Serge Gouin

Epinephrine and Dexamethasone in Children with Bronchiolitis

BACKGROUND Although numerous studies have explored the benefit of using nebulized epinephrine or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established. METHODS We conducted a multicenter, double-blind, placebo-controlled trial in which 800 infants (6 weeks to 12 months of age) with bronchiolitis who were seen in the pediatric emergency department were randomly assigned to one of four study groups. One group received two treatments of nebulized epinephrine (3 ml of epinephrine in a 1:1000 solution per treatment) and a total of six oral doses of dexamethasone (1.0 mg per kilogram of body weight in the emergency department and 0.6 mg per kilogram for an additional 5 days) (the epinephrine-dexamethasone group), the second group received nebulized epinephrine and oral placebo (the epinephrine group), the third received nebulized placebo and oral dexamethasone (the dexamethasone group), and the fourth received nebulized placebo and oral placebo (the placebo group). The primary outcome was hospital admission within 7 days after the day of enrollment (the initial visit to the emergency department). RESULTS Baseline clinical characteristics were similar among the four groups. By the seventh day, 34 infants (17.1%) in the epinephrine-dexamethasone group, 47 (23.7%) in the epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the placebo group had been admitted to the hospital. In the unadjusted analysis, only the infants in the epinephrine-dexamethasone group were significantly less likely than those in the placebo group to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 to 0.95, P=0.02). However, with adjustment for multiple comparisons, this result was rendered insignificant (P=0.07). There were no serious adverse events. CONCLUSIONS Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions. (Current Controlled Trials number, ISRCTN56745572.)

Practice Variations in the Treatment of Febrile Infants Among Pediatric Emergency Physicians

OBJECTIVES: The objectives of this study were to characterize variations in treatment decisions for young febrile infants in pediatric emergency departments across Canada and to document the extent of practice variations among pediatric emergency department practitioners. METHODS: This was a prospective, concurrent, cohort study of consecutive infants up to 90 days of age who presented to 6 pediatric emergency departments in Canada with fever (rectal temperature of ≥38.0°C). We recorded information in the emergency department and contacted the families by telephone to confirm the final disposition. RESULTS: A total of 257 infants were recruited over 2 to 4 months. Patients were similar across centers in terms of gestational age and weight, chronologic age at arrival, weight, and gender. Temperatures measured at home and during triage and durations of fever also were similar among centers. In one center, significantly more children arrived with cough; in another center, fewer parents reported sick contacts at home. Rates of blood and urine testing were not significantly different across sites, but rates of lumbar puncture, respiratory virus testing, and chest radiography were different. A total of 55% of infants received antibiotics, and significant practice variations in the numbers and types of antibiotics used were documented. CONCLUSIONS: Practices in the evaluation of young infants with fever in tertiary pediatric emergency departments varied substantially. Blood and urine tests were ordered in the majority of centers, but rates of cerebrospinal fluid testing and antibiotic treatment differed across centers.

Effect of a Pediatric Observation Unit on the Rate of Hospitalization for Asthma

STUDY OBJECTIVE To determine the asthma admission rate and the rate of repeat visits to the emergency department for asthma within 72 hours before and after the introduction of an observation unit (OU). When necessary, admission to the ward from the OU is usually made within 12 hours. METHODS We conducted a before-and-after study with retrospective data collection in an urban tertiary care pediatric ED. Our subjects were patients aged 1 to 18 years who presented to the ED with asthma. The pre-OU group comprised patients seen between July 1, 1991, and June 30, 1992, before the opening of the OU. The post-OU group consisted of children seen between July 1, 1993, and June 30, 1994, after the opening of the OU. RESULTS The pre- and post-OU groups had 1,979 and 2,248 asthma visits, respectively. The admission rate decreased from 31% in the pre-OU group to 24% in the post-OU group (P < .01). The frequency of inpatient admissions of less than 24 hours decreased from 17% in the pre-OU group to 10% in the post-OU group (P < or = 01). The rate of repeat ED visits within 72 hours was 3% in the pre-OU group and 5% in the post-OU group (P = .01). CONCLUSION The use of an OU in the ED was associated with a reduction in the hospitalization rate for children with acute asthma exacerbation. However, we also noted an increased rate of repeat visits to the ED after the introduction of the OU.

Agreement among Pediatric health care professionals With the Pediatric Canadian Triage and Acuity Scale guidelines

Objectives: To compare triage level assignment, using case scenarios, in a pediatric emergency department between registered nurses (RNs) and pediatric emergency physicians (PEPs) based on the Pediatric Canadian Triage and Acuity Scale (P-CTAS) guidelines. To compare triage level assignment of the RNs and PEPs to that done by a panel of experts using the same P-CTAS guidelines. Methods: A cross-sectional questionnaire survey (55 case scenarios) was sent to all RNs and PEPs working in the emergency department after the P-CTAS was implemented. Participants were instructed to assign a triage level for each case. A priori, all cases were assigned a triage level by a panel of experts using the P-CTAS guidelines. Kappa statistics and the mean number (±1SD) of correct responses were calculated. Results: A response rate of 85% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (95% CI) among RNs was 0.51 (0.50-0.52) and was 0.39 (0.38-0.41) among PEPs (P < 0.001). The mean number of correct responses (±1SD) for RNs was 64% ± 27% and for PEPs 60% ± 22% (P = 0.31). Levels of agreement did not vary according to experience or type of shift work done or work status of RNs and PEPs. Conclusions: With the introduction of the P-CTAS, the level of agreement and accuracy of triage categorization remained moderate for both RNs and PEPs. The reliability of the P-CTAS needs to be further assessed and the requirements for revisions considered prior to its widespread use.

