Bronchiolitis trends in out-of-hospital urgent care services in the Community of Madrid: Observational study, 2016-2023

INTRODUCTION

Bronchiolitis poses a considerable challenge during its seasonal peak, overwhelming the material and human resources available to care for affected patients. As a result, interhospital transfers increase exponentially. We did not find any studies analysing the characteristics of patients with bronchiolitis managed in out-of-hospital urgent care (OHUC) services and the impact of the COVID-19 pandemic on the epidemiology of bronchiolitis.

OBJECTIVE

To establish the characteristics of paediatric and neonatal patients with acute bronchiolitis (AB) managed in OHUC services in the Community of Madrid and to analyse the impact of the COVID-19 pandemic on the epidemiology of bronchiolitis.

METHODS

Retrospective cross-sectional observational and descriptive study carried out in OHUC settings in the Community of Madrid between 2016 and 2023. We included patients with a diagnosis of acute bronchiolitis based on the ICD-10 codes documented in the electronic records of urgent care visits and interhospital transports. We collected data on sociodemographic, clinical and treatment (ventilation and medication) variables.

RESULTS

The sample included 630 patients with AB: 343 managed in non-neonatal OHUC (non-neo) services and 287 by the mobile neonatal intensive care unit transport team (NTT). The median age was 3.7 months (IQR, 2.8-4.7) in patients in the non-neo OHUC group and 19 days (IQR, 14.2-23.7) in the NTT group. There was a statistically significant increase in age in the 2020/2021 season in the non-neo OHUC group. The severity score was significantly higher in the NTT group. There was an unusual peak in bronchiolitis cases in June 2021, coinciding with the end of the 4th wave of the COVID-19 pandemic. The incidence of bronchiolitis was highest after the 6th wave of the pandemic (13.5 cases per 10 000 children aged < 2 years).

CONCLUSIONS

The median age of paediatric patients with AB managed in OHUC services increased following the end of the lockdown imposed due to the COVID-19 pandemic, which was probably associated with the lack of exposure to the viruses that cause it. This also may explain why the incidence of bronchiolitis was highest in the season following the 6th wave of the pandemic. The severity score was higher in neonatal patients. Epidemiological surveillance, the introduction of protocols and the implementation of an ongoing training programme for non-specialized health care staff involved in the transport of these patients could improve their management.

Rate of methicillin-resistant Staphylococcus aureus in pediatric emergency departments in Spain

INTRODUCTION

Staphylococcus aureus is a common germ in bacterial infections in children. The rate of methicillin-resistant S. aureus (MRSA) is increasing lately.

OBJECTIVES

The main aim is to know the rate of positive cultures to MRSA in Spanish pediatric emergency departments. The secondary aims are to analyse the risk factors for MRSA isolation (patient origin, history of hospitalization or surgery in the previous 90 days, antibiotherapy in the previous 60 days, presence of comorbidity, invasive devices, prior MRSA isolation) and to analyse the morbidity of these infections.

METHODOLOGY

Retrospective multicenter study (07/01/2017-06/30/2018) with review of patient histories with isolation of S. aureus in samples of any origin obtained in 8 pediatric emergency departments of the Infectious Diseases Working Group of the Spanish Society of pediatric Emergencies.

RESULTS

During this period, S. aureus was detected in 403 patients (average age 75.8 ± 59.2 months; 54.8% male): 28.8% hospital-related infections (HRI) and 71.2% community-related infections (CRI). Overall, MRSA rate was 16.6% (95% CI: 13-20.2%); 18.1% in HRI and 16.2% in CRI (p > 0.05). The highest rates of MRSA were obtained in skin abscesses (29.3%, CI 95%: 21.8-36.8%), patients not born in Spain (52%; CI 95%: 32-72%) or patients with a previous MRSA infection (90%; CI 95% 71.4-100%). 167 (41%) patients were admitted, 12 (3%) had complications and 4 (1%) suffered sequels. There were no deaths.

CONCLUSIONS

The overall MRSA rate was one in 6 staphylococcal infections. Higher MRSA rates were detected in samples of suppurating skin injuries and in foreign children or in children with a history of previous MRSA infection. In suppurative skin lesions, early drainage is essential and the change to an antibiotic with MRSA coverage should be considered if the evolution is inadequate.

[Rate of methicillin-resistant Staphylococcus aureus in pediatric emergency departments in Spain]

INTRODUCTION

Staphylococcusaureus (S. aureus) is a common germ present in bacterial infections in children. Lately, the rate of methicillin-resistant S. aureus (MRSA) is increasing.

