Children’s Emergency Department Research Articles

1569 Paediatric Upper Limb Fracture Manipulation in A Children’s Emergency Department: Practice Changes During The COVID-19 Pandemic

Abstract Background Trauma theatre time is valuable and previous studies reported cost of £24.77/minute. BSUH Children’s emergency department (CED) guidelines were implemented in December 2016, allowing reduction of forearm and distal radius (DR) fractures in CED using 70% nitrous (N2O) sedation. Due to COVID-19 pandemic and the risks associated with aerosol generating procedures as well as staffing levels, CED shifted to using 50%N2O with or without intranasal fentanyl. Method Relevant fractures presenting to CED from Feb-Dec 2020 were identified and compared to previous years. Demographics, treatment modality, timings, and outcomes were reviewed for 275 patients. Results In 2017-2018, 56% were manipulated in CED under 70%N2O (compared to only 3% in 2016). The main barrier identified was shortage of doctors trained in sedation to supervise use of 70%N20. In 2020, 101 patients were suitable for manipulation in CED. 64 had DR fractures, 37 midshaft fractures, 65 were male. Mean age: 10 years. 92 patients (91%) were manipulated in CED/fracture clinic. One was under 70%N2O; the rest used 50%N2O with or without intranasal fentanyl. 8 (9%) had manipulation under GA. Of those manipulated in CED, 3 were re-manipulated in clinic for cast problems. A typical MUA takes 30minutes indicating a saving of £743 per case; therefore, £68,356 over the study period. Conclusions Paediatric upper limb fracture manipulation in CED under N2O is effective and provides significant cost savings. Due to changes related to COVID-19 pandemic, considerably more patients in 2020 were safely treated in CED/clinic. Using 50%N2O improves uptake due to lower staffing requirements.

Nebulised normal saline in moderate acute bronchiolitis and pneumonia in a low- to middle-income country: a randomised trial in Papua New Guinea

ABSTRACT Background Acute lower respiratory tract infections are the commonest cause of hospitalisation in young children and supportive care remains the cornerstone of management. A randomised open trial was undertaken at the Port Moresby General Hospital Children’s Emergency Department (CED) to determine whether nebulised normal saline had beneficial effects. Methods Children <2 years of age presenting with a clinical diagnosis of moderate acute bronchiolitis or moderate pneumonia were randomised to receive standard care alone or with nebulised normal saline administered hourly. The outcomes were the difference in respiratory distress scores (RDS) and oxygen saturation between 0 and 4 hours, and admission rates. Results A total of 199 patients participated; 100 patients were randomised to normal saline and 99 to standard care. At 4 hours there was a significant difference in the change of the respiratory distress scores: mean RDS reduced by 3.41 (95% CI 3.0–3.8) in the normal saline group, and for the standard group, the RDS reduced by 1.96 (95% CI 1.5–2.4, p < 0.0001). In those receiving normal saline oxygen saturation measured by pulse oximetry (SpO2) increased by a mean of 7% (95% CI 6.0–7.9) to 90.7% at 4 hours. For those receiving standard care, the SpO2 increased by a mean of 4% (95% CI 2.8–5.2) to 87.5% at 4 hours (p < 0.001). Of 100 patients, 58 (58%) in the normal saline group and 24 of 99 (24.2%) in the standard arm were discharged from the Children’s Emergency Department (p < 0.001). Conclusions This study supports the use of nebulised normal saline in the treatment of moderate acute bronchiolitis or pneumonia in an emergency department setting in a low- to middle-income country. Abbreviations ALRI, acute lower respiratory infection; CED, Children’s Emergency Department; NaCl, sodium chloride; PMGH, Port Moresby General Hospital; PNG, Papua New Guinea; RDS, respiratory distress score; SpO2, oxygen saturation by pulse oximetry.

Oral Rehydration in Children with Acute Diarrhoea and Moderate Dehydration-Effectiveness of an ORS Tolerance Test.

