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Bakel LA, Richardson T, De Souza HG, Kaiser SV, Mahant S, Treasure JD, Waynik IY, Winer JC, Bajaj L. Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions. J Hosp Med 2022; 17:417-426. [PMID: 35535935 DOI: 10.1002/jhm.12811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.
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Affiliation(s)
- Leigh Anne Bakel
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ilana Y Waynik
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, Mansfield, Connecticut, USA
| | - Jeffrey C Winer
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lalit Bajaj
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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2
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Levine AC, O’Connell KJ, Schnadower D, VanBuren TJM, Mahajan P, Hurley KF, Tarr P, Olsen CS, Poonai N, Schuh S, Powell EC, Farion KJ, Sapien RE, Roskind CG, Rogers AJ, Bhatt S, Gouin S, Vance C, Freedman SB. Derivation of the Pediatric Acute Gastroenteritis Risk Score to Predict Moderate-to-Severe Acute Gastroenteritis. J Pediatr Gastroenterol Nutr 2022; 74:446-453. [PMID: 35129163 PMCID: PMC9203936 DOI: 10.1097/mpg.0000000000003395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Although most acute gastroenteritis (AGE) episodes in children rapidly self-resolve, some children go on to experience more significant and prolonged illness. We sought to develop a prognostic score to identify children at risk of experiencing moderate-to-severe disease after an index emergency department (ED) visit. METHODS Data were collected from a cohort of children 3 to 48 months of age diagnosed with AGE in 16 North American pediatric EDs. Moderate-to-severe AGE was defined as a Modified Vesikari Scale (MVS) score ≥9 during the 14-day post-ED visit. A clinical prognostic model was derived using multivariable logistic regression and converted into a simple risk score. The model's accuracy was assessed for moderate-to-severe AGE and several secondary outcomes. RESULTS After their index ED visit, 19% (336/1770) of participants developed moderate-to-severe AGE. Patient age, number of vomiting episodes, dehydration status, prior ED visits, and intravenous rehydration were associated with MVS ≥9 in multivariable regression. Calibration of the prognostic model was strong with a P value of 0.77 by the Hosmer-Lemenshow goodness-of-fit test, and discrimination was moderate with an area under the receiver operator characteristic curve of 0.68 (95% confidence interval [CI] 0.65-0.72). Similarly, the model was shown to have good calibration when fit to the secondary outcomes of subsequent ED revisit, intravenous rehydration, or hospitalization within 72 hours after the index visit. CONCLUSIONS After external validation, this new risk score may provide clinicians with accurate prognostic insight into the likely disease course of children with AGE, informing disposition decisions, anticipatory guidance, and follow-up care.
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Affiliation(s)
- Adam C. Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children’s Hospital and Brown University, Providence, RI
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan
- Wayne State University, Detroit
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Katrina F. Hurley
- Department of Emergency Medicine, IWK Health, Halifax, Nova Scotia, Canada
| | - Phillip Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Naveen Poonai
- Departments of Pediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry
- Children’s Health Research Institute, London Health Sciences Centre, London
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, SickKids Research Institute, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL
| | - Ken J. Farion
- Departments of Pediatrics and Emergency Medicine, University of Ottawa
- Pediatric Emergency Department, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Cindy G. Roskind
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Seema Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Serge Gouin
- Departments of Pediatric Emergency Medicine & Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Cheryl Vance
- Departments of Pediatrics and Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
| | - Stephen B. Freedman
- Divisions of Pediatric Emergency Medicine and Gastroenterology, Alberta, Children’s Hospital, Alberta, Canada
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB
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3
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Alona I, Harahap J, Aribi A, Ikhsan R, Siregar MIR. Assessment of Healthcare Professional’s Knowledge, Skills, Motivation, and Commitment to Clinical Pathways Implementation. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.5656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Healthcare providers are facing challenges to deliver qualified and efficient health services in response to the current health system. Clinical pathways (CPs) are a tool to achieve the best clinical outcomes at the lowest cost. The implementation should be supported by healthcare professional’s capacity involved in the process.
AIM: The aim of the study was to assess healthcare professionals’ knowledge, skills, motivation, and commitment to clinical pathways (CPs) implementation in Universitas Sumatera Utara (USU) Hospital.
METHODS: This cross-sectional study was conducted at USU Hospital with 65 healthcare professionals as participants who consist of 10 specialist doctors, 50 nurses, and 5 pharmacists. These participants were selected using quota sampling and interviewed using a developed and structured questionnaire. This questionnaire was tested for its validity and reliability with r > 0.5 and Cronbach’s Alpha > 0.6. Pearson correlation test with p < 0.05 was used for analyzing the relationship among variables on CPs implementation.
RESULTS: The healthcare professionals in USU Hospital had high knowledge, motivation, and commitment, but moderate skills in CPs implementation. There were positive correlations between knowledge and skill (p = 0.039), motivation and skill (p = 0.001), commitment and skill (p = 0.001), and motivation and commitment (p = 0.001) on CPs implementation.
CONCLUSION: USU Hospital healthcare professional’s knowledge, motivation, and commitment to CPs implementation were adequate, but their skills were moderate. The motivation is substantially related to the healthcare professional’s commitment to CPs implementation. This study recommended the hospital explore and grow skills in communication, coordination, and affective commitment among individuals, teamwork, and leaders for the sake of willingness to achieve the values or goals of the CP implementation in their organization.
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Lloyd-Martin E. Outcomes of ondansetron use in children with gastroenteritis in the emergency department: a literature review. Emerg Nurse 2021; 29:21-27. [PMID: 33755371 DOI: 10.7748/en.2021.e2069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/09/2022]
Abstract
In the UK, the use of antiemetics in children with gastroenteritis is not standardised. The antiemetic ondansetron is often administered, in clinical practice, to children presenting with gastroenteritis. However, it is not listed in the British National Formulary for Children for use in gastroenteritis and it is not included in the National Institute for Health and Care Excellence algorithm for the management of gastroenteritis in children under 5 years. This article discusses the findings of a literature review of the outcomes of ondansetron use in children with gastroenteritis in the emergency department. The article concludes that ondansetron appears to be a beneficial and useful adjunct to the treatment of gastroenteritis in children.
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Affiliation(s)
- Elizabeth Lloyd-Martin
- emergency department, Birmingham Children's Hospital, Birmingham, England, and senior lecturer in children's nursing, University of Wolverhampton, Walsall, England
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5
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Baker AH, Eisenberg M. Gastroenteritis Care in the US and Canada: Can Comparative Analysis Improve Resource Use? Pediatrics 2021; 147:peds.2021-050436. [PMID: 34016657 DOI: 10.1542/peds.2021-050436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Matthew Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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Freedman SB, Roskind CG, Schuh S, VanBuren JM, Norris JG, Tarr PI, Hurley K, Levine AC, Rogers A, Bhatt S, Gouin S, Mahajan P, Vance C, Powell EC, Farion KJ, Sapien R, O'Connell K, Poonai N, Schnadower D. Comparing Pediatric Gastroenteritis Emergency Department Care in Canada and the United States. Pediatrics 2021; 147:e2020030890. [PMID: 34016656 PMCID: PMC8785749 DOI: 10.1542/peds.2020-030890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data. METHODS We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit. RESULTS In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8). CONCLUSIONS Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada;
| | - Cindy G Roskind
- Department of Emergency Medicine, Medical Center, Columbia University, New York, New York
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario
| | - John M VanBuren
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jesse G Norris
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Katrina Hurley
- Department of Emergency Medicine, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adam C Levine
- Department of Emergency Medicine, Hasbro Children's Hospital, Rhode Island Hospital and Brown University, Providence, Rhode Island
| | - Alexander Rogers
- Departments of Emergency Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Seema Bhatt
- Division of Emergency Medicine, Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Serge Gouin
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Elizabeth C Powell
- Department of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ken J Farion
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Robert Sapien
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Karen O'Connell
- Departments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University and Children's National Hospital, Washington, DC; and
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
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7
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Heath A, Rios JD, Williamson-Urquhart S, Pechlivanoglou P, Offringa M, McCabe C, Hopkin G, Plint AC, Dixon A, Beer D, Gouin S, Joubert G, Klassen TP, Freedman SB. A pragmatic randomized controlled trial of multi-dose oral ondansetron for pediatric gastroenteritis (the DOSE-AGE study): statistical analysis plan. Trials 2020; 21:735. [PMID: 32838813 PMCID: PMC7445935 DOI: 10.1186/s13063-020-04651-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background Acute gastroenteritis is a leading cause of emergency department visits and hospitalizations among children in North America. Oral-rehydration therapy is recommended for children with mild-to-moderate dehydration, but children who present with vomiting are frequently offered intravenous rehydration in the emergency department (ED). Recent studies have demonstrated that the anti-emetic ondansetron can reduce vomiting, intravenous rehydration, and hospitalization when administered in the ED to children with dehydration. However, there is little evidence of additional benefit from prescribing ondansetron beyond the initial ED dose. Moreover, repeat dosing may increase the frequency of diarrhea. Despite the lack of evidence and potential adverse side effects, many physicians across North America provide multiple doses of ondansetron to be taken following ED disposition. Thus, the Multi-Dose Oral Ondansetron for Pediatric Gastroenteritis (DOSE-AGE) trial will evaluate the effectiveness of prescribing multiple doses of ondansetron to treat acute gastroenteritis-associated vomiting. This article specifies the statistical analysis plan (SAP) for the DOSE-AGE trial and was submitted before the outcomes of the study were available for analysis. Methods/design The DOSE-AGE study is a phase III, 6-center, placebo-controlled, double-blind, parallel design randomized controlled trial designed to determine whether participants who are prescribed multiple doses of oral ondansetron to administer, as needed, following their ED visit have a lower incidence of experiencing moderate-to-severe gastroenteritis, as measured by the Modified Vesikari Scale score, compared with a placebo. To assess safety, the DOSE-AGE trial will investigate the frequency and maximum number of diarrheal episodes following ED disposition, and the occurrence of palpitations, pre-syncope/syncope, chest pain, arrhythmias, and serious adverse events. For the secondary outcomes, the DOSE-AGE trial will investigate the individual elements of the Modified Vesikari Scale score and caregiver satisfaction with the therapy. Discussion The DOSE-AGE trial will provide evidence on the effectiveness of multiple doses of oral ondansetron, taken as needed, following an initial ED dose in children with acute gastroenteritis-associated vomiting. The data from the DOSE-AGE trial will be analyzed using this SAP. This will reduce the risk of producing data-driven results and bias in our reported outcomes. The DOSE-AGE study was registered on ClinicalTrials.gov on February 22, 2019. Trial registration ClinicalTrials.gov NCT03851835. Registered on 22 February 2019.