OBJECTIVES

The main aim of this study is to know the rate of positive cultures to MRSA in Spanish pediatric emergency departments. The secondary aims are to analyze the risk factors for MRSA isolation (patient origin, history of hospitalization or surgery in the previous 90 days, antibiotherapy in the previous 60 days, presence of comorbidity, invasive devices, prior MRSA isolation) and to analyze the morbidity of these infections.

METHODOLOGY

Retrospective multicenter study (07/01/2017-06/30/2018) with review of patient histories with isolation of S. aureus in samples of any origin obtained in 8 pediatric emergency departments of the Infectious Diseases Working Group of the Spanish Society of Pediatric Emergencies.

RESULTS

During this period, S. aureus was detected in 403 patients (average age 75.8±59.2 months; 54.8% male): 28.8% hospital-related infections and 71.2% community-related infections. Overall, MRSA rate was 16.6% (95% CI: 13-20.2%); 18.1% in hospital-related infections and 16.2% in community-related infections (P>.05). The highest rates of MRSA were obtained in skin abscesses (29.3%, 95% CI: 21.8-36.8%), patients not born in Spain (52%; 95% CI: 32-72%) or patients with a previous MRSA infection (90%; 95% CI: 71.4-100%). 167 (41%) patients were admitted, 12 (3%) had complications and 4 (1%) suffered sequels. There were no deaths.

CONCLUSIONS

The overall MRSA rate was one in six staphylococcal infections. Higher MRSA rates were detected in samples of suppurating skin injuries and in foreign children or in children with a history of previous MRSA infection. In suppurative skin lesions, early drainage is essential and the change to an antibiotic with MRSA coverage should be considered if the evolution is inadequate.

COVID-19 impact on the emergency and hospitalization of a tertiary hospital. Management lessons learned

INTRODUCTION

The objective is to analyze the impact of the COVID-19 pandemic on the pediatric emergencies and hospital admissions.

METHODS

Retrospective cohort study of patients treated in a tertiary hospital, from March 14 to April 26, 2020, compared to the same period of the previous 3 years.

RESULTS

A notable overall reduction in emergency room visits and admissions is observed in all pediatric areas, maintaining care in neonatology and scheduled admissions in oncology.

DISCUSSION

The reduction in global activity in pediatric emergencies is not only explained by the decrease in contagious diseases. The decrease in inadequate demand and inappropriate income may have contributed. The availability of pediatric beds would make the reduction of programmed surgical activity unnecessary and would allow the redistribution of resources to areas with greater healthcare pressure.

[Adecuacy of pediatric antimicrobial prescribing in the Emergency Department at discharge]

INTRODUCTION

In January 2019, Community of Madrid's Health Department published a guide about the use of antimicrobials in outpatient children. Taking this regional Guide as reference, this study was aimed at estimating the adequacy of the antimicrobial stewardship at discharge from a pediatric Emergency Department (ED). Secondarily, the differences in adequacy according to the diagnosis and the prescriber were studied, and the agreement between this Guide and the protocols of the ED was assessed.

MATERIAL AND METHODS

An observational, descriptive, retrospective study was conducted on patients under 16 years old, with a diagnosis included in the regional Guide who were discharged from a pediatric ED between March of 2018 and February of 2019. Prescription was considered adequate when the indication, the antibiotic and the posology (dosage, dosing interval, length of treatment and route of administration) were correct.

RESULTS

165 out of 648 (25,5%) infectious diseases processes analyzed received antimicrobial treatment. In 23 processes treated with antimicrobial, the adequacy could not be evaluated due to the absence of data necessary to assess any aspect of posology. Therapy was considered appropriate in 550/625 processes (88.0%). When antimicrobial treatment was prescribed, 70/142 (49.3%) were appropriate and no statistically significant differences in adequacy were found between prescribers. Posology was the worst handled point of the prescription (26.3%). Tract urinary infection, conjunctivitis and otitis media were the pathologies with the lowest adecuacy (44.4%; 50.0% and 52.2%) and presented the highest discrepancy between the Guide and the center protocols (k=0.308; k=0.000; k=0.586).

CONCLUSIONS

The adequacy of the management of infectious processes to the reference Guide in our pediatric ED was high, but it was below 50% when antimicrobial treatment was required. The degree of adequacy to the local protocols of the center was greater than to the regional Guide. This reveals a discrepancy between the 2documents that should be analyzed and corrected according to the available scientific evidence.

