E.)
| | | | - Ene I. Ette
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia; (R.K.V.); (E.I.E.)
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Rutledge C, Waddell K, Gaither S, Whitfill T, Auerbach M, Tofil N. Evaluation of Pediatric Readiness Using Simulation in General Emergency Departments in a Medically Underserved Region. Pediatr Emerg Care 2024; 40:335-340. [PMID: 37973039 DOI: 10.1097/pec.0000000000003056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Regionalization of pediatric care in the United States was developed to improve care by directing patients to hospitals with optimal pediatric resources and experience, leading to less pediatric-trained providers in medically underserved areas. Children with emergencies, however, continue to present to local general emergency departments (GEDs), where pediatric emergencies are low-frequency, high-risk events. OBJECTIVE The goals of this project were to: increase exposure of GEDs in the southeast United States to pediatric emergencies through simulation, assess pediatric emergency clinical care processes with simulation, describe factors associated with readiness including volume of pediatric patients and ED location (urban/rural), and compare these findings to the 2013 National Pediatric Readiness Project. METHODS This prospective in situ simulation study evaluated GED readiness using the Emergency Medical Services for Children Pediatric Readiness Score (PRS) and team performance in caring for 4 simulated pediatric emergencies. Comparisons between GED and pediatric ED (PED) performance and PRS, GED performance, and PRS based on pediatric patient volume and hospital location were evaluated. A Composite Quality Score (CQS) was calculated for each ED. RESULTS Seventy-five teams from 40 EDs participated (39 GED; 1 PED). The PED had a significantly higher volume of pediatric patients (73,000 vs 4492; P = 0.003). The PRS for GEDs was significantly lower (57% [SD, 17] vs 98%; P = 0.022). The CQSs for all GEDs were significantly lower than the PED (55% vs 87%; P < 0.004). Among GEDs, there was no statistically significant difference in PRS or CQS based on pediatric patient volume, but urban GEDs had significantly higher CQSs versus rural GEDs (59.8% vs 50.6%, P = 0.001). CONCLUSIONS This study shows a significant disparity in the performance and readiness of GEDs versus a PED in a medically underserved area. More education and better access to resources is needed in these areas to adequately care for critically ill pediatric patients.
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Affiliation(s)
- Chrystal Rutledge
- From the Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Kristen Waddell
- Pediatric Critical Care, Children's of Alabama, Birmingham, AL
| | - Stacy Gaither
- From the Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Travis Whitfill
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Marc Auerbach
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Nancy Tofil
- From the Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Jain R, Hudson S, Osmond MH, Trottier ED, Poonai N, Ali S. Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician's knowledge, attitudes, and practices. CAN J EMERG MED 2024; 26:47-56. [PMID: 37855985 DOI: 10.1007/s43678-023-00602-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/24/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES Nitrous oxide (N2O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians' knowledge and practices with N2O and b) site-specific N2O protocols in Canadian pediatric EDs to help optimize its use nationally. METHODS This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N2O policies and procedures. RESULTS N2O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N2O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N2O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N2O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use. CONCLUSIONS Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N2O in their clinical practice for treating procedure-related pain and distress. Increased availability of N2O equipment, protocols, and training may improve clinicians' abilities to better manage pediatric acute pain and distress in the ED.
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Affiliation(s)
- Rini Jain
- Faculty of Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
- Faculty of Medicine, Department of Pediatrics, Division of Emergency Medicine, Jim Pattison Children's Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Summer Hudson
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Martin H Osmond
- Faculty of Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Evelyne D Trottier
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Naveen Poonai
- Departments of Pediatrics, Internal Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Samina Ali
- Faculty of Medicine and Dentistry, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada
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Titze N, Bhargava R, Montalvo AJ, Shin G, Haley CB, Saadat S, Chakravarthy B. Opioid prescription patterns in a children's hospital from 2012 to 2016. J Opioid Manag 2023; 19:489-494. [PMID: 38189190 DOI: 10.5055/jom.0833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
STUDY OBJECTIVE Pain management is a widely discussed topic, especially in the setting of the current opioid epidemic. Previous studies have shown that the use of opioids increased in the adult population. We aimed to look at the use of narcotic and non-narcotic pain medications at a large pediatric hospital to discern if patterns of pediatric pain management changed over time. METHODS 58,402 analgesic prescriptions of patients 0-21 years of age were analyzed from May 2012 to November 2016. A logistic regression model was fitted to examine the association of age, sex, primary diagnosis, and the length of hospital stay with probability of opioid prescription. RESULTS 36,560 patients aged 0-21 years (mean: 10.5, median: 11.0, and standard deviation (SD): 7.42) received analgesic pain medications. 21,847 (59.8 percent) patients were prescribed more than one analgesic. There was a male predominance in patients <15 years of age; however, in adolescents >16 years, females constituted 57.1 percent of patients. Data also showed a statistically significant reduction of opioid prescriptions from 2012 to 2016 (p < 0.001). Age and length of hospital stay were directly associated with opioid prescription (p < 0.001). CONCLUSION Data show that there is a decrease in overall opioid prescriptions among pediatric patients, which may be secondary to new Food and Drug Administration regulations and increased awareness of morbidity associated with opioid use. Not surprisingly, increased hospital stay and increase in age lead to more analgesic prescriptions. Further investigation is needed to determine the differences within opioid prescription patterns.
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Affiliation(s)
- Nicole Titze
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrence, California
| | - Rishi Bhargava
- Department of Emergency Medicine, Miller Children's & Women's Hospital, Long Beach, California
| | - Ara Jamasbi Montalvo
- Department of Emergency Medicine, Golisano Children's Hospital, Rochester, New York
| | - Gawon Shin
- University of California Irvine, School of Medicine, Irvine, California. ORCID: https://orcid.org/0000-0001-9888-9853
| | | | - Soheil Saadat
- Department of Emergency Medicine, University of California Irvine, Irvine, California
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California Irvine, Irvine, California
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Takagi D, Less Elazari S, Shles A, Yechiam H, Schujovitzky D, Rosenbloom E. Pain management of upper limb fractures in pediatric emergency department versus general orthopedics emergency department. Eur J Pediatr 2022; 181:1541-1546. [PMID: 35059827 DOI: 10.1007/s00431-021-04310-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/01/2022]
Abstract
UNLABELLED Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the "Meir" Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0-18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001). COMPLICATIONS Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups. CONCLUSIONS The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay. WHAT IS KNOWN • Pain management and control is a major issue to address in their treatment. • Traumatic injuries and especially fractures are common causes for ED admissions. WHAT IS NEW • Comparing pain management and upper limb fractures treatment between general and pediatric ED. • Pain is better treated in the PED than in the GED, without an increased rate of complications.
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Affiliation(s)
- Dania Takagi
- Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel. .,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
| | - Saharon Less Elazari
- Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Shles
- Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Yechiam
- Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Dana Schujovitzky
- Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Rosenbloom
- Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Kopp TM, Frey TM, Zakrajsek M, Nystrom J, Koutsounadis GN, Falcone KS, Zhang Y, Wall E, Byczkowski T, Mittiga MR. Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice. Pediatr Emerg Care 2022; 38:e410-e416. [PMID: 34986594 DOI: 10.1097/pec.0000000000002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences. METHODS We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis. RESULTS Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale. CONCLUSIONS A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.