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Affiliation(s)
- Anna Heath
- University of Toronto, Toronto, Ontario, Canada. .,University College London, London, United Kingdom. .,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Juan David Rios
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah Williamson-Urquhart
- Pediatric Emergency Research Team, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Gareth Hopkin
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital Research Institute, Ottawa, Canada
| | - Andrew Dixon
- Stollery Children's Hospital, University of Alberta, Women's and Children's Health Research Institute, Edmonton, Canada
| | - Darcy Beer
- Pediatrics/Pediatric Emergency Medicine, Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Serge Gouin
- Université de Montréal, Montréal, Québec, Canada.,CHU Sainte-Justine, Montréal, Québec, Canada
| | - Gary Joubert
- Children's Hospital, Western University, London, Ontario, Canada
| | - Terry P Klassen
- University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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8
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Creedon JK, Eisenberg M, Monuteaux MC, Samnaliev M, Levy J. Reduction in Resources and Cost for Gastroenteritis Through Implementation of Dehydration Pathway. Pediatrics 2020; 146:peds.2019-1553. [PMID: 32487592 DOI: 10.1542/peds.2019-1553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Management decisions for patients with gastroenteritis affect resource use within pediatric emergency departments (EDs), and algorithmic care using evidence-based guidelines (EBGs) has become widespread. We aimed to determine if the implementation of a dehydration EBG in a pediatric ED resulted in a reduction in intravenous (IV) fluid administration and the cost of care. METHODS In a single-center quality improvement initiative between 2010 and 2016, investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluids. The EBG assigned the patient a dehydration score with subsequent rehydration strategy on the basis of presenting signs and symptoms. The primary outcome was proportion of patients receiving IV fluid, which was analyzed using statistical process control methods. The secondary outcome was cost of the episode of care. Balancing measures included ED length of stay, admission rate, and return visit rate within 72 hours. RESULTS A total of 7145 patients met inclusion criteria with a median age of 17 months. Use of IV fluid decreased from a mean of 15% to 9% postimplementation. Average episode of care-related health care costs decreased from $599 to $410. For our balancing measures, there were improvements in ED length of stay, rate of admission, and rate of return visits. CONCLUSIONS Implementation of an EBG for patients with gastroenteritis led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.
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Affiliation(s)
| | | | | | | | - Jason Levy
- Boston Children's Hospital, Boston, Massachusetts
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9
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A prospective comparative study of children with gastroenteritis: emergency department compared with symptomatic care at home. Eur J Clin Microbiol Infect Dis 2019; 38:2371-2379. [PMID: 31502119 DOI: 10.1007/s10096-019-03688-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/26/2019] [Indexed: 12/20/2022]
Abstract
Little is known about the epidemiology and severity of gastroenteritis among children treated at home. We sought to compare illness severity and etiology between children brought for emergency department (ED) care to those managed at home (i.e., community). Prospective cohort study of children enrolled between December 2014 and December 2016 in two pediatric EDs in Alberta, Canada along with children treated at home after telephone triage (i.e., community). Primary outcomes were maximal frequency of vomiting and diarrhea in the 24-h pre-enrollment period; secondary outcomes included etiologic pathogens, dehydration severity, future healthcare visits, and treatments provided. A total of 1613 patients (1317 ED, 296 community) were enrolled. Median maximal frequency of vomiting was higher in the ED cohort (5 (3, 10) vs. 5 (2, 8); P < 0.001). Proportion of children with diarrhea and its 24-h median frequency were lower in the ED cohort (61.3 vs. 82.8% and 2 (0, 6) vs. 4 (1, 7); P < 0.001, respectively). In regression analysis, the ED cohort had a higher maximum number of vomiting episodes pre-enrollment (incident rate ratio (IRR) 1.25; 95% CI 1.12, 1.40) while the community cohort had higher maximal 24-h period diarrheal episodes (IRR 1.20; 95% CI 1.01, 1.43). Norovirus was identified more frequently in the community cohort (36.8% vs. 23.6%; P < 0.001). Children treated in the ED have a greater number of vomiting episodes; those treated at home have more diarrheal episodes. Norovirus is more common among children treated symptomatically at home and thus may represent a greater burden of disease than previously thought.
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10
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Query LA, Olson KR, Meyer MT, Drendel AL. Minding the Gap: A Qualitative Study of Provider Experience to Optimize Care for Critically Ill Children in General Emergency Departments. Acad Emerg Med 2019; 26:803-813. [PMID: 30267596 DOI: 10.1111/acem.13624] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pediatric emergency care provision in the United States is uneven. Institutional barriers to readiness in the general emergency department (GED) are known, but little is understood about the frontline providers. Our objective was to explore the lived experiences of emergency medicine (EM) providers caring for acutely ill children in the GED and identify opportunities to optimize their pediatric practice. METHODS This grounded theory study used theoretical sampling with snowball recruitment to enroll EM physicians and advanced practice providers from 25 Wisconsin GEDs. Participants completed one-on-one, semistructured interviews. Audio recordings were transcribed and coded by a multi-investigator team drawing on theory produced from comparative analysis. RESULTS We reached theoretical saturation with 18 participants. The data suggested that providers felt competent managing routine pediatric care, but critically ill children outstripped their resources and expertise. They recognized environmental constraints on the care they could safely provide, which were intensified by unanticipated knowledge gaps and lack of awareness regarding pediatric practice guidelines. A fragmented medical network to support their pediatric practice was identified as a challenge to their care provision at critical junctures. Due to lack of guidance and feedback, providers internalized their experience with critically ill children with uncertainty, which limited learning and practice change. They benefited from meaningful relationships with pediatricians and pediatric subspecialists, targeted education, timely consults, and looped feedback about care provided and patient outcomes. CONCLUSIONS General ED providers struggled with critically ill children because they could not anticipate their pediatric-specific knowledge gaps and only realized them at critical junctures. EM providers were isolated and frustrated when seeking help; without guidance and feedback they internalized their experience with uncertainty and were left underprepared for subsequent encounters. The data suggested the need for provider-focused interventions to address gaps in pediatric-specific continuing medical education, just-in-time assistance, and knowledge transfer.
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Affiliation(s)
- Lindsey A. Query
- Department of Pediatrics Medical College of Wisconsin Milwaukee WI
- Division of Emergency Medicine Medical College of Wisconsin Milwaukee WI
| | - Krisjon R. Olson
- Department of Pediatrics Medical College of Wisconsin Milwaukee WI
- Division of Critical Care Medical College of Wisconsin Milwaukee WI
| | - Michael T. Meyer
- Department of Pediatrics Medical College of Wisconsin Milwaukee WI
- Division of Critical Care Medical College of Wisconsin Milwaukee WI
| | - Amy L. Drendel
- Department of Pediatrics Medical College of Wisconsin Milwaukee WI
- Division of Emergency Medicine Medical College of Wisconsin Milwaukee WI
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11
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Outcomes From Referrals and Unscheduled Visits From Community Emergency Departments to a Regional Pediatric Emergency Department in Canada. Pediatr Emerg Care 2019; 35:185-189. [PMID: 28072666 DOI: 10.1097/pec.0000000000001013] [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: 11/26/2022]
Abstract
OBJECTIVES Existing pediatric literature describing repeat visits to the emergency department (ED) for the same medical complaint has yet to report on patient flow patterns from general EDs (GEDs) to a pediatric ED (PED). We sought to characterize the population of patients who are treated in a GED and subsequently present to a PED for further care. METHODS We conducted a retrospective cohort study reviewing all pediatric visits (age < 17 y) at 5 GEDs in Vancouver. Our primary outcome measure was the proportion of visits with a subsequent visit to a PED (<7 days) during the 2012 to 2013 fiscal year. Secondary outcomes included reasons for PED consultation, the clinical services accessed, and disposition at the PED. RESULTS During the study period, 581 (3.3%) of the 17,824 children seen at GEDs subsequently presented to the PED within 7 days. The top 3 diagnoses among these were fracture, viral infection, and musculoskeletal complaints. Of the 581 children with a visit to the PED, 180 (31.0%) were referred to the PED for a consultation, whereas the rest were family initiated. Referred visits were more frequently associated with pediatric subspecialist consultation than family-initiated visits (45.0% vs 19.5%, P < 0.01). The referred group more frequently resulted in a surgical procedure (13.9% vs 2.5%, P < 0.01) or hospital admission (51.7% vs 8.7%, P < 0.01). CONCLUSIONS Knowing the proportion, management, and outcomes of children who are treated in a GED and subsequently at a PED may provide an important quality measure and opportunities to improve the management of common pediatric emergencies in the community.
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Jabbour M, Newton AS, Johnson D, Curran JA. Defining barriers and enablers for clinical pathway implementation in complex clinical settings. Implement Sci 2018; 13:139. [PMID: 30419942 PMCID: PMC6233585 DOI: 10.1186/s13012-018-0832-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/22/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. METHODS This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel. RESULTS Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. CONCLUSIONS Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. TRIAL REGISTRATION ClinicalTrials.gov, NCT01815710 .
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Affiliation(s)
- Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Road, Room W1415, Ottawa, ON, K1H 8L1, Canada.
