Core outcomes and factors influencing the experience of care for children with severe acute exacerbations of asthma: a qualitative study

OBJECTIVE

To identify the outcomes considered important, and factors influencing the patient experience, for parents and caregivers of children presenting to hospital with a severe acute exacerbation of asthma. This work contributes to the outcome-identification process in developing a core outcome set (COS) for future clinical trials in children with severe acute asthma.

DESIGN

A qualitative study involving semistructured interviews with parents and caregivers of children who presented to hospital with a severe acute exacerbation of asthma.

SETTING

Hospitals in 12 countries associated with the global Pediatric Emergency Research Networks, including high-income and middle-income countries. Interviews were conducted face-to-face, by teleconference/video-call, or by phone.

FINDINGS

Overall, there were 54 interviews with parents and caregivers; 2 interviews also involved the child. Hospital length of stay, intensive care unit or high-dependency unit (HDU) admission, and treatment costs were highlighted as important outcomes influencing the patient and family experience. Other potential clinical trial outcomes included work of breathing, speed of recovery and side effects. In addition, the patient and family experience was impacted by decision-making leading up to seeking hospital care, transit to hospital, waiting times and the use of intravenous treatment. Satisfaction of care was related to communication with clinicians and frequent reassessment.

CONCLUSIONS

This study provides insight into the outcomes that parents and caregivers believe to be the most important to be considered in the process of developing a COS for the treatment of acute severe exacerbations of asthma.

International perspective on research priorities and outcome measures of importance in the care of children with acute exacerbations of asthma: a qualitative interview study

BACKGROUND

Acute exacerbations of asthma are common in children, however, treatment decisions for severe exacerbations are challenging due to a lack of robust evidence. In order to create more robust research, a core set of outcome measures needs to be developed. In developing these outcomes, it is important to understand the views of clinicians who care for these children in particular, views that relate to outcome measures and research priorities.

METHODS

To determine the views of clinicians, a total of 26 semistructured interviews based on the theoretical domains framework were conducted. These included experienced clinicians from emergency, intensive care and inpatient paediatrics across 17 countries. The interviews were recorded, and later transcribed. All data analyses were conducted in Nvivo by using thematic analysis.

RESULTS

The length of stay in hospital and patient-focused parameters, such as timing to return to school and normal activity, were the most frequently highlighted outcome measures, with clinicians identifying the need to achieve a consensus on key core outcome measure sets. Most research questions focused on understanding the best treatment options, including the role of novel therapies and respiratory support.

CONCLUSION

Our study provides an insight into what research questions and outcome measures clinicians view as important. In addition, information on how clinicians define asthma severity and measure treatment success will assist with methodological design in future trials. The current findings will be used in parallel with a further Paediatric Emergency Research Network study focusing on the child and family perspectives and will contribute to develop a core outcome set for future research.

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

RATIONALE

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

OBJECTIVES

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

METHODS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

The integral role of the clinical pharmacist in drug-assisted intubation at a newly established children's major trauma center

This commentary outlines how the clinical pharmacist can support the safe administration of emergency medications in trauma anesthesia for seriously injured children. Promoting the professional development of the clinical pharmacist provided an opportunity to strengthen a key step in our trauma care pathway. We describe the implementation of this process in a new hospital, which was to become the designated children's trauma center for an entire country. Although the literature documents the use of pharmacists in emergency intubation, ours was a unique set of circumstances, where empowering the pharmacist in frontline clinical care provided additional quality assurance for rapid sequence induction and intubation in trauma. Medical simulation was a core part of socializing the advanced clinical practice role of pharmacy within the trauma team. It was our experience that the pharmacist helps to promote confidence and decision making among other members of the trauma team.

Question 5: Magnesium Sulphate for Acute Asthma in children

Most children who present to the emergency department with acute asthma, respond well to inhaled β₂-agonists (spacer or nebuliser), oxygen (if required) and systemic steroids. Guidelines across the world agree on this simple, straight forward evidenced based approach. In children with more severe asthma attacks and those who do not respond to initial treatment, the evidence base for the secondary level treatment is less clear. Many regimens exist for the next step. Intravenous Magnesium Sulphate (MgSO₄) is now used frequently in these situations and some centres are starting to use nebulized MgSO₄ as part of the initial maximal inhaled therapy options. This paper examines the role of MgSO₄ in acute asthma in children. It focusses on how MgSO₄ might work, what are the current recommendations for use and then what is the current evidence base to support its use. We have presented the evidence for the use of both nebulized and intravenous MgSO₄. At the end of the paper we have suggested future directions for research in this area. Our aim is to present a synthesis of the current role of MgSO₄ in the management of an acute asthma attack.

