1
|
Cave DG, Bautista MJ, Mustafa K, Bentham JR. Cardiac output monitoring in children: a review. Arch Dis Child 2023; 108:949-955. [PMID: 36927620 DOI: 10.1136/archdischild-2022-325030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
Cardiac output monitoring enables physiology-directed management of critically ill children and aids in the early detection of clinical deterioration. Multiple invasive techniques have been developed and have demonstrated ability to improve clinical outcomes. However, all require invasive arterial or venous catheters, with associated risks of infection, thrombosis and vascular injury. Non-invasive monitoring of cardiac output and fluid responsiveness in infants and children is an active area of interest and several proven techniques are available. Novel non-invasive cardiac output monitors offer a promising alternative to echocardiography and have proven their ability to influence clinical practice. Assessment of perfusion remains a challenge; however, technologies such as near-infrared spectroscopy and photoplethysmography may prove valuable clinical adjuncts in the future.
Collapse
Affiliation(s)
- Daniel Gw Cave
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, West Yorkshire, UK
| | - Melissa J Bautista
- General Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
- General Surgery, University of Leeds, Leeds, West Yorkshire, UK
| | - Khurram Mustafa
- Paediatric Intensive Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James R Bentham
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
2
|
Tsze DS, Cruz AT, Mistry RD, Gonzalez AE, Ochs JB, Richer L, Kuppermann N, Dayan PS. Interobserver Agreement in the Assessment of Clinical Findings in Children with Headaches. J Pediatr 2020; 221:207-214. [PMID: 32446483 PMCID: PMC7251971 DOI: 10.1016/j.jpeds.2020.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/10/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the interobserver agreement of history and physical examination findings in children undergoing evaluation in the emergency department (ED) for headaches. STUDY DESIGN We conducted a prospective, cross-sectional study of children aged 2-17 years evaluated at 3 tertiary-care pediatric EDs for non-traumatic headaches. Two clinicians independently completed a standardized assessment of each child and documented the presence or absence of history and physical examination variables. Unweighted κ statistics were determined for 68 history and 24 physical examination variables. RESULTS We analyzed 191 paired observations; median age was 12 years, with 19 (9.9%) children younger than 7 years. Interrater reliability was at least moderate (κ ≥ 0.41) for 41 (60.3%) patient history variables. Eleven (61.1%) of 18 physical examination variables for which κ statistics could be calculated had a κ that was at least moderate. CONCLUSIONS A substantial number of history and physical examination findings demonstrated at least moderate κ statistic values when assessed in children with headaches in the ED. These variables may be generalizable across different types of clinicians for evaluation of children with headaches. If also found to predict the presence or absence of emergent intracranial abnormalities, the more reliable clinical findings may be helpful in the development of clinical prediction rules or risk stratification models that could be used across settings for children with headaches.
Collapse
Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine. Houston, TX
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine. Aurora, CO
| | - Ariana E. Gonzalez
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Julie B. Ochs
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta. Edmonton, Alberta, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine. Sacramento, CA
| | - Peter S. Dayan
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| |
Collapse
|
3
|
Tsze DS, Ochs JB, Gonzalez AE, Dayan PS. Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging. Cephalalgia 2019; 39:185-196. [PMID: 29874930 PMCID: PMC10693908 DOI: 10.1177/0333102418781814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging. OBJECTIVES We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population. METHODS A prospective cohort study of otherwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities. RESULTS We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging. CONCLUSIONS Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.
Collapse
Affiliation(s)
- Daniel S Tsze
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Julie B Ochs
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ariana E Gonzalez
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
4
|
van Diessen E, Lamberink HJ, Otte WM, Doornebal N, Brouwer OF, Jansen FE, Braun KPJ. A Prediction Model to Determine Childhood Epilepsy After 1 or More Paroxysmal Events. Pediatrics 2018; 142:peds.2018-0931. [PMID: 30389715 DOI: 10.1542/peds.2018-0931] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The clinical profile of children who had possible seizures is heterogeneous, and accuracy of diagnostic testing is limited. We aimed to develop and validate a prediction model that determines the risk of childhood epilepsy by combining available information at first consultation. METHODS We retrospectively collected data of 451 children who visited our outpatient department for diagnostic workup related to 1 or more paroxysmal event(s). At least 1 year of follow-up was available for all children who were diagnosed with epilepsy or in whom diagnosis remained inconclusive. Clinical characteristics (sex, age of first seizure, event description, medical history) and EEG report were used as predictor variables for building a multivariate logistic regression model. Performance was validated in an external cohort (n = 187). RESULTS Model discrimination was excellent, with an area under the receiver operating characteristic curve of 0.86 (95% confidence interval [CI]; 0.80-0.92), a positive predictive value of 0.93 (95% CI 0.83-0.97) and a negative predictive value of 0.76 (95% CI 0.70-0.80). Model discrimination in a selective subpopulation of children with uncertain diagnosis after initial clinical workup was good, with an area under the receiver operating characteristic curve of 0.73 (95% CI 0.58-0.87). CONCLUSIONS This model may prove to be valuable because predictor variables together with a first interictal EEG can be available at first consultation. A Web application is provided (http://epilepsypredictiontools.info/first-consultation) to facilitate the diagnostic process for clinicians who are confronted with children with paroxysmal events, suspected of having an epileptic origin.
