Canadian Pediatric Emergency Departments Research Articles

Postresuscitation debriefing in the pediatric emergency department: a national needs assessment

The objectives of this study were to assess current postresuscitation debriefing (PRD) practices in Canadian pediatric emergency departments (EDs) and identify areas for improvement. A national needs assessment survey was conducted to collect information on current PRD practices and perspectives on debriefing practice in pediatric EDs. A questionnaire was distributed to ED nurses, fellows, and attending physicians at 10 pediatric tertiary care hospitals across Canada. Summary statistics are reported. Data were analyzed from 183 participants (48.7% response rate). Although 88.8% of the participants believed that debriefing is an important process, 52.5% indicated that debriefing after real resuscitations occurs less than 25% of the time and 68.3% indicated that no expectation exists for PRD at their institution. Although 83.7% of participants believed that facilitators should have a specific skill set developed through formal training sessions, 63.4% had no previous training in debriefing. Seventy-two percent felt that medical and crisis resource management issues are dealt with adequately when PRD occurs, and 90.4% indicated that ED workload and time shortages are major barriers to effective debriefing. Most responded that a debriefing tool to guide facilitators might aid in multiple skills, such as creating realistic debriefing objectives and providing feedback with good judgment. PRD in Canadian pediatric EDs occurs infrequently, although most health care providers agreed on its importance and the need for skilled facilitators.

205: C-Care: Comparing Two Years of Anaphylaxis in a Canadian Pediatric Emergency Department

205: C-Care: Comparing Two Years of Anaphylaxis in a Canadian Pediatric Emergency Department

Uninsured immigrant and refugee children presenting to Canadian paediatric emergency departments: Disparities in help-seeking and service delivery

Access to health care for medically uninsured immigrant and refugee children is a public health concern due to the consequences of delayed or substandard care for child development and health. To explore possible differences in help-seeking and service delivery across migratory statuses, institutions and provinces. A review was undertaken of 2035 emergency files of immigrant, refugee and undocumented children without provincial health care coverage who sought care at three major paediatric hospitals in Montreal (Quebec) and Toronto (Ontario) during 2008 and 2009. Refugee claimant children with Interim Federal Health Program benefits consulted for less urgent problems than the overall hospital population, except in one hospital that had a multicultural paediatric ambulatory clinic. Undocumented children and new permanent resident immigrant children within the three-month waiting period for provincial health care coverage were over-represented in the very urgent triage category and presented more often for injuries, trauma and mental health problems than did refugee claimant children. Wide interhospital differences suggest that the predicament of limited access to health care of these groups of vulnerable medically uninsured children needs to be addressed through further research to inform policies and develop training.

The role of physician assistants in pediatric emergency medicine: the physician's view

To define the range of clinical conditions Canadian emergency pediatricians consider appropriate for management by physician assistants (PAs) and the degree of autonomy PAs should have in the pediatric emergency department (PED). We conducted a cross-sectional, pan-Canadian survey using electronic questionnaire technology: the Active Campaign Survey tool. We targeted PED physicians using the Pediatric Emergency Research Canada (PERC) network database (N = 297). Three outcome measures were assessed: demographic information, familiarity with PAs, and PA clinical roles in the PED. The level of PA involvement was assessed for 57 common nonemergent clinical conditions. Of 297 physicians, 152 completed the survey, for a response rate of 51.2%. None of the 57 clinical categories achieved at least 85% agreement regarding PA management without direct physician involvement. Twenty-four clinical conditions had ≥ 15% agreement that any PA involvement would be inappropriate. For the remaining 33 clinical conditions, more than 85% of respondents felt that PA could appropriately manage but were divided between requiring direct and only indirect physician supervision. Respondents' selection of the number of conditions felt to be appropriate for PA involvement varied between the size of the emergency department (ED) in which they work (larger EDs 87.7-89.1% v. smaller EDs 74.2%) and familiarity with the clinical work of PAs in the ED (90.5-91.5% v. 82.2-84.7%). This national survey of Canadian PED physicians suggests that they feel PAs could help care for a large number of nonemergent clinical cases coming to the PED, but these clinical encounters would have to be directly supervised by a physician.

Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion

IntroductionPersistent postconcussive symptoms (PCSs) is the persistence of somatic, cognitive, physical, psychological and/or behavioural changes lasting more than 1 month following concussion. Persistent concussion impacts the quality of life through...