Efficacy, safety and impact on antimicrobial resistance of duration and dose of amoxicillin treatment for young children with Community-Acquired Pneumonia: a protocol for a randomIsed controlled Trial (CAP-IT)

INTRODUCTION

Community-acquired pneumonia (CAP) is a common indication for antibiotic treatment in young children. Data are limited regarding the ideal dose and duration of amoxicillin, leading to practice variation which may impact on treatment failure and antimicrobial resistance (AMR). Community-Acquired Pneumonia: a randomIsed controlled Trial (CAP-IT) aims to determine the optimal amoxicillin treatment strategies for CAP in young children in relation to efficacy and AMR.

METHODS AND ANALYSIS

The CAP-IT trial is a multicentre, randomised, double-blind, placebo-controlled 2×2 factorial non-inferiority trial of amoxicillin dose and duration. Children are enrolled in paediatric emergency and inpatient environments, and randomised to receive amoxicillin 70-90 or 35-50 mg/kg/day for 3 or 7 days following hospital discharge. The primary outcome is systemic antibacterial treatment for respiratory tract infection (including CAP) other than trial medication up to 4 weeks after randomisation. Secondary outcomes include adverse events, severity and duration of parent-reported CAP symptoms, adherence and antibiotic resistance. The primary analysis will be by intention to treat. Assuming a 15% primary outcome event rate, 8% non-inferiority margin assessed against an upper one-sided 95% CI, 90% power and 15% loss to follow-up, 800 children will be enrolled to demonstrate non-inferiority for the primary outcome for each of duration and dose.

ETHICS AND DISSEMINATION

The CAP-IT trial and relevant materials were approved by the National Research Ethics Service (reference: 16/LO/0831; 30 June 2016). The CAP-IT trial results will be published in peer-reviewed journals, and in a report published by the National Institute for Health Research Health Technology Assessment programme. Oral and poster presentations will be given to national and international conferences, and participating families will be notified of the results if they so wish. Key messages will be constructed in partnership with families, and social media will be used in their dissemination.

TRIAL REGISTRATION NUMBER

ISRCTN76888927, EudraCT2016-000809-36.

Variability of outcome measures in trials of intravenous therapy in acute severe paediatric asthma: a systematic review

OBJECTIVE

To determine the variability of primary and secondary outcomes used in trials of intravenous bronchodilators in children with acute severe paediatric asthma.

METHODS

Systematic search of MEDLINE, EMBASE, Cochrane CENTRAL and the WHO International Clinical Trials Registry Platform for randomised trials in children (less than18 years) with acute severe paediatric asthma comparing intravenous bronchodilator therapy to another treatment. Initial search was performed on 7 January 2016 with an updated search performed on 6 September 2018. Primary and secondary outcomes were collated.

RESULTS

We identified 35 published papers and four registered study protocols. 56 primary outcomes were found, the most common being a clinical asthma score (23/56; 41%). Other identified primary outcomes included bedside tests of respiratory function (11/56; 20%) and measures of length of stay (9/56; 16%). There were a total of 60 different secondary outcomes, the most common were various length of stay measures (24/60; 40%) and adverse events (11/60; 18%).

CONCLUSION

Studies comparing intravenous treatment modalities for children with acute severe paediatric asthma exhibit great variation in the type, number and timing of outcome measures used. There are no patient or family-specific outcomes reported. There is a need to develop international consensus.

TRIAL REGISTRATION NUMBER

CRD42017055331.

A survey of facilitators and barriers to recruitment to the MAGNETIC trial

Background

Recruitment to randomised controlled trials with children is challenging. It is imperative to understand the factors that boost or hinder recruitment of children to clinical trials. We conducted a survey of facilitators and barriers to recruitment to the MAGNETIC trial, using a previously developed web-based tool.

Methods

MAGNETIC is a multicentre randomised trial of nebulised magnesium in acute severe asthma, recruiting 508 children from 30 UK sites. Recruiters were asked to grade a list of factors from –3 to +3 depending on whether the factor was perceived as a strong, intermediate or weak barrier (–3 to –1) or facilitator (+1 to + 3), and using (0) if it was thought to be not applicable. Free text responses were invited on strategies applied to counter the identified barriers.

Results

The commonly identified facilitators were motivation and experience of study teams, effective communication and coordination between teams at site and between sites and the Clinical Trials Unit, the presence of designated research nurses, good trial management, clinical trial publicity, simple inclusion criteria, effective communication with parents and presentation of trial information in a simple and clear manner. The commonly identified barriers were heavy clinical workload, shift patterns of work, Good Clinical Practice (GCP) training, inadequate number of trained staff, time and setting of consent seeking, non-availability of research staff out of hours and parents' concerns about their child taking an experimental medicine. Having a designated research nurse, arranging GCP training and trial-related training sessions for staff were the most commonly reported interventions.

