Canadian Pediatric Emergency Departments Research Articles

Screening for Iron Deficiency Anemia in at Risk Children in the Pediatric Emergency Department

To determine the attitudes and reported practices of physicians regarding screening for iron deficiency anemia in at-risk children in pediatric emergency departments (PEDs) across Canada. A standardized survey was mailed to 183 PED physicians at 10 tertiary care PED across Canada. The practices and attitudes regarding screening for iron deficiency anemia were collected via a questionnaire consisting of single select closed-ended items and items which required ranking in order of importance. Sixty-one percent (111/183) of physicians responded to the survey. Ninety-six percent of respondents do not routinely screen for iron deficiency anemia. One third of respondents believed that screening for iron deficiency anemia in the PED is possible. The remaining stated lack of time, difficulty with follow-up, it not being an emergent issue and cost as prohibitive factors. One third of participants stated that 21% to 40% of the pediatric patients seen in their PED did not have a primary care physician. The main considerations in deciding on whom to perform venipuncture were based on dietary history and physical examination with a history of consumption of milk greater than 24 ounces per day (94%) and conjunctival or skin pallor (97%, 94%, respectively) selected as the most important items. The results of this study indicate that Canadian PED physicians are not routinely screening for iron deficiency anemia, although they demonstrate knowledge of the risk factors for iron deficiency anemia and recognize the importance of diagnosis and treatment to prevent long-term morbidity.

Use of Single-dose Activated Charcoal Among Canadian Pediatric Emergency Physicians

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. A standardized survey consisting of 5 clinical scenarios was mailed to all physicians with a primary clinical appointment to the ED at 9 Canadian children's hospitals. 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. 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.

Barriers to Metered-dose Inhaler/Spacer Use in Canadian Pediatric Emergency Departments

Barriers to Metered-dose Inhaler/Spacer Use in Canadian Pediatric Emergency Departments

Practice variation among pediatric emergency departments in the treatment of bronchiolitis.

Bronchiolitis is the most common disease of the lower respiratory tract in the first year of life. Treatment is controversial, with studies giving conflicting views on the benefits of bronchodilators and steroids. The objectives of this study were 1) to characterize the management of bronchiolitis in pediatric emergency departments (PEDs) in Canada, 2) to determine patient outcomes following emergency department (ED) visits, and 3) to provide descriptive data regarding bronchiolitis symptoms and family/personal medical history of these patients. A prospective consecutive cohort of children with bronchiolitis presenting to seven Canadian PEDs was enrolled during a seven-to-21-day period. Standardized interviews with parents provided data regarding symptoms, previous treatment, and past history. Charts were reviewed for treatment, investigations, and disposition. Telephone follow-up at two to three weeks collected information regarding duration of illness and return visits. Two hundred thirty-seven (91%) of 260 eligible patients were enrolled. One hundred eighty-nine patients (80%) had both an interview and chart review, and 48 (20%) had only chart reviews; follow-up was completed for 163 (69%) patients. One hundred fifteen (63%) had seen their primary care provider during their illness prior to the ED visit. Seventy-three percent of patients (range per site 59-100%) were treated in the ED with bronchodilators (usually salbutamol or epinephrine) and 5% (range per site 0-14%) with oral steroids. Twenty-four percent (58/237) were prescribed bronchodilators on discharge, 3% (7/237) inhaled steroids, and 2% (5/237) oral steroids. Chi-square tests indicated significant practice variation by site in ED bronchodilator use (p < 0.001) and bronchodilator use at discharge (p = 0.0003). Admission rate was 31% (range by site 22-43%), 17% of patients had more than one ED visit, and 1% were admitted more than once. Admission rates were increased in younger children, children with comorbidities, and children with lower oxygen saturation. Viral studies were obtained in 53%, with 76% of these positive for respiratory syncytial virus (RSV). Median duration of cough was 12 days, poor sleeping and irritability eight days, and wheeze and poor feeding seven days. This study prospectively describes the treatment of bronchiolitis in the pediatric ED. The findings are consistent with the literature regarding the reported use of bronchodilators; however, use of steroids was found to be much lower than reported in other studies. Bronchodilator use in the ED and at discharge varied significantly by site. The results capture variation in treatment practices in Canadian PEDs, which may be the result of discordant randomized controlled trial evidence. Further research is needed to establish best practices.

Demographics of Physicians Working in Canadian Pediatric Emergency Departments

Demographics of Physicians Working in Canadian Pediatric Emergency Departments

Management of moderate head injury in childhood: degree of consensus among Canadian pediatric emergency physicians.

The purpose of this study was to assess the degree of consensus among Canadian pediatric emergency physicians regarding the management of moderate head injury in children. A questionnaire regarding the management of moderate head injury in a child was developed, and it concentrated on indications for admission and policies regarding skull radiograph. The questionnaire was given to all pediatricians who are members of the Emergency Section of the Canadian Pediatric Society (n = 33) and who represent 15 Canadian pediatric emergency departments. The outcome was measured by the degree of consensus regarding management of children with moderate head injury. Twenty-three of 33 (70%) questionnaires, representing 14 of 15 (93%) emergency departments, were returned. Only five of 23 (22%) questionnaires report routinely admitting otherwise well children with short (three minutes or less) loss of consciousness; five (22%) routinely order a skull radiograph - three (13%) routinely do both. Certain clinical indicators led to 70 to 80% agreement regarding admission: severe headache, seizures, depressed skull fracture, and persistent vomiting. Agreement of more than 70% regarding indications for ordering a skull radiograph was achieved only for clinical suspicion of a depressed skull fracture. In conclusion, for the average child who is well after a loss of consciousness after a head injury lasting three minutes or less, the majority of respondents do not routinely admit the child or order a routine skull radiograph. A reasonable degree of consensus (70-80%) regarding ordering of skull radiographs and admission is based on clinical criteria.

Trauma one! Advanced trauma life support simulator

Understanding triage nurses' perspectives of pain management is essential for timely pain care for children in the emergency department. Objectives of this study were to describe the triage pain treatment protocols used, knowledge of pain management modalities, and barriers and attitudes towards implementation of pain treatment protocols.A paper-based survey was administered to all triage nurses at three Canadian pediatric emergency departments, between December 2011 and January 2012.The response rate was 86% (n=126/147). The mean respondent age was 40 years (standard deviation [SD] 9.3) with 8.6 years (SD 7.7) of triage experience. General triage emergency department (GTED) nurses rated adequacy of triage pain treatment lower than pediatric-only triage emergency department (PTED) nurses (P < .001). GTED nurses reported a longer acceptable delay between triage time and administration of analgesia than PTED nurses (P < .002). Most nurses rated more comfort with a protocol involving administration of acetaminophen (97mm, interquartile range [IQR] 92, 99) or ibuprofen (97mm, IQR 93, 100) than for oral morphine (67mm, IQR 35, 94) or oxycodone (57mm, IQR 15, 81). The top three reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. Willingness to implement a triage-initiated pain protocol was rated as 81mm (IQR 71, 96).Triage nurses are willing to implement pain protocols for children in the emergency department, but differences in comfort and experience exist between PTED and GTED nurses. Provision of triage initiated pain protocols and associated education may empower nurses to improve care for children in pain in the emergency department.