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Affiliation(s)
- Tara M Kopp
- From the Department of Pediatrics, Norton Children's and University of Louisville School of Medicine, Louisville, KY
| | | | | | - Jennifer Nystrom
- Section of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Gena N Koutsounadis
- New York Institute of Technology School of Osteopathic Medicine, Old Westbury, NY
| | | | - Yin Zhang
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center
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Abu-Omer M, Chayen G, Jacob R. Differences in pain management for children with fractures. General and pediatric emergency departments. Eur J Emerg Med 2021; 28:483-485. [PMID: 34714817 DOI: 10.1097/mej.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Gilad Chayen
- Pediatric Emergency Department, Ha'Emek Medical center, Afula
| | - Ron Jacob
- Pediatric Emergency Department, Ha'Emek Medical center, Afula
- Technion institute of technology, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Aaberg Lauridsen J, Lefort Sønderskov M, Hetmann F, Hamilton A, Salmi H, Wildgaard K. Investigating the use of physical restraint of children in emergency departments: A Scandinavian survey. Acta Anaesthesiol Scand 2021; 65:1116-1121. [PMID: 33866540 DOI: 10.1111/aas.13833] [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: 02/02/2021] [Revised: 03/15/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
AIM The aim of the study is to describe the current frequency of physical restraint and the use of analgesics and sedatives for treating pediatric pain in emergency departments (EDs) in Scandinavia. METHODS We performed a nation-wide electronic survey asking nurses in the emergency departments in Denmark, Norway, and Sweden about their experience treating children in pain. RESULTS Responses from 103 Danish, Norwegian and Swedish nurses were included (79% response rate). Physical restraint was reported used at 79% [70.0-85.9] (N = 78) of the surveyed departments (DK: 96%, NO: 67%, SE: 77%) with two participants reporting daily use of physical restraint. Paracetamol was available at all departments and used most frequently. Sedation was available at 88% [78.8-92.0] of the departments with midazolam as the most recurrent sedative (83%, [74.8-89.4]). Seventy-three percent of respondents reported a need for better treatments. Lack of education was the most frequently reported obstacle for providing both pain treatment (29%) and sedation (43%) followed by lack of guidelines. CONCLUSION Physical restraint of children during painful procedures is used in the majority of Scandinavian emergency departments (79%). There appears to be a lack of local guidelines for both pain treatment and sedation.
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Affiliation(s)
- Julie Aaberg Lauridsen
- Department of Anaesthesiology and Herlev ACES Herlev Anaesthesia Critical and Emergency Care Science Unit Copenhagen University Hospital, Herlev‐Gentofte Copenhagen Denmark
| | | | - Fredrik Hetmann
- Department of Nursing and Health Promotion Faculty of Health Sciences Oslo Metropolitan University Oslo Norway
| | - Annika Hamilton
- Department of Anaesthesiology Hvidovre University Hospital Hvidovre Denmark
| | - Heli Salmi
- Department of Anaesthesia and Intensive Care New Children's HospitalUniversity of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kim Wildgaard
- Department of Anaesthesiology and Herlev ACES Herlev Anaesthesia Critical and Emergency Care Science Unit Copenhagen University Hospital, Herlev‐Gentofte Copenhagen Denmark
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Ortega HW, Velden HV, Truong W, Arms JL. Socioeconomic Status and Analgesia Provision at Discharge Among Children With Long-Bone Fractures Requiring Emergency Care. Pediatr Emerg Care 2021; 37:456-461. [PMID: 30399066 DOI: 10.1097/pec.0000000000001667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Inadequate treatment of painful conditions in children is a significant and complex problem. The objective of this study was to examine the effect of socioeconomic status on the provision of analgesic medicines at discharge in children treated emergently for a long-bone fracture. METHODS A retrospective review of all patients during a 1-year period with a long-bone fracture treated in 2 urban pediatric emergency departments (EDs) was performed. RESULTS Eight hundred seventy-three patients were identified who met our inclusion criteria. Sixty percent of patients received a prescription for an opioid-containing medicine, and 22% received a prescription for an over-the-counter analgesic medicine at ED discharge. Socioeconomic status had no effect on opioid analgesic prescriptions at discharge. Patients in the lowest-income group were younger, presented to the ED longer after an injury, were likely nonwhite, and had higher rates of over-the-counter analgesic medicine prescriptions provided at discharge. Higher-income patients were likely white and non-Hispanic, presented to the ED sooner, and were less likely to receive a prescription for a nonopioid analgesic medicine. CONCLUSIONS Socioeconomic status is associated with different nonopioid analgesic prescription patterns in children treated in the ED for a long-bone fracture, but had no effect on opioid analgesic prescriptions.
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Affiliation(s)
| | | | - Walter Truong
- Orthopedic Surgery, Children's Minnesota, Minneapolis, MN
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Wilson S, Quinlan J, Beer S, Darwent M, Dainty JR, Sheehan JR, Keating L. Prescription of analgesia in emergency medicine (POEM) secondary analysis: an observational multicentre comparison of pain relief provided to adults and children with an isolated limb fracture and/or dislocation. Emerg Med J 2021; 38:830-833. [PMID: 33500266 DOI: 10.1136/emermed-2020-209835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 11/19/2020] [Accepted: 12/29/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute pain is a common reason for emergency department (ED) attendance. Royal College of Emergency Medicine (RCEM) pain management audits have shown national variation and room for improvement. Previous evidence suggests that children receive less satisfactory pain management than adults. METHODS Prescription of analgesia in emergency medicine is a cross-sectional observational study of consecutive patients presenting to 12 National Health Service EDs with an isolated long bone fracture and/or dislocation, and was carried out between 2015 and 2017. Using the recommendations in the RCEM Best Practice Guidelines, pain management in ED was assessed for differences of age (adults vs children) and hospital type (children's vs all patients). RESULTS From the total 8346 patients, 38% were children (median age 8 years). There was better adherence to the RCEM guidance for children than adults (24% (766/3196) vs 11% (579/5123)) for the combined outcome of timely assessment, pain score and appropriate analgesia. In addition, children were significantly more likely than adults to receive analgesia appropriate to the pain score (of those with a recorded pain score 67% (1168/1744) vs 52% (1238/2361)). Children's hospitals performed much better across all reported outcomes compared with general hospitals. CONCLUSIONS In contrast to previous studies, children with a limb fracture/dislocation are more likely than adults to have a pain score documented and to receive appropriate analgesia. Unexpectedly, children's EDs performed better than general EDs in relation to timely and appropriate analgesia but the reasons for this are not apparent from the present study.
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Affiliation(s)
- Sarah Wilson
- Emergency Department, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Jane Quinlan
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Sally Beer
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Melanie Darwent
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Jack R Dainty
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | | | - Liza Keating
- Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
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Pediatric Preparedness of the Emergency Departments. Pediatr Emerg Care 2020; 36:602-605. [PMID: 33086361 DOI: 10.1097/pec.0000000000002257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Emergency departments (EDs) varied in their preparedness to provide pediatric emergency care, with mortality rates being higher when EDs were unprepared. Guidelines are available to aid EDs in their preparedness. We aimed to determine the preparedness of EDs in our healthcare cluster using the guidelines from the Royal College of Pediatrics and Child Health (RCPCH) and International Federation for Emergency Medicine (IFEM) as references for audit. METHODS This was a cross-sectional study involving a pediatric ED and 3 general EDs within a healthcare cluster. A survey was completed by a pediatric representative at each ED who assessed his/her own ED's effort against each recommended standard with reference to calendar year of 2018. The availability of pediatric equipment, supplies, and medications was checked against the items recommended list by the IFEM. RESULTS The response rate was 100%. The proportion of agreement with reference standards was lower for general EDs (RCPCH: 11.4%-70.0% and IFEM: 39.6%-84.0%) than pediatric ED (RCPCH: 85.7% and IFEM: 91.7%). Unmet standards were predominantly in the categories of management of pediatric patients with complex medical needs, management of pediatric death, adolescents, mental health and substance misuse, protection and safeguarding of pediatric patients, as well as advanced training and research. The proportion of available equipment, supplies, and medications was also lower for general EDs (77.2%-82.0%) than pediatric ED (89.4%). CONCLUSIONS The standards of pediatric emergency care were met to different extents in the healthcare cluster. Using available references, EDs should identify lapses unique to their own settings to improve the delivery of pediatric emergency care.
