Robert Porter

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.

Efficacy of computer-assisted instruction in the continuing education of paramedics

STUDY OBJECTIVE To determine the relative effectiveness of lecture, video, and computer-assisted instruction (CAI) for the continuing education of paramedics. DESIGN The study was a statewide, cross-sectional, and prospective. It used premethod, post method and 60-day evaluations addressing both cognitive knowledge and attitude toward the method. Subjects were required to complete a 20-question cognitive examination and a ten-point satisfaction inventory. Each study site was randomly assigned a method by a computer-generated table. SETTING The study involved 11 sites, systematically distributed throughout Michigan. TYPE OF PARTICIPANTS 111 Michigan licensed paramedics. RESULTS CAI subjects scored an average of 79.6% on the post-test, while lecture and video subjects scored 70.5% and 68.9%, respectively. At 60 days, CAI subjects scored 70.9%, while lecture and video subjects averaged 59.4 and 59.1, respectively. The difference among the scores was significant post method (P = .01) and at 60 days (P = .02). The subject method preference was lecture, video, and CAI premethod; lecture, CAI, and video immediately post method; and lecture, CAI, and video at 60 days. CONCLUSION Although lecture was the preferred method, CAI was best able to impart knowledge and enhance participant knowledge retention.

Magnesium Use in Asthma Pharmacotherapy: A Pediatric Emergency Research Canada Study

OBJECTIVES: To examine the use of intravenous magnesium in Canadian pediatric emergency departments (EDs) in children requiring hospitalization for acute asthma and association of administration of frequent albuterol/ipratropium and timely corticosteroids with hospitalization. METHODS: Retrospective medical record review at 6 EDs of otherwise healthy children 2 to 17 years of age with acute asthma. Data were extracted on history, disease severity, and timing of ED stabilization treatments with inhaled albuterol, ipratropium, corticosteroids, and magnesium. Primary outcome was the proportion of hospitalized children given magnesium in the ED. Secondary outcome was the ED use of “intensive therapy” in hospitalized children, defined as 3 albuterol inhalations with ipratropium and corticosteroids within 1 hour of triage. RESULTS: A total of 19 (12.3%) of 154 hospitalized children received magnesium (95% confidence interval 7.1, 17.5) versus 2 of 962 discharged patients. Children given magnesium were more likely to have been previously admitted to ICU (odds ratio [OR] 11.2), hospitalized within the past year (OR 3.8), received corticosteroids before arrival (OR 4.0), presented with severe exacerbation (OR 6.1), and to have been treated at 1 particular center (OR 14.9). Forty-two (53%) of 90 hospitalized children were not given “intensive therapy.” Children receiving “intensive therapy” were more likely to present with severe disease to EDs by using asthma guidelines (ORs 8.9, 3.0). Differences in the frequencies of all stabilization treatments were significant across centers. CONCLUSIONS: Magnesium is used infrequently in Canadian pediatric EDs in acute asthma requiring hospitalization. Many of these children also do not receive frequent albuterol and ipratropium, or early corticosteroids. Significant variability in the use of these interventions was detected.

Developing Measures of Quality for the Emergency Department Management of Pediatric Suicide-Related Behaviors

Objective Given the public health importance of suicide-related behaviors and the corresponding gap in the performance measurement literature, we sought to identify key candidate process indicators (quality of care measures) and structural measures (organizational resources and attributes) important for emergency department (ED) management of pediatric suicide-related behaviors. Methods We reviewed nationally endorsed guidelines and published research to establish an inventory of measures. Next, we surveyed expert pediatric ED clinicians to assess the level of agreement on the relevance (to patient care) and variability (across hospitals) of 42 candidate process indicators and whether 10 hospital and regional structural measures might impact these processes. Results Twenty-three clinicians from 14 pediatric tertiary-care hospitals responded (93% of hospitals contacted). Candidate process indicators identified as both most relevant to patient care (≥87% agreed or strongly agreed) and most variable across hospitals (≥78% agreed or strongly agreed) were wait time for medical assessment; referral to crisis intervention worker/program; mental health, psychosocial, or risk assessment requested; any inpatient admission; psychiatric inpatient admission; postdischarge treatment plan; wait time for first follow-up appointment; follow-up obtained; and type of follow-up obtained. Key hospital and regional structural measures (≥87% agreed or strongly agreed) were specialist staffing and type of specialist staffing in or available to the ED; regional policies, protocols, or procedures; and inpatient psychiatric services. Conclusions This study highlighted candidate performance measures for the ED management of pediatric suicide-related behaviors. The 9 candidate process indicators (covering triage, assessment, admission, discharge, and follow-up) and 4 hospital and regional structural measures merit further development.