International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England

Harron K, Gilbert R, Cromwell D, et al.   International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England
BMJ Qual Saf Published Online First: 12 June 2017. doi: 10.1136/bmjqs-2016-006253

Abstract
Objectives  To compare emergency hospital use for infants in Ontario (Canada) and England.
Methods We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission.
Results The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age.
Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.

Full text is available here

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Prevalence of non-accidental trauma among children at ACS verified pediatric trauma centers

Child abuse remains a national epidemic that has detrimental effects if unnoticed in the clinical setting | Journal of Trauma and Acute Care Surgery

Background: Extreme cases of child abuse, or non-accidental trauma (NAT), have large financial burdens associated with them due to treatment costs and long-term effects of abuse. Clinicians that have additional training and experience with pediatric trauma are better equipped to detect signs of NAT and have more experience reporting it. This additional training and experience can be measured by using the American College of Surgeons (ACS) Pediatric Trauma Verification. It is hypothesized that ACS verified Pediatric Trauma Centers (vPTCs) have an increased prevalence of NAT due to this additional experience and training when relative to non-ACS vPTCs.

Conclusions: The greater prevalence of NAT at vPTCs likely represents a more accurate measure of NAT among pediatric trauma patients, likely due to more experience and training of clinicians.

Full reference: Bogumil, D.D.A. et al. (2017) Prevalence of non-accidental trauma among children at ACS verified pediatric trauma centers. Journal of Trauma and Acute Care Surgery: Published online: 20 June 2017

 

Ultrasound for children with abdominal trauma

Despite evidence showing that the routine use of sonography in hospital emergency departments can safely improve care for adults when evaluating for possible abdominal trauma injuries, researchers at UC Davis Medical Center could not identify any significant improvements in care for pediatric trauma patients | ScienceDaily

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The findings, which resulted from a randomized clinical study involving 925 children with blunt torso trauma who were evaluated in the emergency department at the medical center, showed no difference in important clinical outcomes. The outcomes assessed were developed for the study mainly based on previous research in injured adults.

The UC Davis team investigated the Focused Assessment with Sonography for Trauma (FAST) to determine whether the use of the FAST examination could safely lead to a decrease in the use of computed tomography (CT) scans for children, and other outcomes. FAST is a bedside ultrasound examination using a portable ultrasound machine. It has not been routinely used in the initial emergency department evaluations of injured children. CT scans represent the “gold standard” in diagnostic imaging for clinicians, including the identification of intra-abdominal injuries, but they also pose a greater radiation risk for children than they do for adults.

The role of nurses’ clinical impression in the first assessment of children at the emergency department

This study explores the diagnostic value and determinants of nurses’ clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED) | Archives of Disease in Childhood

Main outcome measures: Diagnostic accuracy of nurses’ clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses’ impression that a child appeared ill.

Results: Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses’ clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses’ impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

Conclusion: The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.

Full reference: Zachariasse, J.M. et al. (2017)  The role of nurses’ clinical impression in the first assessment of children at the emergency department. Archives of Disease in Childhood. Published Online First: 10 June 2017

Improving Recognition of Pediatric Severe Sepsis in the Emergency Department

Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department | Annals of Emergency Medicine

Methods: This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.

Conclusion: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert–negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

Full reference: Balamuth, F. et al. (2017) Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign–Based Electronic Alert and Bedside Clinician Identification. Annals of Emergency Medicine. Published online: 2 June 2017

Acceptability of Universally Offered Gonorrhea and Chlamydia Screening

This study is an exploration of adolescent and parent or guardian attitudes about benefits and barriers to universally offered gonorrhea and chlamydia screening and modalities for assessing interest in screening in the pediatric emergency department | Annals of Emergency Medicine

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Methods: A convenience sample of forty 14- to 21-year-olds and parents or guardians of adolescents presenting to an urban and community pediatric ED with any chief complaint participated in individual, semistructured, confidential interviews. Topics included support of universally offered gonorrhea and chlamydia screening, barriers and benefits to screening, and modalities for assessing interest in screening. Data were analyzed with framework analysis.

Results: Almost all adolescents (37/40; 93%) and parents (39/40; 98%) support offering ED gonorrhea or chlamydia screening. Benefits included earlier diagnosis and treatment, convenience and transmission prevention (cited by both groups), and improved education and long-term health (cited by parents/guardians). Barriers included concerns about confidentiality and cost (cited by both groups), embarrassment (cited by adolescents), and nondisclosure to parents or guardians (cited by parents/guardians). Adolescents preferred that the request for gonorrhea or chlamydia screening be presented in a private room, using tablet technology. Both groups noted that the advantages to tablets included confidentiality and adolescents’ familiarity with technology. Adolescents noted that tablet use would address concerns about bringing up gonorrhea or chlamydia screening with clinicians, whereas parents or guardians noted that tablets might increase screening incidence but expressed concern about the lack of personal interaction.

Conclusion: Universally offered gonorrhea and chlamydia screening in a pediatric ED was acceptable to the adolescents and parents or guardians in this study. Offering a tablet-based method to assess interest in screening may increase participation.

Full reference: Reed, J.L. et al. (2017) A Qualitative Analysis of Adolescent and Caregiver Acceptability of Universally Offered Gonorrhea and Chlamydia Screening in the Pediatric Emergency Department. Annals of Emergency Medicine. DOI:10.1016/j.annemergmed.2017.04.017.

Ultrasound for children with broken arms: Accurate, faster, less painful than X-rays

Point-of-Care Ultrasound (POCUS) assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction | ScienceDaily

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There are many goals when managing children with suspected fractures of the arm. These include being fast and accurate in the diagnosis, not causing more pain and limiting exposure to radiation. Achieving these goals can result in high rates of caregiver satisfaction. Dr. Poonai’s study suggests that POCUS may be a viable alternative to x-ray with respect to diagnostic accuracy, cost effectiveness, pain, caregiver satisfaction, and procedure duration.

Read the full overview via ScienceDaily here

The original research article is available here