Perspectives of hospital emergency department staff on traumaâ informed care for injured children: An Australian and New Zealand analysis

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138230/1/jpc13644_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138230/2/jpc13644.pd

51 Paediatric emergency clinicians are rarely exposed to non-airway critical procedures: a predict/PERN study

© 2017, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. BACKGROUND: Recent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how often critical non-airway procedures such as chest decompression, CPR, ED thoracotomy, defibrillation, pacing, and advanced vascular access techniques are performed by paediatric emergency clinicians.OBJECTIVE: To determine the recent performance or supervision, and confidence for various paediatric critical non-airway procedures by senior paediatric emergency clinicians.DESIGN/METHODS: Web based survey of senior paediatric emergency clinicians regarding performance, supervision, and confidence relating to critical non-airway procedures in children aged 0-18 years. The survey was distributed through Paediatric Emergency Research Networks (PERN) in the UK and Ireland, USA, Canada, Europe, South America, Australia and New Zealand.RESULTS: 1602 clinicians responded to the survey, with an overall response rate of 65%. 1508 (94%) respondents reported their most recent non-airway procedural experience. In the last 12 months, 979 (64%) had personally inserted an intraosseous line, 283 (19%) a central venous line, and 265 (18%) an arterial line. In the same time period, 962 (64%) had performed CPR, 190 (13%) had performed needle thoracostomy, 245 (16%) had performed tube thoracostomy, 380 (25%) had performed DC cardioversion or defibrillation, and 57 (4%) had performed transcutaneous pacing. 18 (1%) had performed pericardiocentesis, 19 (1%) a venous cutdown, and 21 (1%) ED thoracotomy. More than 70% of respondents had never supervised or performed pacing, pericardiocentesis, venous cutdown or ED thoracotomy. 332 (22%) and 348 (23%) had never performed or supervised insertion of a central venous line or arterial line respectively.Procedural confidence for intraosseous lines and CPR was high, while confidence increased with increasing patient age for central venous access and arterial lines. ED thoracotomy, pericardiocentesis and venous cutdown had the lowest frequency of respondents reporting confidence in performing the procedure.CONCLUSIONS: More than half of the paediatric emergency clinicians surveyed had performed CPR and inserted an intraosseous needle within the last 12 months. Performance of other non-airway critical procedures was less common, and associated with less procedural confidence

Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trial (protocol): A Paediatric Acute Respiratory Intervention Study (PARIS)

Background Bronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis. Methods/Design Prospective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 ≥ 40 % to maintain SpO2 ≥ 92 % (or ≥94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds >2L/min to maintain SpO2 ≥ 92 % (or ≥94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-invasive/invasive ventilation, intubation, adverse events, and cost. Discussion This large multicenter randomised trial will allow the definitive assessment of the efficacy of HFNC therapy as compared to standard subnasal oxygen in the treatment of bronchiolitis

Clinical prediction rules for abusive head trauma: a systematic review

Objective: Misdiagnosis of abusive head trauma (AHT) has serious consequences for children and families. This systematic review identifies and compares clinical prediction rules (CPredRs) assisting clinicians in assessing suspected AHT. Design: We searched MEDLINE, Embase, PubMed and Cochrane databases (January 1996–August 2016). Externally validated CPredRs focusing on the detection of AHT in the clinical setting were included. Results: Of 110 potential articles identified, three studies met the inclusion criteria: the Pediatric Brain Injury Research Network (PediBIRN) 4-Variable AHT CPredR, the Predicting Abusive Head Trauma (PredAHT) tool and the Pittsburgh Infant Brain Injury Score (PIBIS). The CPredRs were designed for different populations and purposes; PediBIRN: intensive care unit admissions (<3 years) with head injury, to inform early decisions to launch or forego an evaluation for abuse (sensitivity 0.96), PredAHT: hospital admissions (<3 years) with intracranial injury, to assist clinicians in discussions with child abuse specialists (sensitivity 0.72), and PIBIS: well-appearing children (<1 year) in the emergency department with no history of trauma, temperature <38.3°, and ≥1 symptom associated with high risk of AHT, to determine the need for a head CT scan (sensitivity 0.93). There was little overlap between the predictive variables. Conclusion: Three CPredRs for AHT were relevant at different stages in the diagnostic process. None of the CPredRs aimed to diagnose AHT but to act as aids/prompts to clinicians to seek further clinical, social or forensic information. None were widely validated in multiple settings. To assess safety and effectiveness in clinical practice, impact analyses are required and recommended

A comprehensive systematic review of stakeholder attitudes to alternatives to prospective informed consent in paediatric acute care research

