Emergency Departments In Australia Research Articles

Factors predictive of hospital admission for children via emergency departments in Australia and Sweden: an observational cross-sectional study

BackgroundIdentifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden.MethodsA multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission.ResultsOf the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children’s EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children’s) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children’s only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2–2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7–2.9), referral from primary health aOR:1.5 (95%CI: 1.4–1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5–2.8 and aOR:1.5, 95%CI: 1.4–1.6, respectively). Predictors were similar when each site was considered separately.ConclusionsAlthough the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

Treatment of Pain Revisited ‐ The argument against too rapid resort to narcotic analgesics in Emergency Departments in Australia

Introduction: Pain is a common neurological complaint with many patients already taking narcotic analgesics at presentation to the neurologist. This paper examines an approach to pain management aimed to avoid narcotic analgesics. Clinical Practice: Pain is subjective and may be considered as either acute or chronic pain, differentiated between pain provoking avoidance or pain without benefit. Pain management is determined by the underlying diagnosis and clinical status. Use of Narcotic Analgesics: Narcotic analgesics have the potential for abuse and pose public health risks. Abuse has increased among street and recreational drug users. The Australian Government restricted access to combination codeine containing medications, requiring a prescription and medical supervision. Discussion: While there exist specific pain syndromes, the use of narcotic analgesics should be judicious. Their use should be restricted to refractory pain but should not exclude their legitimate use, once alternative remediation has been exhausted and entails medical supervision. Conclusion: Narcotic analgesics should not be the first line treatment for pain, with initial approach directed towards diagnosis and treating the underlying cause. Once refractory chronic pain has been established, narcotic analgesics should be available under medical supervision, acknowledging the risk of overuse and addiction.

Planning for the next pandemic: Reflections on lessons from the uncontained transmission phases of the COVID-19 pandemic and their impacts on emergency departments in Australia.

Australia was a world leader in managing the earlier waves of the COVID-19 pandemic. Subsequently, three major turning points changed the trajectory of the pandemic: mass vaccinations, emergence of more transmissible variants and re-opening of Australia's borders. However, there were also concomitant missteps and premature shifts in pandemic response policy that led to mixed messaging, slow initial vaccination uptake and minimal mitigation measures in response to the Omicron variant. The latter marked Australia's entry into a new phase of (or approach to) the pandemic: widespread transmission. This led to an exponential increase in cases and significant impacts on the health system, particularly, EDs. This paper reflects on this phase of the pandemic to urge for system-level changes that instal better safeguards for ED capacity, safety and staff well-being for future pandemics. This is essential to strengthening our health system's resilience and to better protecting our communities against such emergencies.

Understanding experiences of Aboriginal and/or Torres Strait Islander patients at the emergency departments in Australia.

The present study describes the experiences of Aboriginal and/or Torres Strait Islander patients and the factors that shaped their experiences of ED visits in regional settings. This is a qualitative descriptive study. We conducted semi-structured in-depth interviews with Aboriginal and/or Torres Strait Islander patients who used the ED services at three hospitals in New South Wales, Northern Territory and South Australia. We coded the collected data and analysed them using a thematic analysis technique. A total of 33 Aboriginal and/or Torres Strait Islander patients participated. Analyses of their experiences revealed four themes, which included: (i) patients' waiting times in ED; (ii) cultural determinants of health; (iii) treatment services; and (iv) safety, security and privacy. A holistic approach and a robust hospital commitment to address cultural needs while considering overall health, social and emotional wellbeing, will enhance Aboriginal and/or Torres Strait Islander patients' satisfaction for ED visits.

Temporal changes in the epidemiology of sepsis-related intensive care admissions from the emergency department in Australia and New Zealand.

The Australasian Resuscitation in Sepsis Evaluation (ARISE) study researched septic shock treatment within EDs. This study aims to evaluate whether: (i) conduct of the ARISE study was associated with changes in epidemiology and care for adults (≥18 years) admitted from EDs to ICUs with sepsis in Australia and New Zealand; and (ii) such changes differed among 45 ARISE trial hospitals compared with 120 non-trial hospitals. Retrospective study using interrupted time series analysis in three time periods; 'Pre-ARISE' (January 1997 to December 2007), 'During ARISE' (January 2008 to May 2014) and 'Post-ARISE' (June 2014 to December 2017) using data from the Australian and New Zealand Intensive Care Society Adult Patient Database. Over 21 years there were 54 121 ICU admissions from the ED with sepsis; which increased from 8.1% to 16.4%; 54.6% male, median (interquartile range) age 66 (53-76) years. In the pre-ARISE period, pre-ICU ED length of stay (LOS) decreased in trial hospitals but increased in non-trial hospitals (P= 0.174). During the ARISE study, pre-ICU ED LOS declined more in trial hospitals (P= 0.039) as did the frequency of mechanical ventilation in the first 24 h (P= 0.003). However, ICU and hospital LOS, in-hospital mortality and risk of death declined similarly in both trial and non-trial hospitals. Sepsis-related admissions increased from 8.1% to 16.4%. During the ARISE study, there was more rapid ICU admission and decreased early ventilation. However, these changes were not sustained nor associated with decreased risk of death or duration of hospitalisation.

