Pathways to care for critically ill or injured children: A cohort study from first presentation to healthcare services through to admission to intensive care or death

Purpose Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. METHODS: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. RESULTS: The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. CONCLUSIONS: The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care

Challenges to undertaking randomised trials with looked after children in social care settings.

BACKGROUND: Randomised controlled trials (RCTs) are widely viewed as the gold standard for assessing effectiveness in health research; however many researchers and practitioners believe that RCTs are inappropriate and un-doable in social care settings, particularly in relation to looked after children. The aim of this article is to describe the challenges faced in conducting a pilot study and phase II RCT of a peer mentoring intervention to reduce teenage pregnancy in looked after children in a social care setting. METHODS: Interviews were undertaken with social care professionals and looked after children, and a survey conducted with looked after children, to establish the feasibility and acceptability of the intervention and research design. RESULTS: Barriers to recruitment and in managing the intervention were identified, including social workers acting as informal gatekeepers; social workers concerns and misconceptions about the recruitment criteria and the need for and purpose of randomisation; resource limitations, which made it difficult to prioritise research over other demands on their time and difficulties in engaging and retaining looked after children in the study. CONCLUSIONS: The relative absence of a research infrastructure and culture in social care and the lack of research support funding available for social care agencies, compared to health organisations, has implications for increasing evidence-based practice in social care settings, particularly in this very vulnerable group of young people

Impact of Social Stories on social and emotional health of autism spectrum primary school children:the ASSSIST2 RCT with economic evaluation

BACKGROUND: Differences in the way autistic children experience the world can contribute to anxiety and stress. Carol Gray's Social Stories™ are a highly personalised intervention to support children by providing social information about specific situations in an individual story. OBJECTIVES: This randomised controlled trial aimed to establish whether Social Stories are clinically effective and cost-effective in improving social responsiveness and social and emotional health in children on the autism spectrum in schools. DESIGN: A multisite pragmatic cluster randomised controlled trial comparing Social Stories with care as usual. SETTING: Eighty-seven schools (clusters) across Yorkshire and the Humber. PARTICIPANTS: Two hundred and forty-nine children were randomised via a bespoke system hosted at York Trials Unit (129 Social Stories and 120 care as usual). Recruitment was completed in May 2021. Participants were children aged 4-11 years with a diagnosis of autism, alongside teachers, interventionists and caregivers. Recruitment was via schools, NHS trusts, support groups and local publicity. INTERVENTION: The intervention included training for educational professionals and caregivers covering psychoeducation and implementation of Social Stories. Stories were written around contextualised goals around the child's need for social information. Interventionists read the Social Story™ with the child at least six times over 4 weeks during school. MAIN OUTCOME MEASURE: The primary outcome was the Social Responsiveness Scale-2 completed by teachers at 6 months (the primary end point), which measures social awareness, cognition, communication and behaviour. Data were collected from caregivers and educational professionals at 6 weeks and 6 months through questionnaires. Blinding of participants was not possible. RESULTS: At 6 months, the estimated difference in expected teacher-reported Social Responsiveness Scale-2 T-score (the primary end point) was -1.61 (95% confidence interval -4.18 to 0.96, p  = 0.220), slightly favouring the intervention group. The estimated differences for the parent-reported secondary outcomes at 6 months were small and generally favoured the control group except the measure of children's quality-adjusted life-year (+ 0.001, 95% confidence interval -0.032 to 0.035) and parental stress (-1.49, 95% confidence interval -5.43 to 2.46, p  = 0.460), which favoured the intervention group. Children in the intervention group met their individual goals more frequently than children who received usual care alone (0.97 confidence interval 0.21 to 1.73, p  = 0.012). The intervention is likely to save small costs (-£191 per child, 95% confidence interval -767.7 to 337.7) and maintain a similar quality of life compared to usual care. The probability of Social Stories being a preferred option is 75% if the society is willing to pay £20,000 per quality-adjusted life-year gained. Limitations include considerable disruptions during the coronavirus disease 2019 pandemic. CONCLUSION: Social Stories are used in schools and represent a low-cost intervention. There is no clinically evident impact on social responsiveness, anxiety and/or depression, parental stress or general health. Benefits were observed for specific behavioural goals as assessed by the teacher, and Social Stories may serve as a useful tool for facilitating dialogue between children and school staff to address specific behavioural challenges. Usage should be at the school's discretion. FUTURE WORK: Given the uncertainty of the results in light of coronavirus disease 2019, further work to establish the impact of Social Stories is merited. TRIAL REGISTRATION: This trial is registered as ISRCTN11634810. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/111/91) and is published in full in Health Technology Assessment; Vol. 28, No. 39. See the NIHR Funding and Awards website for further award information