Conclusions

This study highlights important generic and trial-specific facilitators and barriers to recruitment to a paediatric trial in the acute setting and provides information on the recruitment strategies or interventions that were applied to overcome these barriers. This information can be very useful in informing the design and conduct of future clinical trials with children, particularly in the acute or emergency setting.

Trial registration

ISRCTN, ISRCTN81456894. Registered on 15 November 2007.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1724-3) contains supplementary material, which is available to authorized users.

Cohort study to test the predictability of the NHS Institute for Innovation and Improvement Paediatric Early Warning System

OBJECTIVE

To test the predictability of the National Health Service Institute for Innovation and Improvement (NHSIII) Paediatric Early Warning System (PEWS) score to identify children at risk of developing critical illness.

DESIGN

Cohort study.

SETTING

Admissions to all paediatric wards at the University Hospital of Wales between 1 December 2005 and 30 November 2006.

OUTCOME MEASURES

Unscheduled paediatric high dependency unit (PHDU) admission, paediatric intensive care unit (PICU) admission and death.

RESULTS

There were 9075 clinical observations from 1000 children. An NHSIII PEWS score of 2 or more, which triggers review, has a sensitivity of 73.2% (95% CI 62.2% to 82.4%), specificity of 75.2% (95% CI 74.3% to 76.1%), positive predictive value (PPV) of 2.6% (95% CI 2.0% to 3.4%), negative predictive value of 99.7% (95% CI 99.5% to 99.8%) and positive likelihood ratio of 3.0 (95% CI 2.6 to 3.4) for predicting PHDU admission, PICU admission or death. Six (37.5%) of the 16 children with an adverse outcome did not have an abnormal NHSIII PEWS score. The area under the receiver operating characteristic curve for the NHSIII PEWS score was 0.83 (95% CI 0.77 to 0.88).

CONCLUSIONS

The NHSIII PEWS has a low PPV and its full implementation would result in a large number of false positive triggers. The issue with PEWS scores or triggers is neither their sensitivity nor children with high scores which require clinical interventions who are not 'false positives'; but their low specificity and low PPV arising from the large number of children with low but raised scores.

Variation in treatment of acute childhood wheeze in emergency departments of the United Kingdom and Ireland: an international survey of clinician practice

OBJECTIVE

National clinical guidelines for childhood wheeze exist, yet despite being one of the most common reasons for childhood emergency department (ED) attendance, significant variation in practice occurs in other settings. We, therefore, evaluated practice variations of ED clinicians in the UK and Ireland.

DESIGN

Two-stage survey undertaken in March 2013. Stage one examined department practice and stage two assessed ED consultant practice in acute childhood wheeze. Questions interrogated pharmacological and other management strategies, including inhaled and intravenous therapies.

SETTING AND PARTICIPANTS

Member departments of Paediatric Emergency Research in the United Kingdom and Ireland and ED consultants treating children with acute wheeze.

RESULTS

30 EDs and 183 (81%) clinicians responded. 29 (97%) EDs had wheeze guidelines and 12 (40%) had care pathways. Variation existed between clinicians in dose, timing and frequency of inhaled bronchodilators across severities. When escalating to intravenous bronchodilators, 99 (54%) preferred salbutamol first line, 52 (28%) magnesium sulfate (MgSO4) and 27 (15%) aminophylline. 87 (48%) administered intravenous bronchodilators sequentially and 30 (16%) concurrently, with others basing approach on case severity. 146 (80%) continued inhaled therapy after commencing intravenous bronchodilators. Of 170 who used intravenous salbutamol, 146 (86%) gave rapid boluses, 21 (12%) a longer loading dose and 164 (97%) an ongoing infusion, each with a range of doses and durations. Of 173 who used intravenous MgSO4, all used a bolus only. 41 (24%) used non-invasive ventilation.

CONCLUSIONS

Significant variation in ED consultant management of childhood wheeze exists despite the presence of national guidance. This reflects the lack of evidence in key areas of childhood wheeze and emphasises the need for further robust multicentre research studies.

Which intravenous bronchodilators are being administered to children presenting with acute severe wheeze in the UK and Ireland?