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Fowler M, Ali S, Gouin S, Drendel AL, Poonai N, Yaskina M, Sivakumar M, Jun E, Dong K. Knowledge, attitudes and practices of Canadian pediatric emergency physicians regarding short-term opioid use: a descriptive, cross-sectional survey. CMAJ Open 2020; 8:E148-E155. [PMID: 32184278 PMCID: PMC7082107 DOI: 10.9778/cmajo.20190101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the midst of the current opioid crisis, physicians are caught between balancing children's optimal pain management and the risks of opioid therapy. This study describes pediatric emergency physicians' practice patterns for prescribing, knowledge and attitudes regarding, and perceived barriers to and facilitators of short-term use of opioids. METHODS We created a survey tool using published methodology guidelines and distributed it from October to December 2017 to all physicians in the Pediatric Emergency Research Canada database using Dillman's tailored design method for mixed-mode surveys. We performed bivariable binomial logistic regressions to ascertain the effects of clinically significant variables (e.g., training, age, sex, degree of worry regarding severe adverse events) on use of opioids as a first-line treatment for moderate pain in the emergency department, and prescription of opioids for moderate or severe pain for at-home use in children. RESULTS Of the 224 physicians in the database, 136 (60.7%) completed the survey (60/111 [54.1%] women; median age 44 yr). Of the 136, 74 (54.4%) had subspecialty training. Intranasally administered fentanyl was the most commonly selected opioid for first-line treatment of moderate (47 respondents [34.6%]) and severe (82 [60.3%]) pain due to musculoskeletal injury. On a scale of 0 (not worried) to 100 (extremely worried), physicians' median score for worry regarding physical dependence was 6.0 (25th percentile 0.0, 75th percentile 16.0), for worry regarding addiction 10.0 (25th percentile 2.0, 75th percentile 20.0) and for worry regarding diversion of opioids 24.5 (25th percentile 14.0, 75th percentile 52.0). On a scale of 0 (not at all) to 100 (extremely), the median score for influence of the opioid crisis on willingness to prescribe opioids was 22.0 (25th percentile 8.0, 75th percentile 49.0). The top 3 reported barriers to prescribing opioids were parental reluctance (57 [41.9%]), lack of clear guidelines for pediatric opioid use (35 [25.7%]) and concern about adverse effects (33 [24.3%]). Binomial logistic regression did not identify any statistically significant variables affecting use of opioids in the emergency department or prescribed for use at home. INTERPRETATION Emergency department physicians appeared minimally concerned about physical dependence, addiction risk and the current opioid crisis when prescribing opioids to children. Evidence-based development of guidelines and protocols for use of opioids in children may improve physicians' ability to manage pain in children responsibly and adequately.
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Affiliation(s)
- Megan Fowler
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Samina Ali
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta.
| | - Serge Gouin
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Amy L Drendel
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Naveen Poonai
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Maryna Yaskina
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Mithra Sivakumar
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Esther Jun
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
| | - Kathryn Dong
- Department of Pediatrics (Fowler, Ali, Sivakumar, Jun) and Women and Children's Health Research Institute (Ali, Yaskina), University of Alberta, Edmonton, Alta.; Department of Pediatric Emergency Medicine (Gouin), Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Section of Emergency Medicine (Drendel), Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisc.; Division of Emergency Medicine (Poonai), London Health Sciences Centre, Western University, London, Ont.; Department of Emergency Medicine (Dong), University of Alberta, Edmonton, Alta
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Evaluation of Hydrocodone/Acetaminophen for Pediatric Laceration Repair: A Randomized Trial. Plast Reconstr Surg 2019; 145:126e-134e. [PMID: 31881621 DOI: 10.1097/prs.0000000000006383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laceration repair is a common procedure, and causes pain and distress in children. The purpose of this study was to measure the effect of hydrocodone/acetaminophen elixir in reducing both pain and anxiety in children undergoing sutured laceration repair in the emergency department. METHODS The authors conducted a randomized, double-blinded, placebo-controlled trial in children aged 2 to 17 years, stratified by age younger than 8 years, with topical lidocaine-treated lacerations requiring sutured repair in the emergency department. The primary outcome was pain score at 5 minutes of laceration repair. Secondary outcomes included progression to procedural sedation and anxiety scores in older children. RESULTS Eighty-five children were randomized, 43 to the hydrocodone/acetaminophen group and 42 to the placebo group. Median 5-minute pain scores in children aged 2 to 7 years were significantly lower in the medication group (5.0; interquartile range, 4.0 to 6.50) compared with the placebo group (7.0; interquartile range, 5.25 to 10.0; p = 0.01). Three patients (12 percent) in the placebo group proceeded to procedural sedation. For children aged 8 to 17 years, there was no significant difference in pain scores between the treatment (0.5; interquartile range, 0.0 to 0.1; p = 0.81) and placebo groups (0.1; interquartile range, 0.01 to 0.4) or in anxiety scores using the State-Trait Anxiety Inventory for Children. CONCLUSION Adjuvant oral hydrocodone/acetaminophen is more effective than placebo in reducing pain in children younger than 8 years undergoing topical lidocaine-treated laceration repair, but it does not decrease pain or anxiety in older children. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Thomas J, Rosello O, Oborocianu I, Solla F, Clement JL, Rampal V. Can Gartland II and III supracondylar humerus fractures be treated using Blount's method in the emergency room? Orthop Traumatol Surg Res 2018; 104:1079-1081. [PMID: 30219552 DOI: 10.1016/j.otsr.2018.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/05/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Studies have established that Blount's method is reliable for treating extension supracondylar fractures (SCFs) in paediatric patients. Reduction in the emergency room (ER) under procedural sedation followed by orthopaedic treatment is increasingly used for many fracture types. The primary objective of this study was to determine whether SCF reduction in the ER was feasible, by determining the failure rate. The secondary objective was to identify causes of failure with the goal of improving patient selection to reduction in the ER. HYPOTHESIS Gartland II and III SCFs (Lagrange-Rigault grades 2-4) can be treated in the emergency room under fluoroscopic guidance and with procedural sedation. MATERIAL AND METHODS A retrospective study was conducted in 128 paediatric patients who underwent ER reduction of an SCF in 2014-2015. Mean age was 5.6 years. Reduction was performed either by an orthopaedic surgery resident or by a specially trained emergency physician. RESULTS Of the 128 SCFs, 101 (79%) were Gartland II and 27 Gartland III. In the Lagrange-Rigault classification, 55 (43%) fractures were grade 2, 59 (46%) were grade 3, and 14 (11%) were grade 4. The arm was immobilised using the cuff-and-collar method described by Blount for 4 weeks. All 128 fractures healed without delay. Blount's method alone was effective in 112 (87.5%) patients. Of the 16 other patients, 15 (Lagrange-Rigault 3, n=14; and 4, n=1) had an unstable fracture after ER reduction and were managed by reduction and internal fixation in the operating room. The remaining patient (0.5%) experienced secondary displacement requiring revision surgery in the operating room. CONCLUSION SCFs grades 2 to 4 in the Lagrange-Rigault classification (Gartland II and III) can be treated in the ER by specially trained physicians. Lagrange-Rigault grade 3/Gartland III SCFs are more likely to require subsequent internal fixation but do not contraindicate reduction in the ER. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Jonathan Thomas
- Service d'orthopédie pédiatrique, CHU de Lenval, hôpitaux pédiatriques de Nice, 57, avenue de la Californie, 06000 Nice, France
| | - Olivier Rosello
- Service d'orthopédie pédiatrique, CHU de Lenval, hôpitaux pédiatriques de Nice, 57, avenue de la Californie, 06000 Nice, France
| | - Ioana Oborocianu
- Service d'orthopédie pédiatrique, CHU de Lenval, hôpitaux pédiatriques de Nice, 57, avenue de la Californie, 06000 Nice, France
| | - Federico Solla
- Service d'orthopédie pédiatrique, CHU de Lenval, hôpitaux pédiatriques de Nice, 57, avenue de la Californie, 06000 Nice, France
| | - Jean-Luc Clement
- Service d'orthopédie pédiatrique, CHU de Lenval, hôpitaux pédiatriques de Nice, 57, avenue de la Californie, 06000 Nice, France
| | - Virginie Rampal
- Service d'orthopédie pédiatrique, CHU de Lenval, hôpitaux pédiatriques de Nice, 57, avenue de la Californie, 06000 Nice, France.
