Sarah Reid

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems. Methods We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number. Results Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001). Conclusions Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.

Use of personal protective equipment in Canadian pediatric emergency departments.

OBJECTIVE Numerous barriers to maintaining infection control practices through the use of personal protective equipment (PPE) exist in the emergency department (ED). This study examined the knowledge, self-reported behaviours, and barriers to compliance with infection control practices and the use of PPE in Canadian pediatric EDs. METHODS A self-administered survey instrument consisting of 21 questions was developed and piloted for this study. The survey was mailed to all individuals listed in the Pediatric Emergency Research Canada database of physicians practicing pediatric emergency medicine in Canada. RESULTS A total of 186 physicians were surveyed, and 123 (66%) participated. Twenty-two percent of participants reported that they had never received PPE training and 32% had not been trained in the previous 2 years. Fifty-three percent reported being very or somewhat comfortable with their knowledge of transmission-based isolation practices. Participants were correct on a mean of 4.9 of 11 knowledge-based questions (SD 1.7). For scenarios assessing self-reported use of PPE, participants selected answers that reflected PPE use in accordance with national infection control standards in a mean of 1.0 of 6 scenarios (SD 1.0). Participants reported that they would be more likely to use PPE if patients were clearly identified prior to physician assessment, equipment was accessible, and PPE use was made a priority in their ED. CONCLUSIONS Knowledge and self-reported adherence to recommended infection control practices among Canadian pediatric emergency physicians is suboptimal. Early identification of patients requiring PPE, convenient access to PPE, and improved education regarding isolation and PPE practices may improve adherence.

Use of single-dose activated charcoal among Canadian pediatric emergency physicians.

Objective: Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency department (ED) treatment of ingestions. Guidelines updated in 2005 encourage practitioners to use SDAC only in toxic ingestions presenting within 1 hour. Despite these guidelines, adult studies demonstrate a significant lack of consensus. This study examined the proposed use of SDAC for gastric decontamination in common pediatric ingestion scenarios by emergency physicians working in Canadian pediatric EDs. Methods: A standardized survey consisting of 5 clinical scenarios was mailed to all physicians with a primary clinical appointment to the ED at 9 Canadian childrens hospitals. Results: One hundred thirty-one physicians were surveyed, and 95 (72%) responded. The majority of respondents were pediatricians (68.1%) with a mean of 15.0 years of experience (SD, 6.8 years). Of those surveyed; 91 (97.8%) would use SDAC for a toxic ingestion presenting in less than 1 hour; 35 (36.8%) would use SDAC for a toxic ingestion presenting after 3 hours; 61 (64.9%) would use SDAC for a nontoxic exploratory ingestion presenting in less than 1 hour; and 29 (30.5%) would use SDAC for a mildly symptomatic intentional ingestion presenting at an unknown time. Eleven (11.7%) would use SDAC for an ingestion of a substance that does not adsorb to SDAC. Conclusions: There is variation in the use of SDAC among emergency physicians working in Canadian pediatric EDs. This variation suggests that optimal management is not clear and that continued education and research are required.

Education in the Waiting Room: Description of a Pediatric Emergency Department Educational Initiative

Objective The aim of this study was to understand parents’ awareness of and reactions to a slide presentation based waiting-room educational initiative. Methods This was a prospective observational study at a Canadian tertiary-care pediatric emergency department (ED) with an annual census of 68,000 visits. An anonymous parental survey was developed de novo, and parents were asked to complete the survey during their low-acuity ED visit over a 2-week study period. Descriptive statistics were used to describe responses and themes. Results Parents completed 520 surveys (733 approached, 70.9% response rate). Eighty-three percent of respondents had previously sought care in the ED. Most parents (68.9%) were aware of the slide presentation, but only 33.7% were able to watch it in its entirety (20 minutes’ duration). Of those who watched the whole presentation, 62.9% understood that lower-acuity cases are assessed in the ambulatory zone of the ED, and sicker children are assessed in the acute zone (89.4%), 79.9% felt the presentation helped them to understand how the ambulatory zone functions, and 83.2% appreciated the current wait-time information. General questions about common health concerns were answered correctly in 58.3% (fever), 56.0% (gastroenteritis), 50.5% (abdominal pain/constipation), 35.7% (earache), and 17.0% (head injury). Conclusions The majority of parents were aware of this waiting-room educational initiative, but there was variable uptake of information. Parents watching the entire presentation appreciated the information provided, especially wait-time information, and felt it improved their experience. Knowledge of common health conditions was low; novel methods of knowledge transfer must be utilized and evaluated.

Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children

Introduction Rest until symptom-free, followed by a progressive stepwise return to activities, is often prescribed in the management of paediatric concussions. Recent evidence suggests prolonged rest may hinder recovery, and early resumption of physical activity may be associated with more rapid recovery postconcussion. The primary objective is to determine whether the early reintroduction of non-contact physical activity beginning 72 hours postinjury reduces postconcussive symptoms at 2 weeks in children following an acute concussion as compared with a rest until asymptomatic protocol. Methods and analysis This study is a randomised clinical trial across three Canadian academic paediatric emergency departments. A total of 350 participants, aged 10–17.99 years, who present within 48 hours of an acute concussion, will be recruited and randomly assigned to either the study intervention protocol (resumption of physical activity 72 hours postconcussion even if experiencing symptoms) or physical rest until fully asymptomatic. Participants will document their daily physical and cognitive activities. Follow-up questionnaires will be completed at 1, 2 and 4 weeks postinjury. Compliance with the intervention will be measured using an accelerometer (24 hours/day for 14 days). Symptoms will be measured using the validated Health and Behaviour Inventory. A linear multivariable model, adjusting for site and prognostically important covariates, will be tested to determine differences between groups. The proposed protocol adheres to the RCT-CONSORT guidelines. Discussion This trial will determine if early resumption of non-contact physical activity following concussion reduces the burden of concussion and will provide healthcare professionals with the evidence by which to recommend the best timing of reintroducing physical activities. Trial registration number Trial identifier (Clinicaltrials.gov) NCT02893969.

A nurse-initiated jaundice management protocol improves quality of care in the paediatric emergency department

Background Hyperbilirubinemia is a common neonatal condition requiring timely management to prevent acute bilirubin encephalopathy. Management protocols allow nonphysicians to initiate designated actions prior to physician assessment. Objective To assess the effectiveness of a nurse-initiated neonatal jaundice management protocol for serum bilirubin sampling and phototherapy for neonates presenting with hyperbilirubinemia to the Paediatric Emergency Department (PED). Methods A health records review was performed for jaundiced neonates 12 months prior to the introduction of the management protocol (control period) and 12 months after (intervention period). Randomly selected charts were evaluated for time to serum bilirubin sampling, phototherapy initiation, ED length of stay, admission rate, completion of direct antiglobulin test and nursing documentation. Results Two hundred and sixty-six neonates (131 control and 135 intervention) were included. Median time to serum bilirubin sampling was reduced by 22% (36 min versus 28 min; P<0.001) with 34 min difference at the 90th percentile (94 min [95% confidence interval (CI) 63.7 to 116.9] versus 60 min [95% CI 49.0 to 78.2]). Statistically significant improvements were found in time to phototherapy initiation (127 min [95% CI 72.0 to 160.7] versus 65 min [95% CI 50.0 to 72.4] at 90th percentile), ED length of stay (267 min [95% CI 180.9 to 292.9] versus 216 min [95% CI 171.1 to 247.4] at 90th percentile) and hospital admissions (36% versus 17%; P<0.001). Improvements were also observed in direct antiglobulin test measurement (P<0.001) and nursing documentation (P=0.017). Conclusions Implementation of a PED neonatal jaundice management protocol was associated with improved timeliness and standardization of care for this common and important condition.