During a prospective 10-week assessment period, 3238 children aged 1-16 years presented with acute wheeze to Paediatric Emergency Research in the UK and Ireland centres. 110 (3.3%) received intravenous bronchodilators. Intravenous magnesium sulfate (MgSO4) was used in 67 (60.9%), salbutamol in 61 (55.5%) and aminophylline in 52 (47.3%) of cases. In 35 cases (31.8%), two drugs were used together, and in 18 cases (16.4%), all three drugs were administered. When used sequentially the most common order was salbutamol, then MgSO4, then aminophylline. Overall, 30 different intravenous treatment regimens were used varying in drugs, dose, rate and duration.

MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo-controlled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children

BACKGROUND

There are few data on the role of nebulised magnesium sulphate (MgSO4) in the management of acute asthma in children. Those studies that have been published are underpowered, and use different methods, interventions and comparisons. Thus, no firm conclusions can be drawn.

OBJECTIVES

Does the use of nebulised MgSO4, when given as an adjunct to standard therapy in acute severe asthma in children, result in a clinical improvement when compared with standard treatment alone?

DESIGN

Patients were randomised to receive three doses of MgSO4 or placebo, each combined with salbutamol and ipratropium bromide, for 1 hour. The Yung Asthma Severity Score (ASS) was measured at baseline, randomisation, and at 20, 40, 60 (T60), 120, 180 and 240 minutes after randomisation.

SETTING

Emergency departments and children's assessment units at 30 hospitals in the UK.

PARTICIPANTS

Children aged 2-15 years with acute severe asthma.

INTERVENTIONS

Patients were randomised to receive nebulised salbutamol 2.5 mg (ages 2-5 years) or 5 mg (ages ≥ 6 years) and ipratropium bromide 0.25 mg mixed with either 2.5 ml of isotonic MgSO4 (250 mmol/l, tonicity 289 mOsm; 151 mg per dose) or 2.5 ml of isotonic saline on three occasions at approximately 20-minute intervals.

MAIN OUTCOME MEASURES

The primary outcome measure was the ASS after 1 hour of treatment. Secondary measures included 'stepping down' of treatment at 1 hour, number and frequency of additional salbutamol administrations, length of stay in hospital, requirement for intravenous bronchodilator treatment, and intubation and/or admission to a paediatric intensive care unit. Data on paediatric quality of life, time off school/nursery, health-care resource usage and time off work were collected 1 month after randomisation.

RESULTS

A total of 508 children were recruited into the study; 252 received MgSO4 and 256 received placebo along with the standard treatment. There were no differences in baseline characteristics. There was a small, but statistically significant difference in ASS at T60 in those children who received nebulised MgSO4 {0.25 [95% confidence interval (CI) 0.02 to 0.48]; p = 0.034} and this difference was sustained for up to 240 minutes [0.20 (95% CI 0.01 to 0.40), p = 0.042]. The clinical significance of this gain is uncertain. Assessing treatment-covariate interactions, there is evidence of a larger effect in those children with more severe asthma exacerbations ( p = 0.034) and those with a shorter duration of symptoms ( p = 0.049). There were no significant differences in the secondary outcomes measured. Adverse events (AEs) were reported in 19% of children in the magnesium group and 20% in the placebo group. There were no clinically significant serious AEs in either group. The results of the base-case economic analyses are accompanied by considerable uncertainty, but suggest that, from an NHS and Personal Social Services perspective, the addition of magnesium to standard treatment may be cost-effective compared with standard treatment only. The results of economic evaluation show that the probability of magnesium being cost-effective is over 60% at cost-effectiveness thresholds of £1000 per unit decrement in ASS and £20,000 per quality-adjusted life-year (QALY) gained, respectively; it is noted that for some parameter variations this probability is much lower, reflecting the labile nature of the cost-effectiveness ratio in light of the small differences in benefits and costs shown in the trial and the relation between the main outcome measure (ASS) and preference based measures of quality of life used in cost-utility analysis (European Quality of Life-5 Dimensions; EQ-5D).

CONCLUSIONS

This study supports the use of nebulised isotonic MgSO4 at the dose of 151 mg given three times in the first hour of treatment as an adjuvant to standard treatment when a child presents with an acute episode of severe asthma. No harm is done by adding magnesium to salbutamol and ipratropium bromide, and in some individuals it may be clinically helpful. The response is likely to be more marked in those children with more severe attacks and with a shorter duration of exacerbation. Although the study was not powered to demonstrate this fully, the data certainly support the hypotheses that nebulised magnesium has a greater clinical effect in children who have more severe exacerbation with shorter duration of symptoms.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81456894.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

OBJECTIVE

To determine the use of paediatric early warning systems (PEWS) and rapid response teams (RRTs) in paediatric units in Great Britain.

DESIGN

Cross sectional survey.

SETTING

All hospitals with inpatient paediatric services in Great Britain.