- University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
| | - Amanda S Newton
- Department of Pediatrics, Division of General Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David Johnson
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
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Abstract
OBJECTIVE Despite a substantial consistency in recommendations for the management of children with acute gastroenteritis (AGE), a high variability in clinical practice and a high rate of inappropriate medical interventions persist in both developing and developed countries.The aim of this study was to develop a set of clinical recommendations for the management of nonseverely malnourished children with AGE to be applied worldwide. METHODS The Federation of International Societies of Pediatric Gastroenterology, Hepatology, and Nutrition (FISPGHAN) Working Group (WG) selected care protocols on the management of acute diarrhea in infants and children aged between 1 month and 18 years. The WG used a 3-step approach consisting of: systematic review and comparison of published guidelines, agreement on draft recommendations using Delphi methodology, and external peer-review and validation of recommendations. RESULTS A core of recommendations including definition, diagnosis, nutritional management, and active treatment of AGE was developed with an overall agreement of 91% (range 80%-96%). A total of 28 world experts in pediatric gastroenterology and emergency medicine successively validated the set of 23 recommendations with an agreement of 87% (range 83%-95%). Recommendations on the use of antidiarrheal drugs and antiemetics received the lowest level of agreement and need to be tailored at local level. Oral rehydration and probiotics were the only treatments recommended. CONCLUSIONS Universal recommendations to assist health care practitioners in managing children with AGE may improve practitioners' compliance with guidelines, reduce inappropriate interventions, and significantly impact clinical outcome and health care-associated costs.
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Stanley RM, Jabbour M, Saunders JM, Zuspan SJ. The Pediatric Emergency Care Applied Research Network and Knowledge Translation. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Featherstone RM, Leggett C, Knisley L, Jabbour M, Klassen TP, Scott SD, Van De Mosselaer G, Hartling L. Creation of an Integrated Knowledge Translation Process to Improve Pediatric Emergency Care in Canada. HEALTH COMMUNICATION 2018; 33:980-987. [PMID: 28537762 DOI: 10.1080/10410236.2017.1323538] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
TREKK (Translating Emergency Knowledge for Kids) was established to address knowledge needs to support care of children in general emergency departments. To achieve this goal, we developed an integrated knowledge translation (KT) process based on identified priorities to create the TREKK Evidence Repository, containing "knowledge pyramids" and Bottom Line Recommendations (summary documents) on the diagnosis and treatment of emergency pediatric conditions. The objective of this article is to describe our methods for developing and disseminating the TREKK Evidence Repository to improve pediatric emergency care in Canada. Our work was guided by the research question: Can an integrated KT process address an information gap in healthcare practice? We utilized a pyramid-shaped framework, built upon the "4S" hierarchy of evidence model, to provide detailed evidence appropriate to stakeholders' needs. For each priority condition (asthma, bronchiolitis, croup, etc.), clinical advisors and KT experts collaborated to create a Bottom Line Recommendation and to select guidelines, reviews, and key studies for that condition's topic area in the Evidence Repository on the TREKK website (trekk.ca). Targeted promotion, including a social media campaign, communicated the availability of new topics in the Evidence Repository and available knowledge tools. Feedback from 35 end-users on pilot versions of the Evidence Repository was positive with 91% indicating that they would use the resource in the emergency department. Using an integrated KT process, we responded to end-users' requests for varying level of information on priority pediatric conditions through the creation of knowledge tools and development of a process to identify and vet high quality evidence-based resources.
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Affiliation(s)
- Robin M Featherstone
- a Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics , University of Alberta
| | - Carly Leggett
- b Children's Hospital Research Institute of Manitoba
| | - Lisa Knisley
- b Children's Hospital Research Institute of Manitoba
| | - Mona Jabbour
- c Children's Hospital of Eastern Ontario , University of Ottawa
| | | | | | | | - Lisa Hartling
- a Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics , University of Alberta
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Gates A, Featherstone R, Shave K, Scott SD, Hartling L. Dissemination of evidence in paediatric emergency medicine: a quantitative descriptive evaluation of a 16-week social media promotion. BMJ Open 2018; 8:e022298. [PMID: 29880576 PMCID: PMC6009559 DOI: 10.1136/bmjopen-2018-022298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES TRanslating Emergency Knowledge for Kids (TREKK) and Cochrane Child Health collaborate to develop knowledge products on paediatric emergency medicine topics. Via a targeted social media promotion, we aimed to increase user interaction with the TREKK and Cochrane Child Health Twitter accounts and the uptake of TREKK Bottom Line Recommendations (BLRs) and Cochrane systematic reviews (SRs). DESIGN Quantitative descriptive evaluation. SETTING We undertook this study and collected data via the internet. PARTICIPANTS Our target users included online healthcare providers and health consumers. INTERVENTION For 16 weeks, we used Twitter accounts (@TREKKca and @Cochrane_Child) and the Cochrane Child Health blog to promote 6 TREKK BLRs and 16 related Cochrane SRs. We published 1 blog post and 98 image-based tweets per week. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was user interaction with @TREKKca and @Cochrane_Child. Secondary outcomes were visits to TREKK's website and the Cochrane Child Health blog, clicks to and views of the TREKK BLRs, and Altmetric scores and downloads of Cochrane SRs. RESULTS Followers to @TREKKca and @Cochrane_Child increased by 24% and 15%, respectively. Monthly users of TREKK's website increased by 29%. Clicks to the TREKK BLRs increased by 22%. The BLRs accrued 59% more views compared with the baseline period. The 16 blog posts accrued 28% more views compared with the 8 previous months when no new posts were published. The Altmetric scores for the Cochrane SRs increased by ≥10 points each. The mean number of full text downloads for the promotion period was higher for nine and lower for seven SRs compared with the 16-week average for the previous year (mean difference (SD), +4.0 (22.0%)). CONCLUSIONS There was increased traffic to TREKK knowledge products and Cochrane SRs during the social media promotion. Quantitative evidence supports blogging and tweeting as dissemination strategies for evidence-based knowledge products.
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Affiliation(s)
- Allison Gates
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Kassi Shave
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Cochrane Child Health, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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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
BACKGROUND Guidelines recommend oral rehydration therapy (ORT) and avoidance of laboratory tests and intravenous fluids for mild to moderate dehydration in children with gastroenteritis; oral ondansetron has been shown to be an effective adjunct. OBJECTIVES The aim of this study was to determine if a triage-based, nurse-initiated protocol for early provision of ondansetron and ORT could safely improve the care of pediatric emergency department (ED) patients with symptoms of gastroenteritis. METHODS This study evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated. Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible. Prospective postintervention data were compared with retrospective, preintervention control subjects. RESULTS One hundred twenty-eight (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years. Ondansetron use increased from 36% to 75% (P < 0.001). Time to ondansetron decreased from 60 minutes to 30 minutes (P = 0.004). Documented ORT increased from 51% to 100% (P < 0.001). Blood testing decreased from 37% to 21% (P = 0.007); intravenous fluid decreased from 23% to 9% (P = 0.03). Fifty-two percent of postintervention patients were discharged with prescriptions for ondansetron. There were no significant changes in ED length of stay, admissions, or unscheduled return to care. CONCLUSIONS A triage nurse-initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care.
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Crockett LK, Leggett C, Curran JA, Knisley L, Brockman G, Scott SD, Hartling L, Jabbour M, Klassen TP. Knowledge sharing between general and pediatric emergency departments: connections, barriers, and opportunities. CAN J EMERG MED 2018; 20:1-9. [PMID: 29467040 DOI: 10.1017/cem.2018.7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Translating Emergency Knowledge for Kids (TREKK) is a national network aimed at improving emergency care for children by increasing collaborations and knowledge sharing between general and pediatric emergency departments (EDs). This study aimed to determine patterns of knowledge sharing within the network and to identify connections, barriers, and opportunities to obtaining pediatric information and training. METHODS We conducted 22 semi-structured interviews with health care professionals working in general EDs, purposefully sampled to represent connected and disconnected sites, based on two previous internal quantitative social network analyses (SNA). Data were analyzed by two independent reviewers. RESULTS Participants included physicians (59%) and nurses (41%) from 18 general EDs in urban (68%) and rural/remote (32%) Canada. Health care professionals sought information both formally and informally, by using guidelines, talking to colleagues, and attending pediatric related training sessions. Network structure and processes were found to increase connections, support practice change, and promote standards of care. Participants identified personal, organizational and system level barriers to information and skill acquisition, including resources and personal costs, geography, dissemination, and time. Providing easy access to information at the point of care was promoted through enhancing content visibility and by embedding resources into local systems. There remains a need to share successful methods of local dissemination and implementation across the network, and to leverage local professional champions such as clinical nurse liaisons. CONCLUSIONS These findings reinforce the critical role of ongoing network evaluation to improve the design and delivery of knowledge mobilization initiatives.
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Affiliation(s)
- Leah K Crockett
- *George & Fay Yee Centre for Health Care Innovation,Winnipeg,MB
| | - Carly Leggett
- *George & Fay Yee Centre for Health Care Innovation,Winnipeg,MB
| | | | - Lisa Knisley
- †Children's Hospital Research Institute of Manitoba,Winnipeg,MB
| | | | | | - Lisa Hartling
- ¶Department of Pediatrics,University of Alberta,Edmonton,AB
| | - Mona Jabbour
- **Department of Pediatrics,University of Ottawa,Ottawa,ON
| | - Terry P Klassen
- *George & Fay Yee Centre for Health Care Innovation,Winnipeg,MB
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Abstract
OBJECTIVE The objective of the study was to describe the origins, growth, and progress of a national research network in pediatric emergency medicine. METHODS The success of Pediatric Emergency Research Canada (PERC) is described in terms of advancing the pediatric emergency medicine agenda, grant funding, peer-reviewed publications, mentoring new investigators, and global collaborations. RESULTS Since 1995, clinicians and investigators within PERC have grown the network to 15 active tertiary pediatric emergency medicine sites across Canada. Investigators have advanced the research agenda in numerous areas, including gastroenteritis, bronchiolitis, croup, head injury, asthma, and injury management. Since the first PERC Annual Scientific meeting in 2004, the attendance has increased by approximately 400% to 152 attendees, 65 presentations, and 13 project/investigator meetings. More than $33 million in grant funding has been awarded to the network, and has published 76 peer-reviewed articles. In 2011, PERC's success was recognized with a Top Achievement Award in Health Research from Canadian Institutes of Health Research and the Canadian Medical Association Journal. CONCLUSIONS Moving forward, PERC will continue to focus on the creation of new knowledge, the mentorship of new investigators and fellows in developing research projects, and promoting a pediatric emergency medicine-focused research agenda guided by the pooling of expertise from individuals across the nation. Through collaborations with networks across the globe, PERC will continue to strive for the conduct of high-quality, impactful research that improves outcomes in children with acute illness and injury.