Collapse
Affiliation(s)
- Eric van Diessen
- Department of Pediatric Neurology, Brain Center Rudolf Magnus and
| | - Herm J Lamberink
- Department of Pediatric Neurology, Brain Center Rudolf Magnus and
| | - Willem M Otte
- Department of Pediatric Neurology, Brain Center Rudolf Magnus and.,Biomedical MR Imaging and Spectroscopy Group, Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nynke Doornebal
- Department of Pediatrics, Martini Hospital, Groningen, Netherlands; and
| | - Oebele F Brouwer
- Department of Pediatrics, Martini Hospital, Groningen, Netherlands; and.,Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Floor E Jansen
- Department of Pediatric Neurology, Brain Center Rudolf Magnus and
| | - Kees P J Braun
- Department of Pediatric Neurology, Brain Center Rudolf Magnus and
| |
Collapse
|
5
|
Sansevere AJ, Avalone J, Strauss LD, Patel AA, Pinto A, Ramachandran M, Fernandez IS, Bergin AM, Kimia A, Pearl PL, Loddenkemper T. Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy. J Child Neurol 2017; 32:774-788. [PMID: 28503985 DOI: 10.1177/0883073817706028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
By definition, unprovoked seizures are not precipitated by an identifiable factor, such as fever or trauma. A thorough history and physical examination are essential to caring for pediatric patients with a potential first unprovoked seizure. Differential diagnosis, EEG, neuroimaging, laboratory tests, and initiation of treatment will be reviewed. Treatment is typically initiated after 2 unprovoked seizures, or after 1 seizure in select patients with distinct epilepsy syndromes. Recent expansion of the definition of epilepsy by the ILAE allows for the diagnosis of epilepsy to be made after the first seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure. This review summarizes the current literature on the diagnostic and therapeutic management of first unprovoked seizure in children and adolescents while taking into consideration the revised diagnostic criteria of epilepsy.
Collapse
Affiliation(s)
- Arnold J Sansevere
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Avalone
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren Doyle Strauss
- 2 Department of Neurology, Wake Forest Baptist Health, Wake Forest Medical School, Winston Salem, NC, USA
| | - Archana A Patel
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Pinto
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Ann M Bergin
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amir Kimia
- 4 Department of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Phillip L Pearl
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Loddenkemper
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Lindgren C, Neuman MI, Monuteaux MC, Mandl KD, Fine AM. Patient and Parent-Reported Signs and Symptoms for Group A Streptococcal Pharyngitis. Pediatrics 2016; 138:peds.2016-0317. [PMID: 27279649 DOI: 10.1542/peds.2016-0317] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Identifying symptomatic patients who are at low risk for group A streptococcal (GAS) pharyngitis could reduce unnecessary visits and antibiotic use. The accuracy with which patients and parents report signs and symptoms of GAS has not been studied. Our objectives were to measure agreement between patient or parent and physician-reported signs and symptoms of GAS and to evaluate the performance of a modified Centor score, based on patient or parent and physician reports, for identifying patients at low risk for GAS pharyngitis. METHODS Children 3 to 21 years old presenting to a single tertiary care emergency department between October 2013 and January 2015 were included if they complained of a sore throat and were tested for GAS. Patients or parents and physicians completed surveys assessing signs and symptoms to determine a modified age-adjusted Centor score for GAS. We evaluated the overall agreement and κ between patient or parent and physician-reported signs and symptoms and compared the performance of the scores based on assessments by patients or parents and physicians and the risk of GAS. RESULTS Of 320 patients enrolled, 107 (33%) tested GAS positive. Agreement was higher for symptoms (fever [agreement = 82%, κ = 0.64] and cough [72%, 0.45]) than for signs (exudate [80%, 0.41] and tender cervical nodes [73%, 0.18]). Agreement was highest when no signs and symptoms contained in the Centor score were present (94%, κ = 0.61). The proportion of patients testing GAS positive rose as the modified Centor score increased. CONCLUSIONS For identifying GAS pharyngitis, patients or parents and physicians showed moderate to substantial agreement for 3 of 4 key pharyngitis signs and symptoms.
