PREDICT prioritisation study: establishing the research priorities of paediatric emergency medicine physicians in Australia and New Zealand

Sepsis epidemiology in Australan and New Zealand children (SENTINEL): protocol for a multicountry prospective observational study

INTRODUCTION

Sepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes.

METHODS AND ANALYSIS

This prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures.

ETHICS AND DISSEMINATION

Ethics approval was received from the Royal Children's Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences.

TRIAL REGISTRATION NUMBER

ACTRN12621000920897; Pre-results.

Setting priorities for an agenda within the Spanish pediatric emergency medicine research network

The research network of the Spanish Pediatric Emergency Society (RISeuP-SPERG Network) needs to establish its research agenda relevant to pediatric emergency medicine (PEM) to guide the development of future projects, as other networks have done before. The aim of our study was to identify priority areas in PEM for a collaborative network of pediatric emergency research in Spain. A multicenter study was developed including pediatric emergency physicians from 54 Spanish emergency departments, endorsed by the RISeuP-SPERG Network. Initially, a group of seven PEM experts was selected among the members of the RISeuP-SPERG. In the first phase, these experts elaborated a list of research topics. Then, using a Delphi method, we sent a questionnaire with that list to all RISeuP-SPERG members, to rank each item using a 7-point Likert scale. Finally, the seven PEM experts, using a modified Hanlon Process of Prioritization, weighted prevalence (A), seriousness of the condition (B), and feasibility of conducting research projects (C) on that condition to prioritize the selected items. Once the list of topics was chosen, the seven experts selected a list of research questions for each of the selected items. The Delphi questionnaire was answered by 74/122 (60.7%) members of RISeuP-SPERG. We established a list of 38 research priorities related to quality improvement (11), infectious diseases (8), psychiatric/social emergencies (5), sedoanalgesia (3), critical care (2), respiratory emergencies (2), trauma (2), neurologic emergencies (1), and miscellanea (4).   Conclusion: The RISeuP-SPERG prioritization process identified high-priority PEM topics specific to multicenter research that may help guide further collaborative research efforts within the RISeuP-SPERG network to improve PEM care in Spain. What is Known: • Some pediatric emergency medicine networks have established their priorities for research. What is New: • After a structured process, we have set the research agenda for pediatric emergency medicine in Spain. By identifying high-priority pediatric emergency medicine research topics specific to multicenter research, we may guide further collaborative research efforts within our network.

Diagnosing acute bone and joint infection in children

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Research priority setting in emergency care: A scoping review

Objective

Priority areas for emergency care research are emerging and becoming ever more important. The objectives of this scoping review were to (1) provide a comprehensive overview of published emergency care priority‐setting studies by collating and comparing priority‐setting methodology and (2) describe the resulting research priorities identified.

Methods

The Joanna Briggs Institute methodological framework was used. Inclusion criteria were peer‐review articles available in English, published between January 1, 2008 and March 31, 2019 and used 2 or more search terms. Five databases (Scopus, AustHealth, EMBASE, CINAHL, and Ovid MEDLINE) were searched. REporting guideline for PRIority SEtting of health research (REPRISE) criteria were used to assess the quality of evidence of included articles.

Results

Forty‐five studies were included. Fourteen themes for emergency care research were considered within 3 overarching research domains: emergency populations (pediatrics, geriatrics), emergency care workforce and processes (nursing, shared decision making, general workforce, and process), and emergency care clinical areas (imaging, falls, pain management, trauma care, substance misuse, infectious diseases, mental health, cardiology, general clinical care). Variation in the reporting of research priority areas was evident. Priority areas to drive the global agenda for emergency care research are limited given the country and professional group‐specific context of existing studies.

Conclusion

This comprehensive summary of generated research priorities across emergency care provides insight into current and future research agendas. With the nature of emergency care being inherently broad, future priorities may warrant population (eg, children, geriatrics) or subspecialty (eg, trauma, toxicology, mental health) focus and be derived using a rigorous framework and patient engagement.

