1
|
Stokle M, Tinker RJ, Munro SP, Mullen N. Early reattenders to the paediatric emergency department: A prospective cohort study and multivariate analysis. J Paediatr Child Health 2022; 58:1616-1622. [PMID: 35726728 DOI: 10.1111/jpc.16061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/12/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
AIMS The rate of unplanned reattendances is used as an indicator of the quality of care delivered in a paediatric emergency department (PED). With early reattendance in the UK well above the national target of 1-5%, we aimed to identify the factors which predict unplanned early reattendance to the PED. METHODS This is a prospective, single-centre cohort study undertaken over 12 months. Data were collected on all patients who reattended the PED within 7 days of their initial visit as well as for a comparative cohort of patients with no visit in the preceding or subsequent 7 days. Multiple patient and departmental variables were recorded and analysed using a multivariate regression model. RESULTS There were a total of 19 420 index visits to the PED, of which 1461 patients had an unscheduled reattendance within 7 days - a rate of 7.5%. Factors associated with unplanned but related reattendance include young age and diagnosis with a respiratory or other medical illness. Interestingly, the grade of clinician appeared to be relevant with patients seen by junior members of the medical team less likely to reattend. Acuity of illness was not a significant factor. A substantial number of unplanned early reattenders (36.3%) would have been missed had a time period of 72 h been used rather than 7 days. CONCLUSIONS This study identifies the typical patient who will have an unplanned, related early reattendance to a PED. This study also supports the use of a 7-day time period when using early reattendance as a performance indicator.
Collapse
Affiliation(s)
- Matthew Stokle
- Paediatric Emergency Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom
| | - Rory J Tinker
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Samuel P Munro
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Niall Mullen
- Paediatric Emergency Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom
| |
Collapse
|
2
|
Chaudhary P, Choudhary B, Budania A. An infant with extensive blood-filled rashes. Emerg Med J 2022; 39:456-482. [PMID: 35613740 DOI: 10.1136/emermed-2021-211617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Puja Chaudhary
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Bharat Choudhary
- Trauma & Emergency (Pediatrics), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Anil Budania
- Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|
3
|
Cozzi G, Cortellazzo Wiel L, Bassi A, Giangreco M, Dibello D, Rozzo M, Di Carlo V, Genovese MRL, Barbi E. Need for pharmacological analgesia after cast immobilisation in children with bone fractures: an observational cross-sectional study. Emerg Med J 2021; 39:595-600. [PMID: 34649940 DOI: 10.1136/emermed-2020-210989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 09/28/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Bone fractures are a common reason for children and adolescents to seek evaluation in the ED. Little is known about the pain experienced after cast immobilisation and discharge from the ED and its optimal management. We aimed to investigate the administration of pharmacological analgesia in the first days after cast immobilisation and to identify possible influencing variables. METHODS A prospective observational cross-sectional study was conducted at the ED of the children's hospital, Institute for Maternal and Child Health of Trieste, Italy, from October 2019 to June 2020. Patients aged 0-17 years with bone fractures were included. The primary outcome was the administration of analgesia during the 10 days following discharge, while secondary outcomes were the associated variables, including age, gender, fracture type and location, the mean limitation in usual activities and the frequency of re-evaluation at the ED for pain. Data were recorded through a questionnaire, completed by caregivers and collected by the researchers mainly through a telephone interview. The primary endpoint was evaluated as the ratio between the number of children who took at least one analgesic dose and the total enrolled children, while Χ2 or Fisher's exact tests were used to assess secondary outcomes. RESULTS During the study period, 213 patients, mean age 10 years (IQR: 8-13), were enrolled. Among them, 137 (64.3%) did not take any analgesic during follow-up. Among children who were administered analgesia, 22 (28.9%) received it only on the first day, and 47 (61.8%) for less than 5 days. One hundred and sixty one patients (75.6%) did not report any limitation in usual activities because of pain. The administration of analgesia was not related to the child's age, gender or fracture site. Displaced fractures were associated with significantly more frequent analgesia being taken (OR 5.5, 95% CI 1.4 to 21.0). CONCLUSION Although some studies recommend scheduled analgesic treatment after discharge for bone fractures, this study would suggest analgesia on demand in children with non-displaced fractures, limiting scheduled analgesia to children with displaced fractures.
Collapse
Affiliation(s)
- Giorgio Cozzi
- Department of Paediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Luisa Cortellazzo Wiel
- Clinical Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Anna Bassi
- Clinical Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Manuela Giangreco
- Department of Paediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Daniela Dibello
- UOC Orthopedics and Traumatology, Giovanni XXIII Pediatric Hospital, Bari, Italy
| | - Marco Rozzo
- Department of Paediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Valentina Di Carlo
- Department of Paediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | | | - Egidio Barbi
- Department of Paediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy.,Clinical Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| |
Collapse
|
4
|
Place R. Applying clinical decision rules to paediatric cervical spine injuries: if at first you don't succeed. Emerg Med J 2021; 38:328-329. [PMID: 34449408 DOI: 10.1136/emermed-2020-211125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/03/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Rick Place
- Emergency Medicine, Inova Fairfax Hospital, Falls Church, Virginia, USA
| |
Collapse
|
5
|
Yao SHW, Chong SL, James V, Lee KP, Ong GYK. Associations of initial haemodynamic profiles and neurological outcomes in children with traumatic brain injury: a secondary analysis. Emerg Med J 2021; 39:527-533. [PMID: 34344733 DOI: 10.1136/emermed-2020-210641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 07/09/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI. METHODS This was a secondary analysis of our primary study that analysed the association of TBI-associated coagulopathy with mortality and neurological outcome in isolated, moderate-to-severe paediatric head injury. A trauma registry-based, retrospective study of children <18 years old who presented to the emergency department with isolated, moderate-to-severe TBI from January 2010 to December 2016 was conducted. The association between initial haemodynamic variables and less favourable outcomes using Glasgow Outcome Scale-Extended Paediatric) at 6 months post injury was analysed using logistic regression. RESULTS Among 152 children analysed, initial systolic and diastolic hypotension (<5th percentile) (OR) for SBP 11.40, 95% CI 3.60 to 36.05, p<0.001; OR for DBP 15.75, 95% CI 3.09 to 80.21, p<0.001) and Glasgow Coma Scale scores <8 (OR 14.50, 95% CI 3.65 to 57.55, p<0.001) were associated with 'moderate-to-severe neurological disabilities', 'vegetative state' and 'death'. After adjusting for confounders, only SBP was significant (adjusted OR 5.68, 95% CI 1.40 to 23.08, p=0.015). CONCLUSIONS Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.
Collapse
Affiliation(s)
| | - Shu-Ling Chong
- Children's Emergency, KK Women's and Children's Hospital, Singapore.,Department of Emergency Medicine, Duke-NUS Medical School, Singapore
| | - Vigil James
- Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Khai Pin Lee
- Children's Emergency, KK Women's and Children's Hospital, Singapore.,Department of Emergency Medicine, Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Children's Emergency, KK Women's and Children's Hospital, Singapore.,Department of Emergency Medicine, Duke-NUS Medical School, Singapore
| |
Collapse
|
6
|
Aldridge P, Parish R, Castle H, Russell E, Rout R, Singh R. Head home: implementation during COVID-19 pandemic. Emerg Med J 2021; 38:692-693. [PMID: 34289965 PMCID: PMC8380872 DOI: 10.1136/emermed-2020-211007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recent research suggests that between 20% and 50% of paediatric head injuries attending our emergency department (ED) could be safely discharged soon after triage, without the need for medical review, using a 'Head Injury Discharge At Triage' tool (HIDAT). We sought to implement this into clinical practice. METHODS Paediatric ED triage staff underwent competency-based assessments for HIDAT with all head injury presentations 1 May to 31 October 2020 included in analysis. We determined which patients were discharged using the tool, which underwent CT of the brain and whether there was a clinically important traumatic brain injury or representation to the ED. RESULTS Of the 1429 patients screened; 610 (43%) screened negative with 250 (18%) discharged by nursing staff. Of the entire cohort, 32 CTs were performed for head injury concerns (6 abnormal) with 1 CT performed in the HIDAT negative group (normal). Of those discharged using HIDAT, four reattended, two with vomiting (no imaging or admission) and two with minor scalp wound infections. Two patients who screened negative declined discharge under the policy with later medical discharge (no imaging or admission). Paediatric ED attendances were 29% lower than in 2018. CONCLUSION We have successfully implemented HIDAT into local clinical practice. The number discharged (18%) is lower than originally described; this is likely multifactorial. The relationship between COVID-19 and paediatric ED attendances is unclear but decreased attendances suggest those for whom the tool was originally designed are not attending ED and may be accessing other medical/non-medical resources.
Collapse
Affiliation(s)
- Patrick Aldridge
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Rachel Parish
- Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, Surrey, UK
| | - Heather Castle
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Emma Russell
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Raj Rout
- Global Medical Affairs, Sanofi Genzyme, Guildford, UK
| | - Roohi Singh
- University of East Anglia Norwich Medical School, Norwich, Norfolk, UK
| |
Collapse
|
7
|
Bradman K, Stannage K, O'Brien S, Green S, Bear N, Borland M. Randomised controlled trial comparing immobilisation in above-knee plaster of Paris to controlled ankle motion boots in undisplaced paediatric spiral tibial fractures. Emerg Med J 2021; 38:600-606. [PMID: 34158387 DOI: 10.1136/emermed-2020-210299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/13/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Management of common childhood spiral tibial fractures, known as toddler's fractures, has not significantly changed in recent times despite the availability of immobilisation devices known as controlled ankle motion (CAM) boots. We compared standard therapy with these devices on quality-of-life measures. METHODS A prospective randomised controlled trial, comparing immobilisation with an above-knee plaster of Paris cast (AK-POP) with a CAM boot in children aged 1-5 years with proven or suspected toddler's fractures presenting to a tertiary paediatric ED in Perth, Western Australia, between March 2018 and February 2020. The primary outcome measure was ease of personal care, as assessed by a Care and Comfort Questionnaire (eight questions scored from 0, very easy, to 8, impossible) completed by the caregiver and assessed during three treatment time-points and preintervention and postintervention. Secondary outcome measures included weight-bearing status as well as complications of fracture healing and number of pressure injuries. RESULTS 87 patients were randomised (44 CAM boot, median age 2 (IQR 1.5-2.3), 71% male; 43 AK-POP, median age 2 (IQR 1.7-2.8), 80% male), a significant difference in the care and comfort score was demonstrated at all treatment time-points; with the AK-POP group reporting greater personal care needs on assessment on day 2, day 7-10 and 4-week review (all p≤0.001). Weight-bearing status was significantly different at day 7-10 (77.5% CAM vs 53.8% AK-POP, p=0.027). There was no difference in fracture healing or pressure areas between the two treatment groups. CONCLUSIONS Immobilisation of toddler's fractures in a CAM boot allows faster return to activities of daily living and weight-bearing without any effect on fracture healing. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12618001311246).
