Understanding factors influencing sustainability and sustainment of evidence-based bronchiolitis management of infants in Australian and New Zealand hospital settings: a qualitative process evaluation.

BackgroundUnderstanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals.MethodsA mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome; composite score); and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework.DiscussionThis study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care.Trial registrationAustralian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

In 2017, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network conducted a cluster randomised controlled trial (cRCT) at 26 Australian and New Zealand hospitals to improve bronchiolitis care. Findings demonstrated that targeted interventions significantly improved adherence with five evidence-based low-value bronchiolitis practices (no chest radiography, salbutamol, glucocorticoids, antibiotics and epinephrine) in the first 24 hours of hospitalisation (adjusted risk difference, 14.1%; 95% CI: 6.5% to 21.7%; p<0.001). During the intervention year (2017), intervention hospital (n=13) compliance was 85.1% (95% CI: 82.6% to 89.7%). This study aimed to determine if improvements in bronchiolitis management were sustained at intervention hospitals 2 years post-trial completion. International, multicentre follow-up study of hospitals in Australia and New Zealand that participated in a cRCT of de-implementation of low-value bronchiolitis practices, 1 year (2018) and 2 years (2019) post-trial completion, obtained retrospectively from medical audits. Sustainability was defined a priori as no more than a <7% decrease to any level of improvement in adherence for all five low-value practices (composite outcome) from the cRCT intervention year. Of the 26 hospitals, 11 intervention and 10 control hospitals agreed to participate in the follow-up study. Data were collected on 3299 infants with bronchiolitis 1 year (intervention and control hospitals) and 1689 infants 2 years post-trial (intervention hospitals). Adherence with no use of the five low-value practices 2 years post-trial completion was 80.9% (adjusted predicted adherence, 80.8%, 95% CI: 77.4% to 84.2%; estimated risk difference from cRCT outcome -3.9%, 95% CI: -8.6% to 0.8%) at intervention hospitals, fulfilling the a priori definition of sustainability. Targeted interventions, delivered over one bronchiolitis season, resulted in sustained improvements in bronchiolitis management in infants 2 years later. This follow-up study provides evidence for sustainability in de-implementing low-value care in bronchiolitis management. Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

BackgroundThe Paediatric Research in Emergency Departments International Collaborative (PREDICT) performs multicentre research in Australia and New Zealand. Research priorities are difficult to determine, often relying on individual interests or prior...

The Paediatric Research in Emergency Departments International Collaborative (PREDICT) has operated as an emergency research network in Australia and Aotearoa New Zealand for 20 years. A focus on both knowledge generation and, over the last decade, knowledge translation research has produced more than 200 network publications. Active research sites have increased from the original 12 sites to 47, with enhanced representation of where children with acute illness present in both countries. We outline ongoing challenges across the network, which will be relevant for those providing acute paediatric care and to other emergency clinicians interested in multicentre research collaboration.

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 children's 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.

Supraglottic airway devices (SGAs) are used in airway management to provide non-invasive ventilation and oxygenation. SGAs can be used as rescue tools in failed endotracheal intubation, difficult bag-mask ventilation, or as a bridge to intubation in cardiac arrest. The aim of this study was to describe the frequency of SGA use in children in emergency departments (EDs) across Australia and New Zealand and indications for their use. We conducted a retrospective observational study using paediatric data from the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) to describe the frequency of SGA use in children aged 0-18 years at Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites over an 11-year period. Additionally, we surveyed 20 PREDICT sites to identify which SGA were used and describe their positions in their emergency airway management protocols and received 11 responses. SGAs were used during 14 out of 403 paediatric intubations (3.5%) across 12 PREDICT sites. The overall first pass success rate for intubation was 81.05% (325/401). SGAs were used prior to intubation in 14 cases, and as a rescue device following unsuccessful intubation in one case. Among the surveyed PREDICT EDs, 8 out of 11 (72%) reported having a difficult airway plan that included SGAs as a rescue device following unsuccessful intubation. SGAs were used infrequently during emergency airway management outside of the operating room. SGA use as a rescue device following unsuccessful intubation was rare, despite their inclusion in most departments' difficult airway plan. Australia and New Zealand Clinical Trials Registry: ACTRN12613001052729.

Clinical debriefing (CD) in emergency medicine improves team performance and patient care outcomes. Its use in Australian and New Zealand paediatric emergency departments (PED) was first described in 2009. We aimed to delineate changes in CD over 15 years and explore the barriers and enablers. An electronic survey was distributed to members of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network to explore their CD experiences and opinions of CD in PED. Between February and March 2023, 170 PREDICT members were emailed the survey link with 48 surveys returned (return rate 28%). The respondents were senior doctors (33/48 (68.8%)), junior doctors (5/48 (10.4%)) or nurses/nurse practitioners (7/48 (14.6%)). Thirty respondents (63.8%) had more than 15 years of clinical experience, and 23 (47.9%) worked in tertiary paediatric hospitals. In the preceding year, 36/45 (80%) had participated in at least one debrief immediately following an event, and 27/45 (60%) at a scheduled debrief. Sixteen of 40 respondents (40%) used a department-specific debriefing tool. Resuscitation team leaders facilitated most CDs (27/40 (67.5%)) with 12 clinicians having prior facilitator training. Education, quality and service improvement, and psychological debriefing were reported as important objectives. Leadership and psychological safety were enablers, whereas departmental pressures and lack of training were major barriers. We demonstrated that CD implementation in paediatric EDs has increased over 15 years while individual clinician participation was infrequent. Key enablers were leadership, psychological safety, and promoting a debriefing culture. Facilitation training opportunities were identified as a need.