Identification of sepsis in paediatric emergency departments: A scoping review

AIM

Sepsis is an acute illness associated with significant morbidity and mortality. Early detection and time-sensitive management of sepsis has been shown to improve outcomes. We report the results of a scoping review to explore methods evaluated for the identification of sepsis in children presenting to emergency departments.

METHODS

A systematic literature search was carried out on two databases, Medline and Web of Science, to identify relevant studies published from 1990 to 2022. Data were extracted for age groups including study design, reference standard used for comparison, sepsis identification method evaluated and study quality.

RESULTS

A total of 89 studies were identified from the literature search. There was significant heterogeneity in the age groups including study design and reference standards used for evaluating the performance of the sepsis identification methods. There has been a substantial increase in the number of published studies in the last 2 years.

CONCLUSION

Our scoping review identifies marked heterogeneity in approaches to identifying sepsis but demonstrates a recent focus of research on patient outcomes. Using appropriate core outcome sets, developing reference standards, monitoring sepsis prevalence via registries and continuously monitoring process measures will provide robust evidence to identify the best performing identification tools and the impact they have on patient-orientated outcomes.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study

BACKGROUND

The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research.

METHODS

Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility.

RESULTS

Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception.

CONCLUSIONS

This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

Priorities for child health research across the UK and Ireland

BACKGROUND

The General and Adolescent Paediatric Research Network in the UK and Ireland (GAPRUKI) was established in 2016. The aims of GAPRUKI are to unite general paediatricians around the UK and Ireland, to develop research ideas and protocols, and facilitate delivery of multicentre research.

OBJECTIVES

To undertake a research prioritisation exercise among UK and Ireland general paediatricians.

METHODS

This was a four-phase study using a modified Delphi survey. The first phase asked for suggested research priorities. The second phase developed ideas and ranked them in priority. In the third phase, priorities were refined; and the final stage used the Hanlon Prioritisation Process to agree on the highest priorities.

RESULTS

In phase one, there were 250 questions submitted by 61 GAPRUKI members (66% of the whole membership). For phase two, 92 priorities were scored by 62 members and the mean Likert scale (1-7) scores ranged from 3.13 to 5.77. In a face-to-face meeting (phases three and four), 17 research questions were identified and ultimately 14 priorities were identified and ranked. The four priorities with the highest ranking focused on these three respiratory conditions: asthma, bronchiolitis and acute wheeze. Other priorities were in the diagnosis or management of constipation, urinary tract infection, fever, gastro-oesophageal reflux and also new models of care for scheduled general paediatric clinics.

CONCLUSION

Research priorities for child health in the UK and Ireland have been identified using a robust methodology. The next steps are for studies to be designed and funded to address these priorities.

Treatment patterns and frequency of key outcomes in acute severe asthma in children: a Paediatric Research in Emergency Departments International Collaborative (PREDICT) multicentre cohort study

RATIONALE

Severe acute paediatric asthma may require treatment escalation beyond systemic corticosteroids, inhaled bronchodilators and low-flow oxygen. Current large asthma datasets report parenteral therapy only.

OBJECTIVES

To identify the use and type of escalation of treatment in children presenting to hospital with acute severe asthma.

METHODS

Retrospective cohort study of children with an emergency department diagnosis of asthma or wheeze at 18 Australian and New Zealand hospitals. The main outcomes were use and type of escalation treatment (defined as any of intensive care unit admission, nebulised magnesium, respiratory support or parenteral bronchodilator treatment) and hospital length of stay (LOS).

MEASUREMENTS AND MAIN RESULTS

Of 14 029 children (median age 3 (IQR 1-3) years; 62.9% male), 1020 (7.3%, 95% CI 6.9% to 7.7%) had treatment escalation. Children with treatment escalation had a longer LOS (44.2 hours, IQR 27.3-63.2 hours) than children without escalation 6.7 hours, IQR 3.5-16.3 hours; p<0.001). The most common treatment escalations were respiratory support alone (400; 2.9%, 95% CI 2.6% to 3.1%), parenteral bronchodilator treatment alone (380; 2.7%, 95% CI 2.5% to 3.0%) and both respiratory support and parenteral bronchodilator treatment (209; 1.5%, 95% CI 1.3% to 1.7%). Respiratory support was predominantly nasal high-flow therapy (99.0%). The most common intravenous medication regimens were: magnesium alone (50.4%), magnesium and aminophylline (24.6%) and magnesium and salbutamol (10.0%).

