Catherine Bevan

Functional and health-related quality of life outcomes after pediatric trauma.

BACKGROUND Pediatric trauma results in lower mortality than adults and a high potential for lifelong functional impairment and reduced health-related quality of life (HRQL). There is no consensus regarding the best approach to measuring outcomes in this group. METHODS One hundred and fifty injured children admitted to a pediatric trauma center participated in this study. The Pediatric Quality of Life Inventory (PedsQL), Child Health Questionnaire (CHQ-PF28), Kings Outcome Scale for Childhood Head Injury (KOSCHI), modified Glasgow Outcome Scale (mGOS), and the Functional Independence Measure (FIM) were administered at 1 month, 6 months, and 12 months after injury by telephone. Change in instrument scores was assessed using multilevel mixed effects models. Mean HRQL scores were compared with population norms for the CHQ-PF28 and with healthy children for the PedsQL. RESULTS Follow-up at all time points was completed for 144 (96%) cases. The median injury severity score was 10, and 65% of the patients enrolled were men. At 12 months, the percentage of cases with ongoing disability was 14% for the FIM, 61% using the mGOS, and 58% for the KOSCHI. CHQ-PF28 physical and PedsQL psychosocial health scores were below healthy child norms at 12 months. Improvement across all time points was demonstrated for the KOSCHI, mGOS, CHQ-PF28 physical, and PedsQL psychosocial summary scores. CONCLUSIONS Seriously injured children showed ongoing disability and reduced HRQL 12 months after injury. The CHQ-PF28 and PedsQL, and the mGOS and KOSCHI, performed comparably. The FIM demonstrated considerable ceiling effects, and improvement over time was not shown. The results inform the methodology of pediatric outcomes studies and protocol development for the routine follow-up of pediatric trauma patients.

Agreement between parent and child report of health-related quality of life: impact of time postinjury.

BACKGROUND Health-related quality of life (HRQL) is subjective concept and, therefore, should be captured directly from the patient. However, proxy reporting of HRQL is widespread, particularly in pediatric studies where children have been considered unreliable respondents. This study assessed the level of agreement between proxy (parent) and child reports of HRQL at key time points after injury. METHODS Thirty-seven seriously injured children aged 13 years to 16 years participated in this study. The Pediatric Quality of Life inventory was administered to the parent and child at 1 month, 6 months, and 12 months after injury by telephone interview. Agreement between child and parent responses was compared using Bland-Altman plots, and Pediatric Quality of Life inventory physical and psychosocial summary scales were compared using paired t tests or Wilcoxon signed-rank tests, respectively. RESULTS At 1-month (psychosocial t = -4.6, p < 0.001; physical t = -6.5 p < 0.001) and 6-month (psychosocial z = -2.5, p = 0.01; physical z = -2.6, p = 0.01) postinjury there was a significant difference between the parent and child reports, with children rating their HRQL higher than their parents. At 12-months, there was no difference between the scores reported by parents and their children (psychosocial z = -0.3, p = 0.76; physical t = -0.7, p = 0.51). CONCLUSIONS Agreement between parent and child ratings of HRQL improved with time postinjury. The findings have implications for the design of pediatric trauma outcomes studies and the routine collection of pediatric HRQL data. Parent and child reports should be considered separate but important information, particularly in the early stages following injury. Where collection of both is not feasible, parent or child report should be chosen, and interchangeable use of parent and child reports limited.