The current state of mental health services in Canada's paediatric emergency departments

To describe emergency mental health services in major paediatric centres across Canada. A cross-sectional study of mental health services in emergency departments (EDs) from all 15 Canadian tertiary care paediatric centres was conducted. Fifteen individuals participated and were either a paediatric emergency physician with administrative responsibilities (60%) or an emergency mental health care provider (40%). Four participants reported that their ED used an evidence-based guideline, tool or policy, and one participant reported their ED based its services on published research evidence. Reported ED-based mental health resources included a crisis intervention team (five EDs), a mental health nurse (six EDs) and a social worker (five EDs). Thirteen participants reported on-site consultation with child psychiatry and six reported urgent follow-up as an adjunct service to ED care. There is a wide variety of mental health care practices in Canadian paediatric EDs. Consideration of which resources are required to ensure evidence-based, effective services are provided to children and youth is necessary.

Health Care Provider and Caregiver Preferences Regarding Nasogastric and Intravenous Rehydration

Despite evidence supporting its use, nasogastric rehydration is rarely used in North America. We conducted a prospective, cross-sectional, 3-phase study to evaluate current perspectives. We compared the proportions of respondents in favor of nasogastric (as opposed to intravenous) rehydration, should oral rehydration fail, between clinicians and caregivers. Phase 1: caregivers of children aged 3 to 48 months, who presented to a Canadian pediatric emergency department with symptoms of gastroenteritis, were invited to complete a survey. Phase 2: phase 1 participants administered intravenous or nasogastric rehydration had the procedure observed and outcome data recorded. Phase 3: pediatric emergency medicine physicians, fellows, and nurses completed a survey. Four hundred thirty-five children-parent dyads and 113 health care providers participated. If oral rehydration were to fail, 10% (47 of 435) of caregivers and 14% (16 of 113) of clinicians would choose nasogastric rehydration (difference = 3.4%; 95% confidence interval: -2.8 to 11.4). Caregivers were more familiar with the term intravenous than nasogastric rehydration (80% vs 20%; P < .001). Sixty-four children (15%) received intravenous rehydration; none received nasogastric rehydration. Participating nurses have inserted 90 (interquartile range: 25-150) intravenous cannulas compared with 4 (interquartile range: 2-10) nasogastric tubes during the preceding 6 months (P < .001). After a brief educational intervention, the proportion recommending nasogastric rehydration increased to 27% (117 of 435) among caregivers (P < .001) and 43% (49 of 113) among health care providers (P < .001). In keeping with caregiver desires, health care providers in a Canadian emergency department employ intravenous rehydration when oral rehydration fails. Enhanced change management strategies will be required for nasogastric rehydration to become adopted in this environment.

Practice Patterns in Asthma Discharge Pharmacotherapy in Pediatric Emergency Departments: A Pediatric Emergency Research Canada Study

The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4). The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.

The Role of Physician Assistants in a Pediatric Emergency Department

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. 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. 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. 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.

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

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. 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. 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. 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.

Use of personal protective equipment in Canadian pediatric emergency departments

Use of personal protective equipment in Canadian pediatric emergency departments

Use of personal protective equipment in Canadian pediatric emergency departments

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. 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. 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. 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.

Vitamin use among children attending a Canadian pediatric emergency department

Increasing use of vitamins has been documented worldwide in children and adolescents, and potential for vitamin-drug interactions exists. The aim of this study was to identify vitamin use by children visiting a pediatric emergency department (ED). A survey of parents and/or patients 0-18 years was conducted at a large pediatric ED in Canada. A total of 1804 families were interviewed. The main outcome measure was prevalence of vitamin use by children in the preceding 3 months. A third (32.3%) of the patients in our cohort had used vitamins in the preceding 3 months, and 48% of them were taking vitamins daily. Over 8% of all children used vitamins within the last 24 h. The use of vitamins was higher with older patient and parental age (P<0.001), chronic patient illness (P<0.001), completed immunization (P<0.001), concurrent patient use of prescribed medications (P=0.02), higher parental education (P<0.01), and English as a primary language spoken at home (P=0.002). Prevalence of vitamin use among children in the ED is 32% in the preceding 3 months and 8% within the last 24 h. In light of these findings, pediatricians should ask about vitamin use and discuss with parents potential interactions and possible adverse effects.