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Lind CH, Johnson DP. Things We Do For No Reason: Electrolyte Testing in Pediatric Acute Gastroenteritis. J Hosp Med 2018; 13:49-51. [PMID: 29186214 DOI: 10.12788/jhm.2884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Carrie H Lind
- Division of Pediatric Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA.
| | - David P Johnson
- Division of Pediatric Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
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Schnadower D, Tarr PI, Charles CT, Gorelick MH, Dean MJ, O’Connell KJ, Mahajan P, Chun TH, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Gao F, Freedman SB. Randomised controlled trial of Lactobacillus rhamnosus (LGG) versus placebo in children presenting to the emergency department with acute gastroenteritis: the PECARN probiotic study protocol. BMJ Open 2017; 7:e018115. [PMID: 28947466 PMCID: PMC5623493 DOI: 10.1136/bmjopen-2017-018115] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Acute gastroenteritis (AGE) is a common and burdensome condition that affects millions of children worldwide each year. Currently available strategies are limited to symptomatic management, treatment and prevention of dehydration and infection control; no disease-modifying interventions exist. Probiotics, defined as live microorganisms beneficial to the host, have shown promise in improving AGE outcomes, but existing studies have sufficient limitations such that the use of probiotics cannot currently be recommended with confidence. Here we present the methods of a large, rigorous, randomised, double-blind placebo-controlled study to assess the effectiveness and side effect profile of Lactobacillus rhamnosus GG (LGG) (ATCC 53103) in children with AGE. METHODS AND ANALYSIS The study is being conducted in 10 US paediatric emergency departments (EDs) within the federally funded Pediatric Emergency Care Applied Research Network, in accordance with current SPIRIT and CONSORT statement recommendations. We will randomise 970 children presenting to participating EDs with AGE to either 5 days of treatment with LGG (1010colony-forming unit twice a day) or placebo between July 2014 to December 2017. The main outcome is the occurrence of moderate-to-severe disease over time, as defined by the Modified Vesikari Scale. We also record adverse events and side effects related to the intervention. We will conduct intention-to-treat analyses and use an enrichment design to restore the statistical power in case the presence of a subpopulation with a substantially low treatment effect is identified. ETHICS AND DISSEMINATION Institutional review board approval has been obtained at all sites, and data and material use agreements have been established between the participating sites. The results of the trial will be published in peer-reviewed journals. A deidentified public data set will be made available after the completion of all study procedures. TRIAL REGISTRATION NUMBER NCT01773967.
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Affiliation(s)
- David Schnadower
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Phillip I Tarr
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Washington University, School of Medicine, St. Louis, Missouri, USA
| | - Casper T Charles
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Marc H Gorelick
- Central Administration, Children’s Hospital Minnesota, Minneapolis, Minnesota, USA
| | - Michael J Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Karen J O’Connell
- Division of Emergency Medicine, Children’s National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan Wayne State University, Detroit, Michigan, USA
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas H Chun
- Department of Emergency Medicine and Pediatrics Providence, Hasbro Children’s Hospital and Brown University, Providence, Rhode Island, USA
| | - Seema R Bhatt
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cindy G Roskind
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Elizabeth C Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Feng Gao
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Tavarez MM, Ayers B, Jeong JH, Coombs CM, Thompson A, Hickey RW. Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department. Acad Emerg Med 2017; 24:948-956. [PMID: 28470786 DOI: 10.1111/acem.13211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/07/2017] [Accepted: 04/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. METHODS We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders. RESULTS There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods. CONCLUSIONS Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.
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Affiliation(s)
- Melissa M. Tavarez
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Brandon Ayers
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
| | - Jong H. Jeong
- Department of Biostatistics; Graduate School of Public Health; University of Pittsburgh; Pittsburgh PA
| | - Carmen M. Coombs
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Ann Thompson
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Robert W. Hickey
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
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Beglinger S. [Not Available]. PRAXIS 2017; 106:209-217. [PMID: 28211756 DOI: 10.1024/1661-8157/a002607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Die häufigsten Gründe, weshalb ein Kind in der Praxis oder im Spital vorgestellt wird, sind Dehydratation und Trink-/Essensverweigerung aufgrund einer akuten Gastroenteritis (AGE). Die häufigste Ursache einer AGE ist das Rotavirus, gefolgt von Norovirus und seltenen bakteriellen Erkrankungen. Eine Erregerdiagnostik ist dabei nur selten nötig. Der Dehydratationsgrad wird vornehmlich klinisch anhand eines Dehydratations-Scores gestellt. Ziel der Dehydratationstherapie sind die rasche Rehydrierung und Wiederaufnahme von Flüssigkeit und Nahrung durch das Kind. Eine Rehydratationstherapie (RT) sollte wenn immer möglich per os oder per Magensonde stattfinden und nur in schweren Fällen intravenös. Bei einem prolongierten Verlauf sind weitere Abklärungen beim gastroenterologischen Spezialisten empfehlenswert.
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Affiliation(s)
- Svetlana Beglinger
- 1 Interdisziplinäre Notfallstation, Universitäts-Kinderspital beider Basel
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Pediatric information seeking behaviour, information needs, and information preferences of health care professionals in general emergency departments: Results from the Translating Emergency Knowledge for Kids (TREKK) Needs Assessment. CAN J EMERG MED 2017; 20:89-99. [DOI: 10.1017/cem.2016.406] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractThe majority of children requiring emergency care are treated in general emergency departments (EDs) with variable levels of pediatric care expertise. The goal of the Translating Emergency Knowledge for Kids (TREKK) initiative is to implement the latest research in pediatric emergency medicine in general EDs to reduce clinical variation.ObjectivesTo determine national pediatric information needs, seeking behaviours, and preferences of health care professionals working in general EDs.MethodsAn electronic cross-sectional survey was conducted with health care professionals in 32 Canadian general EDs. Data were collected in the EDs using the iPad and in-person data collectors.ResultsTotal of 1,471 surveys were completed (57.1% response rate). Health care professionals sought information on children’s health care by talking to colleagues (n=1,208, 82.1%), visiting specific medical/health websites (n=994, 67.7%), and professional development opportunities (n=941, 64.4%). Preferred child health resources included protocols and accepted treatments for common conditions (n=969, 68%), clinical pathways and practice guidelines (n=951, 66%), and evidence-based information on new diagnoses and treatments (n=866, 61%). Additional pediatric clinical information is needed about multisystem trauma (n=693, 49%), severe head injury (n=615, 43%), and meningitis (n=559, 39%). Health care professionals preferred to receive child health information through professional development opportunities (n=1,131, 80%) and printed summaries (n=885, 63%).ConclusionBy understanding health care professionals’ information seeking behaviour, information needs, and information preferences, knowledge synthesis and knowledge translation initiatives can be targeted to improve pediatric emergency care. The findings from this study will inform the following two phases of the TREKK initiative to bridge the research-practice gap in Canadian general EDs.
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Lind CH, Hall M, Arnold DH, Browning W, Johnson DP, Plemmons G, Zaman N, Williams DJ. Variation in Diagnostic Testing and Hospitalization Rates in Children With Acute Gastroenteritis. Hosp Pediatr 2016; 6:714-721. [PMID: 27899409 DOI: 10.1542/hpeds.2016-0085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Donald H Arnold
- Emergency Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee; and
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Marchetti F, Bonati M, Maestro A, Zanon D, Rovere F, Arrighini A, Barbi E, Bertolani P, Biban P, Da Dalt L, Guala A, Mazzoni E, Pazzaglia A, Perri PF, Reale A, Renna S, Urbino AF, Valletta E, Vitale A, Zangardi T, Clavenna A, Ronfani L. Oral Ondansetron versus Domperidone for Acute Gastroenteritis in Pediatric Emergency Departments: Multicenter Double Blind Randomized Controlled Trial. PLoS One 2016; 11:e0165441. [PMID: 27880811 PMCID: PMC5120790 DOI: 10.1371/journal.pone.0165441] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 10/07/2016] [Indexed: 01/28/2023] Open
Abstract
The use of antiemetics for vomiting in acute gastroenteritis in children is still a matter of debate. We conducted a double-blind randomized trial to evaluate whether a single oral dose of ondansetron vs domperidone or placebo improves outcomes in children with gastroenteritis. After failure of initial oral rehydration administration, children aged 1–6 years admitted for gastroenteritis to the pediatric emergency departments of 15 hospitals in Italy were randomized to receive one oral dose of ondansetron (0.15 mg/kg) or domperidone (0.5 mg/kg) or placebo. The primary outcome was the percentage of children receiving nasogastric or intravenous rehydration. A p value of 0.014 was used to indicate statistical significance (and 98.6% CI were calculated) as a result of having carried out two interim analyses. 1,313 children were eligible for the first attempt with oral rehydration solution, which was successful for 832 (63.4%); 356 underwent randomization (the parents of 125 children did not give consent): 118 to placebo, 119 to domperidone, and 119 to ondansetron. Fourteen (11.8%) needed intravenous rehydration in the ondansetron group vs 30 (25.2%) and 34 (28.8%) in the domperidone and placebo groups, respectively. Ondansetron reduced the risk of intravenous rehydration by over 50%, both vs placebo (RR 0.41, 98.6% CI 0.20–0.83) and domperidone (RR 0.47, 98.6% CI 0.23–0.97). No differences for adverse events were seen among groups. In a context of emergency care, 6 out of 10 children aged 1–6 years with vomiting due to gastroenteritis and without severe dehydration can be managed effectively with administration of oral rehydration solution alone. In children who fail oral rehydration, a single oral dose of ondansetron reduces the need for intravenous rehydration and the percentage of children who continue to vomit, thereby facilitating the success of oral rehydration. Domperidone was not effective for the symptomatic treatment of vomiting during acute gastroenteritis.