Treatment of Children With Migraine in Emergency Departments: National Practice Variation Study

OBJECTIVE: Children with migraine may present to an emergency department (ED) when outpatient management has failed; however, only limited research has examined migraine-abortive medications among children. METHODS: A retrospective chart review of ED presentations for migraine or headache between July 1, 2004, and June 30, 2005, in 10 Canadian pediatric EDs was conducted. A priori, evidence-based treatments were defined as any treatment that was based on high-quality evidence and an absence of opioids as first-line agents. RESULTS: A total of 2515 records were screened, and 1694 (67.4%) met inclusion criteria. The average age of patients was 12.1 years, 14.5% (95% confidence interval [CI]: 12.1%–17.2%) of patients experienced headache >15 days per month, and 62.6% (95% CI: 55.7%–68.9%) had already used migraine-abortive therapy. Significant variations in practice for all classes of migraine-abortive medications were observed. Dopamine receptor antagonists (prochlorperazine, metoclopramide, or chlorpromazine) (39% [95% CI: 28.4%–50.8%]) and orally administered analgesics (acetaminophen and ibuprofen) (24.5% [95% CI: 23.9%–46.8%]) were prescribed most commonly. Predictors for the use of evidence-based treatment included older age (odds ratio: 1.15 [95% CI: 1.07–1.24]) and a discharge diagnosis of migraine (odds ratio: 1.84 [95% CI: 1.11–3.05]). CONCLUSIONS: Children presenting to EDs for treatment often have frequent attacks and have experienced failure of outpatient, migraine-abortive efforts. Practice variations were impressive for the care of children with migraine in these Canadian EDs.

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.

The Canadian Triage and Acuity Scale for Children: A Prospective Multicenter Evaluation

STUDY OBJECTIVE The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity. METHODS This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED. RESULTS A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay. CONCLUSION The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.

Prospective evaluation of two clinical scores for acute asthma in children 18 months to 7 years of age.

OBJECTIVES The objective was to evaluate the discriminatory ability of two clinical asthma scores, the Preschool Respiratory Assessment Measure (PRAM) and the Pediatric Asthma Severity Score (PASS), during an asthma exacerbation. METHODS This was a prospective cohort study in an academic pediatric emergency department (ED; 60,000 visits/year) conducted from March 2006 to October 2007. All patients 18 months to 7 years of age who presented for an asthma exacerbation were eligible. The primary outcome was a length of stay (LOS) of >6 hours in the ED or admission to the hospital. Clinical findings and components of the PRAM and the PASS were assessed by a respiratory therapist (RT) at the start of the ED visit and after 90 minutes of treatment. RESULTS During the study period, 3,845 patients were seen in the ED for an asthma exacerbation. Of these, 291 were approached to participate, and eight refused. Moderate levels of discrimination were found between a LOS of >6 hours and/or admission and PRAM (area under the receiver-operating characteristic curve [AUC] = 0.69, 95% confidence interval [CI] = 0.59 to 0.79) and PASS (AUC = 0.70, 95% CI = 0.60 to 0.80) as calculated at the start of the ED visit. Significant similar correlations were seen between the physicians judgment of severity and PRAM (r = 0.54, 95% CI = 0.42 to 0.65) and PASS (r = 0.55, 95% CI = 0.43 to 0.65). CONCLUSIONS The PRAM and PASS clinical asthma scores appear to be measures of asthma severity in children with discriminative properties.

Interrater Agreement between Nurses for the Pediatric Canadian Triage and Acuity Scale in a Tertiary Care Center

OBJECTIVES The objective was to measure the interrater agreement between nurses assigning triage levels to children visiting a pediatric emergency departments (EDs) assisted by a computerized version of the Pediatric Canadian Triage and Acuity Scale (PedCTAS). METHODS This was a prospective cohort study evaluating children triaged from Level 2 (emergent) to Level 5 (nonurgent). A convenience sample of patients triaged during 38 shifts from April to September 2007 in a tertiary care pediatric ED was evaluated. All patients were initially triaged by regular triage nurses using a computerized version of the PedCTAS. Research nurses performed a second evaluation blinded to the first evaluation using the same triage tool. These research nurses were regular ED nurses performing extra hours for research purposes exclusively. The primary outcome measure was the interrater agreement between the two nurses as measured by the linear weighted kappa score. Secondary outcomes included the proportion of patient for which nurses did not apply the triage level suggested by Staturg (override) and agreement for these overrides. RESULTS A total of 499 patients were recruited. The overall interrater agreement was moderate (linear weighted kappa score of 0.55 [95% confidence interval {CI} = 0.48 to 0.61] and quadratic weighted kappa score of 0.61 [95% CI = 0.42 to 0.80]). There was a discrepancy of more than one level in only 10 patients (2% of the study population). Overrides occurred in 23.2 and 21.8% for regular and research triage nurses, respectively. These overrides were equally distributed between increase and decrease in triage level. CONCLUSIONS Nurses using Staturg, which is a computerized version of the PedCTAS, demonstrated moderate interrater agreement for assignment of triage level to children presenting to a pediatric ED.