Paediatric and adolescent trauma care within an integrated trauma system

BACKGROUND The aim of this study was to establish the profile and outcomes of paediatric major trauma care (PTMC) within an integrated inclusive regionalised trauma system. METHODS Prospectively collected data from July 2001 to June 2009 from the Victorian State Trauma Registry of patients aged <18 years were reviewed. RESULTS There were 1634 major trauma cases with a median (IQR) age of 13 (6-16) years and 69% were male. The median ISS (IQR) was 18 (16-26). There were 1361 patients treated at a major trauma centre of which 69% (n=943) were treated at the PMTC. Head injury (AIS>2) was the most frequent injury (n=950, 58%). Surgery was required in 39% (n=637) of all cases; 437 patients in the 10-17 year old group and 200 patients in the 0-9 year old group; the mortality was 6.6%. There were 530 patients (32.4%) ventilated in ICU; these had a median ISS (IQR) of 25 (17-34) and mortality of 7.4%. Improvements in risk-adjusted mortality have occurred as the years have progressed [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a Level 1 trauma centre was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)]. CONCLUSION The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of major trauma requiring surgery in the 0-9 year old age group is notable, creating a challenging environment for maintaining skills and institutional preparedness.

Reducing "cry wolf"--changing trauma team activation at a pediatric trauma centre.

BACKGROUND To improve utilization of scarce surgical resources, we changed from a single tier trauma paging system (TPS) to a three tiered TPS at a tertiary pediatric trauma center. We investigated if patients were appropriately classified into the three levels of trauma team activation. METHODS Trauma registry data were used to review data 12 months before and after implementation of a three tiered TPS (level I entire team present, level II surgical subspecialties within 10 minutes, level III emergency department team only at patient arrival). We correlated TPS activation with proxies of injury severity (admission status and major/nonmajor trauma). RESULTS There were 192 activations during 12 months of the single tier TPS and 216 during the three tier TPS (33 level I, 49 level II, and 134 level III). The entire team was to attend in all 192 single tier and in 82 (40%) level I and II three tier TPS activations i.e., there were 60% fewer surgical team activations. During single tier TPS, 96% patients were admitted and 23% classified as major trauma. Three tiered TPS level I, II and III were admitted in 97%, 94%, and 81% and classified as major trauma in 58%, 35%, and 15%, respectively. Of the 20 level III patients classified as major trauma, TPS level was deemed appropriate in 18 and inappropriately low in 2, although patient care had not been compromised. CONCLUSION Our results suggest that a three tiered TPS more efficiently utilizes limited surgical resources without leading to major misclassifications.

Pediatric Emergency Research in the UK and Ireland (PERUKI): developing a collaborative for multicentre research

Paediatric Emergency Medicine (PEM) has evolved significantly in the UK and Ireland. Recognition as a subspecialty by the Royal College of Paediatrics & Child Health (RCPCH) and the College of Emergency Medicine, and the existence of the Association of Pediatric Emergency Medicine (PEM), have resulted in structured training programmes and enhanced paediatric emergency care. However, the limited evidence base for a number of childhood conditions treated in Emergency Departments (EDs) leads to variability in practice.1 To further improve emergency care of children in our population, further evidence must be generated. This can only be achieved through cohesive multicentre PEM research. With presentations encompassing the full spectrum of childhood illness and injury, EDs theoretically provide an ideal research environment, yet there are a number of perceived challenges. These are resource, clinical, attitudinal, or system based, and impact on development, delivery and translation of findings. They include:

Establishing the research priorities of paediatric emergency medicine clinicians in the UK and Ireland

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.

The full spectrum of handlebar injuries in children: A decade of experience

BACKGROUND Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI. METHODS Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI. RESULTS 1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5-3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p=0.4) or need for operative intervention (OR 1.1; 95% CI 0.9-1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p=0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2-5.4). The majority of splenic, renal and hepatic injuries were managed conservatively. CONCLUSIONS Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion.