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Affiliation(s)
- Federico Marchetti
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo”, Trieste, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo”, Trieste, Italy
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo”, Trieste, Italy
| | - Francesca Rovere
- Pharmacy and Clinical Pharmacology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo”, Trieste, Italy
| | - Alberto Arrighini
- Pediatric Emergency Department, Presidio Ospedale dei Bambini, A.O. Spedali Civili, Brescia, Italy
| | - Egidio Barbi
- Pediatric Emergency Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo”, Trieste, Italy
| | - Paolo Bertolani
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Biban
- Pediatric Emergency Department, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Andrea Guala
- Department of Pediatrics, Ospedale Castelli, Verbania, Italy
| | - Elisa Mazzoni
- Department of Pediatrics, Ospedale Maggiore, Bologna, Italy
| | - Anna Pazzaglia
- Emergency Department, Pediatric Hospital A. Meyer, Firenze, Italy
| | | | - Antonino Reale
- Emergency Department, Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Salvatore Renna
- Emergency Room and Emergency Medicine Division, G. Gaslini Institute, Genova, Italy
| | | | - Enrico Valletta
- Department of Pediatrics, Ospedale G.B. Morgagni - L. Pierantoni, Forlì, Italy
| | - Antonio Vitale
- Department of Pediatrics and Pediatric Emergency, "San Giuseppe Moscati" National Hospital (AORN), Avellino, Italy
| | - Tiziana Zangardi
- Pediatric Emergency Department, Azienda Ospedaliera - University of Padova, Padova, Italy
| | - Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo”, Trieste, Italy
- * E-mail:
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Pediatric acute gastroenteritis: understanding caregivers' experiences and information needs. CAN J EMERG MED 2016; 19:198-206. [PMID: 27608979 DOI: 10.1017/cem.2016.363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Pediatric acute gastroenteritis (AGE) is a common condition with high health care utilization, persistent practice variation, and substantial family burden. An initial approach to resolve these issues is to understand the patient/caregiver experience of this illness. The objective of this study was to describe caregivers' experiences of pediatric AGE and identify their information needs, preferences, and priorities. METHODS A qualitative, descriptive study was conducted. Caregivers of a child with AGE were recruited for this study in the pediatric emergency department (ED) at a tertiary hospital in a major urban centre. Individual interviews were conducted (n=15), and a thematic analysis of interview transcripts was completed using a hybrid inductive/deductive approach. RESULTS Five major themes were identified and described: 1) caregiver management strategies; 2) reasons for going to the ED; 3) treatment and management of AGE in the ED; 4) caregivers' information needs; and 5) additional factors influencing caregivers' experiences and decision-making. A number of subthemes within each major theme were identified and described. CONCLUSIONS This qualitative descriptive study has identified caregiver information needs, preferences, and priorities regarding pediatric AGE. This study also identified inconsistencies in the treatment and management of pediatric AGE at home and in the ED that influence health care utilization and patient outcomes related to pediatric AGE.
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Vecchio AL, Dias JA, Berkley JA, Boey C, Cohen MB, Cruchet S, Liguoro I, Lindo ES, Sandhu B, Sherman P, Shimizu T, Guarino A. Comparison of Recommendations in Clinical Practice Guidelines for Acute Gastroenteritis in Children. J Pediatr Gastroenterol Nutr 2016; 63:226-35. [PMID: 26835905 PMCID: PMC6858859 DOI: 10.1097/mpg.0000000000001133] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Acute gastroenteritis (AGE) is a major cause of child mortality and morbidity. This study aimed at systematically reviewing clinical practice guidelines (CPGs) on AGE to compare recommendations and provide the basis for developing single universal guidelines. METHODS CPGs were identified by searching MEDLINE, Cochrane-Library, National Guideline Clearinghouse and Web sites of relevant societies/organizations producing and/or endorsing CPGs. RESULTS The definition of AGE varies among the 15 CPGs identified. The parameters most frequently recommended to assess dehydration are skin turgor and sunken eyes (11/15, 73.3%), general appearance (11/15, 66.6%), capillary refill time, and mucous membranes appearance (9/15, 60%). Oral rehydration solution is universally recognized as first-line treatment. The majority of CPGs recommend hypo-osmolar (Na 45-60 mmol/L, 11/15, 66.6 %) or low-osmolality (Na 75 mmol/L, 9/15, 60%) solutions. In children who fail oral rehydration, most CPGs suggest intravenous rehydration (66.6%). However, nasogastric tube insertion for fluid administration is preferred according by 5/15 CPGs (33.3%). Changes in diet and withdrawal of food are discouraged by all CPGs, and early refeeding is strongly recommended in 13 of 15 (86.7%). Zinc is recommended as an adjunct to ORS by 10 of 15 (66.6%) CPGs, most of them from low-income countries. Probiotics are considered by 9 of 15 (60%) CPGs, 5 from high-income countries. Antiemetics are not recommended in 9 of 15 (60%) CPGs. Routine use of antibiotics is discouraged. CONCLUSIONS Key recommendations for the management of AGE in children are similar in CPGs. Together with accurate review of evidence-base this may represent a starting point for developing universal recommendations for the management of children with AGE worldwide.
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Affiliation(s)
- Andrea Lo Vecchio
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Jorge Amil Dias
- Departamento de Pediatria Médica, Hospital de São João, Porto, Portugal
| | | | - Chris Boey
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mitchell B. Cohen
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | | | - Ilaria Liguoro
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | | | - Bhupinder Sandhu
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Philip Sherman
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Toshiaki Shimizu
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Alfredo Guarino
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
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Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings. J Pediatr Nurs 2016; 31:235-54. [PMID: 26786910 DOI: 10.1016/j.pedn.2015.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/14/2015] [Accepted: 12/11/2015] [Indexed: 11/21/2022]
Abstract
UNLABELLED Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice. METHODS A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables. RESULTS Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention. CONCLUSIONS This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.
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Bahm A, Freedman SB, Guan J, Guttmann A. Evaluating the Impact of Clinical Decision Tools in Pediatric Acute Gastroenteritis: A Population-based Cohort Study. Acad Emerg Med 2016; 23:599-609. [PMID: 26824763 DOI: 10.1111/acem.12915] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/06/2015] [Accepted: 11/05/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Acute gastroenteritis (AGE) is a leading cause of pediatric emergency department (ED) visits. Despite evidence-based guidelines, variation in adherence exists. Clinical decision tools can enhance evidence-based care, but little is known about their use and effectiveness in pediatric AGE. This study sought to determine if the following tools-1) pathways/order sets, 2) medical directives for oral rehydration therapy (ORT) or ondansetron, and 3) printed discharge instructions-are associated with AGE admission and ED revisits. METHODS This was a retrospective population-based cohort study of all children 3 months-18 years with an AGE ED visit in Ontario, Canada, from 2008 to 2010, using linked survey and health administrative databases. Logistic regression models associating clinical decision tools (CDTs) with hospitalizations and revisits controlling for hospital and patient characteristics were employed. RESULTS Of the 57,921 patient visits during the study period, there were 2,401 hospitalizations (4.2%). A total of 55,520 patients were discharged from the ED, with 2,378 (4.3%) experiencing a 72-hour return visit. In adjusted models, none of the tools were significantly associated with admission. Medical directive for ORT was associated with lower return visit rates (adjusted odds ratio [aOR] = 0.86, 95% confidence interval [CI] = 0.79-0.94] and printed discharge instructions with higher return visits (aOR = 1.33, 95% CI = 1.08-1.65); pathways/order sets and medical directives for ondansetron had no association. CONCLUSIONS Admissions in children with AGE are not associated with the presence of CDTs. While ORT medical directives are associated with lower ED revisits, printed discharge instructions have the opposite effect. The simple presence/absence of decision support tools does not guarantee improved clinical outcomes.
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Affiliation(s)
- Allison Bahm
- Hospital for Sick Children and the Department of Paediatrics; University of Toronto; Toronto Ontario Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology; Alberta Children's Hospital; Alberta Children's Hospital Research Institute; University of Calgary; Calgary Alberta Canada
| | - Jun Guan
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Astrid Guttmann
- Hospital for Sick Children and the Department of Paediatrics; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Department of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
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Caffarelli C, Cardinale F, Povesi-Dascola C, Dodi I, Mastrorilli V, Ricci G. Use of probiotics in pediatric infectious diseases. Expert Rev Anti Infect Ther 2015; 13:1517-35. [PMID: 26496433 DOI: 10.1586/14787210.2015.1096775] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We summarize current evidence and recommendations for the use of probiotics in childhood infectious diseases. Probiotics may be of benefit in treating acute infectious diarrhea and reducing antibiotic-associated diarrhea. Potential benefits of probiotic on prevention of traveler's diarrhea,Clostridium difficile-associated diarrhea, side effects of triple therapy in Helicobacter pylori eradication, necrotizing enterocolitis, acute diarrhea, acute respiratory infections and recurrent urinary tract infections remain unclear. More studies are needed to investigate optimal strain, dosage, bioavailability of drops and tablets, duration of treatment and safety. Probiotics and recombinant probiotic strain represent a promising source of molecules for the development of novel anti-infectious therapy.