Oral rehydration solution (ORS) is the mainstay of treatment of acute watery diarrhoea, but it is underutilized in many hospitals, resulting in children with moderate degrees of dehydration being unnecessarily hospitalized and receiving intravenous fluids. We aimed to assess the utility of an ORS tolerance test on initial presentation to an emergency department, and determine the volume of ORS a child with diarrhoea and moderate dehydration needed to tolerate to be successfully managed at home. One hundred and twenty-nine children with acute watery diarrhoea and moderate dehydration were given ORS and observed in a Children's Emergency Department (CED) over a period of 2-4 h. Patients were admitted, kept in the CED for further management or discharged, based on the assessment of oral intake and the clinical judgement of the treating health workers. Seventy-nine (61.2%) patients tolerated ORS well. They drank a median [interquartile range (IQR)] of 24.4 ml (IQR 12.5-28.8) ml/kg, were judged to have passed the ORS test and were discharged to continue oral rehydration treatment at home. At follow-up on days 2 and 5, 63/79 (79.7%) children had improved, were adequately hydrated and the diarrhoea had reduced. Sixteen of the 79 (20.3%) failed oral home treatment, with persisting diarrhoea, vomiting, hypokalaemia and/or weakness. The 63 who succeeded had tolerated a median of 25.8 (IQR 18.4-30.0) ml/kg of ORS in the CED, whilst the 16 who failed oral home treatment had tolerated 11.1 (IQR 9.1-23.0) ml/kg ORS (p < 0.001).

G555(P) Quality improvement in endotracheal intubation in a paediatric emergency department: checklist development and implementation using simulationand action cards

Background Endotracheal intubation in paediatric emergency medicine is a relatively infrequent event with a significant complication rate. Strong evidence exists for the use of checklists around emergency intubations to improve safety. This QI project took place in a dedicated Children’s Emergency Department (CED), seeing 33 000 presentations a year. Our institution takes part in the National Emergency Airway Registry for Children (NEAR4KIDS), an international, multi-centre advanced airway registry and quality improvement initiative. Measures such as number of attempts to successful advanced airway placement, saturation changes during RSI and tracheal intubation-associated adverse events are being used to regularly evaluate airway management within each participating institution. Out-of-theatre endotracheal intubation data has been captured since March 2013. Previously, we successfully increased inconsistent end-tidal CO2 use to almost 100% after a quality improvement push based on NEAR4KIDS data. No intubation checklist was used at our institution until December 2014, when an Emergency Intubation Checklist was implemented in our Paediatric Intensive Care Unit (PICU) and CED. It was deemed important to create a hospital-wide checklist. This would promote team coherence for CED emergency intubations, when often both PICU and CED staff are involved. PICU sees around 150 intubations annually; CED intubates around 25 children a year. The team members’ familiarity with advanced airway management is therefore potentially very different. Method We decided on a step-wise, simulation-based checklist development and implementation. Step 1 involved identifying key checklist elements, using other intubation checklists and expert opinions from within our institution and externally. Step 2 involved developing a checklist of essential actions and tasks based on the roles of the airway team members. Step 3 involved running low-fidelity simulated scenarios using the checklist with the CED Nurse Educators. Step 4 consisted of medium-fidelity simulation training for CED junior doctors. We amended the checklist based on feedback given by the Nurse Educators and CED doctors. Step 3 and 4 elucidated the need for a tool to speed up and aid preparation for intubation prior to completing the checklist. A solution was found in creating role-specific action cards for airway team members: event manager, airway doctor, airway assistant, medication nurse, circulation nurse. These are laminated A5 size cards, stating a role and its actions required to prepare for intubation. Step 5 involved introduction of the intubation quality improvement package to all CED staff, using a variety of simulated scenarios aimed at each level of nursing and medical staff involved in advanced airway management. The final step is assessment of the QI tool’s effect on patient care, with adaptations actioned as needed. Results Introduction of this quality improvement package has been well received. Team member feedback (both nursing and medical) was uniformly positive. The cards aided role allocation, allowed speedier preparation for intubation and promoted role flexibility. The effects on patient outcome are measured as part of the Near 4 kids airway collaboration. We anticipate being able to report some simulation based results over the next 3 months. Conclusion A shared checklist for PICU and ED appears to be helpful. Involvement of all levels of medical and nursing staff in the development of this quality improvement tool ensured buy-in. Simulation-based introduction of an intubation checklist in a low-volume setting such as a paediatric emergency department allows timely implementation. Action cards are an excellent way to teach and reinforce checklist-related roles. Effect on patient outcomes will be reported in the near future.

