David Krieser

Parental weight estimation of their child's weight is more accurate than other weight estimation methods for determining children's weight in an emergency department?

Objective: To compare the various paediatric weight estimation methods (Advanced Pediatric Life Support, Broselow Tape, Argall, and Best Guess) and parental estimate to measured weight. Patients and method: A convenience sample of children aged 1–11 years who presented to the emergency department over a 6 month period were eligible for inclusion. Data collected included height, age, ethnicity, parent estimate of weight and measured weight. Body mass index (BMI) was calculated. The outcome of interest was agreement between estimated weight and measured weight for each method. Data were analysed by descriptive statistics and performance of each weight estimation method was compared using mean difference (MD), root mean square error (RMSE) and agreement within 10%. Results: 410 cases were included in this study. The median age was 4 years, there were more boys (54.4%), and the majority of cases were of Caucasian ethnicity (74.9%). The mean BMI of the sample was 17 kg/m2 and mean actual weight was 21.2 kg. Parent estimate was the most accurate method with 78% of parent estimates within 10% of measured weight and the lowest mean difference (−0.6 kg) and RMSE (3.1 kg). The Broselow tape was the most accurate of the other methods, with 61% of estimations within 10% of measured weight. Conclusion: Parental estimation of weight is more accurate than the other weight estimation methods studied. When this is not available, the Broselow tape is the most accurate alternative method.

Paediatric Research in Emergency Departments International Collaborative (PREDICT): First steps towards the development of an Australian and New Zealand research network

Paediatric emergency research is hampered by a number of barriers that can be overcome by a multicentre approach. In 2004, an Australia and New Zealand‐based paediatric emergency research network was formed, the Paediatric Research in Emergency Departments International Collaborative (PREDICT). The founding sites include all major tertiary childrens hospital EDs in Australia and New Zealand and a major mixed ED in Australia. PREDICT aims to provide leadership and infrastructure for multicentre research at the highest standard, facilitate collaboration between institutions, health‐care providers and researchers and ultimately improve patient outcome. Initial network‐wide projects have been determined. The present article describes the development of the network, its structure and future goals.

Paediatric acute asthma management in Australia and New Zealand: practice patterns in the context of clinical practice guidelines

Objectives: To compare clinical practice guideline (CPG) recommendations and reported physician management of acute paediatric asthma in the 11 largest paediatric emergency departments, all of which have CPGs, in Australia (n = 9) and New Zealand (n = 2). All 11 sites participate in the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network. Methods: (a) A review of CPGs for acute childhood asthma from all PREDICT sites. (b) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of acute childhood asthma. Results: CPGs for mild to moderate asthma were similar across sites and based on salbutamol delivery by metered dose inhaler with spacer and oral prednisolone. In severe to critical asthma, differences between sites were common and related to recommendations for: ipratropium use; metered-dose inhaler versus nebulised delivery of salbutamol in severe asthma; use of intravenous aminophylline, intravenous magnesium and dosing of intravenous salbutamol in critical asthma. The questionnaire (78 of 83 doctors responded) also revealed significant differences between doctors in the treatment of moderate to severe asthma. Ipratropium was used for moderate asthma by 42%. For severe to critical asthma, nebulised delivery of salbutamol was preferred by 79% of doctors over metered dose inhalers. For critical asthma, doctors reported using intravenous aminophylline in 45%, intravenous magnesium in 55%, and intravenous salbutamol in 87% of cases. Thirty-nine different dosing regimens for intravenous salbutamol were reported. Conclusions: CPG recommendations and reported physician practice for mild to moderate paediatric asthma management were broadly similar across PREDICT sites and consistent with national guidelines. Practice was highly variable for severe to critical asthma and probably reflects limitations of available evidence. Areas of controversy, in particular the comparative efficacy of intravenous bronchodilators, would benefit from multi-centre trials. Collaborative development of CPGs should be considered.

Patterns of presentation to the Australian and New Zealand Paediatric Emergency Research Network

Objective:  To describe epidemiological data concerning paediatric ED visits to an Australian and New Zealand research network.

Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial.