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Affiliation(s)
- Carlo Caffarelli
- a Clinica Pediatrica, Dipartimento di Medicina Clinica e Sperimentale , Azienda Ospedaliero Universitaria di Parma, Università di Parma , Parma , Italy
| | - Fabio Cardinale
- b Azienda Ospedaliero-Universitaria "Consorziale-Policlinico", Ospedale Pediatrico Giovanni XXIII , Bari , Italy
| | - Carlotta Povesi-Dascola
- c Clinica Pediatrica , Azienda Ospedaliero Universitaria di Parma, Università di Parma , Parma , Italy
| | - Icilio Dodi
- d Dipartimento Cure Primarie, Pediatria Di Comunita` , Azienda Unità Sanitaria Locale di Parma , Parma , Italy
| | - Violetta Mastrorilli
- b Azienda Ospedaliero-Universitaria "Consorziale-Policlinico", Ospedale Pediatrico Giovanni XXIII , Bari , Italy
| | - Giampaolo Ricci
- e Gozzadini" Children's Hospital , Policlinico S.Orsola - Malpighi University of Bologna , Bologna , Italy
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Freedman SB, Lee BE, Louie M, Pang XL, Ali S, Chuck A, Chui L, Currie GR, Dickinson J, Drews SJ, Eltorki M, Graham T, Jiang X, Johnson DW, Kellner J, Lavoie M, MacDonald J, MacDonald S, Svenson LW, Talbot J, Tarr P, Tellier R, Vanderkooi OG. Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE): epidemiology, emerging organisms, and economics. BMC Pediatr 2015; 15:89. [PMID: 26226953 PMCID: PMC4521468 DOI: 10.1186/s12887-015-0407-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/15/2015] [Indexed: 01/05/2023] Open
Abstract
Background Each year in Canada there are 5 million episodes of acute gastroenteritis (AGE) with up to 70 % attributed to an unidentified pathogen. Moreover, 90 % of individuals with AGE do not seek care when ill, thus, burden of disease estimates are limited by under-diagnosing and under-reporting. Further, little is known about the pathogens causing AGE as the majority of episodes are attributed to an “unidentified” etiology. Our team has two main objectives: 1) to improve health through enhanced enteric pathogen identification; 2) to develop economic models incorporating pathogen burden and societal preferences to inform enteric vaccine decision making. Methods/Design This project involves multiple stages: 1) Molecular microbiology experts will participate in a modified Delphi process designed to define criteria to aid in interpreting positive molecular enteric pathogen test results. 2) Clinical data and specimens will be collected from children aged 0–18 years, with vomiting and/or diarrhea who seek medical care in emergency departments, primary care clinics and from those who contact a provincial medical advice line but who do not seek care. Samples to be collected will include stool, rectal swabs (N = 2), and an oral swab. Specimens will be tested employing 1) stool culture; 2) in-house multiplex (N = 5) viral polymerase chain reaction (PCR) panel; and 3) multi-target (N = 15) PCR commercially available array. All participants will have follow-up data collected 14 days later to enable calculation of a Modified Vesikari Scale score and a Burden of Disease Index. Specimens will also be collected from asymptomatic children during their well child vaccination visits to a provincial public health clinic. Following the completion of the initial phases, discrete choice experiments will be conducted to enable a better understanding of societal preferences for diagnostic testing and vaccine policy. All of the results obtained will be integrated into economic models. Discussion This study is collecting novel samples (e.g., oral swabs) from previously untested groups of children (e.g., those not seeking medical care) which are then undergoing extensive molecular testing to shed a new perspective on the epidemiology of AGE. The knowledge gained will provide the broadest understanding of the epidemiology of vomiting and diarrhea of children to date.
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Affiliation(s)
- Stephen B Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - Bonita E Lee
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
| | - Marie Louie
- Provincial Laboratory for Public Health (ProvLab, Alberta Health Services), Departments of Microbiology, Immunology & Infectious Disease and Pathology & Laboratory Medicine, University of Calgary, Calgary, AB, Canada.
| | - Xiao-Li Pang
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada.
| | - Samina Ali
- Department of Pediatrics & Emergency Medicine, University of Alberta, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, Stollery Children's Hospital, Edmonton, AB, Canada.
| | - Andy Chuck
- Institute of Health Economics, Edmonton, AB, Canada.
| | - Linda Chui
- University of Alberta, Edmonton, AB, Canada.
| | - Gillian R Currie
- Department of Pediatrics, Alberta Children's Hospital Research Institute, O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, Alberta Children's Hospital Research Institute, O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
| | - James Dickinson
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Steven J Drews
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada.
| | - Mohamed Eltorki
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada.
| | - Tim Graham
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Xi Jiang
- Division of Infectious Diseases, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
| | - David W Johnson
- Departments of Pediatrics and Physiology and Pharmacology, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - James Kellner
- Department of Pediatrics, Section of Infectious Diseases, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - Martin Lavoie
- Alberta Health, University of Alberta, Edmonton, AB, Canada.
| | - Judy MacDonald
- Alberta Health Services, Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannon MacDonald
- Department of Pediatrics, University of Calgary, Edmonton, AB, Canada. .,Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
| | | | - James Talbot
- Alberta Health, University of Alberta, Edmonton, AB, Canada.
| | - Phillip Tarr
- Division of Gastroenterology, Washington University, St. Louis, MO, USA.
| | - Raymond Tellier
- Department of Microbiology, Immunology and Infectious Disease, University of Calgary, Calgary, AB, Canada.
| | - Otto G Vanderkooi
- Department of Pediatrics, Section of Infectious Diseases, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Department of Pathology and Laboratory Medicine, Section of Microbiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Department of Microbiology, Immunology & Infectious Diseases, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
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Nicastro E, Lo Vecchio A, Liguoro I, Chmielewska A, De Bruyn C, Dolinsek J, Doroshina E, Fessatou S, Pop TL, Prell C, Tabbers MM, Tavares M, Urenden-Elicin P, Bruzzese D, Zakharova I, Sandhu B, Guarino A. The Impact of E-Learning on Adherence to Guidelines for Acute Gastroenteritis: A Single-Arm Intervention Study. PLoS One 2015; 10:e0132213. [PMID: 26148301 PMCID: PMC4493016 DOI: 10.1371/journal.pone.0132213] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 06/12/2015] [Indexed: 02/05/2023] Open
Abstract
Objective E-learning is a candidate tool for clinical practice guidelines (CPG) implementation due to its versatility, universal access and low costs. We aimed to assess the impact of a five-module e-learning course about CPG for acute gastroenteritis (AGE) on physicians’ knowledge and clinical practice. Study design This work was conceived as a pre/post single-arm intervention study. Physicians from 11 European countries registered for the online course. Personal data, pre- and post-course questionnaires and clinical data about 3 to 5 children with AGE managed by each physician before and after the course were collected. Primary outcome measures included the proportion of participants fully adherent to CPG and number of patients managed with full adherence. Results Among the 149 physicians who signed up for the e-learning course, 59 took the course and reported on their case management of 519 children <5 years of age who were referred to their practice because of AGE (281 and 264 children seen before and after the course, respectively). The course improved knowledge scores (pre-course 8.6 ± 2.7 versus post-course 12.8 ± 2.1, P < 0.001), average adherence (from 87.0 ± 7.7% to 90.6 ± 7.1%, P = 0.001) and the number of patients managed in full adherence with the guidelines (from 33.6 ± 31.7% to 43.9 ± 36.1%, P = 0.037). Conclusions E-learning is effective in increasing knowledge and improving clinical practice in paediatric AGE and is an effective tool for implementing clinical practice guidelines.
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Affiliation(s)
- Emanuele Nicastro
- Department of Translational Medical Science, Sector of Pediatrics. University Federico II, Naples, Italy
- Paediatric Hepatology Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Sector of Pediatrics. University Federico II, Naples, Italy
| | - Ilaria Liguoro
- Department of Translational Medical Science, Sector of Pediatrics. University Federico II, Naples, Italy
| | - Anna Chmielewska
- Department of Pediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Caroline De Bruyn
- Universitair Ziekenhuis Brussel Kinderen, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Elena Doroshina
- Russian Medical Postgraduate Academy, Moscow, Russian Federation
| | | | - Tudor Lucian Pop
- 2nd Pediatric Clinic, Iuliu Haţieganu, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Christine Prell
- Dr. von Hauner Children’s Hospital, University of Munich Medical Center, Munich, Germany
| | | | - Marta Tavares
- Department of Pediatrics, Hospital Sao Joao, Porto, Portugal
| | | | - Dario Bruzzese
- Department of Public Health, University of Naples “Federico II,” Italy
| | - Irina Zakharova
- Russian Medical Postgraduate Academy, Moscow, Russian Federation
| | - Bhupinder Sandhu
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Alfredo Guarino
- Department of Translational Medical Science, Sector of Pediatrics. University Federico II, Naples, Italy
- * E-mail:
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Thompson GC, Schuh S, Gravel J, Reid S, Fitzpatrick E, Turner T, Bhatt M, Beer D, Blair G, Eccles R, Jones S, Kilgar J, Liston N, Martin J, Hagel B, Nettel-Aguirre A. Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals. Acad Emerg Med 2015; 22:811-22. [PMID: 26130319 DOI: 10.1111/acem.12709] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/12/2014] [Accepted: 01/12/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. METHODS Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. RESULTS Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). CONCLUSIONS Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.
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Affiliation(s)
- Graham C. Thompson
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
| | - Suzanne Schuh
- Hospital for Sick Children; University of Toronto; Toronto ON
| | - Jocelyn Gravel
- Centre Hospitalier Universitaire Ste-Justine; Universite de Montreal; Montreal QC
| | - Sarah Reid
- Children's Hospital of Eastern Ontario; University of Ottawa; Ottawa ON
| | | | - Troy Turner
- Stollery Children's Hospital; University of Alberta; Edmonton AB
| | - Maala Bhatt
- Hospital for Sick Children; University of Toronto; Toronto ON
| | - Darcy Beer
- Winnipeg Children's Hospital; University of Manitoba; Winnipeg MB
| | - Geoffrey Blair
- British Columbia Children's Hospital; University of British Columbia; Vancouver BC
| | - Robin Eccles
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
| | - Sarah Jones
- Children's Hospital London Health Sciences Centre; Western University; London ON
| | - Jennifer Kilgar
- Children's Hospital London Health Sciences Centre; Western University; London ON
| | - Natalia Liston
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
| | - John Martin
- Janeway Children's Health and Rehabilitation Centre; Memorial University; St. John's NL
| | - Brent Hagel
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
- Department of Community Health Sciences; University of Calgary; Calgary AB
| | - Alberto Nettel-Aguirre
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
- Department of Community Health Sciences; University of Calgary; Calgary AB
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Freedman SB, Pasichnyk D, Black KJL, Fitzpatrick E, Gouin S, Milne A, Hartling L. Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0128754. [PMID: 26075617 PMCID: PMC4468143 DOI: 10.1371/journal.pone.0128754] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 04/09/2015] [Indexed: 01/27/2023] Open
Abstract
Context Gastroenteritis remains a leading cause of childhood morbidity. Objective Because prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected. Data Sources MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings. Study Selection Randomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate. Data Extraction The study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models. Results 31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92). Conclusions There is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.