Collapse
Affiliation(s)
- Kate Bradman
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Katherine Stannage
- Department of Orthopaedic Surgery, Perth Children's Hospital, Perth, Western Australia
| | - Sharon O'Brien
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Simon Green
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Natasha Bear
- Institute of Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Meredith Borland
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Paediatric and Emergency Medicine, The University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
| |
Collapse
|
8
|
Roper L, Lyttle MD, Gamble C, Humphreys A, Messahel S, Lee ED, Noblet J, Hickey H, Rainford N, Iyer A, Appleton R, Woolfall K. Planning for success: overcoming challenges to recruitment and conduct of an open-label emergency department-led paediatric trial. Emerg Med J 2021; 38:191-197. [PMID: 33051276 PMCID: PMC7907583 DOI: 10.1136/emermed-2020-209487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Key challenges to the successful conduct of The Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children (EcLiPSE) trial were identified at the pre-trial stage. These included practitioner anxieties about conducting research without prior consent (RWPC), inexperience in conducting an ED-led trial and use of a medication that was not usual ED practice. As part of an embedded study, we explored parent and practitioner experiences of recruitment, RWPC and conduct of the trial to inform the design and conduct of future ED-led trials. METHODS A mixed-methods study within a trial involving (1) questionnaires and interviews with parents of randomised children, (2) interviews and focus groups with EcLiPSE practitioners and (3) audio-recorded trial discussions. We analysed data using thematic analysis and descriptive statistics as appropriate. RESULTS A total of 143 parents (93 mothers, 39 fathers, 11 missing information) of randomised children completed a questionnaire and 30 (25 mothers, 5 fathers) were interviewed. We analysed 76 recorded trial recruitment discussions. Ten practitioners (4 medical, 6 nursing) were interviewed, 36 (16 medical, 20 nursing) participated in one of six focus groups. Challenges to the success of the trial were addressed by having a clinically relevant research question, pragmatic trial design, parent and practitioner support for EcLiPSE recruitment and research without prior consent processes, and practitioner motivation and strong leadership. Lack of leadership negatively affected practitioner engagement and recruitment. EcLiPSE completed on time, achieving its required sample size target. CONCLUSIONS Successful trial recruitment and conduct in a challenging ED-led trial was driven by trial design, recruitment experience, teamwork and leadership. Our study provides valuable insight from parents and practitioners to inform the design and conduct of future trials in this setting.
Collapse
Affiliation(s)
- Louise Roper
- Institute of Population Health & Society, University of Liverpool, Liverpool, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Amy Humphreys
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Shrouk Messahel
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Elizabeth D Lee
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Joanne Noblet
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Anand Iyer
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Richard Appleton
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Kerry Woolfall
- Institute of Population Health & Society, University of Liverpool, Liverpool, UK
| |
Collapse
|
9
|
Affiliation(s)
- Emily Neill
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA .,Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Nida Felicija Degesys
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sally Graglia
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
10
|
Goldman RD, Grafstein E, Barclay N, Irvine MA, Portales-Casamar E. Paediatric patients seen in 18 emergency departments during the COVID-19 pandemic. Emerg Med J 2020; 37:773-777. [PMID: 33127743 PMCID: PMC7604790 DOI: 10.1136/emermed-2020-210273] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/30/2020] [Accepted: 10/03/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Public health mitigation strategies in British Columbia during the pandemic included stay-at-home orders and closure of non-essential services. While most primary physicians' offices were closed, hospitals prepared for a pandemic surge and emergency departments (EDs) stayed open to provide care for urgent needs. We sought to determine whether ED paediatric presentations prior and during the COVID-19 pandemic changed and review acuity compared with seasonal adjusted prior year. METHODS We analysed records from 18 EDs in British Columbia, Canada, serving 60% of the population. We included children 0-16 years old and excluded those with no recorded acuity or discharge disposition and those left without being seen by a physician. We compared prepandemic (before the first COVID-19 case), early pandemic (after first COVID-19 case) and peak pandemic (during public health emergency) periods as well as a similar time from the previous year. RESULTS A reduction of 57% and 70% in overall visits was recorded in the children's hospital ED and the general hospitals EDs, respectively. Average daily visits declined significantly during the peak-pandemic period (167.44±40.72) compared with prepandemic period (543.53±58.8). Admission rates increased mainly due to the decrease in the rate of visits with lower acuity. Children with complaints of 'fever' and 'gastrointestinal' symptoms had both the largest overall volume and per cent reduction in visits between peak-pandemic and prior year (79% and 74%, respectively). CONCLUSION Paediatric emergency medicine attendances were reduced to one-third of normal numbers during the 2020 COVID-19 lockdown in British Columbia, Canada, with the reduction mainly seen in minor illnesses that do not usually require admission.
Collapse
MESH Headings
- Adolescent
- Betacoronavirus/pathogenicity
- British Columbia/epidemiology
- COVID-19
- Child
- Child, Preschool
- Coronavirus Infections/diagnosis
- Coronavirus Infections/epidemiology
- Coronavirus Infections/prevention & control
- Coronavirus Infections/transmission
- Emergencies/epidemiology
- Emergency Medicine/organization & administration
- Emergency Medicine/statistics & numerical data
- Emergency Service, Hospital/organization & administration
- Emergency Service, Hospital/statistics & numerical data
- Female
- Health Services Accessibility/organization & administration
- Health Services Accessibility/statistics & numerical data
- Hospitals, Pediatric/organization & administration
- Hospitals, Pediatric/statistics & numerical data
- Humans
- Infant
- Infant, Newborn
- Male
- Pandemics/prevention & control
- Patient Admission/statistics & numerical data
- Patient Discharge/statistics & numerical data
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/epidemiology
- Pneumonia, Viral/prevention & control
- Pneumonia, Viral/transmission
- SARS-CoV-2
- Triage/organization & administration
- Triage/statistics & numerical data
Collapse
Affiliation(s)
- Ran D Goldman
- The Pediatric Research in Emergency Therapeutics (PRETx) Program, Division of Emergency Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Eric Grafstein
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Neil Barclay
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Fraser Health, Vancouver, British Columbia, Canada
| | - Michael A Irvine
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Elodie Portales-Casamar
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
11
|
Jafar AJN. Advocating for those who need it most: our responsibility for delivering appropriate care to refugee and asylum seeking patients. Emerg Med J 2020; 38:3-4. [PMID: 33214198 DOI: 10.1136/emermed-2020-210800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 11/03/2022]
|
12
|
Hansen ML, Wagner A, Schnapp A, Lin A, Le N, Deverman S, Pedigo E, Johnson A, Cusick J, Gries H, Kato M. Cluster cross-over randomised trial of paediatric airway management devices in the simulation lab and operating room among paramedic students. Emerg Med J 2020; 38:27-32. [PMID: 33046528 DOI: 10.1136/emermed-2020-209929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The objective of this study was to compare paediatric emergency airway management strategies in the simulation lab and operating room environments. METHODS This was a two-part cluster cross-over randomised trial including simulation lab and operating room environments conducted between January 2017 and June 2018 in Portland, Oregon, USA. In simulated infant cardiac arrests, paramedic students placed an endotracheal tube, an i-gel or a laryngeal mask airway in random order. In the operating room, paramedic students placed a laryngeal mask airway or i-gel device in random order in sequential patients. The primary outcome for both portions of the study was time to ventilation. In the operating room portion, we also evaluated leak pressures and average initial tidal volumes. RESULTS There were 58 paramedic students who participated in the simulation lab and 22 who participated in the operating room study. The mean time to airway placement in the simulation lab was 48.5 s for the i-gel, 68.9 s for the laryngeal mask and 129.5 s for the endotracheal tube. In the operating room, mean time to i-gel placement was 34.3 s with 45.2 s for the laryngeal mask. In multivariable analysis of the simulation study, the laryngeal mask and i-gel were significantly faster than the endotracheal tube, and the i-gel was faster than the laryngeal mask. In the operating room, there was no significant difference in time to placement, leak pressure and average volume of the first five breaths between the i-gel and laryngeal mask. CONCLUSIONS We found that paramedic students were able to place supraglottic devices rapidly with high success rates in simulation lab and operating room environments. Supraglottic devices, particularly the i-gel, were rated as easy to use. The i-gel may be easiest to use since it lacks an inflable cuff and requires fewer steps to place.
Collapse
Affiliation(s)
- Matthew Lee Hansen
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Adam Wagner
- Oregon Institute of Technology, Wilsonville, Oregon, US
| | - Ashley Schnapp
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Amber Lin
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Nancy Le
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Sarah Deverman
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Elizabeth Pedigo
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Johnson
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jordan Cusick
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Heike Gries
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Meredith Kato
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
13
|
Snelling PJ, Jones P, Keijzers G, Bade D, Herd DW, Ware RS. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emerg Med J 2020; 38:139-145. [PMID: 32900856 DOI: 10.1136/emermed-2020-209689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Paediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray. METHODS This prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4-16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as 'no', 'buckle' or 'other' fracture for both modalities. The primary outcome was diagnostic accuracy for 'any' fracture ('buckle' and 'other' fractures combined). Secondary outcomes included diagnostic accuracy for 'other' fractures versus 'buckle' and 'no' fractures combined, and pain, imaging duration and preference for modality. RESULTS Of 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. 'Other' fractures (mostly cortical breach fractures), when compared with 'buckle'/ 'no' fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs. CONCLUSIONS NP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of 'any' fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia .,Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Sonography Innovation and Research Group (Sonar Group), Southport, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Philip Jones
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Southport, Queensland, Australia
| | - David Bade
- Department of Orthopaedics, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - David W Herd
- Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
14
|
Roper L, Lyttle MD, Gamble C, Humphreys A, Messahel S, Lee ED, Noblet J, Hickey H, Rainford N, Iyer A, Appleton R, Woolfall K. Seven-step framework to enhance practitioner explanations and parental understandings of research without prior consent in paediatric emergency and critical care trials. Emerg Med J 2020; 38:198-204. [PMID: 32862140 PMCID: PMC7907554 DOI: 10.1136/emermed-2020-209488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/27/2020] [Accepted: 06/24/2020] [Indexed: 11/06/2022]
Abstract
Background Alternatives to prospective informed consent enable the conduct of paediatric emergency and critical care trials. Research without prior consent (RWPC) involves practitioners approaching parents after an intervention has been given and seeking consent for their child to continue in the trial. As part of an embedded study in the ‘Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children’ (EcLiPSE) trial, we explored how practitioners described the trial and RWPC during recruitment discussions, and how well this information was understood by parents. We aimed to develop a framework to assist trial conversations in future paediatric emergency and critical care trials using RWPC. Methods Qualitative methods embedded within the EcLiPSE trial processes, including audiorecorded practitioner–parent trial discussions and telephone interviews with parents. We analysed data using thematic analysis, drawing on the Realpe et al (2016) model for recruitment to trials. Results We analysed 76 recorded trial discussions and conducted 30 parent telephone interviews. For 19 parents, we had recorded trial discussion and interview data, which were matched for analysis. Parental understanding of the EcLiPSE trial was enhanced when practitioners: provided a comprehensive description of trial aims; explained the reasons for RWPC; discussed uncertainty about which intervention was best; provided a balanced description of trial intervention; provided a clear explanation about randomisation and provided an opportunity for questions. We present a seven-step framework to assist recruitment practice in trials involving RWPC. Conclusion This study provides a framework to enhance recruitment practice and parental understanding in paediatric emergency and critical care trials involving RWPC. Further testing of this framework is required.