Leadership for all : an investigation into the benefits of student leadership in secondary schools

“Leadership is not something you do to people. It’s something you do with them” Ken Blanchard (2003) Background: Student leadership in schools is traditionally modelled on an outdated ideology of leadership. The traditional model consists of a group of selected prefects, who are given leadership responsibility, allowed privileges, and are tasked with representing the student body. Contemporary views of leadership are relationship based, collaborative and distributed rather than hierarchical. Purpose: This research focuses on the experiences of designated student leaders and non-designated students. It explores the benefits, the challenges, and the degree to which the student’s value school leadership experience. Methodology: Through interviews and observations, past students, current students, and staff at a case study school share their experiences and opinions about student leadership. The data is presented in two ways; using common themes and as three composite narratives. These stories give insight into the lives of the students through their eyes. Findings / Conclusion: The data shows that student leadership is an empowering and valuable educational experience, one which should be available to all senior students. The school’s approach to student leadership; through its ideology, structure, and support, dictates its effectiveness. Implications: A model for student leadership, based on the findings of the research, is presented. The model is structured around an ideology that views student leadership as a supported learning opportunity for all senior students who choose to be involved

An act of catharsis or a cry for help? Decreased anxiety as a postcedent of a non-fatal suicide attempt

Introduction More than 40 years ago, an American physician called R. Gregory Austin suggested that suicide was an act of catharsis. He coined the terms attempters (mostly women appealing for a change in their lives) and committers (mostly men driven by self-hatred) to describe two distinct populations of suicidal patients. Austin was convinced that only the latter group really sought catharsis. Method We compared reported mean anxiety levels in male and female inpatients (N = 629) presenting with either no suicidal behavior, death wish, suicidal ideation or who had recently made a non-fatal suicide attempt. Results We found that female patients with suicidal ideation had much higher levels of anxiety compared to their non-suicidal counterparts. However, the anxiety levels of female patients who had recently made a non-fatal suicide attempt were not significantly different to those of non-suicidal women. No similar trends were found in male patients. Conclusion Catharsis (Greek: κάθαρσις) means to purge or cleanse the emotions (of fear, pity). Our results suggest that, in contrast to Austin’s original observation, both women and men undertake acts of catharsis: it is simply that the focus of their cathartic act differs. For men, anxiety appears to play no significant role or has no consequence in their suicidal behavior. For women, their catharsis appears to be the purging or normalizing of anxiety

Features of the transposed seasonality of the 2021 RSV epidemic in the UK and Ireland: Analysis of the first 10,000 patients

Non-pharmaceutical interventions (NPIs) introduced globally to limit the spread of SARS-CoV-2 led to disruption of the typical respiratory syncytial virus (RSV) seasonality.1 Studies examining the resurgence of RSV have been limited by sample size and lack of information on secondary care episodes and clinical features. The BronchStart study is a prospective multicentre cohort study. Paediatric emergency departments (PED) within PERUKI (Paediatric Emergency Research in the UK and Ireland) submit data on all children under 2 years of age who visit a PED with symptoms of an acute lower respiratory tract infection (diagnosed as bronchiolitis, lower respiratory tract infection or first episode of acute wheeze). Follow-up information is submitted 7 days later and study data are made available on a live online dashboard hosted by Microreact.2We present initial data for 10 347 infants and children from 44 study sites for the period 1 June–5 December 2021. The 2021 RSV epidemic in the UK has finished with infections having peaked in August (figure 1A). Comparing the age distribution of hospitalised infants <12 months with that of previous years at two large paediatric centres participating in BronchStart (Leicester Children’s Hospital and Bristol Royal Hospital for Children), we observed a similar age distribution (figure 1B). This suggests either reduced community exposure to RSV during the 15 months preceding the start of the season did not result in a clinically significant lack of protective maternal antibody transfer to those <3 months of age or the NPIs introduced did not prevent low-level transmission

LMIC-PRIEST: Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19 in a middle-income setting.