BackgroundHead injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting.Methods/designThis study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria.DiscussionThis study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting.Trial registrationThe study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)-ACTRN12614000463673 (registered 2 May 2014).

To describe epidemiological data concerning paediatric ED visits to an Australian and New Zealand research network. We conducted a cross-sectional study of paediatric ED visits to all Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites in 2004. Epidemiological data, including demographics, admission rates and diagnostic grouping, were examined and analysed using descriptive and comparative statistical methods. We compared the data, if possible, with published data from a US paediatric emergency research network (Pediatric Emergency Care Applied Research Network). A total of 351 440 ED presentations were analysed from 11 PREDICT sites. Mean patient age was 4.6 years and 55% were boys. Presentations were identified as 3% Aboriginal at Australian sites and 44% Maori/Pacific in New Zealand locations. According to Australasian Triage Scale (ATS), 5% were ATS 1 or 2 (to be seen immediately or within 10 min), 27% ATS 3 (to be seen within 30 min) and 67% ATS 4 or 5. Although ED visits peaked in late winter and early spring, admission rates remained unchanged throughout the year with an overall admission rate of 24%. Most frequent diagnoses were acute gastroenteritis, acute viral illness and upper respiratory tract infection. Asthma was the next most common. Pediatric Emergency Care Applied Research Network and PREDICT data showed differences in terms of ethnicity descriptions/distribution and admission rates. This is the first description of the epidemiology of patient presentations to major paediatric ED in Australia and New Zealand. It details baseline data important to future collaborative studies and for planning health services for children.

The aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT). A retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap). Three hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%. Treatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.

Comparison of clinical practice guideline (CPG) recommendations and reported physician management of croup at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites as baseline for planned randomized controlled trials. Review of CPGs for croup from PREDICT sites and survey of specialist pediatric emergency physicians regarding croup management. PREDICT sites included 8 tertiary pediatric hospitals and 3 large mixed emergency departments in Australia and New Zealand. Nine of the 11 sites had a CPG for croup. Response rate was 94% (78/83). Adrenaline was recommended for moderate croup (3%), severe croup (52%), and life-threatening croup by (100%). Steroid therapy was recommended for mild croup (45%), for moderate croup (97%), for severe croup (97%), and for life-threatening croup (96%). Steroid choice was oral dexamethasone (60%) and oral prednisolone (38%). In severe croup, 77% used intravenous/intramuscular dexamethasone, 10% used intravenous/intramuscular methylprednisolone, and 8% used nebulized budesonide. Commonest dosage regimens were 0.15 mg/kg dexamethasone or 1 mg/kg prednisolone. A standard volume dosage regimen for nebulized adrenaline was used by 54%, whereas 39% used a weight-based formula. Clinical practice guidelines recommended 5 mg (11%) or 10 mg (33%) for standard volume dosing, and all CPGs using weight-based dosing recommend 0.5 mg/kg with maximum doses ranging from 5 to 15 mg. Croup management at PREDICT emergency departments is similar, based on oral steroids and nebulized adrenaline. The steroid and adrenaline regimens used by respondents and their CPGs were not consistent. This reflects limitations of available evidence for management of this common disease, highlighting the need for definitive trials, particularly in the management of mild croup.

Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.

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. A questionnaire of specialist emergency physicians regarding demographics, general procedural sedation practice and specific sedation agents given to children. CPG for general sedation and sedation agents were obtained for each site. Seventy-five (71%) useable surveys returned from 105 potential respondents. Most commonly used agents were nitrous oxide (N(2)O) (75, 100%), ketamine (total 72, 96%; i.v. 59, 83% and i.m. 22, 31%) and midazolam (total 68, 91%; i.v. 52, 81%, oral 47, 73%, intranasal 26, 41% and i.m. 6, 9%). Sedation was used for therapeutic and diagnostic procedures. Forty-three (57%) used formal sedation records and sedation checklists and thirty-one (41%) respondents reported auditing sedations. Four sites ran staff education and competency programmes. Nine sites had general sedation CPG, eight for ketamine, nine for N(2)O, eight for midazolam (four parenteral, five oral and six intranasal) and three for fentanyl. No site had a guideline for propofol administration. Procedural sedation in this research network commonly uses N(2)O, ketamine and midazolam for a wide range of procedures. Areas of improvement are the lack of guidelines for certain agents, documentation, staff competency training and auditing processes. Multicentre research could close gaps in terms of age cut-offs, fasting times and optimal indications for various agents.

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. (i) Review of CPGs for acute seizure management at PREDICT sites. (ii) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of status epilepticus (SE). Ten sites used seven different seizure CPGs. One site had no seizure CPG. First line management was with benzodiazepines (10 sites). Second line and subsequent management included phenytoin (10), phenobarbitone (10), thiopentone (9), paraldehyde (6) and midazolam infusion (5). Of 83 available consultants, 78 (94%) responded. First line management of SE without intravenous (IV) access included diazepam per rectum (PR) (49%), and midazolam intramuscular (41%) and via the buccal route (9%). First line management of SE with IV access included midazolam IV (50%) and diazepam IV (44%). The second line agent was phenytoin (88%); third line agents were phenobarbitone (33%), thiopentone and intubation (32%), paraldehyde PR (22%) and midazolam infusion (6%). Fourth line agents were thiopentone and intubation (60%), phenobarbitone (16%), midazolam infusion (13%) and paraldehyde (9%). Initial seizure management by CPG recommendations and reported physician practice was broadly similar across PREDICT sites and consistent with APLS guidelines. Practice was variable for second/third line SE management. Areas of controversy would benefit from multi-centred trials.

Epidemiology of community acquired sepsis in children in Australia and New Zealand: a multicentre prospective cohort study