Collapse
Affiliation(s)
- Louise Roper
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Carrol Gamble
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Amy Humphreys
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Shrouk Messahel
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Elizabeth D Lee
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Joanne Noblet
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Helen Hickey
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Anand Iyer
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Richard Appleton
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Kerry Woolfall
- Institute of Population Health, University of Liverpool, Liverpool, UK
| |
Collapse
|
15
|
Aldridge P, Castle H, Phillips C, Russell E, Guerrero-Luduena R, Rout R. Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital. Emerg Med J 2020; 37:680-685. [PMID: 32759348 DOI: 10.1136/emermed-2019-208892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 05/22/2020] [Accepted: 06/20/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess if a nurse-led application of a paediatric head injury clinical decision tool would be safe compared with current practice. METHODS All paediatric (<17 years) patients with head injuries presenting to Frimley Park Emergency Department (ED), England from 1 May to 31 October 2018 were prospectively screened by a nurse using a mandated electronic 'Head Injury Discharge At Triage' questionnaire (HIDATq). We determined which patients underwent CT of brain and whether there was a clinically important intracranial injury or re-presentation to the ED. The negative predictive value of the screening tool was assessed. We determined what proportion of patients could have been sent home from triage using this tool. RESULTS Of the 1739 patients screened, 61 had CTs performed due to head injury (six abnormal) with a CT rate of 3.5% and 2% re-presentations. Of the entire cohort, 1052 screened negative. 1 CT occurred in this group showing no abnormalities. Of those screened negative, 349 (33%)/1052 had 'no other injuries' and 543 (52%)/1052 had 'abrasions or lacerations'. HIDATq's negative predictive value for CT was 99.9% (95% CI 99.4% to 99.9%) and 100% (95% CI 99.0% to 100%) for intracranial injury. The positive predictive value of the tool was low. Five patients screened negative and re-presented within 72 hours but did not require CT imaging. CONCLUSION A negative HIDATq appears safe in our ED. Potentially 20% (349/1739) of all patients with head injuries presenting to our department could be discharged by nurses at triage with adequate safety netting advice. This increases to 50% (543/1739), if patients with lacerations or abrasions were given advice and discharged at triage. A large multicentre study is required to validate the tool.
Collapse
Affiliation(s)
- Patrick Aldridge
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Heather Castle
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Clare Phillips
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Emma Russell
- Paediatric Emergency Department, Frimley Park Hospital NHS Foundation Trust, Frimley, UK
| | - Richard Guerrero-Luduena
- School of Health Sciences, Centre for Implementation Science, University of Southampton, Southampton, Hampshire, UK
| | - Raj Rout
- Global Medical Affairs, Sanofi Genzyme, Guildford, UK
| |
Collapse
|
16
|
Gravel J, Ledoux AA, Tang K, Yeates KO, Craig W, Osmond M, Boutis K, Burns E, Sangha G, Dubrovsky AS, Beer D, Zemek R. Early versus delayed emergency department presentation following mild Traumatic Brain Injury and the presence of symptom at 1, 4 and 12 weeks in children. Emerg Med J 2020; 37:338-343. [PMID: 32139516 DOI: 10.1136/emermed-2019-209054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 02/02/2020] [Accepted: 02/04/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the association between timing of presentation and postconcussive symptoms (PCS) at 1, 4 and 12 weeks after injury. METHODS This was a secondary analysis of a prospective cohort study conducted in nine Canadian paediatric EDs in 2013-2015 (5P study). Participants were children who suffered a head injury within the preceding 48 hours and met Zurich consensus concussion diagnostic criteria. The exposure was the time between head injury and ED presentation. The primary outcome was the presence of PCS at 1 week defined by the presence of at least three symptoms on the Post-Concussion Symptom Inventory (PCSI). Secondary outcomes evaluated PCS at 4 and 12 weeks. Multivariable logistic regression analyses were adjusted for ED PCSI and other potential confounders. RESULTS There were 3041 patients with a concussion in which timing of the injury was known. 2287 (75%) participants sought care in the first 12 hours, 388 (13%) 12-24 hours after trauma and 366 (12%) between 24 and 48 hours. Compared with children who sought care >24 hours after trauma, children who sought care in the first 12 hours had a significantly lower incidence of PCS at 1 week (OR: 0.55 (95% CI 0.41 to 0.75)) and 4 weeks (OR: 0.74 (95% CI 0.56 to 0.99)) but not at 12 weeks (OR: 0.88 (95% CI 0.63 to 1.23)). CONCLUSIONS Patients who present early after a concussion appear to have a shorter duration of PCS than those presenting more than 12 hours later. Patients/families should be informed of the higher probability of PCS in children with delayed presentation.
Collapse
Affiliation(s)
- Jocelyn Gravel
- Department of Pediatrics, CHU Sainte-Justine, Montreal, Québec, Canada .,Paediatrics, Universite de Montreal, Montreal, Québec, Canada
| | | | - Ken Tang
- CHEO Research Institute, Ottawa, Ontario, Canada
| | | | - William Craig
- Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Kathy Boutis
- Pediatrics, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Paediatrics, Children's Hospital, London, Ontario, Canada
| | - Emma Burns
- Emergency, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | - Darcy Beer
- Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | | |
Collapse
|
17
|
Chandy M, Dewey A, Fogg C, Pilkington K. Non-invasive techniques for stimulating urine production in non-toilet trained children: a systematic review. Emerg Med J 2020; 37:162-169. [PMID: 32033959 DOI: 10.1136/emermed-2019-208580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 01/01/2020] [Accepted: 01/04/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Urinary tract infection requires collection of a sterile urine specimen for diagnosis, which is difficult and time consuming in pre-continent children. This systematic review summarises evidence of the effectiveness of bladder stimulation techniques on urine collection in pre-continent children, compared with standard techniques. METHODS MEDLINE, PubMed, EMBASE and CINAHL were searched to May 2019. Selection, data extraction, risk of bias and quality assessment were undertaken by two independent reviewers. Inclusion: (1) all study designs; (2) pre-continent, age <3 years receiving bladder stimulation techniques; (3) outcomes including time to urine collection or contamination rates; (4) English-language articles. Exclusion: coexisting neurological disorders. RESULTS Three randomised controlled trials (RCTs) were identified using three techniques in 568 participants aged 1 day to 35 months. Two RCTs demonstrated an increased success in voiding within 5 min, one using a finger tapping and lumbar paravertebral massage technique and the other cold saline-soaked gauze rubbed over the suprapubic region, compared with no active intervention. A third RCT using a mechanical vibration device demonstrated no difference in time to voiding from advice alone. Non-randomised studies compared different temperatures for the gauze intervention and tapping alone versus urine bags. Six uncontrolled studies tested the finger tapping and massage technique. Risk of bias was low for one RCT and unclear for two RCTs with the other studies rated poor to fair quality. Overall, the evidence on success rates was graded low for tapping plus massage and moderate for the gauze rubbing intervention. Adverse effects included crying and mild distress. DISCUSSION The results suggest a positive effect of stimulation techniquesbut lack of replication in rigorous RCTs and heterogeneity of techniques and outcomes assessed prevent conclusive recommendations being made. Further RCTs are required comparing non-invasive stimulation methods and assessing time to successful collection, contamination rates, adverse effects, caregiver and clinical staff acceptability.
Collapse
Affiliation(s)
- Mathew Chandy
- Emergency Department, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Ann Dewey
- School of Health and Care Professions, University of Portsmouth, Portsmouth, Hampshire, UK
| | - Carole Fogg
- Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Karen Pilkington
- School of Health and Care Professions, University of Portsmouth, Portsmouth, Hampshire, UK
| |
Collapse
|
18
|
Pek JH, Ong YKG, Quek ECS, Feng XYJ, Allen JC, Chong SL. Evaluation of the criteria for trauma activation in the paediatric emergency department. Emerg Med J 2019; 36:529-534. [PMID: 31326954 DOI: 10.1136/emermed-2018-207857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED. METHODS A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes. RESULTS Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged. CONCLUSION As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.