Collapse
Affiliation(s)
| | - Mark I Neuman
- Division of Emergency Medicine and Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine and Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kenneth D Mandl
- Division of Emergency Medicine and Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts; and
| | - Andrew M Fine
- Division of Emergency Medicine and Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
7
|
Kapadia S, Shah H, McNair N, Pruitt JN, Murro A, Park Y. Using a structured questionnaire improves seizure description by medical students. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2016; 7:6-10. [PMID: 26752118 PMCID: PMC4715901 DOI: 10.5116/ijme.566c.096c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/12/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate a structured questionnaire for improving a medical students' ability to identify, describe and interpret a witnessed seizure. METHODS Ninety two 3rd year medical students, blinded to seizure diagnosis, viewed videos of a primary generalized seizure and a complex partial seizure. Students next completed an unstructured questionnaire that asked the students to describe the seizure video recordings. The students then completed a structured questionnaire that asked the student to respond to 17 questions regarding specific features occurring during the seizures. We determined the number and types of correct responses for each questionnaire. RESULTS Overall, the structured questionnaire was more effective in eliciting an average of 9.25 correct responses compared to the unstructured questionnaire eliciting an average of 5.30 correct responses (p < 0.001). Additionally, 10 of the 17 seizure features were identified more effectively with the structured questionnaire. Potentially confounding factors, prior knowledge of someone with epilepsy or a prior experience of viewing a seizure, did not predict the student's ability to correctly identify any of the 17 features. CONCLUSIONS A structured questionnaire significantly improves a medical student's ability to provide an accurate clinical description of primary generalized and complex partial witnessed seizures. Our analysis identified the 10 specific features improved by using the structured questionnaire.
Collapse
Affiliation(s)
- Saher Kapadia
- Medical College of Georgia, Georgia Regents University, Augusta, Georgia, 30912, USA
| | - Hemang Shah
- Neurology Department, Medical College of Georgia, Georgia Regents University. Augusta, Georgia, 30912, USA
| | - Nancy McNair
- Neurology Department, Medical College of Georgia, Georgia Regents University. Augusta, Georgia, 30912, USA
| | - J. Ned Pruitt
- Neurology Department, Medical College of Georgia, Georgia Regents University. Augusta, Georgia, 30912, USA
| | - Anthony Murro
- Neurology Department, Medical College of Georgia, Georgia Regents University. Augusta, Georgia, 30912, USA
| | - Yong Park
- Neurology Department, Medical College of Georgia, Georgia Regents University. Augusta, Georgia, 30912, USA
| |
Collapse
|
8
|
Dayan PS, Lillis K, Bennett J, Conners G, Bailey P, Callahan J, Akman C, Feldstein N, Kriger J, Hauser WA, Kuppermann N. Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures. Pediatrics 2015. [PMID: 26195538 PMCID: PMC4516940 DOI: 10.1542/peds.2014-3550] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Prospective data are lacking to determine which children might benefit from prompt neuroimaging after unprovoked seizures. We aimed to determine the prevalence of, and risk factors for, relevant intracranial abnormalities in children with first, unprovoked seizures. METHODS We conducted a 6-center prospective study in children aged >28 days to 18 years with seemingly unprovoked seizures. Emergency department (ED) clinicians documented clinical findings on a standardized form. Our main outcome was the presence of a clinically relevant intracranial abnormality on computed tomography (CT) or MRI, defined as those that might change management, either emergently, urgently, or nonurgently. RESULTS We enrolled 475 of 625 (76%) eligible patients. Of 354 patients for whom cranial MRI or CT scans were obtained in the ED or within 4 months of the ED visit, 40 (11.3%; 95% confidence interval [CI]: 8.0-14.6%) had clinically relevant intracranial abnormalities, with 3 (0.8%; 95% CI: 0.1-1.8%) having emergent/urgent abnormalities. On logistic regression analysis, a high-risk past medical history (adjusted odds ratio: 9.2; 95% CI: 2.4-35.7) and any focal aspect to the seizure (odds ratio: 2.5; 95% CI: 1.2-5.3) were independently associated with clinically relevant abnormalities. CONCLUSIONS Clinically relevant intracranial abnormalities occur in 11% of children with first, unprovoked seizures. Emergent/urgent abnormalities, however, occur in <1%, suggesting that most children do not require neuroimaging in the ED. Findings on patient history and physical examination identify patients at higher risk of relevant abnormalities.