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Affiliation(s)
- Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Dion Pasichnyk
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Karen J. L. Black
- Division of Pediatric Emergency Medicine, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eleanor Fitzpatrick
- IWK Health Centre, Emergency Department, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Serge Gouin
- Section of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Andrea Milne
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Leung JS, Perlman K, Rumantir M, Freedman SB. Emergency department ondansetron use in children with type 1 diabetes mellitus and vomiting. J Pediatr 2015; 166:432-8. [PMID: 25454931 DOI: 10.1016/j.jpeds.2014.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/25/2014] [Accepted: 10/03/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the hypothesis that ondansetron administration to children with type 1 diabetes mellitus (T1DM) presenting for emergency department (ED) care with intercurrent illness and vomiting improves clinical outcomes by reducing hospitalization rates (primary), length of ED stay, intravenous fluid (IVF) administration, and revisits (secondary outcomes). STUDY DESIGN We conducted a single-center, 10-year retrospective cohort study of 345 ED encounters of children aged 6 months-8 years with T1DM and vomiting. We compared outcomes among children receiving and not receiving ondansetron. To avoid selection bias related to ondansetron administration, we also investigated outcomes by conducting comparisons by ondansetron usage periods (ie, low [2002-2004] vs high [2009-2011]). RESULTS Ondansetron usage increased from 0% to 67% of ED encounters between 2002 and 2011. Admission rates were similar among those administered [54% (58/107)] and not administered ondansetron [55% (131/238)]. Length of stay was longer in children receiving ondansetron (409 vs 315 minutes; P = .03). IVF administration (77% vs 77%) and revisits (5.6% vs 5.9%) were similar. Ondansetron administration was not associated with reduced admission in logistic regression modeling. Admission rate (62%; 56/91 vs 49%; 57/111) (-13%, 95% CI -23%, 3%), length of stay (395 vs 327 minutes [IQR 164 501]; P < .001), and IVF administration decreased (84% [77/91] to 70% [78/111]; P = .02] when comparing low and high ondansetron usage periods. CONCLUSIONS Ondansetron administration was not independently associated with lower admission rates. Over time, along with increasing ondansetron use, there have been reductions in admissions, length of stay, and IVF administration in children with T1DM.
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Affiliation(s)
- James S Leung
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Kusiel Perlman
- Division of Pediatric Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Section of Pediatric Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
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Ondansetron and probiotics in the management of pediatric acute gastroenteritis in developed countries. Curr Opin Gastroenterol 2015; 31:1-6. [PMID: 25333367 DOI: 10.1097/mog.0000000000000132] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Acute gastroenteritis (AGE) is a common and impactful disease, typically managed with supportive care. There is considerable interest in the role of adjunctive therapies, particularly ondansetron and probiotics in improving AGE outcomes. The purpose of this review is to present the latest evidence regarding the use of these agents in children with AGE in developed countries. RECENT FINDINGS Single-dose oral ondansetron is effective and safe in reducing hospital admissions and the use of intravenous rehydration in children with AGE in emergency-department-based trials. Ondansetron use has increased significantly; however, 'real-world' studies of effectiveness have documented less impressive clinical impacts. Similarly, probiotic consumption is growing rapidly. Although several strains appear to reduce the duration of diarrhea in hospitalized children, current data are insufficient to support the routine use of probiotics in outpatient pediatric AGE. SUMMARY Ondansetron and probiotics may improve patient outcomes in pediatric AGE. Appropriate strategies are needed to optimally integrate oral ondansetron into clinical practice to maximize its potential benefits. Although probiotics remain a promising option, there are challenges in generalizing the data available to patients presenting for outpatient care. Large randomized controlled trials are needed to definitively guide the clinical use of probiotics in outpatients in developed countries.
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Abstract
BACKGROUND The major burden of acute gastroenteritis (AGE) in childhood is related to its high frequency and the large number of hospitalizations, medical consultations, tests and drug prescriptions. The adherence to evidence-based recommendations for AGE management in European countries is unknown. The purpose of the study was to compare hospital medical interventions for children admitted for AGE with recommendations reported in the European Societies of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Infectious Diseases guidelines. METHODS A multicenter prospective study was conducted in 31 Italian hospitals. Data on children were collected through an online clinical reporting form and compared with European Societies of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Infectious Diseases guidelines for AGE. The main outcomes were the inappropriate hospital admissions and the percentage of compliance to the guidelines (full >90%, partial >80% compliance) based on the number and type of violations to evidence-based recommendations. RESULTS Six-hundred and twelve children (53.6% male, mean age 22.8 ± 15.4 months) hospitalized for AGE were enrolled. Many hospital admissions (346/602, 57.5%) were inappropriate. Once admitted, 20.6% (126/612) of children were managed in full compliance with the guidelines and 44.7% (274/612) were managed in partial compliance. The most common violations were requests for microbiologic tests (404; 35.8%), diet changes (310; 27.6%) and the prescription of non-recommended probiotics (161; 14.2%), antibiotics (103; 9.2%) and antidiarrheal drugs (7; 0.6%). CONCLUSIONS Inappropriate hospital admissions and medical interventions are still common in the management of children with AGE in Italy. Implementation of guidelines recommendations is needed to improve quality of care.
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Bourgeois FT, Monuteaux MC, Stack AM, Neuman MI. Variation in emergency department admission rates in US children's hospitals. Pediatrics 2014; 134:539-45. [PMID: 25113291 PMCID: PMC4144003 DOI: 10.1542/peds.2014-1278] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals. METHODS We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates. RESULTS A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates. CONCLUSIONS We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission.
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Affiliation(s)
- Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Anne M Stack
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Pelc R, Redant S, Julliand S, Llor J, Lorrot M, Oostenbrink R, Gajdos V, Angoulvant F. Pediatric gastroenteritis in the emergency department: practice evaluation in Belgium, France, The Netherlands and Switzerland. BMC Pediatr 2014; 14:125. [PMID: 24884619 PMCID: PMC4045874 DOI: 10.1186/1471-2431-14-125] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Based on European recommendations of ESPGHAN/ESPID from 2008, first line therapy for dehydration caused by acute gastroenteritis (AGE) is oral rehydration solution (ORS). In case of oral route failure, nasogastric tube enteral rehydration is as efficient as intra-venous rehydration and seems to lead to fewer adverse events. The primary objective was to describe rehydration strategies used in cases of AGE in pediatric emergency departments (PEDs) in Belgium, France, The Netherlands, and Switzerland. METHODS An electronic survey describing a scenario in which a toddler had moderate dehydration caused by AGE was sent to physicians working in pediatric emergency departments. Analytical data were analyzed with descriptive statistics and Kruskal -Wallis Rank test. RESULTS We analyzed 68 responses, distributed as follows: Belgium N = 10, France N = 37, The Netherlands N = 7, and Switzerland N = 14. Oral rehydration with ORS was the first line of treatment for 90% of the respondents. In case of first line treatment failure, intravenous rehydration was preferred by 95% of respondents from France, whereas nasogastric route was more likely to be used by those from Belgium (80%), The Netherlands (100%) and Switzerland (86%). Serum electrolyte measurements were more frequently prescribed in France (92%) and Belgium (80%) than in The Netherlands (43%) and Switzerland (29%). Racecadotril was more frequently used in France, and ondansetron was more frequently used in Switzerland. No respondent suggested routine use of antibiotics. CONCLUSION We found variations in practices in terms of invasiveness and testing. Our study supports the need for further evaluation and implementation strategies of ESPGHAN/ESPID guidelines. We plan to extend the study throughout Europe with support of the Young ESPID Group.
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Affiliation(s)
| | | | | | | | | | | | | | - François Angoulvant
- Inserm, CESP Centre for Research in Epidemiology and Population Health, U1018, Reproduction and Child Development Team, Villejuif, France.
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Freedman SB, Williamson-Urquhart S, Schuh S, Sherman PM, Farion KJ, Gouin S, Willan AR, Goeree R, Johnson DW, Black K, Schnadower D, Gorelick MH. Impact of emergency department probiotic treatment of pediatric gastroenteritis: study protocol for the PROGUT (Probiotic Regimen for Outpatient Gastroenteritis Utility of Treatment) randomized controlled trial. Trials 2014; 15:170. [PMID: 24885220 PMCID: PMC4037747 DOI: 10.1186/1745-6215-15-170] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/29/2014] [Indexed: 01/01/2023] Open
Abstract
Background The burden of acute gastroenteritis on children and their families continues to be enormous. Probiotics, defined as viable microbial preparations that have a beneficial effect on the health of the host, represent a rapidly expanding field. Although clinical trials in children with gastroenteritis have been performed, most have significant flaws, and guidelines do not consistently endorse their use. Methods/Design PROGUT is a randomized, placebo-controlled, double-blind, five-center, Canadian, emergency department trial. Children aged 3 months to 48 months who present between November 2013 and June 2017 with <72 hours of gastroenteritis symptoms will be assessed for eligibility. A total of 886 children will be randomized (1:1 allocation via an internet based, third party, randomization service) to receive 5 days of a combination probiotic agent (Lactobacillus rhamnosus and L. helveticus) or placebo. All participants, caregivers, and outcome assessors will be blinded to group assignment. The study includes three key outcomes: 1) clinical - the development of moderate to severe disease following an emergency department (ED) evaluation that employs a validated clinical score (Modified Vesikari Scale); 2) safety - side effect; and 3) mechanism - fecal secretory immunoglobulin A levels. Discussion Definitive data are lacking to guide the clinical use of probiotics in children with acute gastroenteritis. Hence, probiotics are rarely prescribed by North American physicians. However, the following current trends obligate an urgent assessment: 1) probiotics are sold as food supplements, and manufacturers can encourage their use while their relevance has yet to be established; 2) North American and European government agencies remain concerned about their value and safety; 3) some institutions are now recommending the routine use of probiotics; and 4) parents of affected children are often providing probiotics. With probiotic consumption increasing in the absence of solid evidence, there is a need to conduct this definitive trial to overcome the limitations of prior work in this field. Trial registration ClinicalTrials.gov: NCT01853124; first registered 9 May 2013.
