Quynh Doan

A Randomized, Controlled Trial of the Impact of Early and Rapid Diagnosis of Viral Infections in Children Brought to an Emergency Department with Febrile Respiratory Tract Illnesses

OBJECTIVES Acute respiratory tract infections represent a significant burden on pediatric emergency departments (ED) and families. We hypothesized that early and rapid diagnosis of a viral infection alleviates the need for ancillary testing and antibiotic treatment. STUDY DESIGN We conducted a randomized, controlled trial of children 3 to 36 months of age with febrile acute respiratory tract infections at a pediatric ED. Two hundred four subjects were randomly assigned to receive rapid respiratory viral testing on admission or a routine ED admission protocol. Outcome measures were: mean length of visits, rate of ancillary tests, and antibiotic prescription in the ED. A follow-up call was made to all study subjects to inquire about further healthcare visits, ancillary testing, and antibiotic prescription after ED discharge. RESULTS We did not find a statistically significant difference in ED length of visits, rate of ancillary testing, or antibiotic prescription rate in the ED between the study groups. There was, however, a significant reduction in antibiotic prescription after ED discharge (in the group who had rapid viral testing RR = 0.36; 95% CI = 0.14, 0.95). CONCLUSIONS Rapid multi-viral testing in the ED did not significantly affect ED patient treatment but may reduce antibiotic prescription in the community after discharge from the ED, suggesting a novel strategy to alter community physician antibiotic prescription patterns.

Performance of the Canadian Triage and Acuity Scale for children: A multicenter database study

STUDY OBJECTIVE We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs). METHODS This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category. RESULTS A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay. CONCLUSION The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.

Prospective Assessment of Practice Pattern Variations in the Treatment of Pediatric Gastroenteritis

OBJECTIVES: We aimed to determine whether significant variations in the use of intravenous rehydration existed among institutions, controlling for clinical variables, and to assess variations in the use of ancillary therapeutic and diagnostic modalities. METHODS: We conducted a prospective cohort study of children 3 to 48 months of age who presented to 11 emergency departments with acute gastroenteritis, using surveys, medical record reviews, and telephone follow-up evaluations. RESULTS: A total of 647 eligible children were enrolled and underwent chart review; 69% (446 of 647 children) participated in the survey, and 89% of survey participants (398 of 446 children) had complete follow-up data. Twenty-three percent (149 of 647 children) received intravenous rehydration (range: 6%–66%; P < .001) and 13% (81 of 647 children) received ondansetron (range: 0%–38%; P < .001). Children who received intravenous rehydration had lower Canadian Triage Acuity Scale scores at presentation (3.1 ± 0.5 vs 3.5 ± 0.5; P < .0001). Regression analysis revealed that the greatest predictor of intravenous rehydration was institution location (odds ratio: 3.0 [95% confidence interval: 1.8–5.0]). Children who received intravenous rehydration at the index visit were more likely to have an unscheduled follow-up health care provider visit (29% vs 19%; P = .05) and to revisit an emergency department (20% vs 9%; P = .002). CONCLUSIONS: In this cohort, intravenous rehydration and ondansetron use varied dramatically. Use of intravenous rehydration at the index visit was significantly associated with the institution providing care and was not associated with a reduction in the need for follow-up care.

Cost-effectiveness of Metered-Dose Inhalers for Asthma Exacerbations in the Pediatric Emergency Department

OBJECTIVE: To compare the incremental cost and effects (averted admission) of using a metered-dose inhaler (MDI) against wet nebulization to deliver bronchodilators for the treatment of mild to moderately severe asthma in pediatric emergency departments (EDs). METHODS: We measured the incremental cost-effectiveness from the perspective of the hospital, by creating a model using outcome characteristics from a Cochrane systematic review comparing the efficacy of using MDIs versus nebulizers for the delivery of albuterol to children presenting to the ED with asthma. Cost data were obtained from hospitals and regional authorities. We determined the incremental cost-effectiveness ratio and performed probabilistic sensitivity analyses using Monte Carlo simulations. RESULTS: Using MDIs in the ED instead of wet nebulization may result in net savings of Can

Trends in Pediatric Emergency Department Utilization for Mental Health-Related Visits

154.95 per patient. Our model revealed that using MDIs in the ED is a dominant strategy, one that is more effective and less costly than wet nebulization. Probabilistic sensitivity analyses revealed that 98% of the 10 000 iterations resulted in a negative incremental cost-effectiveness ratio. Sensitivity analyses around the costs revealed that MDI would remain a dominant strategy (90% of 10 000 iterations) even if the net cost of delivering bronchodilators by MDI was Can

A presurvey and postsurvey of a web- and simulation-based course of ultrasound-guided nerve blocks for pediatric emergency medicine.