Collapse
Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - En Ci Samuel Quek
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
19
|
Simone L, Lyttle MD, Roland D, Stephens D, Schuh S. Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis. Emerg Med J 2019; 36:148-153. [PMID: 30728189 DOI: 10.1136/emermed-2018-208000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/17/2018] [Accepted: 12/27/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Serious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and lack of clinical practice guidelines for this population. The primary objective was to investigate practice patterns in performance of LPs in the ED management of febrile infants aged ≤30 days with bronchiolitis. METHODS A cross-sectional survey of two national paediatric emergency research networks (PediatricEmergency Research Canada (PERC) and the PediatricEmergency Research UK/Ireland (PERUKI)) was conducted January to November 2017 using a modified Dillman technique. The survey was preceded by a clinical vignette describing a well appearing, 21-day-old infant with low-grade fever, respiratory findings typical of bronchiolitis and no perinatal serious bacterial infection (SBI) risk features. RESULTS The response rate from PERC was 169/250 (68%) and 172/201 (86%) from PERUKI. Nine physicians in training were excluded, leaving 332 eligible participants. Although most physicians believe that neonates with bronchiolitis rarely have meningitis (PERC 141/161 (87.6%); PERUKI 154/171 (90%)) and feel comfortable diagnosing bronchiolitis in this group (PERC 136/161 (84.5%); PERUKI 143/171 (83.6%)), there was significant variation in the proportion who would be likely/very likely to perform an LP (PERC 100/161 (62.1%); PERUKI 15/171 (8.8%)) (p<0.0001). Practice in Canada, <10 years in practice and lack of comfort with diagnosing bronchiolitis represent multivariable predictors of LP; OR 23.7 (95% CI 11.7 to 47.9), 2.3 (95% CI 1.2 to 4.2) and 2.5 (95% CI 1.1 to 5.0), respectively. Rapid knowledge of respiratory syncytial virus positivity would decrease LP probability from 35.4% to 20.2%. CONCLUSION Estimated probability of performing LPs and other interventions in otherwise healthy febrile neonates with bronchiolitis is highly variable between emergency physicians in Canada and the UK/Ireland. Network, <10 years in ED practice and comfort level with diagnosing bronchiolitis in newborns constitute independent predictors of the likelihood of LP performance.
Collapse
Affiliation(s)
- Laura Simone
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University of Leicester, Leicester, UK.,Health Sciences, SAPPHIRE Group, Leicester, UK
| | - Derek Stephens
- Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, ON, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | |
Collapse
|
20
|
Lemoine S, Jost D, Prunet B. During a paediatric traumatic cardiac arrest, is ventricular fibrillation a reversible cause like any other? Emerg Med J 2019; 36:191. [PMID: 30630839 DOI: 10.1136/emermed-2018-208290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Daniel Jost
- Paris Fire Brigade Medical Emergency Department, Paris, France.,Sudden Death Expertise Center (SDEC), INSERM U970, Paris, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, Paris, France
| |
Collapse
|
21
|
Gray CS, Powell CVE, Babl FE, Dalziel SR, Craig S. Variability of outcome measures in trials of intravenous therapy in acute severe paediatric asthma: a systematic review. Emerg Med J 2018; 36:225-230. [PMID: 30482777 DOI: 10.1136/emermed-2018-207929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/16/2018] [Accepted: 11/11/2018] [Indexed: 11/04/2022]
Abstract
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.
Collapse
Affiliation(s)
- Charmaine S Gray
- Emergency Department, Women's and Children's Hospital, University of Adelaide, North Adelaide, South Australia, Australia
| | - Colin V E Powell
- Emergency Department, Sidra Medical and Research Center, Doha, Qatar.,Emergency Department, Weill Cornell University, Doha, Qatar.,School of Medicine, Cardiff University, Cardiff, UK
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Simon Craig
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | |
Collapse
|
22
|
Lillitos PJ, Lyttle MD, Roland D, Powell CV, Sandell J, Rowland AG, Chapman SM, Maconochie IK. Defining significant childhood illness and injury in the Emergency Department: a consensus of UK and Ireland expert opinion. Emerg Med J 2018; 35:685-690. [PMID: 30282629 DOI: 10.1136/emermed-2018-207802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Clarifying whether paediatric early warning scores (PEWS) accurately predict significant illness is a research priority for UK and Ireland paediatric emergency medicine (EM). However, a standardised list of significant conditions to benchmark these scores does not exist. OBJECTIVES To establish standardised significant illness endpoints for use in determining the performance accuracy of PEWS and safety systems in emergency departments (ED), using a consensus of expert opinion in the UK and Ireland. DESIGN Between July 2017 and February 2018, three online Delphi rounds established a consensus on 'significant' clinical conditions, derived from a list of common childhood illness/injury ED presentations. Conditions warranting acute hospital admission in the opinion of the respondent were defined as 'significant', using a 5-point Likert scale. The consensus was a priori ≥80% (positive or negative). 258 clinical conditions were tested. PARTICIPANTS AND SETTINGS Eligible participants were consultants in acute or EM paediatrics, or adult EM, accessed via 53 PERUKI (Paediatric Emergency Research in the UK and Ireland)'s research collaborative sites, and 27 GAPRUKI (General and Adolescent Paediatric Research in the UK and Ireland)'s sites, 17 of which overlap with PERUKI. MAIN OUTCOME MEASURES To create a list of conditions regarded as 'significant'with ≥80% expert consensus. RESULTS 43 (68%) of 63 PERUKI and GAPRUKI sites responded; 295 experts were invited to participate. Participants in rounds 1, 2 and 3 were 223 (76%), 177 (60%) and 148 (50%), respectively; 154 conditions reached positive consensus as 'significant'; 1 condition reached a negative consensus (uncomplicated Henoch-Schönlein purpura); and 37 conditions achieved non-consensus. CONCLUSIONS A list of significant childhood conditions has been created using UK and Irish expert consensus, for research purposes, for the first time. This will be used as the benchmark endpoint list for future research into PEWS/safety systems performance in EDs.
Collapse
Affiliation(s)
- Peter J Lillitos
- Acute Receiving Unit, Royal Hospital for Sick Children, Edinburgh, UK.,Department of Paediatric Emergency Medicine, Imperial College NHS Trust, London, UK
| | - Mark D Lyttle
- Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Academic Department of Emergency Care, University of the West of England, Bristol, UK
| | - Damian Roland
- Department of Health Sciences, SAPPHIRE Group, University of Leicester, Leicester, UK.,Children's Emergency Department, Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Colin Ve Powell
- School of Medicine, Cardiff University, Cardiff, UK.,Department of Emergency Medicine, Sidra Medicine, Doha, Al Rayyan, Qatar
| | - Julian Sandell
- Department of Paediatrics, Poole Hospital NHS Trust, Dorset, UK
| | - Andrew G Rowland
- The School of Health and Society, The University of Salford, Salford, UK.,Emergency Department, North Manchester General Hospital, The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Susan M Chapman
- Gulf Regional Office, Great Ormond Street Hospital, London, UK.,UCL Great Ormond Street Institute for Child Health, London, UK
| | - Ian K Maconochie
- Department of Paediatric Emergency Medicine, Imperial College NHS Trust, London, UK.,Faculty of Medicine, Imperial College London, UK
| | | |
Collapse
|
23
|
Samuels-Kalow ME, Niedzwiecki M, Friedman AB, Sokolove PE, Hsia RY. Comparing resource use between paediatric emergency department visits by triage level. Emerg Med J 2018; 35:681-684. [PMID: 30181161 DOI: 10.1136/emermed-2017-207192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The majority of paediatric ED visits result in discharge but little is known about what ED resources are deployed for these visits. The goal of this study was to understand the utilisation of diagnostic testing, procedures and hospital admission for paediatric ED visits triaged as 'non-urgent'. STUDY DESIGN We examined US ED visits for children aged 0-17 years from 1 January 2009 to 31 December 2011 in the National Hospital Ambulatory Medical Care Survey. Visits triaged on arrival as 'non-urgent' (level 5) were compared with urgent visits (triage levels 1-4) for resource use and disposition. Sensitivity and specificity of triage for predicting resource use and disposition were assessed. RESULTS Among 21 052 observations, representing 86 620 988 visits, 11.1% were triaged as 'non-urgent'. Diagnostic services were provided during 37.6% (95% CI 33.9% to 41.4%) of non-urgent and 55.2% (95% CI 53.3% to 57.2%) of urgent visits. Procedures were performed in 23.9% (95% CI 20.4% to 27.3%) of non-urgent and 33.9% (95% CI 31.2% to 35.9%) of urgent visits. 1.7% (95% CI 0.09% to 2.6%) of the non-urgent visits resulted in admission, with 0.08% (95% CI 0% to 0.2%) to critical care units, compared with 4.4% (95% CI 3.6% to 5.2%) of the urgent visits, with 0.3% (95% CI 0.2% to 0.4%) to critical care. Despite some substantial differences in the rates of resource use, triage score had poor sensitivity for identifying patients who did not receive ED tests, procedures or admission. CONCLUSION A significant percentage of ED patients with non-urgent ED triage scores received ED testing and procedures. More work is needed to improve methods of prospectively identifying patients with low acuity complaints who do not need significant ED resources.
Collapse
Affiliation(s)
- Margaret E Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco, California, USA.,R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Ari B Friedman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Peter E Sokolove
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, California, USA.,R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| |
Collapse
|
24
|
Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, Smith JE. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Emerg Med J 2018; 35:669-674. [PMID: 30154141 DOI: 10.1136/emermed-2018-207739] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/26/2018] [Accepted: 08/04/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Paediatric traumatic cardiac arrest (TCA) is a high acuity, low frequency event. Traditionally, survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population, there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable with that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation. The aim of this study was, by a process of consensus, to develop an algorithm for the management of paediatric TCA for adoption in the UK. METHODS A modified consensus development meeting of UK experts involved in the management of paediatric TCA was held. Statements discussed at the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three-round online Delphi study. 19 statements relating to the diagnosis, management and futility of paediatric TCA were initially discussed in small groups before each participant anonymously recorded their agreement with the statement using 'yes', 'no' or 'don't know'. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm. RESULTS 41 participants attended the meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. CONCLUSION In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first consensus-based algorithm specific to the paediatric population. While this algorithm was developed for adoption in the UK, it may be applicable to similar healthcare systems internationally.
Collapse
Affiliation(s)
- James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | - Tim Nutbeam
- Emergency Department, Derriford Hospital, Plymouth, UK.,University of Plymouth, Plymouth, UK
| | | | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK.,Faculty of Health and Applied Sciences, University of West England, Bristol, UK
| | | | - Ian K Maconochie
- Emergency Department, St Marys Hospital, London, UK.,Trauma Audit and Research Network, University of Manchester, Manchester, UK
| | - Jason E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | | |
Collapse
|
25
|
Stoklosa H, Nour NM. The eye cannot see what the mind does not know: female genital mutilation. Emerg Med J 2018; 35:585-586. [PMID: 30120218 PMCID: PMC6173812 DOI: 10.1136/emermed-2018-207994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Hanni Stoklosa
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Harvard University, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nawal M Nour
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA.,Division of Global Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
26
|
Abstract
Whooping cough is a notifiable bacterial respiratory infection caused by Bordetella pertussis It may produce serious disease, especially in immunocompromised individuals and very young children. The number of reported cases increases in the winter months and the incidence peaks every 4-5 years. However, this periodicity is variable and is inconsistent between different geographical regions. Bordetella pertussis infection (BPI) may be underdiagnosed because of its seasonality and the fact that clinical features may be indistinguishable from other respiratory disorders in the paediatric ED setting. Treatment with antibiotics reduces the period of infectivity but may not shorten the illness. This review discusses the epidemiology of the disease, its clinical features, diagnosis, treatment and the disposition of patients with BPI.