CONCLUSIONS

Overall, 7.3% children with acute severe asthma received some form of escalated treatment, with 4.2% receiving parenteral bronchodilators and 4.3% respiratory support. There is wide variation treatment escalation.

Priorities for paediatric critical care research: a modified Delphi study by the Australian and New Zealand Intensive Care Society Paediatric Study Group

Objective: Most interventions in paediatric critical care lack high grade evidence. We aimed to identify the key research priorities and key clinical outcome measures pertinent to research in paediatric intensive care patients. Design: Modified three-stage Delphi study combining staged online surveys, followed by a face-to-face discussion and final voting. Setting: Paediatric intensive care units in Australia and New Zealand. Participants: Medical and nursing staff working in intensive care. Main outcome measurements: Self-reported priorities for research. Results: 193 respondents provided a total of 267 research questions and 234 outcomes. In Stage 3, the top 56 research questions and 50 outcomes were discussed face to face, which allowed the identification of the top 20 research questions with the Hanlon prioritisation score and the top 20 outcomes. Topics centred on the use of intravenous fluids (restrictive v liberal fluids, use of fluid resuscitation bolus, early inotrope use, type of intravenous fluid, and assessment of fluid responsiveness), and patient- and family-centred outcomes (health-related quality of life, liberation) emerged as priorities. While mortality, length of stay, and organ support/organ dysfunction were considered important and the most feasible outcomes, long term quality of life and neurodevelopmental measures were rated highly in terms of their importance. Conclusions: Using a modified Delphi method, this study provides guidance towards prioritisation of research topics in paediatric critical care in Australia and New Zealand, and identifies study outcomes of key relevance to clinicians and experts in the field.

A European Research Agenda for Geriatric Emergency Medicine: a modified Delphi study

PURPOSE

Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe.

METHODS

A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions.

RESULTS

In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED?

CONCLUSION

This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.

Where are children seen in Australian emergency departments? Implications for research efforts

OBJECTIVE

With most paediatric emergency research in Australia conducted at tertiary EDs, it is important to understand how presentations differ between those at tertiary paediatric EDs and all other EDs.

METHODS

Retrospective epidemiological study assessing paediatric case-mix and time-based performance metrics (aged 0-14 years) obtained from a national health service minimum dataset for the 2017-2018 financial year, comparing tertiary paediatric EDs and all other EDs. We defined a 'major tertiary paediatric hospital' as one which was accredited for training in both paediatric emergency medicine and paediatric intensive care.

RESULTS

Of the 1 695 854 paediatric ED presentations, 23.8% were seen in nine major metropolitan tertiary paediatric hospitals. Reasons for presentations were more distinctive between cohorts among children aged 10-14 years, where psychiatric illness (5.2% vs 2.5%) and neurological illness (4.5% vs 2.5%) were more commonly seen in major tertiary paediatric EDs. Australian Indigenous children were significantly less likely to present to tertiary paediatric EDs (3.0%), compared with other EDs (9.7%) (odds ratio 0.27, 95% confidence interval 0.26-0.27). While median waiting times were longer in major tertiary paediatric EDs (28 min [interquartile range 11-65]) than in other EDs (20 min [interquartile range 8-48], P < 0.001), patients were also less likely to leave without being seen (5.5% in tertiary paediatric EDs vs 6.9% in other EDs; odds ratio 0.80, 95% confidence interval 0.78-0.81).

CONCLUSIONS

The present study identified key areas of difference in paediatric presentations between tertiary paediatric EDs and other EDs. It is vital to broaden paediatric ED research beyond tertiary paediatric centres, to ensure relevance and generalisability.