[Actions that should not be taken with a paediatric patient who has been exposed to a potentially toxic substance]

OBJECTIVE

To show the preparation process by the Poisoning Working Group of the Spanish Society of Paediatric Emergencies (GTI-SEUP), of the list of things «not to do» for a paediatric patient who has been exposed to a potentially toxic substance.

METHOD

The preparation process of the list was carried out in three phases. First: «Brainstorming» that was open to all members of the GTI-SEUP. Second: Recommendations were selected by following modified-Delphi methodology. All participants were asked to rate the proposals (from 1 = strongly disagree to 9 = strongly agree). Those with an average score greater than 8 were accepted (provided that at least two-thirds of the participants had given them a score ≥ 7), and a second consultation was made for the recommendations with an average score between 6 and 8. Third: Writing and creating a consensus of the final document was done.

RESULT

A total of 11 proposals were initially obtained. Thirty-two of the 57 GTI-SEUP participants completed the scoring questionnaire. In the first consultation, seven «not to do» recommendations were accepted, and four obtained a doubtful average score (between 6 and 8). After the second consultation, the list was made up of eight recommendations. Two refer to general management, four to gastrointestinal decontamination techniques, and two to the administration of antidotes.

CONCLUSION

The list of actions that should not be taken with a child that has been exposed to a possible poison is a consensus tool, within the GTI-SEUP, to promote improvement in the quality of care offered to these patients. This improvement is based on avoiding unnecessary measures, which can sometimes be harmful to the child.

[Perceived quality of care by frequent paediatric healthcare users: A qualitative approach]

INTRODUCTION

Assessing the perceived quality of a healthcare department by its users is essential in a quality management system. In Paediatric Emergency Departments (PED), the demand for urgent care has increased in recent years, as well as an increase in frequent attendance. Paying attention to the opinions of these habitual users by means of qualitative methodology is particularly suitable for assessing the quality of care and identifying opportunities to improve the PED.

METHODS

Two focus groups were held with parents of patients (with and without a chronic disease) who visited the PED on 10or more occasions per year in a third level hospital.

RESULTS

The participants were satisfied overall with the PED. The treatment received was very positively valued, and they never felt that they had received poorer care due to being frequent users. As main strengths, they also highlighted the professional expertise, the friendliness of staff, the quality of information given, the medication received on discharge from hospital, and the follow-up carried out by the PED. The major improvement opportunities identified included: the contagion risks, the lack of coordination between different levels of care, and the need to improve the inclusion of families in the health care process.

CONCLUSIONS

Due to the contributions made by these parents, several improvement strategies have been introduced, such as the implementation of sharing information protocols in shift changes, professional training courses, the establishment of a liaison person between the PED and Primary Care, and a proposal to the Hospital Management Department to assess the identified needs.

[Management and serious risk factors associated with unintentional injuries in paediatric emergencies in Spain]

INTRODUCTION

Thirty-eight million patients with injuries are treated in Emergency Departments every year, 90% of them being in the form of unintentional injuries (UIs). There are currently no global records of its management in Spain, or the risk factors that may be associated with them. The objective of this study is to describe the management of UIs in Spanish paediatric emergency departments, and to analyse factors related to the presence of serious injuries.

MATERIAL AND METHODS

A sub-study of a prospective multicentre observational study conducted over 12months in 11hospitals of the Spanish Paediatric Emergency Research Group (RiSEUP-SPERG), including children from 0 to 16years of age consulting for UIs. Epidemiological data, circumstances of the injury, and data on emergency care and discharge destination were recorded on the 13th day of each month.

RESULTS

A total of 10,175 episodes were recorded, of which 1,941 were UIs (19.1%), including 1,673, of which 257 (15.4%) were severe. The most frequent complementary test was simple radiography (60.0%), and the most frequent procedure was limb immobilisation (38.6%). A significant relationship was found between presenting with a severe UI and age >5 years (OR2.24; 95%CI: 1.61-3.16), history of fracture (OR2.05; 95%CI: 1.22-3.43), or sports activity as a mechanism of injury (OR1.76; 95%CI: 1.29-2.38), among others.

CONCLUSION

In Spain, most UIs are not serious. X-rays and immobilisation of extremities are the most frequently performed tests and procedures. Severe UIs were associated with individual factors, such as age >5years or history of fracture, and with sports activity as a mechanism associated with severity. It is vital to implement measures to improve the prevention of these injuries and to support the training of caregivers through educational programmes.