Postnatal depression in mothers bringing infants to the emergency department

Objective To determine the prevalence of postnatal depression (PND) in mothers of young infants presenting to the emergency department (ED). Design, setting and participants Prospective observational study of the prevalence of PND in mothers of infants aged 14 days to 6 months presenting with non-time-critical conditions to the ED of a large tertiary paediatric hospital. Main outcome measures We assessed PND by applying a self-administered validated screening tool, the Edinburgh Postnatal Depression Scale (EPDS). Mothers of patients were approached before clinician consultation when a social worker was available on site. EPDS scores of 13 and above were considered ‘positive’. Univariate analysis was used to determine associations with demographic, maternal and child factors. Results 236 mothers were approached; 200 consented to participate in the study. Thirty-two mothers screened positively, with a prevalence rate of 16% (95% CI 11.2% to 21.8%). A positive screen was most strongly associated with history of depression (relative risk (RR) 4.8, 95% CI 2.3 to 10.1). Other associations were with single-parent status (RR 2.5, 95% CI 1.1 to 5.4), Indigenous status (4.4, 95% CI 1.8 to 10.4) and ‘crying baby’ as the presenting problem (RR 2.9, 95% CI 1.4 to 6.2). Fifty-three per cent of mothers had not completed a PND screen before coming to the ED. Conclusions Mothers of young infants coming to the ED regardless of infants presenting complaint have a high prevalence of PND determined using the EPDS. Many mothers were not screened for PND before coming to the ED. Clinical staff need to be aware of the condition, incorporate appropriate questioning into the consultation, and refer mothers to support services if necessary.

Assessing Bladder Volumes in Young Children Prior to Instrumentation: Accuracy of an Automated Ultrasound Device Compared to Real-time Ultrasound

OBJECTIVES Automated bladder ultrasound (ABUS) devices are portable and designed to provide automated measurement of bladder volume. They are simple and require minimal training compared to conventional real-time ultrasound (RTUS). Their most common application in the acute pediatric setting is to assess bladder volumes prior to performing invasive urine collection such as suprapubic aspiration (SPA) in children younger than 2 years of age. However, data on ABUS in young children are limited. The aim of this study was to assess the repeatability and accuracy of one type of ABUS, the BladderScan, in measuring of bladder volume in children aged 0 to 24 months when compared with RTUS. METHODS Healthy children aged 24 months and younger were scanned twice, 1 hour apart, using ABUS and RTUS. ABUS readings were performed by two senior pediatric emergency physicians who both completed three readings for each child. The measurements were repeated using a second ABUS machine in case of machine variability. RTUS measurements were performed by a pediatric sonographer who was blinded to the ABUS results. ABUS and RTUS measurements were compared by Bland-Altman analysis to determine the repeatability coefficient (repeatability) and the limits of clinical agreement (accuracy). RESULTS Bladder volume measurements were performed on 61 children aged 0 to 24 months (31 males; mean ± SD = age 11 ± 6.2 months; range = 0 to 24 months) using both the ABUS and the RTUS. There was wide variation between ABUS and RTUS measurements. The repeatability coefficient within ABUS readings was 20 mL. By Bland-Altman analysis, the 95% limits of agreement between ABUS and RTUS were -31 to +19 mL. ABUS also detected no values between 0 and 10 mL. CONCLUSIONS This study showed poor repeatability and accuracy in bladder volume measurements using BladderScan ABUS when compared to RTUS. The ABUS method does not appear to be a reliable method for assessing bladder volumes in children aged 0 to 24 months prior to bladder instrumentation.

How do clinicians obtain urine samples in young children

Dear Editor, There are conflicting recommendations on the optimal strategy to collect sterile urine samples in young children. The National Institute for Health and Clinical Excellence (NICE, UK) recommends obtaining urine by clean catch (CCU) from all young children with suspected urinary tract infections (UTI). The American Academy of Pediatrics, however, advises suprapubic aspiration (SPA) or catheter specimen urine (CSU). Although SPA has the lowest contamination rate, the procedure is painful, requires some skill and is not always successful. Conventional Real-time Ultrasound (RTUS) or automated ultrasound (automated US) to confirm bladder fullness can increase the chance of successfully obtaining urine by SPA, yet the parameters for ultrasound are unclear. As a first step to improve evidence we set out to assess physician practice for urine collection by SPA in paediatric EDs in Australia and New Zealand. We conducted a standardized electronic online survey of senior emergency physicians at the 13 Paediatric Research in Emergency Departments International Collaborative (PREDICT) EDs in Australia and New Zealand. We investigated urine collection practices for febrile children 24 months stratified by age, sex and how bladder fullness was assessed before instrumentation.