Collapse
Affiliation(s)
- Peter S. Dayan
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Kathleen Lillis
- Department of Pediatrics, State University of New York at Buffalo, Buffalo, New York
| | - Jonathan Bennett
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Gregory Conners
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Pam Bailey
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - James Callahan
- Departments of Emergency Medicine and Pediatrics, Upstate Medical College, Syracuse, New York
| | - Cigdem Akman
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Neil Feldstein
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Joshua Kriger
- Department of Biostatistics, Columbia University Medical Center, New York, New York
| | - W. Allen Hauser
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York;,Gertrude Sergievsky Center, New York, New York; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, Davis School of Medicine, University of California, Sacramento, California
| |
Collapse
|
9
|
Aprahamian N, Harper M, Prabhu S, Monuteaux M, Sadiq Z, Torres A, Kimia A. Pediatric first time non-febrile seizure with focal manifestations: Is emergent imaging indicated? Seizure 2014; 23:740-5. [DOI: 10.1016/j.seizure.2014.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/31/2014] [Accepted: 06/03/2014] [Indexed: 11/25/2022] Open
|
10
|
Boyle M, Chukwu J, Boyle M, Connolly A, Webb D. An audit of first afebrile seizure management in an Irish tertiary pediatric setting. Eur J Pediatr 2014; 173:525-8. [PMID: 24173658 DOI: 10.1007/s00431-013-2180-7] [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] [Received: 06/30/2013] [Accepted: 10/09/2013] [Indexed: 11/28/2022]
Abstract
UNLABELLED The objective of this study was to compare the first afebrile seizure management with internationally recognized standards in an Irish tertiary pediatric setting. Twenty-one management standards were derived from a combination of British (NICE 2004) and North American (AAN 2003) guidelines. Cases of first afebrile seizure presenting to a pediatric emergency department between July 2007 and June 2010 were assessed against the standards. On completion, the standards developed were presented to the relevant stakeholders, a nurse-developed parental advice sheet was introduced, and a re-audit was performed from July 2010 to June 2011. Forty children were identified in the initial audit period (A1) and 41 over the re-audit (A2). No case achieved full compliance with the devised standards in the audit period. A median compliance score of 15 (range 5-20) was achieved in A1 and 17 (range 11-21) in A2 [mean rank 31.93 versus 49.85; p(1,1) < 0.0001]. Optimal compliance (total score of ≥17) with devised standards was achieved in 6/40 patients in A1 and in 21/41 patients in A2 [χ (2) = 11.95; p(1,1) = 0.001]. CONCLUSION We demonstrated an initial lack of compliance with international guidelines on management of a common medical presentation, first afebrile seizure, and demonstrated that improvements can be achieved by identification of appropriate standards and critical appraisal of the compliance with these standards through both formal and informal education.
Collapse
Affiliation(s)
- Michael Boyle
- Department of Paediatric Neurology, The Adelaide and Meath Hospital, Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland,
| | | | | | | | | |
Collapse
|
11
|
Nigrovic LE, Schonfeld D, Dayan PS, Fitz BM, Mitchell SR, Kuppermann N. Nurse and physician agreement in the assessment of minor blunt head trauma. Pediatrics 2013; 132:e689-94. [PMID: 23979081 DOI: 10.1542/peds.2013-0909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) clinical prediction rules identify children with minor blunt head trauma who are at low risk for clinically important traumatic brain injuries. We measured the agreement between the registered nurse (RN) and physician (MD) assessments. METHODS We performed a cross-sectional study of all children <18 years of age with minor blunt head trauma who presented to a single emergency department. RNs and MDs independently assessed each child and recorded age-based PECARN predictors. As symptoms can change over time, we included cases only when both evaluations were completed within 60 minutes. We used the κ statistic to measure RN-MD agreement, with the main analysis focusing on the overall PECARN rule agreement. RESULTS Of the 1624 eligible children, 1191 (73%) had evaluations completed by both RN and ED providers, of which 437 (37%) were in children <2 years of age. The median time between completions of the provider forms was 12 minutes (interquartile range 4-25 minutes). The overall agreement between the RN and MD was higher for the older children (κ 0.55, 95% confidence interval 0.49-0.61 for children 2-18 years versus κ 0.32, 95% confidence interval 0.23-0.41 for children <2 years). CONCLUSIONS The overall agreement between RN and MD for the PECARN TBI prediction rules was moderate for older children and fair for younger children. Initial RN assessments should be verified by the MD before clinical application, especially for the youngest children.