Intubation practices for children in emergency departments and intensive care units across Australia and New Zealand: A survey of medical staff

OBJECTIVE

Intubation of children in the emergency setting is a high-risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high-quality evidence to support one technique over another. The aim of the present study is to determine clinician preference in intubation practice of children in EDs and ICUs in Australia and New Zealand to provide baseline information to allow future targeted research focused on improving the safety and efficacy of paediatric emergency airway management.

METHODS

The present study was a voluntary questionnaire undertaken by medical staff at registrar level or above in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices, with a focus on pre-oxygenation and apnoeic oxygenation techniques, and the use of video laryngoscopy.

RESULTS

A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responded. There was marked variation in practice between ED clinicians and ICU clinicians in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation and the reported use of video laryngoscopy.

CONCLUSIONS

Within Australia and New Zealand there is considerable variation in paediatric emergency airway clinical practice, in particular with respect to pre-oxygenation, apnoeic oxygenation and use of video laryngoscopy. Definitive clinical trials are required to best inform clinical practice in this area.

Envisioning the future of clinical analytics: a modified Delphi process in New South Wales, Australia

Background

Clinical analytics is a rapidly developing area of informatics and knowledge mobilisation which has huge potential to improve healthcare in the future. It is widely acknowledged to be a powerful mediator of clinical decision making, patient-centred care and organisational learning. As a result, healthcare systems require a strategic foundation for clinical analytics that is sufficiently directional to support meaningful change while flexible enough to allow for iteration and responsiveness to context as change occurs.

Methods

In New South Wales, the most populous state in Australia, the Clinical Analytics Working Group was charged with developing a five-year vision for the public health system. A modified Delphi process was undertaken to elicit expert views and to reach a consensus. The process included a combination of face-to-face workshops, traditional Delphi voting via email, and innovative, real-time iteration between text re-formulation and voting until consensus was reached. The six stage process engaged 35 experts — practising clinicians, patients and consumers, managers, policymakers, data scientists and academics.

Results

The process resulted in the production of 135 ideas that were subsequently synthesised into 23 agreed statements and encapsulated in a single page (456 word) narrative.

Conclusion

The visioning process highlighted three key perspectives (clinicians, patients and managers) and the need for synchronous (during the clinical encounter) and asynchronous (outside the clinical encounter) clinical decision support and reflective practice tools; the use of new and multiple data sources and communication formats; and the role of research and education.

Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians

INTRODUCTION

Injury is a leading cause of death and disability world-wide. Little is known about the day-to-day challenges the trauma clinicians face in their practice that they feel could be improved through an increased evidence base. This study explored and ranked the trauma clinical practice research priorities of trauma care professionals across Australia and New Zealand.

METHODS

A modified-Delphi study was conducted between September 2019 and January 2020. The study employed two rounds of online survey of trauma professionals from relevant Australia and New Zealand professional organisations using snowballing method. Participants were asked to rank the importance of 29 recommendations, each corresponding to a key challenge in trauma care delivery. Decisions on the priorities of the challenges were determined by a consensus of >70% of respondents ranking the challenge as important or very important.

RESULTS

One hundred and fifty-five participants completed Round One, and 106 participants completed Round Two. A total of 15 recommendations reached >70% in Round One. Nine recommendations also reached >70% consensus in Round Two. Recommendations ranked highest were 'Caring for elderly trauma patients', 'Identifying and validating key performance indicators for trauma system benchmarking and improvement', and 'Management of traumatic brain injury'.

CONCLUSION

This study identified the priority areas for trauma research as determined by clinician ranking of the most important for informing and improving their practice. Addressing these areas generates potential to improve the quality and safety of trauma care in Australian and New Zealand.

Establishing a research network

Multicentre research provides advantages over single-centre research by maximising available patient numbers while pooling varied expertise and resources available across different participating investigators and sites. The increased complexity of multicentre regulatory approvals, communication and study management, can be mitigated by the formation of a research network where multicentre efforts move from ad hoc, single projects to formalised ongoing collaboration. Network research helps prioritise research efforts and importantly fosters the development of a collaborative track record in terms of research expertise, research capacity and grant success. It also has the potential to rapidly change patient care across many hospitals as research results will be more generalizable and definitive. This paper sets out the key elements of network research, its benefits and possible challenges drawing on the example of PREDICT (Paediatric Research in Emergency Departments International Collaborative) an established paediatric emergency research network in Australia and New Zealand.