OUTCOME MEASURES

Proportion of units using PEWS, origin of PEWS used, criterion included in PEWS, proportion of units with an RRT and membership of RRT.

RESULTS

The response rate was 95% (149/157). 85% of units were using PEWS and 18% had an RRT in place. Tertiary units were more likely than district general hospital to have implemented PEWS, 90% versus 83%, and an RRT, 52% versus 10%. A large number of PEWS were in use, the majority of which were unpublished and unvalidated systems.

CONCLUSIONS

Despite the inconclusive evidence of effectiveness, the use of PEWS has increased since 2005. The implementation has been inconsistent with large variation in the PEWS used, the activation criteria used, availability of an RRT and the membership of the RRT. There must be a coordinated national evaluation of the implementation, impact and effectiveness of a standardised PEWS programme in the various environments where acutely sick children are managed.

Why some children hospitalized for pneumonia do not consult with a general practitioner before the day of hospitalization

BACKGROUND

Early consultation in primary care may provide an opportunity for early intervention in children developing pneumonia, but little is known about why some children do not consult a general practitioner (GP) before hospitalization.

OBJECTIVES

To identify differences between children who consulted a GP and children who did not consult a GP before the day of hospital presentation with pneumonia or empyema.

METHODS

Carers of children aged six months to 16 years presenting to hospital with pneumonia or empyema completed a questionnaire, with a subset participating in an interview to identify physical, organizational and psychological barriers to consultation. Responses from those who had consulted a GP before the day of hospital presentation were compared with those who had not on a range of medical, social and environmental variables.

RESULTS

Fifty seven (38%) of 151 participants had not consulted a GP before the day of hospital presentation. On multivariate analysis, illness duration ≥ 3 days (odds ratio [OR] 4.36, 95% confidence interval [CI]: 1.67-11.39), prior antibiotic use (OR: 10.35, 95% CI: 2.16-49.55) and home ownership (OR: 3.17, 95% CI: 1.07-9.37) were significantly associated with early GP consultation (P < 0.05). Interviews with 28 carers whose children had not seen a GP before the day of presentation revealed that most had not considered it and/or did not think their child's initial symptoms were serious or unusual; 11 (39.3%) had considered consulting a GP but reported barriers to access.

CONCLUSION

Lack of early GP consultation was strongly associated with rapid evolution of pneumonia.

Toddler diarrhoea: is it a useful diagnostic label?

Toddler diarrhoea is a term coined many years ago to describe a young child who passes several loose stools a day but who is otherwise healthy with excellent growth and normal examination. It could be argued that it is not an appropriate diagnostic term as it potentially stops the clinician from thinking about the possible causes of loose stools in this clinical situation. This article, which follows a debate between the authors on the topic at the 2010 Royal College of Paediatrics and Child Health Annual meeting, discusses the differential diagnoses of a young child presenting with the so-called toddler diarrhoea.

Carers' perspectives on the presentation of community-acquired pneumonia and empyema in children: a case series

OBJECTIVE

To describe carers' perceptions of the development and presentation of community-acquired pneumonia or empyema in their children.

DESIGN

Case series.

SETTING

Seven hospitals with paediatric inpatient units in South Wales, UK.

PARTICIPANTS

Carers of 79 children aged 6 months to 16 years assessed in hospital between October 2008 and September 2009 with radiographic, community-acquired pneumonia or empyema.

METHODS

Carers were recruited in hospital and participated in a structured face-to-face or telephone interview about the history and presenting features of their children's illnesses. Responses to open questions were initially coded very finely and then grouped into common themes. Cases were classified into two age groups: 3 or more years and under 3 years.

RESULTS

The reported median duration of illness from onset until the index hospital presentation was 4 days (IQR 2-9 days). Pain in the torso was reported in 84% of cases aged 3 or more years and was the most common cause for carer concern in this age group. According to carer accounts, clinicians sometimes misjudged the origin of this pain. Almost all carers reported something unusual about the index illness that had particularly concerned them-mostly non-specific physical symptoms and behavioural changes.

CONCLUSIONS

Pain in the torso and carer concerns about unusual symptoms in their child may provide valuable additional information in a clinician's assessment of the risk of pneumonia in primary care. Further research is needed to confirm the diagnostic value of these features.

Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis

OBJECTIVE

To compare the efficacy of 2 nasogastric rehydration regimens for children with acute viral gastroenteritis.

METHODS

Children 6 to 72 months of age with acute viral gastroenteritis and moderate dehydration were recruited from emergency departments (EDs) at 2 metropolitan, pediatric, teaching hospitals. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either standard nasogastric rehydration (SNR) over 24 hours in the hospital ward or rapid nasogastric rehydration (RNR) over 4 hours in the ED. Primary (>2% weight loss, compared with the admission weight) and secondary treatment failures were assessed.