Collapse
Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA.
| | | | | | | | | | | |
Collapse
|
12
|
Yen K, Kuppermann N, Lillis K, Monroe D, Borgialli D, Kerrey BT, Sokolove PE, Ellison AM, Cook LJ, Holmes JF. Interobserver agreement in the clinical assessment of children with blunt abdominal trauma. Acad Emerg Med 2013; 20:426-32. [PMID: 23672355 DOI: 10.1111/acem.12132] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. METHODS This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement. RESULTS A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. CONCLUSIONS Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.
Collapse
Affiliation(s)
- Kenneth Yen
- Department of Pediatrics; Section of Emergency Medicine; Medical College of Wisconsin ; Milwaukee; WI
| | - Nathan Kuppermann
- Department of Emergency Medicine; University of California; Davis School of Medicine ; Sacramento; CA
| | - Kathleen Lillis
- the Department of Pediatrics; Division of Emergency Medicine; State University of New York at Buffalo; Women and Children's Hospital of Buffalo ; Buffalo; NY
| | - David Monroe
- Department of Pediatrics; Howard County General Hospital ; Columbia; MD
| | - Dominic Borgialli
- Department of Emergency Medicine; University of Michigan; Hurley Medical Center ; Flint; MI
| | - Benjamin T. Kerrey
- the Department of Pediatrics; Division of Emergency Medicine; University of Cincinnati College of Medicine ; Cincinnati; OH
| | - Peter E. Sokolove
- Department of Emergency Medicine; University of California; Davis School of Medicine ; Sacramento; CA
| | - Angela M. Ellison
- Department of Pediatrics; Division of Emergency Medicine Perelman School of Medicine; University of Pennsylvania ; Philadelphia; PA
| | - Lawrence J. Cook
- Department of Pediatrics; University of Utah ; Salt Lake City; UT
| | - James F. Holmes
- Department of Emergency Medicine; University of California; Davis School of Medicine ; Sacramento; CA
| | | |
Collapse
|
13
|
Cohn KA, Thompson AD, Shah SS, Hines EM, Lyons TW, Welsh EJ, Nigrovic LE. Validation of a clinical prediction rule to distinguish Lyme meningitis from aseptic meningitis. Pediatrics 2012; 129:e46-53. [PMID: 22184651 DOI: 10.1542/peds.2011-1215] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The "Rule of 7's," a Lyme meningitis clinical prediction rule, classifies children at low risk for Lyme meningitis when each of the following 3 criteria are met: <7 days of headache, <70% cerebrospinal fluid (CSF) mononuclear cells, and absence of seventh or other cranial nerve palsy. The goal of this study was to test the performance of the Rule of 7's in a multicenter cohort of children with CSF pleocytosis. METHODS We performed a retrospective cohort study of children evaluated at 1 of 3 emergency departments located in Lyme disease-endemic areas with CSF pleocytosis and Lyme serology obtained. Lyme meningitis was defined using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans [EM] rash). We calculated the performance of the Rule of 7's in our overall study population and in children without physician-documented EM. RESULTS We identified 423 children, of whom 117 (28% [95% confidence interval (CI): 24%-32%]) had Lyme meningitis, 306 (72% [95% CI: 68%-76%]) had aseptic meningitis, and 0 (95% CI: 0%-1%) had bacterial meningitis. Of the 130 classified as low risk, 5 had Lyme meningitis (sensitivity, 112 of 117 [96% (95% CI: 90%-99%)]; specificity, 125 of 302 [41% (95% CI: 36%-47%)]). In the 390 children without EM, 3 of the 127 low-risk patients had Lyme meningitis (2% [95% CI: 0%-7%]). CONCLUSIONS Patients classified as low risk by using the Rule of 7's were unlikely to have Lyme meningitis and could be managed as outpatients while awaiting results of Lyme serology tests.
Collapse
Affiliation(s)
- Keri A Cohn
- Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston 300 Longwood Ave, Boston, MA 02115, USA
| | | | | | | | | | | | | |
Collapse
|