Challenges to trauma care delivery for Australian and New Zealand trauma clinicians

INTRODUCTION

The availability and implementation of evidence-based care is essential to achieving safe, quality trauma patient outcomes. Little is documented, however, about the challenges trauma clinicians face in their day-to day practice, or their views on the availability of evidence. This paper presents the most significant clinical practice challenges reported by multidisciplinary trauma care professionals in Australia and New Zealand, in particular those that may be resolved with focussed research or enhanced implementation activity.

METHODS

An exploratory survey of trauma professionals from relevant Australia and New Zealand professional organisations was conducted between September 2018 and February 2019 using the Snowballing Method. Participants were recruited via a non-random sampling technique to complete an online survey. Thematic analyses were conducted.

RESULTS

There were nine significant clinical practice challenge themes in trauma care, arising from 287 individual clinical practice challenges reported. The most reported being clinical management (bleeding, spinal, older patients) and operationalisation of the trauma system. There was no consensus as to the availability of evidence to guide each theme.

CONCLUSION

Future research should seek to address the clinical practice challenge of Australian and New Zealand trauma community to enable safe, quality trauma patient outcomes.

An international, Delphi consensus study to identify priorities for methodological research in behavioral trials in health research

Background

Non-communicable chronic diseases are linked to behavioral risk factors (including smoking, poor diet and physical inactivity), so effective behavior change interventions are needed to improve population health. However, uptake and impact of these interventions is limited by methodological challenges. We aimed to identify and achieve consensus on priorities for methodological research in behavioral trials in health research among an international behavioral science community.

Methods

An international, Delphi consensus study was conducted. Fifteen core members of the International Behavioral Trials Network (IBTN) were invited to generate methodological items that they consider important. From these, the research team agreed a “long-list” of unique items. Two online surveys were administered to IBTN members (N = 306). Respondents rated the importance of items on a 9-point scale, and ranked their “top-five” priorities. In the second survey, respondents received feedback on others’ responses, before rerating items and re-selecting their top five.

Results

Nine experts generated 144 items, which were condensed to a long-list of 33 items. The four most highly endorsed items, in both surveys 1 (n = 77) and 2 (n = 57), came from two thematic categories:“Intervention development” (“Specifying intervention components” and “Tailoring interventions to specific populations and contexts”) and “Implementation” (“How to disseminate behavioral trial research findings to increase implementation” and “Methods for ensuring that behavioral interventions are implementable into practice and policy”). “Development of novel research designs to test behavioral interventions” also emerged as a highly ranked research priority.

Conclusions

From a wide array of identified methodological issues, intervention development, implementation and novel research designs are key themes to drive the future behavioral trials’ research agenda. Funding bodies should prioritize these issues in resource allocation.

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand

OBJECTIVES

To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension.

METHODS

This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality.

RESULTS

A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%).

CONCLUSION

Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Delphi assessment of audit and research priorities in an emergency department

OBJECTIVE

Audit and research projects in the ED are important to improve patient care but can be time and resource consuming. We identified and prioritised audit and research topics among multidisciplinary ED staff to fill perceived knowledge gaps, encourage engagement, reduce duplication and facilitate translation of evidence into clinical practice.

METHODS

A two-stage electronic Delphi survey process was undertaken by senior medical, nursing, education and social work staff at the Royal Children's Hospital, Victoria. Survey 1 collected demographic data and audit and research ideas following a series of open-ended questions. Priority themes were defined as those that had more than four responses. Survey 2 used a 7-point Likert ranking of these themes to generate a departmental audit and research prioritisation list.

RESULTS

72/89 (82%) available senior staff responded to survey 1 and 63/83 (76%) responded to survey 2. Survey 1 yielded 208 audit and 130 research topics. Survey 2 established a prioritised list of 17 audit and 14 research topics. Top audit themes were mental healthcare, patient flow, management of sepsis and delays in ED specialist referrals. Top research priorities were the management of sepsis, mental healthcare, management of patients with autism and the management of severe asthma.