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A Scoping Review of Emergency Department Discharge Instructions for Children and Adolescents With Mental Disorders. Pediatr Emerg Care 2018; 34:711-722. [PMID: 29112107 DOI: 10.1097/pec.0000000000001037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although most young people under the age of 25 years with mental health presentations to the emergency department (ED) are discharged home, several studies suggest discharge instructions are inadequate. We conducted a scoping review to characterize and map the literature, identify research gaps, and prioritize targeted areas for future reviews for ED discharge instructions for young people with mental disorders. METHODS Our review was conducted in an iterative approach with 6 stages including identifying the research question, identifying relevant studies, study selection, data extraction, collaring and summarizing, and stakeholder engagement. We characterized the available information on discharge instruction interventions using the Behavior Change Wheel. RESULTS Of the 805 potential publications screened, 25 were included for extraction. Nine of the 25 articles focused on suicide or self-harm, 6 were on mental health in general or mixed groups, and 9 focused on alcohol, tobacco, or substance use in general. Five studies included younger children (ie, less than 12 years) but ages ranged significantly among studies. Education and persuasion were intervention functions most commonly reported in publications (n = 13 and n = 12, respectively). From the policy categories, recommendations regarding service provision were most frequently made from four publications. Descriptions of theory were limited in publications. CONCLUSIONS The available literature regarding discharge instructions in the ED for youth with mental disorders is focused on certain content areas (eg, self injurious behaviors, substance use) with more work required in chronic mental disorders that make up a significant proportion of ED visits. Research that extends beyond education and with theoretical underpinnings to explain how and why various interventions work would be useful for clinicians, policy-makers, and other researchers.
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Schoolman-Anderson K, Lane RD, Schunk JE, Mecham N, Thomas R, Adelgais K. Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation. Am J Emerg Med 2018; 36:1603-1607. [DOI: 10.1016/j.ajem.2018.01.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
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Trottier ED, Ali S, Thull-Freedman J, Meckler G, Stang A, Porter R, Blanchet M, Dubrovsky AS, Kam A, Jain R, Principi T, Joubert G, Le May S, Chan M, Neto G, Lagacé M, Gravel J. Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative. Paediatr Child Health 2018; 23:e85-e94. [PMID: 30046273 PMCID: PMC6054215 DOI: 10.1093/pch/pxx186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period. METHODS A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described. RESULTS All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites. CONCLUSION While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.
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Affiliation(s)
| | - Samina Ali
- Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta
| | | | - Garth Meckler
- BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Antonia Stang
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta
| | - Robert Porter
- Janeway Children’s Hospital, Memorial University, St-Johns, Newfoundl
| | | | | | - April Kam
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario
| | | | - Tania Principi
- Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | | | - Sylvie Le May
- CHU Sainte-Justine, Université de Montréal, Montréal, Québec
| | - Melissa Chan
- Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta
| | - Gina Neto
- CHEO, University of Ottawa, Ottawa, Ontario
| | - Maryse Lagacé
- CHU Sainte-Justine, Université de Montréal, Montréal, Québec
| | - Jocelyn Gravel
- CHU Sainte-Justine, Université de Montréal, Montréal, Québec
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Whitfill T, Auerbach M, Scherzer DJ, Shi J, Xiang H, Stanley RM. Emergency Care for Children in the United States: Epidemiology and Trends Over Time. J Emerg Med 2018; 55:423-434. [PMID: 29793812 DOI: 10.1016/j.jemermed.2018.04.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/09/2018] [Accepted: 04/10/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children. OBJECTIVES To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes. METHODS We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics. RESULTS From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%). CONCLUSIONS Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.
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Affiliation(s)
- Travis Whitfill
- Department of Pediatrics, Section of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Marc Auerbach
- Department of Pediatrics, Section of Emergency Medicine, Yale University, New Haven, Connecticut; Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Daniel J Scherzer
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio
| | - Rachel M Stanley
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Abstract
OBJECTIVE The aim of this study was to identify the 5 most essential discharge instruction content elements that should be communicated to all caregivers of children who present to the emergency department (ED) with asthma, vomiting/diarrhea, abdominal pain, fever, minor head injury, or bronchiolitis. METHODS A discharge information content list was developed for each illness presentation following a review of the literature. Using a modified Delphi technique, 6 lists were distributed to a panel of experts from EDs across Canada using a secure online survey tool with the goal of achieving the 5 most essential discharge instruction elements. RESULTS A total of 37 emergency clinicians completed all 4 rounds of the Delphi. Consensus for the final 30 content items ranged from 51.4% to 100%. Items pertaining to diarrhea/vomiting, abdominal pain, fever, and bronchiolitis obtained relatively high levels of consensus for all top 5 items. The majority of items (n = 19 [63.3%]) that reached consensus across the illness presentations were associated with instructions intended to educate caregivers on instances when they should return to the ED department. CONCLUSIONS Findings from this study provide a better understanding of what should be communicated to caregivers of children who present to the ED with a number of different illness presentations. Results from this study suggest that health care providers agree on the importance of providing information to caregivers regarding when to return to the ED with their child. Reaching consensus among all experts in this study provides insight into the difficulty of standardizing discharge communication in the absence of widely accepted guidelines.
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Abstract
Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.
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Capua T, Kama ZB, Rimon A. The influence of an accredited pediatric emergency medicine program on the management of pediatric pain and anxiety. Isr J Health Policy Res 2018; 7:17. [PMID: 29562929 PMCID: PMC5861707 DOI: 10.1186/s13584-018-0211-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/09/2018] [Indexed: 11/14/2022] Open
Abstract
Background The emergency department (ED) setting is an environment where children may experience intense physical pain and emotional stress. This study sought to determine the availability of pain and anxiety management practices in all Israeli emergency departments which accept children, specifically looking for differences between accredited pediatric emergency medicine departments and others. Methods A cross-sectional survey of all Israeli emergency departments that accept children was performed. One person at each institution was approached to complete the survey. Data were collected between May and June 2016 using an electronic survey tool. Results Responses were collected from 21 of 22 hospitals (95% response rate). Commonly available in all types of emergency departments were nurse ordered analgesia, medical clowns (in 95% of the hospitals), topical analgesia and oral sucrose solution. The accredited pediatric emergency medicine departments showed a tendency for more frequent use of all pharmacologic methods for pain and anxiety relief, specifically oxycodone and ketamine. Conclusions Overall, Israeli emergency departments have similar access to pharmacologic and non-pharmacologic pain and anxiety management strategies in children, but gaps still exist, especially where not all attending physicians are pediatric emergency medicine trained. We suggest that certified pediatric emergency medicine physicians should advise all emergency departments that accept children to promote the use of the various methods of pain and anxiety reduction.
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Affiliation(s)
- Tali Capua
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel.
| | - Zohar Bar Kama
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel
| | - Ayelet Rimon
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel
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Drendel AL, Ali S. Ten Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Le May S, Ali S, Plint AC, Mâsse B, Neto G, Auclair MC, Drendel AL, Ballard A, Khadra C, Villeneuve E, Parent S, McGrath PJ, Leclair G, Gouin S. Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT. Pediatrics 2017; 140:peds.2017-0186. [PMID: 29021235 DOI: 10.1542/peds.2017-0186] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Musculoskeletal injuries (MSK-Is) are a common and painful condition among children that remains poorly treated in the emergency department (ED). We aimed to test the efficacy of a combination of an anti-inflammatory drug with an opioid for pain management of MSK-I in children presenting to the ED. METHODS In this randomized, double-blinded, placebo-controlled trial, we enrolled children between 6 and 17 years presenting to the ED with an MSK-I and a pain score >29 mm on the visual analog scale (VAS). Participants were randomly assigned to oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo of morphine. Primary outcome was children with VAS pain score <30 mm at 60 minutes postmedication administration. RESULTS A total of 501 participants were enrolled and 456 were included in primary analyses (morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9% (morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine + ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to -14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P < .001) and in the morphine group (P < .001) experienced more side effects than those in the ibuprofen group. No serious adverse event was reported. CONCLUSIONS Combination of morphine with ibuprofen did not provide adequate pain relief for children with MSK-I in the ED. None of the study medication provided an optimal pain management because most of children did not reach a mild pain score (NCT02064894).