G93(P) DO AS I SAY, NOT AS I DO? Differences between perceived and actual practice in the follow up of microscopic haematuria/proteinuria in febrile children seen in the children’s emergency department

Aims To examine the follow up of children with microscopic haematuria/proteinuria in the children’s emergency department (CED) and to see if it differs from the perceived practice of CED doctors. Methods An audit of children with a diagnosis of ‘viral URTI’ or ‘viral illness’ during one month in a busy (>30,000 attendances/year) CED was performed. The follow up of those children with a recorded positive urine dipstick was examined. A survey of responses to scenarios of children with an incidental finding of microscopic haematuria/proteinuria (with no overt signs of renal disease) was used. The survey was sent to SHO grade doctors and registrars and asked for their current practice in arranging follow up of children with positive urine dipstick results. Results 174 children were audited with 24 of them having a documented positive urine dipstick result. Seventeen children had a single positive (either haematuria/proteinuria), none had follow up. Seven children had at least 2+ of either proteinuria or haematuria and only one of these had any form of follow up arranged (14%). Online survey of SHO doctors (8) and registrars (12) showed that for a child with a 1+ positive urine dip only 5 doctors (25%) would arrange follow up. However 17 doctors (85%) said they routinely offer follow up to children with at least 2+ on urine dip (either haematuria or proteinuria). Conclusions Approximately 2/3 of microscopic haematuria/proteinuria in children without specific renal symptoms resolves. Ensuring resolution is important since up to 50% of children in whom it persists have renal disease.1 In our CED, only 14% of children with at least 2+ positive urine dipstick had follow up arranged. On survey, 85% of doctors working in CED stated that their current practice is to offer follow up to these same children. In regards to the management of haematuria/proteinuria, doctors’ perceived practice in a busy CED setting differs markedly from their actual practice. Reference Geary DF, Schaefer F. Comprehensive Pediatric Nephrology. Philadelphia: Mosby; 2008

G547(P) ‘just checking’ – implementing a checklist

Context This quality improvement project as performed in a large District General Hospital, Children’s Emergency Department (CED). It reviewed the ‘Wheeze Pathway’ used to treat children presenting with acute exacerbations of wheeze. These children initially receive “burst therapy” – 10 puffs of a Salbutamol inhaler via a spacer device every 20 min for 1 h. Problem A previous audit of the ‘Wheeze Pathway’ highlighted only 79% of children recieving burst therapy had their inhalers at the correct intervals and only 89% had appropriate observations. In a serious adverse event a child was transferred to the in-patient ward without a post burst therapy assessment, which necessitated eventual escalation to IV therapy and HDU admission. Within a busy CED it was difficult to easily establish which children were following the ‘Wheeze Pathway’ and at what time their inhalers, observations and assessments were due. Assessment of problem and analysis of its causes Wheeze is a very common presentation to CED. Following the serious adverse event, nursing staff and doctors were consulted regarding the issues they felt contributed to the problems described. Intervention Following a consultation process a ‘Pathway Checklist’ was developed (Figure 1). The checklist is a timeline of all treatments and assessments (medical and nursing) during the first 4 h of the ‘Wheeze Pathway’. It was also decided children had to remain in the CED during this time to ensure a complete assessment with timely escalation of treatment if necessary and stability prior to transfer to a definitive care bed. Strategy for change The ‘Pathway Checklist’ was developed with significant input from the nursing team to ensure strong support for the change. Upon implementation both the Pathway and Checklist were publicised to all staff and education provided at team meetings. Measurement of improvement A snap shot review of the ‘Wheeze Pathway’ and ‘Pathway Checklist’ was undertaken over a 10-day period in 2014 and 39 consecutive sets of patient notes were reviewed. The implementation achieved a near perfect number of children receiving burst therapy at the correct intervals and 100% having complete observations as well as 37 (95%) cases having timely medical reviews. Effects of changes As a consequence of its implementation there have been no further adverse incidents as children are now transferred to definitive care beds when stable and with clear plans. There is also now an unquantifiable improvement in how the department has a feeling of control and knowledge of all the children on the ‘Wheeze Pathway’, which has improved overall care of these patients. There is an allocated nurse to give all burst therapy and to provide education to families. There is also improved awareness amongst the nursing and medical teams regarding the need for escalation and which children we have greater concern for, leading to early identification of these patients. Lessons learnt Implementation requires buy-in and consensus of the whole team. Next time I would provide more regular feedback of the success of change to ensure continued motivation of users and highlight areas for improvement. Message for others An extremely simple intervention can help to improve efficiency and have a positive effect on patient care safety by prompting key points in patient management, especially in a busy environment.

G94(P) Emergency department team wellbeing. how happy are we really?