RESULTS

Of 9331 children with acute gastroenteritis who were screened, 254 children were assigned randomly to receive either RNR (n = 132 [52.0%]) or SNR (n = 122 [48.0%]). Baseline characteristics for the 2 groups were similar. All patients made a full recovery without severe adverse events. The primary failure rates were similar for RNR (11.8% [95% confidence interval [CI]: 6.0%-17.6%]) and SNR (9.2% [95% CI: 3.7%-14.7%]; P = .52). Secondary treatment failure was more common in the SNR group (44% [95% CI: 34.6%-53.4%]) than in the RNR group (30.3% [95% CI: 22.5%-38.8%]; P = .03). Discharge from the ED after RNR failed for 27 patients (22.7%), and another 9 (7.6%) were readmitted to the hospital within 24 hours.

CONCLUSIONS

Primary treatment failure and clinical outcomes were similar for RNR and SNR. Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients.

Cohort study to test the predictability of the Melbourne criteria for activation of the medical emergency team

OBJECTIVE

To test the predictability of the Melbourne criteria for activation of the medical emergency team (MET) to identify children at risk of developing critical illness.

DESIGN

Cohort study.

SETTING

Admissions to all paediatric wards at the University Hospital of Wales.

OUTCOME MEASURES

Paediatric high dependency unit admission, paediatric intensive care unit admission and death.

RESULTS

Data were collected on 1000 patients. A single abnormal observation determined by the Melbourne Activation Criteria (MAC) had a sensitivity of 68.3% (95% CI 57.7 to 77.3), specificity 83.2% (95% CI 83.1 to 83.2), positive predictive value (PPV) 3.6% (95% CI 3.0 to 4.0) and negative predictive value 99.7% (95% CI 99.5 to 99.8) for an adverse outcome. Seven of the 16 children (43.8%) would not have transgressed the MAC prior to the adverse outcomes. Four hundred and sixty-nine of the 984 children (47.7%) who did not have an adverse outcome would have transgressed the MAC at least once during the admission.

CONCLUSION

The MAC has a low PPV and its full implementation would result in a large number of false positive triggers. Further research is required to determine the relative contribution of the components of this complex intervention (Paediatric Early Warning System, education and MET) on patient outcome.

Prospective cohort study to test the predictability of the Cardiff and Vale paediatric early warning system

OBJECTIVE

To develop and test the predictability of a paediatric early warning score to identify children at risk of developing critical illness.

DESIGN

Prospective cohort study.

SETTING

Admissions to all paediatric wards at the University Hospital of Wales.

OUTCOME MEASURES

Respiratory arrest, cardiac arrest, paediatric high-dependency unit admission, paediatric intensive care unit admission and death.

RESULTS

Data were collected on 1000 patients. A single abnormal observation determined by the Cardiff and Vale paediatric early warning system (C&VPEWS) had a 89.0% sensitivity (95% CI 80.5 to 94.1), 63.9% specificity (95% CI 63.8 to 63.9), 2.2% positive predictive value (95% CI 2.0 to 2.3) and a 99.8% negative predictive value (95% CI 99.7 to 99.9) for identifying children who subsequently had an adverse outcome. The area under the receiver operating characteristic curve for the C&VPEWS score was 0.86 (95% CI 0.82 to 0.91).

CONCLUSION

Identifying children likely to develop critical illness can be difficult. The assessment tool developed from the advanced paediatric life support guidelines on identifying sick children appears to be sensitive but not specific. If the C&VPEWS was used as a trigger to activate a rapid response team to assess the child, the majority of calls would be unnecessary.

Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children's hospitals

AIMS

To compare prevalence, reasons, motivations, initiation, perceived helpfulness, and communication of complementary and alternative medicine (CAM) use between two tertiary children's hospitals.

METHODOLOGY

A study, using a face-to-face questionnaire, of 500 children attending the University Hospital of Wales, Cardiff, UK was compared to an identical study of 503 children attending the Royal Children's Hospital, Melbourne, Australia.