Background: A challenge of performing research in the paediatric emergency and acute care setting is obtaining valid prospective informed consent from parents. The ethical issues are complex, and it is important to consider the perspective of participants, health care workers and researchers on research without prospective informed consent while planning this type of research. Methods: We performed a systematic review according to PRISMA guidelines, of empirical evidence relating to the process, experiences and acceptability of alternatives to prospective informed consent, in the paediatric emergency or acute care setting. Major medical databases and grey sources were searched and results were screened and assessed against eligibility criteria by 2 authors, and full text articles of relevant studies obtained. Data were extracted onto data collection forms and imported into data management software for analysis. Results: Thirteen studies were included in the review consisting of nine full text articles and four abstracts. Given the heterogeneity of the methods, results could not be quantitatively combined for meta-analysis, and qualitative results are presented in narrative form, according to themes identified from the data. Major themes include capacity of parents to provide informed consent, feasibility of informed consent, support for alternatives to informed consent, process issues, modified consent process, child death, and community consultation. Conclusion: Our review demonstrated that children, their families, and health care staff recognise the requirement for research without prior consent, and are generally supportive of enrolling children in such research with the provisions of limiting risk, and informing parents as soon as possible. Australian data and perspectives of children are lacking and represent important knowledge gaps

A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB)

<p>Abstract</p> <p>Background</p> <p>Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG).</p> <p>The evidence to determine the optimum route of hydration therapy for infants with bronchiolitis is inadequate. This randomised trial will be the first to provide good quality evidence of whether nasogastric rehydration (NGR) offers benefits over intravenous rehydration (IVR) using the clinically relevant continuous outcome measure of duration of hospital admission.</p> <p>Methods/Design</p> <p>A prospective randomised multi-centre trial in Australia and New Zealand where children between 2 and 12 months of age with bronchiolitis, needing non oral fluid replacement, are randomised to receive either intravenous (IV) or nasogastric (NG) rehydration.</p> <p>750 patients admitted to participating hospitals will be recruited, and will be followed daily during the admission and by telephone 1 week after discharge. Patients with chronic respiratory, cardiac, or neurological disease; choanal atresia; needing IV fluid resuscitation; needing an IV for other reasons, and those requiring CPAP or ventilation are excluded.</p> <p>The primary endpoint is duration of hospital admission. Secondary outcomes are complications, need for ICU admission, parental satisfaction, and an economic evaluation. Results will be analysed using t-test for continuous data, and chi squared for categorical data. Non parametric data will be log transformed.</p> <p>Discussion</p> <p>This trial will define the role of NGR and IVR in bronchiolitis</p> <p>Trail registration</p> <p>The trial is registered with the Australian and New Zealand Clinical Trials Registry - ACTRN12605000033640</p

Interleukin-8 predicts fatigue at 12 months post-injury in children with traumatic brain injury

Despite many children experiencing fatigue after childhood brain injury, little is known about the predictors of this complaint. To date, traditional indices of traumatic brain injury (TBI) severity have not reliably predicted persisting fatigue (up to 3 years post‐injury). This study aimed to establish if persisting fatigue is predicted by serum biomarker concentrations in child TBI. We examined if acute serum biomarker expression would improve prediction models of 12‐month fatigue based on injury severity. Blood samples were collected from 87 children (1 – 17 years at injury) sustaining mild to severe TBI (GCS range 3‐15; mean 12.43; classified as mild TBI (n=50, 57%) vs moderate/severe TBI n=37, 43%), and presenting to the Emergency Departments (ED) and Pediatric Intensive Care Units (PICU) at one of three tertiary pediatric hospitals (Royal Children’s Hospital (RCH); Hospital for Sick Children (HSC), Toronto St Justine Children’s Hospital (SJH), Montreal). Six serum biomarker concentrations were measured within 24 hours of injury [interleukin‐6 (IL‐6), interleukin‐8 (IL‐8), soluble vascular cell adhesion molecule (SVCAM), S100 calcium binding protein B (S100B), neuron specific enolase (NSE), and soluble neural cell adhesion molecule (sNCAM)]. Fatigue at 12 months post‐injury was measured using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (parent report), classified as present/absent using previously derived cut‐points. At 12 months post‐injury, 22% of participants experienced fatigue. A model including interleukin‐8 (IL‐8) was the best serum biomarker for estimating the probability of children experiencing fatigue at 12 months post‐injury. IL‐8 also significantly improved predictive models of fatigue based on severity

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

Objective To determine the variability of primary and secondary outcomes used in trials of intravenous bronchodilators in children with acute severe paediatric asthma. Methods Systematic search of MEDLINE, EMBASE, Cochrane CENTRAL and the WHO International Clinical Trials Registry Platform for randomised trials in children (less than18 years) with acute severe paediatric asthma comparing intravenous bronchodilator therapy to another treatment. Initial search was performed on 7 January 2016 with an updated search performed on 6 September 2018. Primary and secondary outcomes were collated. Results We identified 35 published papers and four registered study protocols. 56 primary outcomes were found, the most common being a clinical asthma score (23/56; 41%). Other identified primary outcomes included bedside tests of respiratory function (11/56; 20%) and measures of length of stay (9/56; 16%). There were a total of 60 different secondary outcomes, the most common were various length of stay measures (24/60; 40%) and adverse events (11/60; 18%). Conclusion Studies comparing intravenous treatment modalities for children with acute severe paediatric asthma exhibit great variation in the type, number and timing of outcome measures used. There are no patient or family-specific outcomes reported. There is a need to develop international consensus