Current Practice and Tolerance for Risk in Performing Procedural Sedation and Analgesia on Children Who Have Not Met Fasting Guidelines: A Canadian Survey Using a Stated Preference Discrete Choice Experiment

The objectives were to explore the tolerance of pediatric emergency medicine (PEM) physicians for risk in choosing when to perform procedural sedation and analgesia (PSA) and to describe adherence to preprocedural fasting guidelines and factors affecting the physicians' decisions. A survey of Canadian PEM physicians who perform PSA was conducted. Respondents were asked about their PSA practices. Risk tolerance was assessed using an economics-based stated preference elicitation method called a discrete choice experiment (DCE). Using a hypothetical clinical situation of a healthy child needing PSA, three fasting scenarios (ingestion of full meal < 2 hours ago, full meal between 2 and 4 hours ago, liquids less than 1 hour ago) were created. For each fasting scenario, 16-choice questions with varying numeric risks of major and minor adverse events were presented and respondents were asked whether they would administer PSA now or wait for guidelines to be met. In this exploratory study, choice data were analyzed using multivariate regression analysis, and preliminary inferential statistics are presented. A total of 114 (63.6%) completed surveys were returned. Respondents were 54% male, were in practice for a median of 6-10 years, and reported following fasting guidelines 53% of the time. Most had institutional fasting policies (70%), used ketamine (in 78% of PSA by 95% of users), and identified patient variables (prolonged pain, parental concern) as more important than environmental variables (patient flow, use of resources) in deciding when to administer PSA. Both major and minor risks of adverse events affected the choice of whether to do immediate PSA or wait until fasting guidelines were met. A 0.1-percentage-point increase in the probability of a major adverse event reduced physician likelihood of performing immediate PSA before meeting fasting guidelines by 17.6 percentage points. In comparison, a 10-percentage-point increase in the probability of a minor adverse event reduced physician likelihood of performing immediate PSA by 17.2%. Respondents were less likely to perform PSA immediately if a child had a full meal < 2 hours ago versus 2-4 hours ago or liquids < 1 hour ago. Sex, highest level of postgraduate training, frequency of performing PSA, and experience with a prior adverse event did not affect the choice to do immediate PSA. Years in practice affected the decision, with those in practice for 6-10 years more likely to perform immediate PSA than those in practice for shorter or longer. Those who reported having an institutional fasting policy were less likely to perform immediate PSA. These results suggest that fasting guidelines are not strictly adhered to in Canadian pediatric emergency departments (EDs) currently, and there is some willingness of physicians to change their sedation practice in light of evidence from hypothetical surveillance data about risks. On the other hand, some physicians suggest that they will follow guidelines regardless of how low the estimated risk is from surveillance data. An understanding of how physicians respond to evidence about small risks and how the information is best understood by this population is interesting for knowledge translation if evidence-based practice guidelines for procedural sedation in the ED are developed in the future.