BackgroundUneven vaccination and less resilient health care systems mean hospitals in LMICs are at risk of being overwhelmed during periods of increased COVID-19 infection. Risk-scores proposed for rapid triage of need for admission from the emergency department (ED) have been developed in higher-income settings during initial waves of the pandemic.MethodsRoutinely collected data for public hospitals in the Western Cape, South Africa from the 27th August 2020 to 11th March 2022 were used to derive a cohort of 446,084 ED patients with suspected COVID-19. The primary outcome was death or ICU admission at 30 days. The cohort was divided into derivation and Omicron variant validation sets. We developed the LMIC-PRIEST score based on the coefficients from multivariable analysis in the derivation cohort and existing triage practices. We externally validated accuracy in the Omicron period and a UK cohort.ResultsWe analysed 305,564 derivation, 140,520 Omicron and 12,610 UK validation cases. Over 100 events per predictor parameter were modelled. Multivariable analyses identified eight predictor variables retained across models. We used these findings and clinical judgement to develop a score based on South African Triage Early Warning Scores and also included age, sex, oxygen saturation, inspired oxygen, diabetes and heart disease. The LMIC-PRIEST score achieved C-statistics: 0.82 (95% CI: 0.82 to 0.83) development cohort; 0.79 (95% CI: 0.78 to 0.80) Omicron cohort; and 0.79 (95% CI: 0.79 to 0.80) UK cohort. Differences in prevalence of outcomes led to imperfect calibration in external validation. However, use of the score at thresholds of three or less would allow identification of very low-risk patients (NPV ≥0.99) who could be rapidly discharged using information collected at initial assessment.ConclusionThe LMIC-PRIEST score shows good discrimination and high sensitivity at lower thresholds and can be used to rapidly identify low-risk patients in LMIC ED settings

Training and testing of a gradient boosted machine learning model to predict adverse outcome in patients presenting to emergency departments with suspected covid-19 infection in a middle-income setting.

COVID-19 infection rates remain high in South Africa. Clinical prediction models may be helpful for rapid triage, and supporting clinical decision making, for patients with suspected COVID-19 infection. The Western Cape, South Africa, has integrated electronic health care data facilitating large-scale linked routine datasets. The aim of this study was to develop a machine learning model to predict adverse outcome in patients presenting with suspected COVID-19 suitable for use in a middle-income setting. A retrospective cohort study was conducted using linked, routine data, from patients presenting with suspected COVID-19 infection to public-sector emergency departments (EDs) in the Western Cape, South Africa between 27th August 2020 and 31st October 2021. The primary outcome was death or critical care admission at 30 days. An XGBoost machine learning model was trained and internally tested using split-sample validation. External validation was performed in 3 test cohorts: Western Cape patients presenting during the Omicron COVID-19 wave, a UK cohort during the ancestral COVID-19 wave, and a Sudanese cohort during ancestral and Eta waves. A total of 282,051 cases were included in a complete case training dataset. The prevalence of 30-day adverse outcome was 4.0%. The most important features for predicting adverse outcome were the requirement for supplemental oxygen, peripheral oxygen saturations, level of consciousness and age. Internal validation using split-sample test data revealed excellent discrimination (C-statistic 0.91, 95% CI 0.90 to 0.91) and calibration (CITL of 1.05). The model achieved C-statistics of 0.84 (95% CI 0.84 to 0.85), 0.72 (95% CI 0.71 to 0.73), and 0.62, (95% CI 0.59 to 0.65) in the Omicron, UK, and Sudanese test cohorts. Results were materially unchanged in sensitivity analyses examining missing data. An XGBoost machine learning model achieved good discrimination and calibration in prediction of adverse outcome in patients presenting with suspected COVID19 to Western Cape EDs. Performance was reduced in temporal and geographical external validation

Manželské mýty

<p>Schematic of the referral pathway for trauma patients admitted to Paediatric Intensive Care.</p