Collapse
Affiliation(s)
- Patrick Nee
- Emergency Department, Whiston Hospital, Prescot, UK.,Faculty of Education, Health and Community, Liverpool John Moores University, Liverpool, UK
| | - Elaine Weir
- Department of Paediatrics, Alder Hey Children's Hospital, Liverpool, UK
| | | | | |
Collapse
|
27
|
Jung JY, Kwak YH, Kim DK, Suh D, Chang I, Yoon C, Lee JC, Kim HC, Choi JY, Ahn H. An assessment of the accuracy of a novel weight estimation device for children. Emerg Med J 2016; 34:163-169. [PMID: 27633345 DOI: 10.1136/emermed-2016-205817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 08/19/2016] [Accepted: 08/24/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND We sought to validate the accuracy and assess the efficacy of a newly developed electronic weight estimation device (ie, the rolling tape) for paediatric weight estimation. METHODS We enrolled a convenience sample of children aged <17 years presenting to our emergency department who volunteered to participate in the study. The children's heights and weights were measured, and three researchers estimated these values using the rolling tape and Broselow tape at 5 min intervals. The weight estimates of researcher 1, researcher 2 and the Broselow tape were compared with measured values, and mean percentage error (MPE), root mean square error (RMSE) and percentage of estimates within 10% of the actual measured values were calculated. For 30 randomly selected subjects, we compared the time interval from the start of the measurement to the time that orders for epinephrine, defibrillation dose and instrument size could be given in a simulated arrest scenario. RESULTS We enrolled 906 children (median age 4.0 years). For researcher 1, researcher 2 and the Broselow tape, MPE values were 0.11% (RMSE 2.61 kg), 1.41% (RMSE, 2.61 kg) and 1.72% (RMSE 5.41 kg), respectively, and the percentages of children with predictions within 10% of their actual weight were 75.1%, 75.7% and 60.6%, respectively. In the 30 simulated cases, the mean time for measurement to ordering was significantly shorter (25.8 s vs 35.5 s, p<0.001) for the rolling tape compared with the Broselow tape method. CONCLUSIONS The rolling tape is a good weight estimation tool for children compared with other methods. The rolling tape method significantly decreased the time from weight estimation to orders for essential drug dose, instrument size and defibrillation dose for resuscitation.
Collapse
Affiliation(s)
- Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seong-Nam, Korea
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Do Kyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dongbum Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ikwan Chang
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chiyul Yoon
- Interdisciplinary Programme of Bioengineering, Seoul National University Graduate School, Seoul, Korea
| | - Jung Chan Lee
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Engineering, Seoul National University Hospital, Seoul, Korea.,Institute of Medical and Biological Engineering, Medical Research Centre, Seoul National University, Seoul, Korea
| | - Hee Chan Kim
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Engineering, Seoul National University Hospital, Seoul, Korea.,Institute of Medical and Biological Engineering, Medical Research Centre, Seoul National University, Seoul, Korea
| | - Jae Yeon Choi
- Department of Emergency Medicine, Gachon University Gil Medical Centre, Incheon, Korea
| | - HeeJeong Ahn
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
28
|
Kaufman J, Tosif S, Fitzpatrick P, Hopper SM, Bryant PA, Donath SM, Babl FE. Quick-Wee: a novel non-invasive urine collection method. Emerg Med J 2016; 34:63-64. [PMID: 27565196 DOI: 10.1136/emermed-2016-206000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 07/26/2016] [Accepted: 08/04/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Clean catch urine (CCU) collection in precontinent children is often time-consuming, with associated collection failure. We hypothesise that stimulating cutaneous reflexes hastens voiding for CCU. METHODS 40 children aged 1-24 months in the ED. Standard CCU was augmented with gentle suprapubic cutaneous stimulation using saline-soaked gauze (Quick-Wee method). RESULTS 12/40 (30%) children voided within 5 min for successful CCU. Parental and clinician satisfaction was high. CONCLUSIONS Quick-Wee appears to be a simple method to speed CCU in young children.
Collapse
Affiliation(s)
- Jonathan Kaufman
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine Dentistry and Health Sciences, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Shidan Tosif
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine Dentistry and Health Sciences, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Patrick Fitzpatrick
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Sandy M Hopper
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine Dentistry and Health Sciences, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan M Donath
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine Dentistry and Health Sciences, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Abstract
Introduction Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive cases of major injury. Methods The national trauma registry of England and Wales (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals’ submissions were classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons. Results In the study population of 14 845 children, 13 708 (92.3%, CI 91.9% to 92.8%) were classified as accidental injury, 368 as alleged assault (2.5%, CI 2.2% to 2.7%) and 769 as SCA (5.2%, CI 4.8% to 5.5%). Nearly all cases of severely injured children suffering trauma because of SCA occurred in the age group of 0–5 years (751 of 769, 97.7%), with 76.3% occurring in infants under the age of 1 year. Compared with accidental injury, suspected victims of abuse have higher overall injury severity scores, have a higher proportion of head injury and a threefold higher mortality rate of 7.6% (CI 5.51% to 9.68%) vs 2.6% (CI 2.3% to 2.9%). Conclusions This study highlights that major injury occurring as a result of SCA has a typical demographic pattern. These children tend to be under 12 months of age, with more severe injury. Understanding these demographics could help receiving hospitals identify children with major injuries resulting from abuse and ensure swift transfer to specialist care.
Collapse
Affiliation(s)
- Ffion C Davies
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Timothy J Coats
- Department of Emergency Medicine, University of Leicester, Leicester, UK
| | - Ross Fisher
- Department of Surgery, Sheffield Children's Hospital, Sheffield, UK
| | - Thomas Lawrence
- Trauma Audit Research Network, Salford Royal NHS Foundation Trust, Salford, UK
| | - Fiona E Lecky
- Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
30
|
Béquignon E, Teissier N, Gauthier A, Brugel L, De Kermadec H, Coste A, Prulière-Escabasse V. Emergency Department care of childhood epistaxis. Emerg Med J 2016; 34:543-548. [PMID: 27542804 DOI: 10.1136/emermed-2015-205528] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 07/17/2016] [Accepted: 07/24/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aim of this review is to determine an efficient and safe primary strategy care for paediatric epistaxis. DATA SOURCES We searched PubMed and Cochrane databases for studies referenced with key words 'epistaxis AND childhood'. This search yielded 32 research articles about primary care in childhood epistaxis (from 1989 to 2015). Bibliographic references found in these articles were also examined to identify pertinent literature. We compared our results to the specific management of adult epistaxis classically described in the literature. RESULTS Epistaxis is one of the most common reasons for referral of children to a hospital ENT outpatient department. The bleeding usually originates from the anterior septum, as opposed to adults. Crusting, digital trauma, foreign bodies and nasal colonisation with Staphylococcus aureus have been suggested as specific nosebleed factors in children. Rare aetiologies as juvenile nasopharyngeal angiofibroma appear later during adolescence. There are different modes of management of mild epistaxis, which begin with clearing out blood clots and bidigital compression. An intranasal topical local anaesthetic and decongestant can be used over 6 years of age. In case of active bleeding, chemical cauterisation is preferred to anterior packing and electric cauterisation but is only feasible if the bleeding site is clearly visible. In case of non-active bleeding in children, and in those with recurrent idiopathic epistaxis, antiseptic cream is easy to apply and can avoid 'acrobatic' cauterisation liable to cause further nasal cavity trauma. CONCLUSIONS Aetiologies and treatment vary with patient age and the existence or not of active bleeding at the time of the examination. Local treatments are usually easy to perform, but physicians have to ponder their indications depending on the possible complications in order to inform parents and to know paediatric epistaxis specificities.
Collapse
Affiliation(s)
- E Béquignon
- Department of Oto-rhino-laryngology Surgery, Intercommunal Hospital, Créteil, France.,INSERM U955, Créteil, France.,Université Paris-Est, Créteil, France.,Department of Oto-rhino-laryngology, Henri Mondor Hospital, AP-HP, Créteil, France
| | - N Teissier
- Department of Paediatric otorhinolaryngology, Robert Debré Hospital, AP-HP, Paris, France.,INSERM U1141, Paris, France
| | - A Gauthier
- Department of Oto-rhino-laryngology Surgery, Intercommunal Hospital, Créteil, France
| | - L Brugel
- Department of Oto-rhino-laryngology Surgery, Intercommunal Hospital, Créteil, France
| | - H De Kermadec
- Department of Oto-rhino-laryngology Surgery, Intercommunal Hospital, Créteil, France
| | - A Coste
- Department of Oto-rhino-laryngology Surgery, Intercommunal Hospital, Créteil, France.,INSERM U955, Créteil, France.,Université Paris-Est, Créteil, France.,Department of Oto-rhino-laryngology, Henri Mondor Hospital, AP-HP, Créteil, France
| | - V Prulière-Escabasse
- Department of Oto-rhino-laryngology Surgery, Intercommunal Hospital, Créteil, France.,INSERM U955, Créteil, France.,Université Paris-Est, Créteil, France
| |
Collapse
|
31
|
Bowen L, Shaw A, Lyttle MD, Purdy S. The transition to clinical expert: enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions. Emerg Med J 2016; 34:76-81. [PMID: 27496899 PMCID: PMC5384604 DOI: 10.1136/emermed-2015-205211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 06/30/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Rates of unplanned paediatric admissions are persistently high. Many admissions are short-stay events, lasting less than 48 hours. OBJECTIVE This qualitative research explores factors that influence clinical decision making in the paediatric ED (PED) for children under 5 attending with acute respiratory conditions, focusing on how management decisions adapt with increasing experience. METHOD Semi-structured interviews were conducted with 15 PED clinicians (doctors, emergency nurse practitioners and registered nurses) with varying levels of experience in paediatric emergency medicine (PEM), emergency medicine or paediatrics. Audio-recorded interviews were transcribed and analysed thematically. RESULTS There were clear differences in decision-making approaches between experienced clinicians and junior staff. The latter were more risk adverse, relying heavily on guidelines, set admission criteria, clinical theory and second opinions. This was particularly true for doctors. 'Informal' learning was apparent in accounts from less-experienced doctors and nurses, whereby tacit knowledge and risk management played an increasing role in the development of clinical intuition that permitted rapid assessment and treatment of young patients. CONCLUSIONS The emergence of intuition entwined with approaches to risk management and the role of these skills in clinical decision making, carry implications for the development of training programmes for clinicians working in PEM. Enhanced training for such groups to permit development of the supplementary skills described in this study could have the ability to improve care delivery and even reduce paediatric admissions.