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Affiliation(s)
- Sylvie Le May
- Faculties of Nursing and .,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Samina Ali
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Departments of Pediatrics and.,Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Benoit Mâsse
- CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Gina Neto
- Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Amy L Drendel
- Departments of Pediatrics and.,Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ariane Ballard
- Faculties of Nursing and.,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
| | - Christelle Khadra
- Faculties of Nursing and.,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
| | | | | | - Patrick J McGrath
- IWK Health Centre, Nova Scotia Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Serge Gouin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada; and
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Comparing Practice Patterns Between Pediatric and General Emergency Medicine Physicians: A Scoping Review. Pediatr Emerg Care 2017; 33:278-286. [PMID: 28355170 DOI: 10.1097/pec.0000000000000557] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine-trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (≤21 years of age) by PEM-trained physicians to that provided by GEDPs. METHODS The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data. RESULTS Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis. CONCLUSIONS This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.
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Curran JA, Taylor A, Chorney J, Porter S, Murphy A, MacPhee S, Bishop A, Haworth R. Development and feasibility testing of the Pediatric Emergency Discharge Interaction Coding Scheme. Health Expect 2017; 20:734-741. [PMID: 28078763 PMCID: PMC5513006 DOI: 10.1111/hex.12512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2016] [Indexed: 11/28/2022] Open
Abstract
Background Discharge communication is an important aspect of high‐quality emergency care. This study addresses the gap in knowledge on how to describe discharge communication in a paediatric emergency department (ED). Objective The objective of this feasibility study was to develop and test a coding scheme to characterize discharge communication between health‐care providers (HCPs) and caregivers who visit the ED with their children. Design The Pediatric Emergency Discharge Interaction Coding Scheme (PEDICS) and coding manual were developed following a review of the literature and an iterative refinement process involving HCP observations, inter‐rater assessments and team consensus. Setting and participants The coding scheme was pilot‐tested through observations of HCPs across a range of shifts in one urban paediatric ED. Main variables studied Overall, 329 patient observations were carried out across 50 observational shifts. Inter‐rater reliability was evaluated in 16% of the observations. The final version of the PEDICS contained 41 communication elements. Results Kappa scores were greater than .60 for the majority of communication elements. The most frequently observed communication elements were under the Introduction node and the least frequently observed were under the Social Concerns node. HCPs initiated the majority of the communication. Conclusion Pediatric Emergency Discharge Interaction Coding Scheme addresses an important gap in the discharge communication literature. The tool is useful for mapping patterns of discharge communication between HCPs and caregivers. Results from our pilot test identified deficits in specific areas of discharge communication that could impact adherence to discharge instructions. The PEDICS would benefit from further testing with a different sample of HCPs.
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Affiliation(s)
- Janet A Curran
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
| | | | - Jill Chorney
- Department of Anesthesia, Dalhousie University, Halifax, NS, Canada
| | - Stephen Porter
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Murphy
- Department of Psychiatry & College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Shannon MacPhee
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
| | - Andrea Bishop
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Rebecca Haworth
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Gornitzky AL, Milby AH, Gunderson MA, Chang B, Carrigan RB. Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center. Orthopedics 2016; 39:e333-9. [PMID: 26913765 DOI: 10.3928/01477447-20160222-06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/01/2015] [Indexed: 02/03/2023]
Abstract
Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.
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Cummings JAF. Pediatric procedural pain: how far have we come? An ethnographic account. Pain Manag Nurs 2016; 16:233-41. [PMID: 26025793 DOI: 10.1016/j.pmn.2014.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 06/25/2014] [Accepted: 06/30/2014] [Indexed: 11/28/2022]
Abstract
The aim of this ethnographic study was to explore the pediatric procedural pain management practice of health care providers in a non-pediatric emergency department. Data were collected for 5 months and included more than 100 hours of observation. Six key informants were interviewed, and 44 pediatric procedural interactions with 27 health care providers during the treatment of children aged 2 to 8 years undergoing procedures were observed. Other information gathered included documents from the institution, and pain-related information from the patient's medical record. Two major themes with categories are discussed, the treatment of pain, and procedural pain. The findings of this study provide insight into the everyday practice of emergency department health care providers for pediatric pain in a non-pediatric setting, and identify practice issues that may adversely affect the management of pediatric procedural pain, notably the nonuse of pharmacologic techniques for simple needle procedures and the common use of physical restraint during painful procedures.
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Affiliation(s)
- Jo Ann F Cummings
- Department of Nursing, Georgian Court University, Lakewood, New Jersey.
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Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries. Pediatr Emerg Care 2016; 32:830-834. [PMID: 25834964 DOI: 10.1097/pec.0000000000000373] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department. METHODS Forty-four healthy children aged 7 to 18 years were included. The patients were randomly divided into 2 groups. Group 1 (24 patients) received etomidate and fentanyl, and group 2 (20 patients) received ketamine intravenously. The Ramsay Sedation Scale and American Pediatric Association discharge criteria were used to evaluate the patients. RESULTS There were 70 fractured bones and 3 joint dislocations. Except in 1 case (2.3%), all of the injuries were reducted successfully. The mean amount of drugs used to provide adequate sedation and analgesia were 0.25 mg/kg of etomidate and 1.30 μg/kg of fentanyl in group 1 and 1.25 mg/kg of ketamine in group 2. Fourteen patients (31.8%) reported adverse effects, and none required hospitalization. There was no difference between the groups in the recovery times, occurrence of adverse effects, and postsedation observation durations (P > 0.05). The mean (SD) induction time for the patients in group 1 was 4.3 (1.0) minutes, whereas it was 2.2 (1.6) minutes in group 2 (P < 0.001). CONCLUSIONS Etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures. Ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy.
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Radial Head Subluxation: Factors Associated with Its Recurrence and Radiographic Evaluation in a Tertiary Pediatric Emergency Department. J Emerg Med 2016; 51:621-627. [DOI: 10.1016/j.jemermed.2016.07.081] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/13/2016] [Accepted: 07/19/2016] [Indexed: 11/22/2022]
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Huang IA, Tuan PL, Jaing TH, Wu CT, Chao M, Wang HH, Hsia SH, Hsiao HJ, Chang YC. Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department. Pediatr Neonatol 2016; 57:371-377. [PMID: 27178642 DOI: 10.1016/j.pedneo.2015.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/31/2015] [Accepted: 10/30/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED). METHODS The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians. RESULTS An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487-6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2-6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians. CONCLUSION Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation.
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Affiliation(s)
- I-Anne Huang
- Department of Pediatrics, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Pao-Lan Tuan
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tang-Her Jaing
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chang-Teng Wu
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Minston Chao
- Department and Graduate Institute of Health Care Management, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Hsuan Wang
- Department and Graduate Institute of Health Care Management, Chang Gung University, Taoyuan, Taiwan.
| | - Shao-Hsuan Hsia
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Hsiang-Ju Hsiao
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Ching Chang
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Guttmann A, Weinstein M, Austin PC, Bhamani A, Anderson G. Variability in the emergency department use of discretionary radiographs in children with common respiratory conditions: the mixed effect of access to pediatrician care. CAN J EMERG MED 2016; 15:8-17. [PMID: 23283118 DOI: 10.2310/8000.2012.120649] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The objective of this study was to investigate whether different staffing models are associated with variation in radiograph use for children seen for bronchiolitis, croup, and asthma and discharged home from emergency departments (EDs) in Ontario. METHODS We surveyed all Ontario EDs regarding physician staffing models and use of clinical protocols. We used a population-based ED database to determine radiograph rates and patient characteristics. Regression techniques that controlled for patient factors and clustering within EDs were applied. RESULTS From April 2004 to March 2006, 5,186, 10,408, and 35,150 children were discharged home from an ED with bronchiolitis, croup, and asthma, respectively. Radiograph rates were 42.7% for bronchiolitis, 10.1% for croup, and 25.9% for asthma. Over 50% of children were treated in EDs with nonpediatric front-line care but with consultant pediatricians available. Compared to children in these settings, those seen in EDs with front-line pediatric staff were less likely to have radiographs for all three conditions (adjusted odds ratios [ORs] 0.47 [95% CI 0.24-0.95], 0.47 [95% CI 0.27-0.82], 0.13 [95% CI 0.02-0.66] for bronchiolitis, croup, and asthma, respectively). Children in community hospitals with pediatricians were significantly more likely to have a radiograph if seen by a consultant pediatrician (OR 1.40, 95% CI 1.20-1.63 [bronchiolitis]; OR 2.76, 95% CI 2.16-3.53 [croup]; and OR 1.97, 95% CI 1.64-2.36 [asthma]). We found no association between clinical protocol use and radiograph rates. CONCLUSIONS High rates of discretionary radiograph use exist for common respiratory problems of children seen across ED settings. Quality improvement efforts should be focused in this area, and radiograph use in EDs staffed by front-line pediatrics-trained staff could serve as an initial benchmark target for other institutions.