70 more expensive than that of nebulized bronchodilators. CONCLUSIONS: Use of MDIs with spacers in place of wet nebulizers to deliver albuterol to treat children with mild-to-moderate asthma exacerbations in the ED could yield significant cost savings for hospitals and, by extension, to both the health care system and families of children with asthma.

Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions.

OBJECTIVE To describe trends in utilization of pediatric emergency department (PED) resources by patients with mental health concerns over the past 11 [corrected] years at a tertiary care hospital. STUDY DESIGN We conducted a retrospective cohort study of tertiary PED visits from 2002 [corrected] to 2012. All visits with chief complaint or discharge diagnosis related to mental health were included. Variables analyzed included number and acuity of mental health-related visits, length of stay, waiting time, admission rate, and return visits, relative to non-mental health [corrected] PED visits. Descriptive statistics were used to summarize the results. RESULTS We observed a 47% increase in the number of mental health presentations compared with a 27.5% [corrected] increase in the number of total visits to the PED over the study period. Return visits represented a significant proportion of all mental health-related visits (32.2% [corrected] yearly). The proportion of mental health visits triaged to a high acuity level has decreased whereas the proportion of visits triaged to the mid-acuity level has increased. Length of stay for psychiatric patients was significantly longer than for visits to the PED in general. We also observed a 53.7% [corrected] increase in the number of mental health-related visits resulting in admission. CONCLUSION Mental health-related visits represent a significant and growing burden for the emergency department at a tertiary care PED. These results highlight the need to reassess the allocation of health resources to optimize acute management, risk assessment, and linkage to mental health services upon disposition from the PED.

The role of physician assistants in a pediatric emergency department: a center review and survey.

Objectives Fracture pain in the pediatric emergency department generally is treated with systemic analgesia using opioids. Fracture pain can alternatively be controlled with ultrasound (U/S)–guided nerve blocks for which only minimal training is available to pediatric emergency medicine physicians. This study evaluated the effects of a Web- and half-day simulation-based U/S course. Outcome measures were physician comfort level with and intention to use U/S-guided nerve blocks in clinical practice. Methods We conducted a presurvey and postsurvey study targeting pediatric emergency medicine physicians. Participants completed a Web-based tutorial and a half-day simulation program. Participants completed survey questionnaires to document their comfort level and intention to use U/S-guided nerve blocks. Questionnaires were completed before, immediately after, and 1 month after course. Results Eleven physicians participated in the study. The participants’ comfort with and intention to use U/S-guided ulnar and femoral nerve blocks increased immediately after course, but neither increase was sustained 1 month after course. Immediately following the course, participants reported that the course addressed their learning needs (91%) and that they would consider advanced training (91%). One month after course, participants reported that they would partake in refresher courses (82%), particularly if offered once per year (64%). Conclusions This study suggests that Web- and simulation-based learning can increase comfort and intention to use U/S-guided nerve blocks and the need for follow-on training. Participants reported that their learning needs were met but that they would need annual refresher courses.

Trends in use in a Canadian pediatric emergency department.

AIM The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest. METHODS We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate. RESULTS We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p<0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p<0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p<0.001). CONCLUSION The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

Body mass index and the odds of acute injury in children

Objectives The objectives of this study were to outline the clinical conditions presenting to a Canadian pediatric emergency department (ED), survey the opinions of physician assistants (PAs) and emergency pediatricians to determine which conditions they consider could be managed by PAs, and to estimate the proportion of the total pediatric ED volume that PAs could potentially manage. Methods We reviewed the 2007 British Columbia Children’s Hospital database of ED visits to identify clinical presentation and chief complaint of all patients seen. International Classification of Diseases, 10th Revision codes were used to categorize the presenting complaint of each ED visit. Following categorization, the results were discussed by a focus group composed of pediatric emergency medicine–trained physicians and PAs, to review the list of chief complaints. We then surveyed via e-mailed questionnaire a group of emergency pediatricians (n = 17) and PAs (n = 5) to seek their opinion on the categories of clinical presentation appropriate for PA management. Results Of 38,722 visits, 9.2% were triaged as “resuscitation” or “emergent.” We sorted the remaining 35,077 ED visits into 57 clinical categories. More than 85% of respondents selected 30 clinical categories for PA management with physician supervision, representing 74% of the total ED volume. Of these, 3 were also deemed appropriate for PA management without direct physician supervision. There were statistically significant differences in mean length of stay, waiting time, and admission rates between the clinical conditions selected for PA involvement. However, the difference in waiting time was not clinically meaningful. Conclusions A large proportion of pediatric ED visits are designated as semiurgent or nonurgent. Clinicians (ED physicians and PAs) thought that the majority of these ED visits could be managed by PAs.