Collapse
Affiliation(s)
- Leah Bowen
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Alison Shaw
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| |
Collapse
|
32
|
Bosak Versic A, Glavan N, Bukvic N, Tomasic Z, Nikolic H. Does elevated urinary 5-hydroxyindole acetic acid level predict acute appendicitis in children? Emerg Med J 2016; 33:848-852. [PMID: 27466348 DOI: 10.1136/emermed-2015-205559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 06/07/2016] [Accepted: 07/07/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute appendicitis is the most common abdominal surgical emergency in children, and appendectomy is the most frequent acute abdominal operation. Prompt diagnosis and surgical treatment are required to reduce the risk of perforation and prevent complications, especially in small children. Enterochromaffin cells that contain large amounts of serotonin are mostly located in the distal appendix. Serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) could therefore be a marker for acute appendicitis. OBJECTIVE We tested urinary 5-HIAA concentrations in spot urine samples from children with acute appendicitis. METHODS We enrolled 93 patients who underwent surgery for suspicion of acute appendicitis. The diagnosis was made intraoperatively and confirmed histopathologically. Additionally, urine samples from 102 healthy children were collected as controls. Their 5-HIAA was measured using high-performance liquid chromatography. RESULTS Acute appendicitis was diagnosed in 81 patients, whereas there were other explanations for abdominal pain in the remaining 12 patients in the non-appendicitis group. The control group comprised 102 healthy children. Considering the median of all measured 5-HIAA values as the cut-off, we analysed the proportions of patients with elevated values in all the groups. Our analysis showed that statistically there was no significant difference in the distribution of percentages among the groups. The area under the curve for 5-HIAA was 0.55 (95% CI 0.47 to 0.62) with sensitivity and specificity 60.4% and 48.9%, respectively. CONCLUSIONS Urine 5-HIAA concentration measured in spot samples is not a reliable method for diagnosing acute appendicitis in children.
Collapse
Affiliation(s)
- Ana Bosak Versic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Nedeljka Glavan
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Nado Bukvic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Zlatko Tomasic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Harry Nikolic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| |
Collapse
|
33
|
Cotterill S, Rowland AG, Kelly J, Lees H, Kamara M. Diagnostic accuracy of PAT-POPS and ManChEWS for admissions of children from the emergency department. Emerg Med J 2016; 33:756-762. [PMID: 27068865 PMCID: PMC5136718 DOI: 10.1136/emermed-2015-204647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/12/2016] [Accepted: 03/14/2016] [Indexed: 11/23/2022]
Abstract
Background The Pennine Acute Trust (PAT) Paediatric Observation Priority Score (PAT-POPS) is a specific emergency department (ED) physiological and observational aggregate scoring system, with scores of 0–18. A higher score indicates greater likelihood of admission. The Manchester Children's Early Warning System (ManChEWS) assesses six physiological observations to create a trigger score, classified as Green, Amber or Red. Methods Prospectively collected data were used to calculate PAT-POPS and ManChEWS on 2068 patients aged under 16 years (mean 5.6 years, SD 4.6) presenting over 1 month to a UK District General Hospital Paediatric ED. Receiver operating characteristics (ROC) comparison, using STATA V.13, was used to investigate the ability of ManChEWS and PAT-POPS to predict admission to hospital within 72 h of presentation to the ED. Results Comparison of the area under the ROC curve indicates that the ManChEWS ROC is 0.67 (95% CI 0.64 to 0.70) and the PAT-POPS ROC is 0.72 (95% CI 0.68 to 0.75). The difference is statistically significant. At a PAT-POPS cut-off of ≥2, 80% of patients had their admission risk correctly classified (positive likelihood ratio 3.40, 95% CI 2.90 to 3.98) whereas for ManChEWS with a cut off of ≥Amber only 71% of patients were correctly classified (positive likelihood ratio 2.18, 95% CI 1.94 to 2.45). Conclusions PAT-POPS is a more accurate predictor of admission risk than ManChEWS. Replacing ManChEWS with PAT-POPS would appear to be clinically appropriate in a paediatric ED. This needs validation in a multicentre study.
Collapse
Affiliation(s)
- Sarah Cotterill
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Andrew G Rowland
- Emergency Department, North Manchester General Hospital, Manchester, UK.,The University of Salford, Salford, UK
| | - Jacqueline Kelly
- Emergency Department, North Manchester General Hospital, Manchester, UK
| | - Helen Lees
- Emergency Department, North Manchester General Hospital, Manchester, UK
| | - Mohammed Kamara
- Emergency Department, North Manchester General Hospital, Manchester, UK
| |
Collapse
|
34
|
Johnson EL, Hollén LI, Kemp AM, Maguire S. Exploring the acceptability of a clinical decision rule to identify paediatric burns due to child abuse or neglect. Emerg Med J 2016; 33:465-70. [PMID: 27068866 DOI: 10.1136/emermed-2014-204568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 03/16/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE An evidence based clinical decision rule (CDR) was developed from a systematic review and epidemiological study to identify burns due to child maltreatment (abuse or neglect). Prior to an implementation evaluation, we aim to explore clinicians' views of the CDR, the likelihood that it would influence their management and factors regarding its acceptability. METHODS A semistructured questionnaire exploring demographics, views of the CDR and data collection pro forma, ability to recognise maltreatment and likelihood of following CDR recommended child protection (CP) action, was administered to 55 doctors and nurses in eight emergency departments and two burns units. Recognition of maltreatment was assessed via four fictitious case vignettes. ANALYSIS Fisher's exact test and variability measured by coefficient of unalikeability. RESULTS The majority of participants found the CDR and data collection pro forma useful (45/55, 81.8%). Only five clinicians said that they would not take the action recommended by the CDR (5/54, 9.3%). Lower grade doctors were more likely to follow the CDR recommendations (p=0.04) than any other grade, while senior doctors would consider it within their decision making. Factors influencing uptake include: brief training, background to CDR development and details of appropriate actions. CONCLUSIONS It is apparent that clinicians are willing to use a CDR to assist in identifying burns due to child maltreatment. However, it is clear that an implementation evaluation must encompass the influential variables identified to maximise uptake.
Collapse
Affiliation(s)
| | - Linda Irene Hollén
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
| | - Alison Mary Kemp
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Sabine Maguire
- College of Bio-medical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| |
Collapse
|
35
|
McCoy S, Lyttle MD, Hartshorn S, Larkin P, Brenner M, O'Sullivan R. A qualitative study of the barriers to procedural sedation practices in paediatric emergency medicine in the UK and Ireland. Emerg Med J 2016; 33:527-32. [PMID: 26888785 DOI: 10.1136/emermed-2015-205418] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/23/2016] [Indexed: 11/03/2022]
Abstract
INTRODUCTION There is extensive literature on paediatric procedural sedation (PPS) and its clinical applications in emergency departments (EDs). While numerous guidance and policy documents exist from international bodies, there remains a lack of uniformity and consistency of PPS practices within EDs. PPS is now gaining traction in the UK and Ireland and this study aimed to describe existing PPS practices and identify any challenges to training and provision of ED-based PPS. METHODS A qualitative approach was employed to capture data through a focus group interview. Nine consultants in emergency medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group was audio-recorded, transcribed verbatim and analysed using Attride-Stirling's framework for thematic network analysis. RESULTS The global theme 'The Future of PPS in EM-A UK and Ireland Perspective' emerged from the following three organising themes: (1) training and education of ED staff; (2) current realities of PPS in EDs and (3) PPS and the wider hospital community. The main findings were (1) there is variability in ED PPS practice throughout the UK and Ireland; (2) lack of formal PPS training for trainees is a barrier to its implementation as a standard treatment and (3) there is a lack of recognition of PPS at a College level as a specialised EM skill. CONCLUSIONS Establishment of PPS as a standard treatment option in the emergency setting will require implementation of robust training into general and paediatric EM training. This should be supported and enhanced through national and international collaboration in EM-led PPS research and audit.
Collapse
Affiliation(s)
- Siobhán McCoy
- Paediatric Emergency Research Unit (PERU), National Children's Research Centre, Our Lady's Children's Hospital, Dublin , Ireland
| | - Mark D Lyttle
- Department of Emergency Medicine, Bristol Royal Hospital for Children, Bristol, UK Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Stuart Hartshorn
- Department of Emergency Medicine, Birmingham Children's Hospital, Birmingham, UK
| | - Philip Larkin
- School of Nursing, Midwifery and Health Systems & Our Lady's Hospice and Care Services, Health Sciences Centre, University College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Ronan O'Sullivan
- Paediatric Emergency Research Unit (PERU), National Children's Research Centre, Our Lady's Children's Hospital, Dublin , Ireland School of Medicine, University College Cork, Cork, Ireland
| | | |
Collapse
|
36
|
Manzano S, Holzinger IB, Kellenberger CJ, Lacroix L, Klima-Lange D, Hersberger M, La Scala G, Altermatt S, Staubli G. Diagnostic performance of S100B protein serum measurement in detecting intracranial injury in children with mild head trauma. Emerg Med J 2015; 33:42-6. [PMID: 26283067 DOI: 10.1136/emermed-2014-204513] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 07/28/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the accuracy of S100B serum level to detect intracranial injury in children with mild traumatic brain injury. METHODS A multicenter prospective cohort study was carried out in the paediatric emergency departments of three tertiary hospitals in Switzerland between January 2009 and December 2011. Participants included children aged <16 years with a mild traumatic brain injury (GCS ≥13) for whom a head CT was requested by the attending physician. Venous blood was obtained within 6 h of the trauma in all children for S100B measurement before a head CT was performed. As the S100B value was not available during the acute care period, the patient's management was not altered. The main measures were protein S100B value and the CT result. RESULTS 20/73 (27.4%) included children had an intracranial injury detected on CT. S100B receiver operating characteristics area under the curve was 0.73 (95% CI 0.60 to 0.86). With a 0.14 µg/L cut-off point, S100B reached an excellent sensitivity of 95% (95% CI 77% to 100%) and 100% (95% CI 81% to 100%) in all children and in children aged >2 years, respectively. The specificity, however, was 34% (95% CI 27% to 36%) and 37% (95% CI 30% to 37%), respectively. CONCLUSIONS S100B has an excellent sensitivity but poor specificity. It is therefore an accurate tool to help rule out an intracranial injury but cannot be used as the sole marker owing to its specificity. Used with clinical decision rules, S100B may help to reduce the number of unnecessary CT scans.