Validation of the Pediatric Appendicitis Score

Emergency Medicine| November 01 2009 Validation of the Pediatric Appendicitis Score AAP Grand Rounds (2009) 22 (5): 50. https://doi.org/10.1542/gr.22-5-50 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Validation of the Pediatric Appendicitis Score. AAP Grand Rounds November 2009; 22 (5): 50. https://doi.org/10.1542/gr.22-5-50 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: appendicitis Source: Bhatt M, Joseph L, Ducharme FM, et al. Prospective validation of the Pediatric Appendicitis Score in a Canadian pediatric emergency department. Acad Emerg Med. 2009;16(7):591–596; doi:10.1111/j.1553-2712.2009.00445.x To evaluate the diagnostic utility of the Pediatric Appendicitis Score (PAS),1 Canadian investigators prospectively studied a convenience sample of children aged 4 to 18 years with possible appendicitis. Children with acute abdominal pain for less than three days who presented to Montreal Children’s Hospital Emergency Department (ED) between 2003 and 2005 were eligible for the study if the ED physician considered appendicitis as a diagnosis. Nonverbal children, those with a history of chronic abdominal pathology (eg, inflammatory bowel disease) or prior appendectomy, and those who did not have a complete blood count (CBC) performed were excluded. The PAS score ranges from 0 to 10 and includes eight diagnostic indicators. One point each is scored for the presence of anorexia, pyrexia, nausea/emesis, migration of pain, leukocytosis >10,000, and polymorphonuclear neutrophilia. The presence of right lower quadrant tenderness generates two points, and tenderness with cough, percussion, or hopping generates another two points. Physicians with at least two years of post-graduate education completed a standardized data collection form during the child’s ED visit. Imaging, consultation, and disposition occurred at the discretion of the treating physician. One month later, telephone interviews were conducted with parents of children discharged home to detect missed appendicitis cases. Of 246 enrolled patients, 95 children underwent appendectomy, and 83 children had histological confirmation of appendicitis, including 14 with perforation. Approximately 12% of study children who underwent appendectomy had specimens that were histologically negative. No missed cases of appendicitis occurred. A receiver operator characteristic (ROC) curve was constructed to evaluate performance of the PAS and yielded an area under the curve of 0.895 (see AAP Grand Rounds, July 2001;6:8 for explanation of ROC curves). The optimal cut-point for the PAS score in terms of sensitivity and specificity was ≥ 6 for surgical intervention, similar to that from the original description of the PAS.1 Using a score of ≥ 6, sensitivity and specificity were 92.8% and 69.3%, respectively, which would result in 50 (37.6%) negative appendectomies and 6 (7.2%) missed cases. Due to these findings, the authors proposed that children with a PAS of ≤ 4 may be discharged without further intervention, children with a score of ≥ 8 should undergo appendectomy, and children with scores from 5 to 7 require further imaging. This strategy would have resulted in two cases of missed appendicitis (2.4%) with a sensitivity of 97.6% and NPV of 97.7%, and eight negative appendectomies (8.8%) with a specificity of 95.1% and PPV of 85.2%. The authors conclude that the PAS may be a useful clinical tool in the evaluation of children with suspected appendicitis, and argue that categorization of risk via the PAS may be more valuable for directing patient care than using a single cut-point. Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not... You do not currently have access to this content.

Barriers and supports to implementation of MDI/spacer use in nine Canadian pediatric emergency departments: a qualitative study

BackgroundDespite recent research supporting the use of metered dose inhalers with spacer devices (MDI/spacers) in pediatric emergency departments (PEDs) for acute exacerbations of asthma, uptake of this practice has been slow. The objectives of this study were to determine the barriers and supports to implementing MDI/spacer research and to identify factors associated with early and late adoption of MDI/spacers in Canadian PEDs.MethodsUsing a comparative case study design, we classified nine tertiary care pediatric hospital PEDs based on their stage of implementation. Data were collected using focus group interviews with physicians, registered nurses (RNs), and respiratory therapists (RTs), and individual interviews with both patient care and medical directors at each site. Initial coding was based on the Ottawa Model of Research Use (OMRU) categories of elements known to influence the uptake of innovations.ResultsOne hundred and fifty healthcare professionals from nine different healthcare institutions participated in this study. Lack of leadership in the form of a research champion, a lack of consensus about the benefits of MDI/spacers among staff, perceived resistance from patients/parents, and perceived increased cost and workload associated with MDI/spacer use were the most prevalent barriers to the adoption of the MDI/spacer. Common strategies used by early-adopting sites included the active participation of all professional groups in the adoption process in addition to a well-planned and executed educational component for staff, patients, and families. Early adopter sites were also more likely to have the MDI/spacer included in a clinical protocol/pathway.ConclusionPotential barriers and supports to implementation have been identified that will help EDs adopt MDI/spacer use. Future interventions intended to increase MDI/spacer use in PEDs will need to be sensitive to the barriers identified in this study.

Practice Variation With Febrile Infants: Delight in Disorder?

A careless shoe-string, in whose tie I see a wild civility: Do more bewitch me, than when art Is too precise in every part. “Delight in Disorder,” Robert Herrick (1591–1674) Herrick's 17th-century sonnet seems the antithesis of the scientific movement toward evidence-based medicine. And, of course, it mostly is: there is no place for the “careless” or the “wild.” Yet those of us who still exalt in the “art” of medicine are less “bewitched” when guidance becomes “too precise in every part.” This is a subversive sentiment and, if applied to our patients, must be done so thoughtfully and responsibly. However, it may lead us to a useful insight: evidence-based medicine is not incompatible with significant practice variation. In this month's issue of Pediatrics , Goldman et al1 describe (with a perceptible sense of dismay) practice variation across Canadian pediatric emergency departments in the management of febrile infants younger than 90 days. Although most infants had blood and urine work performed, the authors are particularly struck by the variability in lumbar puncture rates. They imply that such variability is hard to justify … Address correspondence to Louis C. Hampers, MD, MBA, University of Colorado School of Medicine, Section of Pediatric Emergency Medicine, 13123 E 16th Ave, B251, Aurora, CO 80045. E-mail: hampers.lou{at}tchden.org