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Affiliation(s)
- Astrid Guttmann
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada.
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Pediatric musculoskeletal pain in the emergency department: a medical record review of practice variation. CAN J EMERG MED 2016; 16:449-57. [PMID: 25358276 DOI: 10.1017/s1481803500003468] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children's MSK pain, both in the ED and postdischarge. METHODS We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care. RESULTS A total of 543 medical records were reviewed (n = 468 pediatric ED, n = 75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving analgesics in the ED, 59% (126 of 214) received ibuprofen. Pain scores were recorded for 6% of patients. At discharge, ibuprofen was recommended to 47% and codeine-containing compounds to 21% of children. The average time from triage to first analgesic in the ED was 121 ± 84 minutes. CONCLUSIONS Documentation of the assessment and management of children's pain in the ED is poor, and pain management appears to be suboptimal. When provided, ibuprofen is the most common analgesic used for children with MSK pain. Pediatric patients with MSK pain do not receive timely medication, and interventions must be developed to improve the "door to analgesia" time for children in pain.
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Ali S, Chambers A, Johnson DW, Newton AS, Vandermeer B, Williamson J, Curtis SJ. Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians. CAN J EMERG MED 2016; 16:352-60. [PMID: 25227643 DOI: 10.2310/8000.2013.131261] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To describe pediatric emergency medicine (PEM) physicians' reported pain management practices across Canada and explore factors that facilitate or hinder pain management. METHODS This study was a prospective survey of Canadian pediatric emergency physicians. The Pediatric Emergency Research Canada physician database was used to identify participants, and a modified Dillman's Total Design Survey Method was used for recruitment. RESULTS The survey response rate was 68% (139 of 206). Most physicians were 31 to 50 years old (82%) with PEM training (56%) and had been in practice for less than 10 years (55%). Almost all pain screening in emergency departments (EDs) occurred at triage (97%). Twenty-four percent of physicians noted institutionally mandated pain score documentation. Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain (88% and 83%, respectively). Over half of urinary catheterizations (60%) and intravenous (53%) starts were performed without any analgesia. The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively. Training background and gender of physicians affected the likelihood of using nonpharmacologic interventions. Physicians noted time restraints to be the greatest barrier to optimal pain management (55%) and desired improved access to pain medications (32%), better policies and procedures (30%), and further education (25%). CONCLUSIONS When analgesia was reported as provided, ibuprofen and acetaminophen were most commonly used. Both procedural and presenting pain remained suboptimally managed. There is a substantial evidence practice gap in children's ED pain management, highlighting the need for further knowledge translation strategies and policies to support optimal treatment.
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Poonai N, Kilgar J, Mehrotra S. Analgesia for fracture pain in children: methodological issues surrounding clinical trials and effectiveness of therapy. Pain Manag 2015; 5:435-45. [DOI: 10.2217/pmt.15.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fractures in childhood are common painful conditions. Suboptimal analgesia has been reported in the emergency department and following discharge. Recently, concern about the safety of narcotics such as codeine has sparked a renewed interest in opioids such as morphine for pediatric fracture pain. Consequently, opioids are being increasingly used in the clinical setting. Despite this, there is ample evidence that clinicians are more willing to offer opioids to adults than children. The existence of limited evidence supporting their use in children is likely a major contributing factor. A closer look at the limitations of designing high-quality analgesic trials in children with fractures is needed to enable investigators to anticipate problems and clinicians to make evidence-based choices.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Paediatric Emergency Department, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jennifer Kilgar
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Shruti Mehrotra
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
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Abstract
OBJECTIVES We explored caregiver perspectives on their children's pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children's pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction. METHODS This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009-2011. RESULTS Most caregivers were female (n=77, 79%) and were the child's mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70-80) and mean score at discharge was 39 mm (95% CI: 32-46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child's pain at ED discharge as severe were less likely to be satisfied than those who rated their child's pain as mild or moderate (p=0.034). CONCLUSIONS Despite continued pain upon discharge, most caregivers report being satisfied with their child's pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.
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Trottier ED, Ali S, Le May S, Gravel J. Treating and Reducing Anxiety and Pain in the Paediatric Emergency Department: The TRAPPED survey. Paediatr Child Health 2015; 20:239-44. [PMID: 26175559 PMCID: PMC4472050 DOI: 10.1093/pch/20.5.239] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Management of children's pain and anxiety in the emergency department is likely suboptimal. OBJECTIVE To determine the availability of currently used strategies in Canadian paediatric emergency departments. METHODS A cross-sectional survey involving all centres of the Pediatric Emergency Research Canada group was performed. The primary outcome was the availability of specific procedures for pain and anxiety management for children in the emergency department. One person per centre was identified to complete the survey. Data were collected from October 2013 to January 2014 using an electronic survey tool. RESULTS All 15 Pediatric Emergency Research Canada centres agreed to participate. The verbal numerical scale was widely used (80%) to assess pain. One-half of respondents (53%) had access to a child life specialist. The following techniques were available for minor procedures: television as a distraction tool (87% of respondents), topical anesthetic before intravenous needle insertion (73%) and positioning of the child on parent's lap (60%); most remaining centres reported that these could be easily implemented. Intravenous morphine was available at every centre. Intranasal fentanyl was available (60%) or considered to be easy to implement (33%). Few centres reported availability of clinical guidelines regarding pain for doctors (27%) and nurses (40%); all respondents considered them to be easy to implement. CONCLUSIONS There was wide variation in paediatric pain and anxiety management strategies among tertiary care Canadian emergency departments. Several pain-reduction procedures (distraction, positioning on parent's lap, topical anesthetic, intranasal administration) were identified that could be easily implemented to address the gap.
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Affiliation(s)
- Evelyne D Trottier
- Division of Pediatric Emergency Medicine, Centre hospitalier universitaire Sainte-Justine, University of Montreal, Montreal, Quebec
| | - Samina Ali
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Sylvie Le May
- Centre hospitalier universitaire Sainte-Justine Research Centre
- Faculty of Nursing, University of Montreal, Montreal, Quebec
| | - Jocelyn Gravel
- Division of Pediatric Emergency Medicine, Centre hospitalier universitaire Sainte-Justine, University of Montreal, Montreal, Quebec
- Centre hospitalier universitaire Sainte-Justine Research Centre
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Abstract
UNLABELLED Damage that arises as a result of injuries is one of the most common causes of children presenting to hospital emergency departments. OBJECTIVES The aim of the study was to assess the implementation of recommendations for prehospital pain management in injured children provided by various health care centers. METHODS A total of 7146 children aged 0 to 18 years because of injury were admitted to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz within the period of 12 months. From this group, 1493 children received prehospital emergency care from various health care centers. RESULTS Health care centers provided prehospital aid to 21% of all children with injuries. Boys (60.3%) and children older than 5 years (80%) predominated among pediatric trauma cases. Prehospital emergency aid was most frequently administered to children by emergency medical services personnel (42.7%) and a primary health care physician (28.1%). Injuries of head (42.1%), neck (1.1%), chest (1.7%), abdomen (2.5%), upper (32.2%), and lower (19.9%) limbs as well as burns (5.3%) were diagnosed in pediatric patients. Indications for prehospital analgesia were found in 489 of 1493 patients (32.7%). Analgesia was administered to 159 children (32%), pain medication was not given to 223 children (46%), and in 107 cases (22%), there was a lack of information on that subject. CONCLUSIONS Despite the training of medical staff, provision of analgesia for children with burns and traumatic injuries of the osteoarticular system is inadequate.