Collapse
Affiliation(s)
- Sergio Manzano
- Pediatric Emergency Department, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Laurence Lacroix
- Pediatric Emergency Department, Geneva University Hospital, Geneva, Switzerland
| | - Dagmar Klima-Lange
- Department of Pediatric Surgery, Ostschweizer Children's Hospital, St. Gallen, Switzerland
| | - Martin Hersberger
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich, Switzerland
| | - Giorgio La Scala
- Pediatric Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Stefan Altermatt
- Pediatric Surgery Department, University Children's Hospital, Zurich, Switzerland
| | - Georg Staubli
- Pediatric Emergency Department, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
37
|
Akenroye AT, Stack AM. The development and evaluation of an evidence-based guideline programme to improve care in a paediatric emergency department. Emerg Med J 2015; 33:109-17. [PMID: 26150121 DOI: 10.1136/emermed-2014-204363] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 06/12/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Care guidelines can improve the quality of care by making current evidence available in a concise format. Emergency departments (EDs) are an ideal site for guidelines given the wide variety of presenting conditions and treating providers, and the need for timely decision making. We designed a programme for guideline development and implementation and evaluated its impact in an ED. METHODS The setting was an urban paediatric ED with an annual volume of 60 000. Common and/or high-risk conditions were identified for guideline development. Following implementation of the guidelines, their impact on effectiveness of care, patient outcomes, efficiency and equitability of care was assessed using a web-based provider survey and performance on identified metrics. Variation in clinical care between providers was assessed using funnel plots. RESULTS Eleven (11) guidelines were developed and implemented. 3 years after the initiation of the programme, self-reported adherence to recommendations was high (95% for physicians and 89% for nurses). 97% of physicians and 92% of nurses stated that the programme improved the quality of care in the ED. For some guidelines, provider-to-provider care practice variation was reduced significantly. We found reduced disparity in imaging when assessing one guideline. There were also reductions in utilisation of diagnostic tests or therapies. As a balancing measure, the percentage of patients with any of the guideline conditions who returned to the ED within 72 h of discharge did not change from before to after guideline initiation. Overall, 80% of physician and 56% of nurse respondents rated the guideline programme at the highest value. CONCLUSIONS A programme for guideline development and implementation helped to improve efficiency, and standardise and eliminate disparities in emergency care without jeopardising patient outcomes.
Collapse
Affiliation(s)
- Ayobami T Akenroye
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne M Stack
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
38
|
Hartshorn S, O'Sullivan R, Maconochie IK, Bevan C, Cleugh F, Lyttle MD. Establishing the research priorities of paediatric emergency medicine clinicians in the UK and Ireland. Emerg Med J 2015; 32:864-8. [PMID: 25678575 DOI: 10.1136/emermed-2014-204484] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/24/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Paediatric Emergency Research in the UK and Ireland (PERUKI) is a collaborative clinical studies group established in August 2012. It consists of a network of 43 centres from England, Ireland, Northern Ireland, Scotland and Wales, and aims to improve the emergency care of children through the performance of robust collaborative multicentre research within emergency departments. A study was conducted regarding the research priorities of PERUKI, to establish the research agenda for paediatric emergency medicine in the UK and Ireland. METHODS A two-stage modified Delphi survey was conducted of PERUKI members via an online survey platform. Stage 1 allowed each member to submit up to 12 individual questions that they identified as priorities for future research. In stage 2, the shortlisted questions were each rated on a seven-point Likert scale of relative importance. PARTICIPANTS Members of PERUKI, including clinical specialists, academics, trainees and research nurses. RESULTS Stage 1 surveys were submitted by 46/91 PERUKI members (51%). A total of 249 research questions were generated and, following the removal of duplicate questions and shortlisting, 60 questions were carried forward for stage 2 ranking. Stage 2 survey responses were submitted by 58/95 members (61%). For the 60 research questions that were rated, the mean score of 'relative degree of importance' was 4.70 (range 3.36-5.62, SD 0.55). After ranking, the top 10 research priorities included questions on biomarkers for serious bacterial illness, major trauma, intravenous bronchodilators for asthma and decision rules for fever with petechiae, head injury and atraumatic limp. CONCLUSIONS Research priorities of PERUKI members have been identified. By sharing these results with clinicians, academics and funding bodies, future research efforts can be focused to the areas of greatest need.
Collapse
Affiliation(s)
- Stuart Hartshorn
- Emergency Department, Birmingham Children's Hospital, Birmingham, UK
| | - Ronan O'Sullivan
- School of Medicine, University College Cork, Cork, Ireland Paediatric Emergency Research Unit (PERU), National Children's Research Centre, Dublin 12, Ireland
| | - Ian K Maconochie
- Emergency Department, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - Catherine Bevan
- Emergency Department, Royal Alexandra Children's Hospital, Brighton, UK
| | - Francesca Cleugh
- Emergency Department, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK Academic Department of Emergency Care, University of the West of England, Bristol, UK
| | | |
Collapse
|
39
|
Bressan S, Franklin KL, Jowett HE, King SK, Oakley E, Palmer CS. Establishing a standard for assessing the appropriateness of trauma team activation: a retrospective evaluation of two outcome measures. Emerg Med J 2014; 32:716-21. [PMID: 25532103 DOI: 10.1136/emermed-2014-203998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 11/27/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation (TTA) is a well-recognised standard of care to provide rapid stabilisation of patients with time-critical, life-threatening injuries. TTA is associated with a substantial use of valuable hospital resources that may adversely impact upon the care of other patients if not carefully balanced. This study aimed to determine which of the two outcome measures would be a better standard for assessing the appropriateness of TTA at a paediatric centre: retrospective major trauma classification as defined within our state, and the use of emergency department high-level resources as recently published by Falcone et al (Falcone Interventions; FI). METHODS Trauma registry data and patients' charts between February 2011 and June 2013 were reviewed. Over-triage and under-triage rates for TTA, using both major trauma and FIs as outcome measures, were compared. RESULTS Totally, 280 patients received TTA, 243 met major trauma definition and 102 received one or more FIs. The rates of over-triage and under-triage were 39.7% (95% CI 35.0 to 44.6%) and 30.5% (95% CI 26.2 to 35.2%), when the major trauma definition was used as the outcome measure, and 67.5% (95% CI 62.2 to 72.5%) and 10.8% (95% CI 7.9 to 14.8%) when FI was used. Only 17.1% (95% CI 11.4% to 24.7%) of the under-triaged patients using the major trauma definition received one or more FIs. CONCLUSIONS Assessment of TTA appropriateness varied significantly based on the outcome measure used. FIs better reflected the use of acute-care TTA-related resources compared with the major trauma definition, and it should be used as the gold standard to prospectively assess and refine TTA criteria.
Collapse
Affiliation(s)
- Silvia Bressan
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Murdoch Children's Research Institute, Victoria, Australia Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | | | - Helen E Jowett
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sebastian K King
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Murdoch Children's Research Institute, Victoria, Australia Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Ed Oakley
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Murdoch Children's Research Institute, Victoria, Australia Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Cameron S Palmer
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| |
Collapse
|
40
|
Affiliation(s)
- Dov Albukrek
- Israeli Defense Forces Medical Corps, Tel Hashomer, Israel Israel Ministry of Health, Jerusalem, Israel
| | - Joseph Mendlovic
- Israeli Defense Forces Medical Corps, Tel Hashomer, Israel Israel Ministry of Health, Jerusalem, Israel
| | - Tal Marom
- Israeli Defense Forces Medical Corps, Tel Hashomer, Israel Department of Otolaryngology-Head & Neck Surgery, Edith Wolfson Medical Center, Tel Aviv University Sackler School of Medicine, Holon, Israel
| |
Collapse
|
41
|
Abstract
BACKGROUND In a resuscitation situation involving a child (age 1-15 years) it is crucial to obtain a weight as most interventions and management depend on it. The APLS formula, '2×(age+4)', is taught via the APLS course and is widely used in Irish hospitals. As the prevalence of obesity is increasing the accuracy of the formula has been questioned and a newer formula has been suggested, the Luscombe and Owens (LO) formula, '(3×age)+7'. AIMS AND OBJECTIVES To gather data on the weights and ages of the Cork paediatric population (ages 1-15 years) attending services at the Cork University Hospital (CUH), and to identify which of the two age-based weight estimation formulae has best diagnostic accuracy. SETTING CUH, Ireland's only level one trauma centre. METHODS Retrospective data collection from charts in the Emergency Department, Paediatric Assessment Unit and the Paediatric wards of CUH. RESULTS 3155 children aged 1-15 years were included in the study. There were 1344 girls and 1811 boys. The formula weight='2×(age+4)' underestimated children's weights by a mean of 20.3% (95% CI 19.7% to 20.9%) for the ages of 1-15 years. The LO formula weight='(3×age)+7' showed a mean underestimation of 4.0% (95% CI 3.3% to 4.6%) for the same age range. CONCLUSIONS The LO formula has been validated in several studies and proven to be a superior age-based weight estimation formula in many western emergency departments. This study shows that the LO formula leads to less underestimation of weights in Irish children than the APLS formula. It is a simple, safe and more accurate age-based estimation formula that can be used over a large age range (1-15 years).