RESULTS

One year CAM use in Cardiff was lower than Melbourne (41% v 51%; OR = 0.67, 95% CI 0.52-0.85), reflected in non-medicinal use (OR = 0.41, 95% CI 0.29-0.58) and general paediatric outpatients (OR = 0.38, 95% CI 0.21-0.67). Compared to Melbourne, factors associated with lower CAM use in Cardiff included families born locally (father: OR = 0.58, 95% CI 0.44-0.77) or non-tertiary educated parents (mother: OR = 0.54, 95% CI 0.38-0.77). Cardiff participants used less vitamin C (OR = 0.31, 95% CI 0.18-0.51) and herbs (OR = 0.49, 95% CI 0.34-0.71), attended less chiropractors (OR = 0.25, 95% CI 0.06-0.37) and naturopaths (OR = 0.08, 95% CI 0.02-0.33), but saw more reflexologists (OR = 3.33, 95% CI 1.08-10.29). In Cardiff, CAM was more popular for relaxation (OR = 1.92, 95% CI 1.03-3.57) but less for colds/coughs (OR = 0.4, 95% CI 0.27-0.73). Most CAM was self-initiated (by parent) in Cardiff and Melbourne (74% v 70%), but Cardiff CAM users perceived it less helpful (OR = 0.46, 95% CI 0.31-0.68). Non-disclosure of CAM use was high in Cardiff and Melbourne (66% v 63%); likewise few doctors/nurses documented recent medicinal CAM use in inpatient notes (0/21 v 2/22).

CONCLUSIONS

The differences in CAM use may reflect variation in sociocultural factors influencing reasons, motivations, attitudes, and availability. The regional variation in use and poor communication highlights the importance of local policy development.

Asthma in emergency departments: combined adult and paediatric versus paediatric only centres

OBJECTIVE

To compare the management of paediatric patients with mild or moderate asthma in paediatric-only emergency departments (POEDs) to treatment in a mixed adult-child emergency departments (mixed EDs).

METHODS

Prospective, observational study conducted in 36 Australian emergency departments (EDs) for 2 weeks in 2001. Children aged 1-15 years with acute asthma classified as mild or moderate severity. Details of demography, severity assessment, and type of treatment facility, treatment and disposition were collected. Analysis used descriptive statistics, comparison of proportions by chi2, and multiple logistic regression.

RESULTS

Two-hundred and nine children were treated at POEDs and 257 at mixed EDs. The groups had similar severity. Spacers to deliver beta-agonists were used more frequently in POEDs (67.5% vs 24.2%; P < 0.01). Children treated at POEDs with a mild attack were more likely to be admitted (20.6% vs 9.5%; P < 0.02) and given salbutamol (82.8% vs 71.9%; P = 0.03). For children with moderate asthma, oral steroid prescription on hospital discharge was more common for those treated in a mixed ED (81.0% vs 95.7%; P = 0.01). Ipratropium bromide (IB) was widely used at both types of ED but more commonly used in mixed EDs (41.7% vs 54.9%; P < 0.01). There were no differences in length-of-stay, representation rate within one month and oral steroid use for attack. Less than 2/3 of children with mild asthma attacks received steroid treatment in the ED.

CONCLUSION

Treatment was similar between the two types of ED. IB was overused in mild asthma and oral steroids were underused in moderate asthma, by both ED types. Spacers were under-utilized in mixed EDs.

Cephalosporin resistant urinary tract infections in young children

OBJECTIVE

To describe the antibiotic resistance pattern of bacteria causing urinary tract infection (UTI) in a cohort of Australian children under 6 years of age.

METHODS

Data were collected over a 12-month period from children under 6 years of age with a provisional diagnosis of UTI made in the Emergency Department of Sunshine Hospital, Victoria.

RESULTS

During the study period 100 culture-proven UTI were identified in 97 children. Three children had two episodes. Out of the 100 episodes, 39% were male, 56% were under 12 months of age at presentation and 61% were managed as outpatients. Clinical features were non-specific in the majority of cases. Hydronephrosis and vesicoureteric reflux was detected in 5.5% and 28.6%, respectively, of children with their first investigated UTI. A single bacterial isolate was cultured from 97 urines and two from three samples. Escherichia coli (n = 90) and Proteus mirabilis (n = 5) were the most common isolates. In vitro resistance to ampicillin/amoxycillin was found in 52% of isolates, to trimethoprim in 14% and to cephalothin/cephalexin in 24%. This resistance rate to first generation cephalosporins is the highest reported to date in adult or paediatric UTI in Australia.

CONCLUSIONS

Ampicillin/amoxycillin or cephalothin/cephalexin may not be the optimal choice of antibiotic for the empiric treatment of UTI in this and possibly other paediatric populations.