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Abstract
OBJECTIVES Dedicated pediatric emergency departments (ED) staffed by pediatric emergency medicine physicians are becoming more common. We compared processes of care and outcomes before and after opening a dedicated pediatric ED. METHODS A before and after trial design was used to estimate whether there were any changes in ordering of laboratory tests, radiographic imaging, admission rates, ED length of stay (LOS), rates of left without being seen (LWBS) and patient satisfaction scores after opening a dedicated pediatric ED staffed by pediatric emergency medicine physicians. RESULTS There were 34,961 pediatric patients; 16,311 (47%) presented before and 18,650 (53%) after opening the pediatric ED. Overall radiologic imaging decreased (42.5% vs. 39.3%; difference, 3.2%; 95% confidence interval [95% CI], 2.1%-4.2%) as did computed tomography (8.9% vs. 7.6%; difference, 1.2%; 95% CI, 0.7%-1.8%) but not magnetic resonance imaging. Laboratory testing decreased from 33.1% to 30.1% (difference, 3%; 95% CI, 2.1%-4.0%) of patients. Mean [SD] ED LOS (3.1 [2.5] vs. 2.8 [2.2] hours; difference, 0.36; 95% CI, 0.31-0.41) as well as the rate of LWBS (1.0% vs. 0.6%; difference, 0.4%; 95% CI, 0.2%-0.5%) also decreased. Admission rates (9.4% vs. 9.4%) and unscheduled return visits within 72 hours (3.2% vs. 3.5%) were unchanged. Mean (SD) monthly satisfaction scores increased from 81.3 (2.2) to 86.3 (2.2) (difference, 5; 95% CI, 3%-7%). CONCLUSIONS Opening of a pediatric ED with pediatric emergency physicians was associated with decreases in ED LOS, rates of LWBS, general radiographic, and computed tomography imaging as well as laboratory testing, and increases in patient satisfaction scores. The clinical significance of these changes is unclear.
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Management of Fever in postpneumococcal vaccine era: comparison of management practices by pediatric emergency medicine and general emergency medicine physicians. Emerg Med Int 2014; 2014:702053. [PMID: 24982807 PMCID: PMC4058597 DOI: 10.1155/2014/702053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 05/17/2014] [Indexed: 12/04/2022] Open
Abstract
Background. The primary objective of this study was to compare management practices of general emergency physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) for well-appearing young febrile children.
Methods. We retrospectively reviewed the charts of well-appearing febrile children aged 3–36 months who presented to a large urban children's hospital (PED), staffed by PEMPs, or a large urban general emergency department (GED), staffed by GEMPs. Demographics, immunization status, laboratory tests ordered, antibiotic usage, and final diagnoses were collected. Results. 224 cases from the PED and 237 cases from the GED were reviewed. Children seen by PEMPs had significantly less CXRs (23 (10.3%) versus 51 (21.5%), P = 0.001) and more rapid viral testing done (102 (45%) versus 40 (17%), P < 0.0001). A diagnosis of a viral infection was more common in the PED, while a diagnosis of bacterial infection (including otitis media) was more common in the GED. More GED patients were prescribed antibiotics (41% versus 27%, P = 0.002), while more PED patients were treated with oseltamivir (6.7% versus 0.4%, P < 0.001). Conclusions. Our findings identify important differences in the care of the young, well-appearing febrile child by PEMPs and GEMPs and highlight the need for standardization of care.
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Anantha RV, Stewart TC, Rajagopalan A, Walsh J, Merritt NH. Analgesia in the management of paediatric and adolescent trauma during the resuscitative phase: the role of the pediatric trauma centre. Injury 2014; 45:845-9. [PMID: 24360669 DOI: 10.1016/j.injury.2013.10.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/23/2013] [Accepted: 10/19/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the use of analgesia in the resuscitative phase of severely injured children and adolescents. METHODS A retrospective cohort of paediatric (age<18 years), severely injured (ISS≥12) patients were identified from the London Health Sciences Centre's Trauma Registry from 2007 to 2010. Variables were compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann-Whitney U tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for age, gender, mechanism, arrival and Trauma Team Activation (TTA). RESULTS Analgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender, age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p=0.026) and having parents in the resuscitation room (17% vs. 6%, p=0.01). Analgesia patients were more injured (median ISS 22 vs. 17, p=0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03-3.93), as did TTA (OR 2.18, 95% CI: 1.01-4.73) and having parents in resuscitation room (3.56, 95% CI: 1.23-10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66% given during the primary survey. CONCLUSION Use of analgesia is important in the acute management of paediatric trauma. Direct presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of analgesia in paediatric trauma resuscitation.
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Affiliation(s)
- Ram V Anantha
- Department of Surgery, Western University, London, Ontario, Canada
| | - Tanya Charyk Stewart
- Trauma Program, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | | | - Jillian Walsh
- Department of Surgery, Western University, London, Ontario, Canada
| | - Neil H Merritt
- Department of Surgery, Western University, London, Ontario, Canada; Trauma Program, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada.
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Rapid bedside triage does not affect the delivery of pain medication for extremity pain in the pediatric emergency department. Pediatr Emerg Care 2013; 29:792-5. [PMID: 23823255 DOI: 10.1097/pec.0b013e31829838c8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rapid bedside triage (RBT), rather than traditional waiting room triage (WRT), is becoming a "best practice" in managing emergency department (ED) patient flow, yet little is known about the impact of this process on other aspects of patient care. This study was designed to compare overall adherence to an existing nurse-driven ED pain protocol after changing from a WRT to an RBT process. METHODS On November 1, 2011, the triage process at our institution changed from a traditional WRT system to an in-department RBT allowing for comparison of the 2 groups. A retrospective chart review assessing compliance with the department's pain protocol was performed on all patients presenting to the ED during October and November 2011, representing the immediate time periods before and after the implementation of the change in triage process. Patients younger than 19 years, with complaint of isolated extremity pain or injury, were included in this analysis. Compliance was defined as patients having a pain score assessed and pain medication given for scores of 4 or more within 30 minutes of arrival. RESULTS In total, 546 patients were identified for inclusion in the study; 306 received traditional WRT, and 240 received RBT. Compliance with the pain protocol was seen in 54.6% of patients receiving WRT versus 57.5% receiving RBT (P = 0.50). CONCLUSIONS Changing from a traditional WRT process to an in-department RBT process resulted in no change in the compliance with the existing pain protocol.
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Race, ethnicity, and analgesia provision at discharge among children with long-bone fractures requiring emergency care. Pediatr Emerg Care 2013; 29:492-7. [PMID: 23528513 DOI: 10.1097/pec.0b013e31828a34a8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inadequate treatment of painful conditions in children is a significant and complex problem. The objective of this study was to examine the effect of race/ethnicity on the provision of analgesic medicines at discharge in children treated emergently for a long-bone fracture. METHODS A retrospective review of all patients during a 1-year period with a long-bone fracture treated in 2 urban pediatric emergency departments was performed. RESULTS Eight hundred seventy-eight patients who met our inclusion criteria were identified. Sixty percent of patients received a prescription for an opioid-containing medicine, and 19% received a prescription for an over-the-counter analgesic medicine at emergency department discharge. Patients identified as African American, non-Hispanic, biracial, and Hispanic/Latino had significantly lower rates of opioid analgesic prescriptions when compared with other ethnic groups. White, non-Hispanic patients had lower rates of over-the-counter analgesic medicine prescriptions provided at discharge. Patients identified as white, non-Hispanic had a higher percentage of fractures that required reduction in the emergency department when compared with other ethnic groups. CONCLUSIONS Race/ethnicity is associated with different analgesic prescription patterns in children treated in the emergency department for a long-bone fracture.