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Affiliation(s)
- Stephen B Freedman
- Sections of Paediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8, Canada.
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Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. ACTA ACUST UNITED AC 2014; 8:1123-37. [PMID: 23877938 DOI: 10.1002/ebch.1932] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute gastroenteritis (AGE) is an extremely common paediatric condition, which results in significant morbidity in children and is a financial burden to the society. OBJECTIVE The purpose of this overview is to critically evaluate the evidence currently available in the Cochrane Database of Systematic Reviews (CDSR) regarding the efficacy and safety of commonly considered treatment options in children with AGE. METHODS All Cochrane reviews evaluating the following treatments in children with AGE were eligible for inclusion: oral rehydration therapy, anti-emetics and probiotics. We excluded those focusing on the treatment of antibiotic associated or nosocomial diarrhoea, persistent (chronic) diarrhoea and the prevention of gastroenteritis. We focused on the following outcomes that were selected a priori as clinically important: rate of admission to the hospital; length of stay in hospital; rate of return visits; administration of intravenous (IV) therapy owing to failure of oral rehydration therapy; adverse events and dysnatremia. MAIN RESULTS Children who received oral rehydration therapy had a shorter length of stay in hospital compared with children who received IV therapy [mean difference, MD = -1.20 days (-2.38, -0.02)]; however, the result was no longer significant when an outlying study was removed. Children who received IV therapy were at increased risk of developing phlebitis [risk difference, RD= - 0.02 (-0.04, -0.01)], while paralytic ileus was more common in children receiving ORT [RD = 0.03 (confidence interval, CI 0.01-0.05)]. Children who received oral ondansetron had lower hospital admission rates to the emergency department (ED) and lower rates of IV rehydration during their ED stay compared with children receiving placebo [risk ration, RR = 0.40 (CI 0.19-0.83) and RR = 0.41 (CI 0.29-0.59), respectively]. Children receiving IV ondansetron had lower hospital admission rates to the ED than patients receiving placebo [RR = 0.21 (0.05, 0.93)]. Probiotic use amongst children hospitalized following AGE reduced the mean duration of hospitalization by 1.12 days (CI -1.16, -0.38). CONCLUSIONS Given that oral rehydration is less invasive than IV rehydration with no evidence of important clinical differences, it is the first choice for rehydration in children with AGE and mild-to-moderate dehydration. As the vast majority of children with AGE do not require IV rehydration, oral ondansetron administration to children with significant vomiting should be performed to reduce the use of IV rehydration and the need for hospital admission. In children deemed too unwell to receive oral rehydration therapy, IV ondansetron administration is an option, as its use is associated with lower hospital admission rates. Although probiotics appear to be an effective option for the treatment of AGE amongst hospitalized children, outpatient data is lacking and more studies are urgently needed to determine the optimal organism, dosing and duration of treatment.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
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Successful Discharge of Children with Gastroenteritis Requiring Intravenous Rehydration. J Emerg Med 2014; 46:9-20. [DOI: 10.1016/j.jemermed.2013.04.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 04/01/2013] [Accepted: 04/30/2013] [Indexed: 11/17/2022]
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Abstract
OBJECTIVES The aim of the study was to determine whether intravenous fluid administration is independently associated with a reduction in unscheduled emergency department (ED) revisits within 7 days. METHODS We conducted a single-center, retrospective observational cohort study in a pediatric ED in Toronto, Canada. Participants were younger than 18 years, diagnosed as having gastroenteritis, and discharged home between July 2003 and June 2008. Multivariable regression models were used to determine the associations between the exposures (intravenous rehydration, triage severity score, age) and ED revisits and revisits with intravenous rehydration. Accuracy was assessed using bootstrap analysis. RESULTS There were 22,125 potentially eligible visits; 3346 were included in our final cohort. A total of 497 children (15%) received intravenous rehydration and 543 (16%) had an unscheduled revisit. Regression analysis included 2874 children with complete data, and identified 5 independent predictors of an ED revisit: intravenous rehydration (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.36-2.26); number of vomiting episodes (1.20; 95% CI 1.04-1.28/5 episode increase); days of diarrhea (OR 0.92; 95% CI 0.88-0.97/day increase); frequency of diarrhea (1.19; 95% CI 1.03-1.38/5 episode increase); and age (OR 0.94; 95% CI 0.91-0.98/year). Bootstrap methodology identified intravenous rehydration, age, number of vomiting episodes, days of diarrhea, and number of diarrheal stools a minimum of 500 of 1000 iterations. CONCLUSIONS Intravenous rehydration is associated with unscheduled ED revisits after adjustment for clinical findings. Although children experiencing revisits were likely more unwell, our data do not support the provision of intravenous fluids to prevent unscheduled ED revisits in children with mild-to-moderate dehydration.
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Shanley L, Mittal V, Flores G. Preventing dehydration-related hospitalizations: a mixed-methods study of parents, inpatient attendings, and primary care physicians. Hosp Pediatr 2013; 3:204-211. [PMID: 24313088 DOI: 10.1542/hpeds.2012-0094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE The goal of this study was to identify the proportion of dehydration-related ambulatory care-sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability. METHODS A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care-sensitive conditions admitted to an urban hospital over 14 months. RESULTS Eighty-five children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identified inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identified parents providing insufficient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P < .01). Parental dissatisfaction with their child's PCP and a history of avoiding primary care due to costs or insurance problems were associated with significantly higher odds of preventable hospitalization. CONCLUSIONS Up to 45% of dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insufficient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.
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Affiliation(s)
- Leticia Shanley
- Division of General Pediatrics, Department of Pediatrics, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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Jabbour M, Curran J, Scott SD, Guttman A, Rotter T, Ducharme FM, Lougheed MD, McNaughton-Filion ML, Newton A, Shafir M, Paprica A, Klassen T, Taljaard M, Grimshaw J, Johnson DW. Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial. Implement Sci 2013; 8:55. [PMID: 23692634 PMCID: PMC3674906 DOI: 10.1186/1748-5908-8-55] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 05/15/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. DESIGN/METHODS We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. DISCUSSION This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. TRIAL REGISTRATION ClinicalTrials.gov: NCT01815710.
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Affiliation(s)
- Mona Jabbour
- Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Canada
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Janet Curran
- IWK Health Centre, Halifax, Canada, School of Nursing, Dalhousie University, Halifax, Canada
| | | | - Astrid Guttman
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Thomas Rotter
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Francine M Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine, University of Montreal, Montreal, Canada
- Research Centre, CHU Sainte-Justine, Montreal, Canada
| | - M Diane Lougheed
- Departments of Medicine (Respirology), Biomedical and Molecular Sciences (Physiology) and Community Health and Epidemiology, Queen’s University, Kingston, Canada
- ICES-Queen’s University, Kingston, Canada
| | - M Louise McNaughton-Filion
- University of Ottawa, Ottawa, Canada
- Montfort Hospital, Ottawa, Canada
- Champlain Local Health Integrated Network, Ottawa, Canada
| | - Amanda Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Mark Shafir
- Department of Emergency Medicine, Cambridge Memorial Hospital, Cambridge, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Alison Paprica
- Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - Terry Klassen
- Faculty of Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba Institute of Child Health, Winnipeg, Canada
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - David W Johnson
- Division of Emergency Medicine, Alberta Children’s Hospital, Calgary, Canada
- Alberta Children’s Hospital Research Institute, Calgary, Canada
- Department of Pediatrics, Physiology and Pharmacology, University of Calgary, Calgary, Canada
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Hagbom M, Sharma S, Lundgren O, Svensson L. Towards a human rotavirus disease model. Curr Opin Virol 2012; 2:408-18. [PMID: 22722079 DOI: 10.1016/j.coviro.2012.05.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/10/2012] [Accepted: 05/15/2012] [Indexed: 12/31/2022]
Abstract
While the clinical importance of human rotavirus (RV) disease is well recognized and potent vaccines have been developed, our understanding of how human RV causes diarrhoea, vomiting and death remains unresolved. The fact that oral rehydration corrects electrolyte and water loss, indicates that enterocytes in the small intestine have a functional sodium-glucose co-transporter. Moreover, RV infection delays gastric emptying and loperamide appears to attenuate RV diarrhoea, thereby suggesting activation of the enteric nervous system. Serotonin (5-HT) receptor antagonists attenuate vomiting in young children with gastroenteritis while zinc and enkephalinase inhibitors attenuate RV-induced diarrhoea. In this review we discuss clinical symptoms, pathology, histology and treatment practices for human RV infections and compile the data into a simplified disease model.
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Affiliation(s)
- Marie Hagbom
- Division of Molecular Virology, University of Linköping, 581 85, Linköping, Sweden
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Hartling L, Hamm M, Klassen T, Chan AW, Meremikwu M, Moyer V, Scott S, Moher D, Offringa M. Standard 2: containing risk of bias. Pediatrics 2012; 129 Suppl 3:S124-31. [PMID: 22661758 DOI: 10.1542/peds.2012-0055e] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
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