CONCLUSIONS

This Delphi study has provided departmental audit and research priorities that are perceived to be of importance across the multidisciplinary ED team. This methodology allows strategic allocation of limited resources and may increase staff engagement.

Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Reserarch Networks (PERN) study

BACKGROUND

Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom.

METHODS/DESIGN

A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim.

DISCUSSION

The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.

Parents' prioritised outcomes for trials investigating treatments for paediatric severe infection: a qualitative synthesis

OBJECTIVE

To identify parents' prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection.

DESIGN

Qualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection.

PARTICIPANTS

n=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved.

RESULTS

In addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that parents' prioritisation of outcomes was influenced by their experience of their child's illness, survival and the point at which they are asked about outcomes of importance in the course of their child's illness.

CONCLUSIONS

Findings provide insight into parent prioritised outcomes to inform the design of future trials investigating treatments for paediatric suspected or proven severe infection as well as core outcome set development work.

Research priorities for European paediatric emergency medicine

OBJECTIVE

Research in European Paediatric Emergency Medicine (REPEM) network is a collaborative group of 69 paediatric emergency medicine (PEM) physicians from 20 countries in Europe, initiated in 2006. To further improve paediatric emergency care in Europe, the aim of this study was to define research priorities for PEM in Europe to guide the development of future research projects.

DESIGN AND SETTING

We carried out an online survey in a modified three-stage Delphi study. Eligible participants were members of the REPEM network. In stage 1, the REPEM steering committee prepared a list of research topics. In stage 2, REPEM members rated on a 6-point scale research topics and they could add research topics and comment on the list for further refinement. Stage 3 included further prioritisation using the Hanlon Process of Prioritisation (HPP) to give more emphasis to the feasibility of a research topic.

RESULTS

Based on 52 respondents (response rates per stage varying from 41% to 57%), we identified the conditions 'fever', 'sepsis' and 'respiratory infections', and the processes/interventions 'biomarkers', 'risk stratification' and 'practice variation' as common themes of research interest. The HPP identified highest priority for 4 of the 5 highest prioritised items by the Delphi process, incorporating prevalence and severity of each condition and feasibility of undertaking such research.

CONCLUSIONS

While the high diversity in emergency department (ED) populations, cultures, healthcare systems and healthcare delivery in European PEM prompts to focus on practice variation of ED conditions, our defined research priority list will help guide further collaborative research efforts within the REPEM network to improve PEM care in Europe.

Clinical clearance and imaging for possible cervical spine injury in children in the emergency department: A retrospective cohort study

OBJECTIVES

While cervical spine injuries (CSIs) are rare in the paediatric population, presentations to EDs with possible neck injuries are common. Based on a lack of Australian data we set out to determine how many possible injuries are clinically cleared, what imaging is used on the remainder and the incidence and characteristics of confirmed paediatric CSIs.

METHODS

We undertook a retrospective electronic medical record review of children <18 years with potential CSIs at a large tertiary paediatric trauma centre in Victoria, Australia over a 12 month period (annual census 87 000). For possible injuries we extracted key epidemiologic, imaging and short-term outcome data.

RESULTS

During the study period, a total of 617 patients with potential neck injuries were seen in the ED (617/87 000, 0.7%). The median age was 11 years. The most common mechanisms of injury were falls (41%), motor vehicle injuries (28%) and sports-related injuries (24%). Four hundred and fourteen of 617 (67%) underwent neck imaging (345/414, 83% plain radiograph; 100/414, 24% computed tomography; 7/414, 1.6% magnetic resonance imaging). Twenty-three of 617 (4.1%) had radiologically documented CSIs. Two required operative interventions for their neck injuries.

CONCLUSION

While two-thirds of children with potential CSIs undergo radiological evaluation, actual injuries are rare (<4%). These data suggest that there is a potential for improved targeting of cervical spine imaging for trauma. The development of a clinical decision tool may help reduce neck radiography.