BACKGROUND Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospital admission. Hydration is a mainstay of treatment, but insufficient evidence exists to guide clinical practice. We aimed to assess whether intravenous hydration or nasogastric hydration is better for treatment of infants. METHODS In this multicentre, open, randomised trial, we enrolled infants aged 2-12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons (April 1-Oct 31, in 2009, 2010, and 2011). We randomly allocated infants to nasogastric hydration or intravenous hydration by use of a computer-generated sequence and opaque sealed envelopes, with three randomly assigned block sizes and stratified by hospital site and age group (2-<6 months vs 6-12 months). The primary outcome was length of hospital stay, assessed in all randomly assigned infants. Secondary outcomes included rates of intensive-care unit admission, adverse events, and success of insertion. This trial is registered with the Australian and New Zealand clinical trials registry, ACTRN12605000033640. FINDINGS Mean length of stay for 381 infants assigned nasogastric hydration was 86·6 h (SD 58·9) compared with 82·2 h (58·8) for 378 infants assigned intravenous hydration (absolute difference 4·5 h [95% CI -3·9 to 12·9]; p=0·30). Rates of admission to intensive-care units, need for ventilatory support, and adverse events did not differ between groups. At randomisation, seven infants assigned nasogastric hydration were switched to intravenous hydration and 56 infants assigned intravenous hydration were switched to nasogastric hydration because the study-assigned method was unable to be inserted. For those infants who had data available for successful insertion, 275 (85%) of 323 infants in the nasogastric hydration group and 165 (56%) of 294 infants in the intravenous hydration group required only one attempt for successful insertion. INTERPRETATION Intravenous hydration and nasogastric hydration are appropriate means to hydrate infants with bronchiolitis. Nasogastric insertion might require fewer attempts and have a higher success rate of insertion than intravenous hydration. FUNDING Australian National Health and Medical Research Council, Samuel Nissen Charitable Foundation (Perpetual), Murdoch Childrens Research Institute, Victorian Government.

Procedural sedation in children in the emergency department: A PREDICT study

Objective:  To investigate current procedural sedation practice and compare clinical practice guidelines (CPG) for procedural sedation at Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites. This will determine areas for improvement and provide baseline data for future multicentre studies.

Emergency management of paediatric status epilepticus in Australia and New Zealand: practice patterns in the context of clinical practice guidelines.

Aims:  To establish current acute seizure management through a review of clinical practice guidelines (CPGs) and reported physician management in the 11 largest paediatric emergency departments in Australia (n= 9) and New Zealand (n= 2) within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, and to compare this with Advanced Paediatric Life Support (APLS) guidelines and existing evidence.

Failed Validation of the Argall Weight Formula for Estimating Children's Weight in an Australian Emergency Department

BACKGROUND An estimate of a childs weight is required for critical interventions, particularly pharmacotherapy. Weight measurement is not always practical, so weight estimation methods are used. Recently, a new weight estimation formula was suggested. The Argall formula estimates weight in kilograms as follows: (age in years + 2) x 3. OBJECTIVES To validate the Argall weight formula. METHODS This was a prospective, observational, cohort study conducted in the pediatric emergency department (ED) of Sunshine Hospital. Children aged up to 11 years who presented to the ED during August 18, 2005, to February 25, 2006, were included. Actual weight, height, age, and ethnicity were obtained. Data were analyzed by descriptive statistics (proportion, mean, median, and SD). Agreement between estimated weight using the Argall formula and measured weight is reported by using mean bias, SD, and root mean square error (RMSE) analysis. RESULTS Four hundred ten cases were included, 46% were female, and the median age was 4 years. The Argall formula had a mean bias of -1.66 kg and RMSE of 5.65. Only 37% of Argall estimates were within 10% of the childs actual weight. The formula performed less well in children weighing more than 35 kg but performed better in Asian children than white children. CONCLUSIONS The Argall weight estimation formula has poor accuracy for weight estimation in Australian children, in particular those weighing more than 35 kg.

Evaluation of a paediatric procedural sedation training and credentialing programme: sustainability of change

Introduction An ongoing comprehensive paediatric procedural sedation (PPS) training and credentialing programme to improve patient safety was introduced into emergency departments (EDs) at a tertiary childrens hospital (Royal Childrens Hospital; RCH) and a suburban mixed ED (Sunshine Hospital; SH) in Melbourne, Australia. The study aimed to establish whether changes in practice had been sustained 3 years after implementation of the PPS programme. Method 100 PPS episodes were identified at both hospitals (50 at each hospital) pre-implementation, 6 months and 3 years after implementation. This study retrospectively analysed 11 proxy markers of sedation safety by review of prospectively collected sedation records and medical records. Performance during the three time periods was compared using χ2 testing. Results Average age was 6 years and sedations were mainly for fracture reduction and laceration repair. Nitrous oxide and ketamine were the most commonly used agents. Midazolam use decreased over the study period. Six months after implementation at both hospitals relevant proxy markers of sedation safety were significantly improved over the pre-implementation level. Three years after implementation markers of sedation safety were still improved over pre-implementation levels. However, based on a minimum compliance with seven of 11 sedation safety markers both sites deteriorated; RCH from 96% to 80% (p=0.028) and SH from 68% to 32% (p=0.001). Conclusion Based on an analysis of proxy markers of sedation safety significant changes over pre-implemenation sedation care were maintained 3 years after implementation of a PPS programme. Documentation of sedation safety markers decreased over the study period, more so at the community hospital. To maintain educational gains and system change in sedation safety requires ongoing resources.

External validation of the Best Guess formulae for paediatric weight estimation.

Objective:  A new method for estimation of weight in children based on their age has been proposed. The present study aims to validate the Best Guess formulae in a new population of children.