Prospective Validation of the Pediatric Appendicitis Score in a Canadian Pediatric Emergency Department

Clinical scoring systems attempt to improve the diagnostic accuracy of pediatric appendicitis. The Pediatric Appendicitis Score (PAS) was the first score created specifically for children and showed excellent performance in the derivation study when administered by pediatric surgeons. The objective was to validate the score in a nonreferred population by emergency physicians (EPs). A convenience sample of children, 4-18 years old presenting to a pediatric emergency department (ED) with abdominal pain of less than 3 days' duration and in whom the treating physician suspected appendicitis, was prospectively evaluated. Children who were nonverbal, had a previous appendectomy, or had chronic abdominal pathology were excluded. Score components (right lower quadrant and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, and neutrophilia) were collected on standardized forms by EPs who were blinded to the scoring system. Interobserver assessments were completed when possible. Appendicitis was defined as appendectomy with positive histology. Outcomes were ascertained by review of the pathology reports from the surgery specimens for children undergoing surgery and by telephone follow-up for children who were discharged home. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. The overall performance of the score was assessed by a receiver operator characteristic (ROC) curve. Of the enrolled children who met inclusion criteria (n = 246), 83 (34%) had pathology-proven appendicitis. Using the single cut-point suggested in the derivation study (PAS 5) resulted in an unacceptably high number of false positives (37.6%). The score's performance improved when two cut-points were used. When children with a PAS of <or=4 were discharged home without further investigations, the sensitivity was 97.6% with a NPV of 97.7%. When a PAS of >or=8 determined the need for appendectomy, the score's specificity was 95.1% with a PPV of 85.2%. Using this strategy, the negative appendectomy rate would have been 8.8%, the missed appendicitis rate would have been 2.4%, and 41% of imaging investigations would have been avoided. The PAS is a useful tool in the evaluation of children with possible appendicitis. Scores of <or=4 help rule out appendicitis, while scores of >or=8 help predict appendicitis. Patients with a PAS of 5-7 may need further radiologic evaluation.

Barriers to Metered-dose Inhaler/spacer Use in Canadian Pediatric Emergency Departments: A National Survey

Barriers to Metered-dose Inhaler/spacer Use in Canadian Pediatric Emergency Departments: A National Survey

Barriers to Metered-dose Inhaler/spacer Use in Canadian Pediatric Emergency Departments: A National Survey

Metered-dose inhalers and spacers (MDI+S) are at least as effective as nebulizers for treating children with mild to moderate asthma exacerbations. Despite advantages in terms of efficacy, side effects, and ease of use, MDI+S are not used in many North American pediatric emergency departments (PEDs). To survey emergency physicians, emergency nurses, and respirologists in Canadian pediatric teaching hospitals regarding their practices, beliefs, and barriers to change with respect to bronchodilator delivery. This was a cross-sectional, mailed survey of all emergency physicians, all respirologists, and a random sample of emergency nurses at ten Canadian PEDs. A total of 291 of 349 health care professionals (83%) responded. Twenty-one percent of emergency physicians use MDI+S in the PED (largely concentrated at two "user sites"). A majority at nonuser sites, and virtually all professionals at user sites, responded that MDI+S are at least as effective as nebulizers, switching to MDI+S is justified by existing research, patient outcomes would be equal or better, and they have the required knowledge and skills to use MDI+S in the emergency department. The largest perceived barriers to MDI+S implementation include concerns regarding safety and costs, related to feasibility of providing and sterilizing spacers, and parental expectations for nebulizers. Other barriers included staff beliefs regarding the effectiveness of MDI+S, changes in nursing workload, and lack of a physician champion for change. MDI+S are infrequently used to treat patients with acute asthma in Canadian PEDs, despite the fact that most emergency staff believe they are effective. Important barriers to using MDI+S have been identified in this study and should be used to guide future implementation strategies.