Pediatric Emergency Research Canada (PERC): Patient/Family-informed Research Priorities for Pediatric Emergency Medicine

BACKGROUND

A growing body of literature supports patient and public involvement in the design, prioritization, and dissemination of research and evidence-based medicine. The objectives of this project were to engage patients and families in developing a prioritized list of research topics for pediatric emergency medicine (PEM) and to compare results with prior research prioritization initiatives in the emergency department (ED) setting.

METHODS

We utilized a systematic process to combine administrative data on frequency of patient presentations to the ED with multiple stakeholder input including an initial stakeholder survey followed by a modified Delphi consensus methodology consisting of two Web-based surveys and a face-to-face meeting.

RESULTS

The prioritization process resulted in a ranked list of 15 research priorities. The top five priorities were mental health presentations, pain and sedation, practice tools, quality of care delivery, and resource utilization. Mental health, pain and sedation, clinical prediction rules, respiratory illnesses/wheeze, patient safety/medication error, and sepsis were identified as shared priorities with prior initiatives. Topics identified in our process that were not identified in prior work included resource utilization, ED communication, antibiotic stewardship, and patient/family adherence with recommendations.

CONCLUSIONS

This work identifies key priorities for research in PEM. Comparing our results with prior initiatives in the ED setting identified shared research priorities and opportunities for collaboration among PEM research networks. This work in particular makes an important contribution to the existing literature by including the patient/family perspective missing from prior work.

Pediatric Emergency Care Research Networks: A Research Agenda

BACKGROUND

Pediatric emergency care research networks have evolved substantially over the past two decades. Some networks are specialized in specific areas (e.g., sedation, simulation) while others study a variety of medical and traumatic conditions. Given the increased collaboration between pediatric emergency research networks, the logical next step is the development of a research priorities agenda to guide global research in emergency medical services for children (EMSC).

OBJECTIVES

An international group of pediatric emergency network research leaders was assembled to develop a list of research priorities for future collaborative endeavors within and between pediatric emergency research networks.

METHODS

Before an in-person meeting, we used a modified Delphi approach to achieve consensus around pediatric emergency research network topic priorities. Further discussions took place on May 15, 2018, in Indianapolis, Indiana, at the Academic Emergency Medicine (AEM) consensus conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." Here, a group of 40 organizers and participants met in a 90-minute "breakout" session to review and further develop the initial priorities.

RESULTS

We reached consensus on five clinical research priorities that would benefit from collaboration among the existing and future emergency networks focused on EMSC: sepsis, trauma, respiratory conditions, pharmacology of emergency conditions, and mental health emergencies. Furthermore, we identified nonclinical research priorities categorized under the domains of technology, knowledge translation, and organization/administration of pediatric emergency care.

CONCLUSION

The identification of pediatric emergency care network research priorities within the domains of clinical care, technology, knowledge translation and organization/administration of EMSC will facilitate and help focus collaborative research within and among research networks globally. Engagement of essential stakeholders including EMSC researchers, policy makers, patients, and their caregivers will stimulate advances in the delivery of emergency care to children around the globe.

Consensus-based clinical research priorities for emergency nursing in Australia

INTRODUCTION

Research is vital to responding to contemporary challenges of providing safe, high quality emergency nursing care, yet the research priorities for emergency nursing practice in Australia are unknown. This study aimed to establish research priorities for emergency nursing in Australia.

METHODS

A two-stage descriptive, exploratory study was conducted. First, research themes were identified through a survey of 232 emergency nurses the Delphi Technique (2 rounds) was used to rank and prioritise the research themes.

RESULTS

There were five research themes with a CVI≥0.90: (i) recognising and responding to deteriorating ED patients; (ii) effect of access block on clinical care of admitted ICU patients; (iii) effects of ED overcrowding on clinical care; (iv) scope of practice of specialist emergency nurses; and (v) effect of access block on clinical care of admitted ward patients. These are reflected in four broad research priority areas: professional issues, patient safety, emergency care of vulnerable populations, and healthcare system issues.

CONCLUSION

Future research should focus on these priority areas in partnership with other emergency disciplines to enable safe, high quality emergency care, and, to inform the practice of emergency nursing in Australia.