Collapse
Affiliation(s)
- Darko Skrobo
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Gemma Kelleher
- Emergency Department, Cork University Hospital, Cork, Ireland
| |
Collapse
|
42
|
Abstract
OBJECTIVE Paediatric myocarditis has remained a diagnostic challenge. We aim to identify distinct characteristics and derive a scoring system that will trigger further investigations to be performed among paediatric patients presenting to the emergency department (ED) with clinically suspected myocarditis. DESIGN We performed an age-matched case-control study of children seen in a large tertiary institution. Cases and controls were patients less than 16 years' old who presented to the ED over a 10-year period from Jan 2001 to Dec 2010. Cases were identified with a final discharge or postmortem diagnosis of acute myocarditis. Controls were those who presented to the ED in the same period and were initially diagnosed with acute myocarditis, but who were later found to have other diagnoses. We compared their vital signs, presenting symptoms, physical examination findings, electrocardiogram and chest radiograph findings. RESULTS Based on domain-specific stepwise conditional logistic regression analyses, five characteristics were found to be potentially discriminating: respiratory distress, poor perfusion, hypotension, an abnormal chest radiograph and any electrocardiogram abnormalities. Satisfactory discrimination was attained using these five parameters. The estimated area under receiver operating characteristic curve was 90% (95% CI 0.83 to 0.97). A cut-off score of 3 would give a positive likelihood ratio of 13 (95% CI 3.31 to 51.06) and a negative likelihood ratio of 0.35 (95% CI 0.22 to 0.55). CONCLUSIONS A cut-off risk score of 3, though not yet validated, may be potentially useful in future to trigger further investigations for children with suspected myocarditis. It allows for the appropriate use of resources, while minimising on misdiagnosis.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore
| | - Dianne Bautista
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Angelina Su-Yin Ang
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
43
|
Abstract
We examined if croup presentations to the emergency department (ED) were associated with weather changes in a warm temperate climate. We collected data on all 729 cases with an ED discharge or admission diagnosis of croup over a 798 day time period. We obtained detailed climatic records from the New South Wales Meteorological Office for the same time period. Only one daily variable, ground temperature at 9:00, was significantly associated with the number of croup attendances (linear regression -0.2062; 95% CI -0.272 to -0.138). There was a stronger correlation (-0.426; 95% CI -0.684 to -0.072) between the calculated mean monthly temperature and the monthly number of croup admissions. Even in this milder climate, croup is associated with cooler weather. We are unable to conclude that hospital attendances for croup are caused by changes in temperature alone, as other factors such as the prevalence of viral illness also follow a seasonal, and therefore, temperature-related pattern.
Collapse
Affiliation(s)
- Paul R T Atkinson
- Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, , Saint John, New Brunswick, Canada
| | | | | |
Collapse
|
44
|
Lyttle MD, Cheek JA, Blackburn C, Oakley E, Ward B, Fry A, Jachno K, Babl FE. Applicability of the CATCH, CHALICE and PECARN paediatric head injury clinical decision rules: pilot data from a single Australian centre. Emerg Med J 2012; 30:790-4. [PMID: 23015114 DOI: 10.1136/emermed-2012-201887] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Clinical decision rules (CDRs) for paediatric head injury (HI) exist to identify children at risk of traumatic brain injury. Those of the highest quality are the Canadian assessment of tomography for childhood head injury (CATCH), Children's head injury algorithm for the prediction of important clinical events (CHALICE) and Pediatric Emergency Care Applied Research Network (PECARN) CDRs. They target different cohorts of children with HI and have not been compared in the same setting. We set out to quantify the proportion of children with HI to which each CDR was applicable. METHODS Consecutive children presenting to an Australian paediatric Emergency Department with HIs were enrolled. Published inclusion/exclusion criteria and predictor variables from the CDRs were collected prospectively. Using these we determined the frequency with which each CDR was applicable. RESULTS 1012 patients (69.9%) were enrolled with 949 available for analysis. Mean age was 6.8 years (21% <2 years). 95% had initial Glasgow Coma Scale 15. CT rate was 12.8% and neurosurgery rate was 0.7%. No CDR was applicable to all patients. CHALICE was applicable to the most (97%, 95% CI 96% to 98%) and CATCH to the fewest (26%, 95% CI 24% to 29%). PECARN was applicable to 76% (95% CI 70% to 82%) aged <2 years, and 74% (95% CI 71% to 77%) aged 2-<18 years. CONCLUSIONS Each CDR is applicable to a different proportion of children with HI. This makes a direct comparison of the CDRs difficult. Prior to selection of any for implementation they should undergo validation outside the derivation setting coupled with an analysis of their performance accuracy, usability and cost effectiveness.
Collapse
Affiliation(s)
- Mark D Lyttle
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Kehler L, Verma S, Krone R, Roper E. Vitamin D deficiency in children presenting to the emergency department: a growing concern. Vitamin D deficiency in Birmingham's children: presentation to the emergency department. Emerg Med J 2012; 30:717-9. [PMID: 22962047 DOI: 10.1136/emermed-2012-201473] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The increase in detected vitamin D deficiency appears to be multifactorial: an increasingly multicultural society, reduced exposure to sunlight due to concern about skin cancer and a more sedentary lifestyle and dietary changes within the population. METHODS This was a retrospective survey of children found to be vitamin D deficient after attending the emergency department from March 2009 until March 2010. These data were then subdivided according to their age, ethnic origin, presenting complaint and biochemical associated features. RESULTS We identified 89 patients with a low vitamin D level (total vitamin D levels less than 50 nmol/l), with 83% of those having very low vitamin D levels (less than 25 nmol/l). The most common presenting features were abdominal pain (19%), a seizure (17%) and limb pain (15%). The most common ethnic origins in our series were Pakistani (37%) followed by black African (11.2%). CONCLUSIONS Vitamin D deficiency should be considered in children with pigmented skin presenting with a range of symptoms. The detected vitamin D deficiency probably represents only a very small proportion of the vitamin D deficiency in children in Birmingham.
Collapse
Affiliation(s)
- Lisa Kehler
- SPR Paediatric ED Emergency Department, Birmingham Children's Hospital, Birmingham, UK.
| | | | | | | |
Collapse
|
46
|
Pawłowicz U, Wasilewska A, Olański W, Stefanowicz M. Epidemiological study of acute poisoning in children: a 5-year retrospective study in the Paediatric University Hospital in Białystok, Poland. Emerg Med J 2012; 30:712-6. [PMID: 22942363 DOI: 10.1136/emermed-2012-201376] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Poisoning among children and youths in the northeastern part of Poland accounted for 25% of the total number of patients admitted to the Hospital Emergency Department of the Paediatric University Hospital of Białystok. We hypothesise that the epidemiology of poisoned paediatric patients admitted is related to increase in 'designer drugs' (mainly amphetamine- and ecstasy-like psychostimulants, hallucinogens and synthetic cannabinoids ('spice') intake, which became popular 5 years ago in our country. METHODS A retrospective chart review of medical records of 489 patients admitted due to poisoning in the 5-year period (2006-2010). The data included: age, sex, place of residence, nature of the substance, causes of poisoning, former use of psychoactive stimulants, accompanying self-mutilation and injuries and length of hospitalisation. Categorical variables were expressed as percentages, and continuous variables as mean and SD. The data were collected in a Microsoft Excel database. Statistical analysis was performed using the Statistical Programme for Social Sciences. RESULTS Out of 2176 hospitalised children, 489 were admitted because of poisoning. Out of these, 244 (49.9%) were hospitalised due to intoxication by alcohol. Only eight children used designer drugs. The mean age of all patients in our group was 12.86±5.04 years, of which 52.4% were male. Poisoning was intentional in 75.5%, and accidental in 24.5% of cases. Appearance of 'designer drugs' had no significant impact on the number and epidemiology of poisonings in our group.
Collapse
Affiliation(s)
- Urszula Pawłowicz
- Hospital Emergency Department (HED), Paediatric University Hospital (PUH), Białystok, Poland
| | | | | | | |
Collapse
|
47
|
Abstract
OBJECTIVE Bell's palsy is a non-life threatening disorder with important functional and psychosocial effects. While recent research has shown significant benefit from treatment with steroids in adults, there have been no conclusive studies demonstrating benefit in children. This study set out to explore the medium term resolution of symptoms in Bell's palsy presenting to the emergency department (ED). PATIENTS AND METHODS This was a retrospective cohort study of children attending an Irish paediatric ED with a diagnosis of Bell's palsy. Patients were identified via the ED database. The primary outcome measure was resolution at follow-up call (6-18 months after presentation). Secondary outcome measures were ED treatment, imaging and time to resolution of symptoms. RESULTS There were 48 presentations, involving 45 patients. Left and right-sided palsies were equally represented. Of these, 16 (33%) received prednisolone. MRI was performed in five cases (10%), four were normal and one did not change management. In follow-up telephone contact, of 35 presentations, 28 (80%, 95% CI 63% to 91%) had complete resolution, six (17%, 95% CI 7% to 34%) partial resolution to variable degrees and one patient showed no improvement. Of the 13 patients who had received prednisolone, nine (69%, 95% CI 39% to 91%) had complete resolution; of the 22 patients who were not treated with prednisolone 19 (86%, 95% CI 65% to 97%) had complete resolution (p=0.22). CONCLUSIONS The majority of children with Bell's palsy have complete resolution of the facial weakness. Steroid use is highly variable and warrants a placebo controlled randomised trial.
Collapse
Affiliation(s)
- Roisin McNamara
- Emergency Department, Children's University Hospital, Dublin, Ireland.
| | | | | | | | | |
Collapse
|
48
|
Cheung R, Ardolino A, Lawrence T, Bouamra O, Lecky F, Berry K, Lyttle MD, Maconochie IK. The accuracy of existing prehospital triage tools for injured children in England--an analysis using trauma registry data. Emerg Med J 2012; 30:476-9. [PMID: 22707475 DOI: 10.1136/emermed-2012-201324] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To investigate the performance characteristics of prehospital paediatric triage tools for identifying seriously injured children in England. DESIGN Eight prehospital paediatric triage tools were identified by literature review and by survey of the Lead Trauma Clinicians across English Strategic Health Authorities. Retrospective clinical registry data from the Trauma Audit and Research Network were used to determine the performance characteristics of each tool, using 'gold standards' for under- and over-triage of <5% and <25-50%, respectively, as benchmarks for performance. PARTICIPANTS 701 patient records were included. Inclusion criteria were all injured patients aged <16 years admitted to a receiving unit direct from the scene of accident in the period 2007-2010, for whom all key discriminator fields were recorded in the Trauma Audit and Research Network database. OUTCOME MEASURES The main outcome measure was how each tool functioned with regard to their under- and over-triaging features. Other performance characteristics, for example, predictive values and likelihood ratios were also calculated. RESULTS Two (of eight) triage tools demonstrated acceptable under-triage rates (3% and 4%) but had unacceptably high over-triage rates (83% and 72%). Two tools demonstrated acceptable over-triage rates (7% and 16%), but with unacceptably high under-triage rates (61% and 63%). Four tools had unacceptably high under- and over-triage rates. CONCLUSIONS None of the prehospital triage tools currently used or being developed in England meet recommended criteria for over- and under-triage rates. There is an urgent need for the development of triage tools to accurately risk-stratify injured children in the prehospital setting.
Collapse
Affiliation(s)
- Ronny Cheung
- Department of Paediatrics, St Thomas' Hospital, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|