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Thompson RW, Krauss B, Kim YJ, Monuteaux MC, Zerriny S, Lee LK. Extremity Fracture Pain After Emergency Department Reduction and Casting: Predictors of Pain After Discharge. Ann Emerg Med 2012; 60:269-77. [DOI: 10.1016/j.annemergmed.2012.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 12/30/2011] [Accepted: 01/24/2012] [Indexed: 11/29/2022]
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A comparison of resource utilization between emergency physicians and pediatric emergency physicians. Pediatr Emerg Care 2012; 28:869-72. [PMID: 22929133 DOI: 10.1097/pec.0b013e31826763bc] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Pediatric patients in the emergency department (ED) are typically seen either by general emergency physicians (EPs) or by pediatric emergency physicians (PEPs) who have completed either a fellowship in pediatric emergency medicine or both pediatric and emergency medicine residencies. This study evaluates admission rates, turnaround times, and test and medication utilization for EPs versus PEPs. METHODS A retrospective chart analysis was conducted at an academic tertiary care hospital with a dedicated pediatric ED. When the pediatric ED is open (from noon to midnight), it is always staffed with dedicated pediatric nurses and residents. In our ED, the only variable is the attending physician, who can either be an EP or a PEP. All visits for patients younger than 18 years who presented during the time the pediatric ED was open from July 1, 2007, to June 30, 2010, were eligible for inclusion. Only patients seen by physicians who saw more than 400 patients during this period were included. Disposition outcomes for patients who were either admitted or discharged were compared between EPs and PEPs. Complete blood count, Chem 7, urinalysis, chest radiography ordering rates, and intravenous fluid and ondansetron administration were used as surrogates for general conclusions about test utilization. RESULTS There were 13,347 patient visits eligible for inclusion, of which 8330 (62.4%) were seen by 2 PEPs, and 5017 (37.6%) were seen by 9 EPs. There was a difference in mean patient age (6.9 vs 7.1 years, P = 0.01), whereas sex (53.6% vs 53.9% male, P = 0.72), race (P = 0.13), acuity (mean Emergency Severity Index 3.35 vs 3.33, P = 0.99), and mode of arrival (10.6% vs 12.3% emergency medical services transport, P = 0.06) were not significantly different. Overall admission rates were similar (17.1% PEP vs 17.5% EP, P = 0.50), as were critical care admissions (2.9% PEP vs 2.7% EP of total admissions, P = 0.40). Turnaround times were significantly different (146.0 ± 2.5 minutes PEP vs 149.7 ± 3.2 minutes EP, P = 0.04). Ordering rates of Chem 7, urinalyses, chest radiographs, and ondansetron were lower by PEPs. CONCLUSIONS In our pediatric ED, which represents a natural experiment where the type of physician is the only variable, PEPs and EPs have similar rates of admission to floor beds and critical care. Pediatric EPs are slightly faster at throughput and order fewer tests and medication.
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Abstract
Identification of specific facilities within a community for the emergency department (ED) treatment of children is a traditional component of Emergency Medical Services for Children systems. In such models, these Emergency Departments Approved for Pediatrics are the preferred EDs to receive patients from Emergency Medical Services providers. This article examines an alternative model developed in New Jersey in which every ED in the state is required by regulation to meet the standards of a traditional Emergency Departments Approved for Pediatrics. The New Jersey model leads to more accessible care and more rapid stabilization of children regardless of their mode of delivery to the ED.
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Crocker PJ, Higginbotham E, King BT, Taylor D, Milling TJ. Comprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED. Am J Emerg Med 2011; 30:861-71. [PMID: 22030197 DOI: 10.1016/j.ajem.2011.05.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 05/25/2011] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND Historically, pain has been poorly managed in the pediatric emergency department (ED) (PED), resulting in measurable psychosocial issues both acute and delayed. OBJECTIVE The aim of the study was to measure the impact of protocolized pain management on patients with painful conditions or undergoing painful procedures in the PED. METHODS We performed an analysis before and after the implementation of the protocol, dubbed the "Comfort Zone." Validated, age-appropriate pain scales were performed. Validation (using Cronbach α, confirmatory factor analysis) was followed by comparison of responses between the pre- and posttests collected (χ(2) and Wilcoxon rank sum tests). Pain scores were collected at triage and at discharge. At triage, patients were asked to report pain levels. At discharge, they were asked to report their current pain and recall the level of pain during their stay. At triage, parents were asked to report about their perception of the child's pain. At discharge, they were asked to report about their perception of the child's current pain and recall the level of pain during the stay and during procedures, if done. RESULTS Five hundred thirty-one patients were enrolled in the preprotocol group; 47% were women with a median age of 5 years (range, 30 days-18 years). Two hundred sixty-three patients were enrolled in the protocol group; 39% were women with a median age of 6 years (range, 30 days-18 years). Patient-recalled pain scores of the ED visit in the protocol group were significantly lower than those of the preprotocol group (Wong-Baker Faces Pain Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a significant change at any point. Patient assessment of pain at ED discharge did not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P = .09). The Faces scale is not well validated for patients younger than 4, so that group had only parental assessment of pain and, consistent with the larger data set, showed no significant pain scale reduction at any point. CONCLUSION Protocolized pain management reduces patients' memory of pain during PED visits but may not affect parental memory of perceived pain or parent- and patient-reported pain at discharge.
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Affiliation(s)
- Patrick J Crocker
- Dell Children's Medical Center of Central Texas, University Medical Center at Brackenridge, Austin, TX 78752, USA
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Strout TD, Baumann MR. Reliability and validity of the Modified Preverbal, Early Verbal Pediatric Pain Scale in emergency department pediatric patients. Int Emerg Nurs 2011; 19:178-85. [DOI: 10.1016/j.ienj.2011.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/04/2011] [Accepted: 01/07/2011] [Indexed: 01/17/2023]
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Abstract
OBJECTIVE We sought to determine which of several simple indicators of emergency department crowding are most predictive of quality of care in 2 pediatric disease models: acute asthma and pain associated with long-bone fractures. METHODS We performed a retrospective, cross-sectional study of patients 2 to 21 years old seen for acute asthma and patients 0 to 21 years old seen for acute, isolated long-bone fractures from November 1, 2007, to October 31, 2008, at a single, academic children's hospital emergency department. The main outcome measures were quality measures based on 3 asthma care-related processes-asthma score, β-agonist, and corticosteroid-and 2 fracture-related processes-analgesic and opioid analgesic. Good quality care was defined as receipt of an indicated process within 1 hour of arrival. Poor quality care was defined as nonreceipt or delayed receipt of an indicated process. Nine crowding measures were assigned based on conditions at each patient's arrival. We calculated the adjusted risk of receiving good quality care for each quality measure at 5 percentiles of crowding for each crowding measure. RESULTS The asthma population included 927 patients, and the fracture population included 1229 patients. Among the 5 quality measures, we found rates of good quality care ranging from 23% to 64%. In adjusted models, we found an inverse association between crowding and quality. The 2 crowding measures with a consistently inverse association with the 5 quality measures across both populations were total patient-care hours and number arriving in prior 6 hours. Across the 10 models combining 1 of 2 key crowding variables with 1 of 5 quality measures, patients in the 2 populations were 0.40 (95% confidence interval, 0.27-0.55) to 0.78 (confidence interval, 0.71-0.85) times as likely to receive the indicated care process within 1 hour when each crowding measure was at the 75th than at the 25th percentile. CONCLUSIONS Two measures of ED crowding are consistently associated with lower-quality asthma- and fracture-specific care in the ED for pediatric patients.
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Kleiber C, Jennissen C, McCarthy AM, Ansley T. Evidence-Based Pediatric Pain Management in Emergency Departments of a Rural State. THE JOURNAL OF PAIN 2011; 12:900-10. [DOI: 10.1016/j.jpain.2011.02.349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 01/11/2011] [Accepted: 02/15/2011] [Indexed: 11/25/2022]
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