[Child abuse in the Emergency department: Epidemiology, management, and follow-up]

OBJECTIVE

To describe the clinical and epidemiological features, management, and follow-up of child abuse suspicions diagnosed in the Paediatric Emergency Unit.

METHODS

A single-centre, observational and retrospective study was conducted between 2008 and 2017. Clinical, epidemiological and follow-up data were collected in those patients younger than 16 that were reported as child abuse suspicions. A descriptive and analytic study was performed, as well as a bivariate and multivariate analysis.

RESULTS

A total of 404 out of 570,648 emergency patients (0.07%) were diagnosed with potential abuse. Physical abuse was the most frequent kind of abuse (40.3%). The median age was 4.3 years (IQR 1.6-10.2), and 55% were girls, with sexual abuse being more common in them (OR 3.71; 95% CI: 2.23-6.17), and physical abuse more frequent in boys (OR 1.72; 95% CI: 1.15-2.57). A total of 89 patients (22%) required admission. Age and type of abuse were independently associated with risk of admission. More than half (56%) of the cases required additional follow-up, with sexual (OR 3.98; 95% CI: 1.93-7.03) and emotional abuse (OR 4.93; 95% CI: 1.82-13.35) requiring more mental health follow-up, and physical abuse requiring more social services follow-up (OR 4.39; 95% CI: 1.61-11.98).

CONCLUSIONS

In our study, child abuse is more frequent in pre-school children. Age and type of abuse are associated with the need of admission. The kind of follow-up is determined by the type of abuse.

[Factors related to the use of pediatric emergency services: results from the Spanish National Health Survey]

OBJECTIVES

To determine the frequency of use of Spanish pediatric emergency services, and to describe user profiles and geographic variations.

MATERIAL AND METHODS

Descriptive study based on data from the Spanish National Health Survey. We calculated descriptive statistics and analyzed crude and adjusted odds ratios (ORs).

RESULTS

Thirty-five percent of the 5495 respondents had come to an emergency department in the past year, and 88.1% of them had used the services of a Spanish national health service hospital. Factors associated with higher use of emergency services were male sex of the patient, (OR, 1.202; 95% CI, 1.047-1.381), a higher educational level of parents (OR, 1.255; 95% CI, 0.983-1.603), and younger age of the child (OR, 0.909; 95% CI, 0.894-0.924). Emergency department use varied widely from one Spanish community to another. There was a positive correlation between use and the presence of a foreign-born population (ρ=0.495, P=.031).

CONCLUSION

The rate of emergency department use is high in Spain. Variability between geographic areas is considerable, and some variation is explained by population characteristics.

[Preparation of sedation-analgesia procedures in spanish paediatric emergency departments: A descriptive study]

INTRODUCTION

The objective of this study was to describe the current practice regarding the preparation of the sedation-analgesia (SA) procedures performed in the paediatric emergency centres in Spain.

MATERIAL AND METHODS

A multicentre, observational and prospective analytical study was carried out on the SA procedures that were performed on children under 18 years-old in 18 paediatric emergency departments between February 2015 and January 2016.

RESULTS

A total of 658 SA procedures were registered in 18 hospitals of Spain, most of them to children older than 24 months. The type of the procedure was: simple analgesia in 57 (8.6%), sedation in 44 (6.7%), SA for a not very painful procedure in 275 (41.8%), and SA for a very painful procedure in 282 (42.9%). Informed consent was requested in 98.6% of the cases. The written form was more frequently preferred in the group of patients that received SA for a very painful procedure (76.6%) in comparison to a painful procedure or to simple analgesia (62.9% and 54.4%, respectively, P<.001). The staff that most frequently performed the SA procedures were the paediatricians of the emergency departments (64.3%), followed by Paediatrics Residents (30.7%). The most frequent reasons for the SA were traumatological (35.9%) and surgical (28.4%). Fasting was observed in 81% of the cases. More than two-thirds (67.3%, n=480) children were monitored, the majority (95.8%) of them using pulse oximetry. The pharmacological strategy used was the administration of one drug in 443 (67.3%) of the cases, mostly nitrous oxide, and a combination of drugs in 215 (32.7%), especially midazolam/ketamine (46.9%).

CONCLUSION

The majority of the SA procedures analysed in this study have been carried out correctly and prepared in accordance with the current guidelines.