Aims There is good evidence that high staff moral and satisfaction improve quality of care. The aim of this study was to assess our baseline levels of staff satisfaction within a busy Children’s Emergency Department (CED) team, to understand what the department does well and not so well and what and how could we improve. Method All staff; nursing, medical and administrative, in CED answered a brief 9 question online survey via email. This included both 1–10 rating and free text questions. Results 80 staff received the questionnaire, 38 (48%) responded. The mean ‘happiness’ rating was 6.19/10 with little difference between professions (nurses 6.6, doctors 7.0), staff rated how ‘valued’ they feel as 6.19. Staff were asked to rate the department in a number of parameters (Figure 1). The results highlighted lots of positives in the department – e.g. tea rounds, social outings, team working and communication. The main areas for improvement suggested were in the relationship and communication between medical and nursing staff. Suggested interventions included: more multidisciplinary meetings, training, and social activities, also listening without interruptions, and valuing all colleagues’ opinions. Conclusion This study has provided a number of ideas for interventions within the department to improve staff wellbeing. The anonymous feedback method allowed true reflections of staff happiness and highlighted areas for future development. Communication was particularly highlighted- e mail is used for a large amount of our interdepartmental communication and on investigation of our poor response rate it appears that staffs rarely check their hospital e mails address. Our first implementation is to improve this basic form of communication. To also implement a short simple department meeting for prior to handover thus capturing more nursing and medical staff who cannot regularly attend the department meetings. Simple service improvements were also suggested which will be considered to enhance patient care.

G92(P) Paediatric cardiac murmur guideline for the children’s emergency department

<h3>Aim</h3> To develop a paediatric cardiac murmur guideline for a Children’s emergency department (CED), following mismanagement of 2 cases of heart murmurs in children. Currently there is no national guideline in place. <h3>Methods</h3> Electronic databases Medline, Embase, Cochrane Cinahl, Psycinfo, Amed, British nursing index, DARE and CENTRAL were searched using title/abstract terms and subject headings: heart/cardio/cardia/murmur/sound AND diagnosis/assessment/evaluation/examination. Results were limited to children aged 0–18 years and no limitations placed on date or language. The results were exported on to Mendeley workstation and analysed. <h3>Results</h3> Medline returned 1204 results, Embase (1168), Cochrane (0), Cinahl (131), Psycinfo (15), Amed (13), British nursing index (5), DARE (0) and CENTRAL (8). When duplicates were removed 2533 results remained from which 560 articles were selected according to suitability. Among these 100 original papers were fully accessed and reviewed. Based on the available evidence a guideline triaging patients into a traffic-light system according to clinical severity with an algorithm for investigation was developed, taking into account patient feedback and opinions from experts in the field (Figures 1 and 2). <h3>Conclusion</h3> A new, easy to follow guideline has been implemented, which will aid clinicians to confidently triage children presenting with murmurs according to clinical need and guide appropriate management. This will promote quality of care and patient safety, and facilitate the management of children with murmurs who attend the CED.

G346 Paediatric ECG interpretation and documentation in a Children’s Emergency Department – a service evaluation and action plan

AimsTo review the practice, usefulness and interpretation of electrocardiogram (ECG) in a Children’s Emergency Department (CED), following a clinical risk incident due to the lack of formal review process of...

G30(P) Paediatric ECG interpretation and documentation in a Children’s Emergency Department – a service evaluation and action plan

AimsTo review the practice, usefulness and interpretation of electrocardiogram (ECG) in a Children’s Emergency Department (CED), following a clinical risk incident due to the lack of formal review process of...

G21(P) An audit of handover from the Children’s Emergency Department (CED) to the ward

BackgroundPatient handover taking place between the Children’s Emergency Department (CED) and the ward to which the patient is being transferred is essential for patient safety. Poor or incomplete information can...

G33(P) “Little patients, big problems”: Neonatal attendances to the Children’s Emergency Department

AimsTo analyse the epidemiological characteristics, presenting complaints and outcomes of all neonatal presentations to a Children’s Emergency Department.MethodsA retrospective review of neonates (aged ≤28 days) who presented to the Children’s...

G238 Make Love Not War: Bridging the Gap Between Primary and Secondary Paediatric Care

AimTo determine the number of presentations to a new Children’s Emergency Department (CED) that could have been managed in primary care.MethodsAll Patients were assessed to determine the appropriateness of attendance....

Enhancing the Reporting of “Near Miss” Events in a Children’s Emergency Department

Approximately 540,000 children a year experience a drug-related, harmful event.1 In an effort to reduce these actual events, it is imperative that staff realize the important information that a near-miss event, an error caught before reaching the patient, can provide.2 Encouraging staff to report these near misses is sometimes difficult in the fast-paced environment of the Children’s Emergency Department (CED) at WakeMed in Raleigh, NC. To increase the reporting of near-miss events in our CED, we conducted an investigation into nursing staff’s knowledge and thoughts regarding near-miss reporting.