How to implement change in clinical practice

Changing clinical practice is a major challenge. It is not acceptable simply to send out a new clinical guideline or care pathway and expect there to be a change in practice. This paper addresses the problems associated with the development of a clinical guideline and sets out a clear strategy for dissemination, implementation and evaluation in a way that should promote the successful change of practice. The first section examines the development of the guideline. National or international guidelines may well exist but local adaptation and refinement of those guidelines are required, along with a local summary document. Valid, reproducible, evidence-based, clear, logical, easily accessible guidelines need to be available after widespread local, multi-professional consultation. Second, prior to dissemination, there needs to be promotion among all the health professionals and families involved with the change in practice. Appropriate educational and multi-disciplinary interventions, highlighting and informing in workshops and preparing people for the changes are recommended. Recognising the barriers to implementation and change and addressing these locally is important. Once the guideline has been disseminated and implemented and the change in practice has occurred, full evaluation and ongoing audit of the changes in practice are required to sustain the changes.

Lack of agreement in classification of the severity of acute asthma between emergency physician assessment and classification using the National Asthma Council Australia guidelines (1998)

AIMS

To determine the level of agreement in classification of the severity of acute asthma at presentation to the emergency department, between emergency physician global assessment and severity classification according to the National Asthma Council Guidelines, Australia 1998 (NACG).

METHODS

Prospective observational study in emergency departments throughout Australia, participating in the Asthma Snapshot 2000 project. Patients between the ages of one and 60 years presenting to participating emergency departments with acute asthma between 21 August and 3 September 2000 were included. Data collected were emergency physician global assessment of asthma severity and severity classification according to the National Asthma Council Guidelines and disposition.

RESULTS

Five hundred and five subjects had completed data for emergency physician assessment of severity and for calculation of severity classification according to the National Asthma Council Guidelines. Weighted kappa for agreement in classification was 0.48 (95% confidence interval: 0.40, 0.56). Emergency physicians assess asthma as less severe compared to the National Asthma Council Guidelines assessment.

CONCLUSIONS

Agreement between physician assessment of severity of acute asthma and severity classification according to National Asthma Council Guidelines is only moderate. This may have implications in treatment and disposition. This also suggests that emergency physicians may be using other methods to classify acute asthma than the National Asthma Council Guidelines classification.

A parent completed questionnaire to describe the patterns of wheezing and other respiratory symptoms in infants and preschool children

AIM

To develop a standardised and validated respiratory symptom questionnaire for use in epidemiological or follow up studies in infants and preschool children.

METHODOLOGY

After initial design and development, the questionnaire was administered to two cohorts of subjects, one recruited from a respiratory clinic and the other from a postnatal ward. The two cohorts then repeated the questionnaire, two weeks apart. The qualities of the questionnaire were assessed.

RESULTS

Response rate to the initial questionnaire was 100% for the clinic based cohort and 64% for postnatally recruited families (total number of subjects 114). Questions showed good to moderate short term reliability (weighted kappa scores 0.47-0.7; average correct classification rates 0.74-0.91). Four domain concept scores showed excellent internal consistency (Cronbach alpha scores 0.87-0.95). Using principal component factor analysis, four new domains were devised showing acceptable construct validity and internal consistency. Criterion validity was assessed using a respiratory physician based diagnosis of asthma (RPBDA) as the gold standard for comparison. All eight scales in the questionnaire could significantly distinguish between infants with RPBDA and well or mildly symptomatic subjects.

CONCLUSION

We have developed a practical, acceptable questionnaire with eight concept domains for use in infants and preschool children. The questionnaire has strong construct validity and internal consistency with good short term reliability of questions. More detailed study of criterion validity and the responsiveness of the questionnaire is required using a larger population and including children with the different phenotypes of wheezy illness.

Asthma in children: gaps between current management and best practice

OBJECTIVES

To determine the extent to which steps three to six of the Australian six-step asthma management plan are being implemented in the community and to identify barriers to the adoption of best practice asthma management.

METHODS

A cross-sectional descriptive study was conducted at the Royal Children's Hospital and Sunshine Hospital, Melbourne. Two hundred and thirty-one 2-5-year old children who visited the emergency department for asthma were enrolled in the study. Main outcome measures were frequency of asthma management practices and barriers, as measured by parent-completed questionnaire.

RESULTS

Gaps: 51% of parents do not feel they have enough information about asthma triggers, more than 60% of children with persistent or frequent episodic asthma are not using regular preventive medication, 48% do not have a written action plan, 39% have not had their asthma reviewed in the last 6 months, and 38% of parents do not feel that they have enough information about their child's asthma. Areas where current practice was close to best practice: 83% of doctors had talked to parents about what causes or 'triggers' their child's asthma, less than 1% of children are using puffers without a spacer, 83% of parents who had an action plan used it for the current visit to the emergency department.

CONCLUSIONS

Large gaps still exist between current management and best practice in this group of emergency department attenders. Improvements in asthma management could be achieved if the child's asthma doctor requested review visits for asthma, provided an action plan and followed best practice in relation to asthma medications.