Just Talk to Me - A Qualitative Study of Patient Satisfaction in Emergency Departments.

Communication between patients and hospital staff is a vital part of patient satisfaction and can contribute to better healthcare outcomes. Especially in emergency departments, where the workload is high, it is difficult to always address the communication needs of patients. In a qualitative study, we interviewed 32 patients in emergency departments in Australia. We found that, in the context of the emergency department, the characteristics of the source assumes an essential role in the appraisal of information. Especially if patients show low health literacy hospital staff needs to engage with them. It is important that patients feel informed as this increases patient satisfaction, even though they may not fully understand the delivered information.

Assessment of patient safety culture in two emergency departments in Australia: a cross sectional study

PurposePatient safety culture is a vital element to create patient safety in healthcare organisations. Emergency department (ED) professionals operate in unstable conditions that may pose risk to patient safety on day-to-day basis. The aim of this study was to assess the status of patient safety culture and to quantify the dimensions of safety culture in the ED setting.Design/methodology/approachThis was a descriptive cross sectional study that used a validated questionnaire distributed to the staff working in the nominated EDs . Perceptions on various dimensions of safety culture were reported and the frequency of positive responses for each dimension was calculated.Findings“Teamwork” is the only dimension that rated positive by over 70% of participants. Other dimensions rated below 50%, except for “Organisational learning–continuous improvement” which rated 51.2%. Areas that rated the lowest were “Handover and transitions”, “Staffing”, “Non-punitive response to error” and “Frequency of event reporting” with average positive response rate of 15.4%, 26%, 26.8% and 27.6%, respectively.Originality/valueThis study displayed a concerning perceptions held by participants about the deficiency of patient safety culture in their EDs. Moreover, it provided a baseline finding giving a clearer vision of the areas of patient safety culture that need improvement.

The phenomenon of caring for older patients who are dying from traumatic injuries in the emergency department: An interpretive phenomenological study

PurposeTo gain greater understanding of what it means to care for older patients dying from traumatic injuries in the emergency department.DesignA Heideggerian phenomenological design using the methods of Van Manen.MethodsIn‐depth, face‐to‐face interviews were conducted with five emergency nurses who worked in an emergency department in Australia. Interview data were interpreted using a Heideggerian hermeneutic approach and guided by Van Manen’s lifeworld analysis focusing on the experiential aspects of lived time (temporality) and lived space (spatiality) in the phenomenon.FindingsThe older patient reflects the passage of chronological time. This temporal aspect shaped the participant experience as there was a sudden awareness of the impact of the injuries sustained on the fragile physical condition of the patients. There was an unexpectedness and unpreparedness which was related to a precognitive assumption that the older patient would die from an age‐related comorbid condition. Also of significance was the sacred liminal space in which the nurses worked to facilitate the dying patient transition from life to death.ConclusionsThe existential dimensions of temporality and spatiality revealed new insights into what it means to care for elderly patients dying from traumatic injuries. Temporal aspects were shaped by the longevity of the lives of patients and spatiality explored the liminal space where participants were morally guided to deliver end of life care with dignity and respect for a long‐lived life taken by trauma.Clinical relevanceThe findings may contribute to further understanding of what shapes the experience for emergency nurses delivering EOL care in the ED, with specific relevance and focus on the older patient with traumatic injuries. Hermeneutic research may also encourage clinicians to explore phenomena to reveal new understandings that will inform further dialogue and future research.

Managing Job‐Related Diversity Processes in High‐Reliability Teams in the Emergency Department

AbstractWe examine how high‐reliability teams (HRTs) manage job‐related diversity, which refers to differences among team members in skills and experiences relevant to work tasks. Managing job‐related diversity is important in HRTs because of the need for consistent performance in time‐pressured situations with serious consequences for error. In a qualitative study, we observe and interview members of HRTs in a public hospital emergency department in Australia. Our findings reveal a set of six strategies that HRTs in emergency departments use to manage different types of job‐related diversity. Strategies of active explanations and experience‐based task assignment manage educational diversity within HRT team processes. Strategies of deferring to a single leader and balancing delegation and participative leadership manage power diversity. Finally, strategies of sequential specialist involvement and a co‐production mindset manage functional diversity. Our theoretical model of these strategies and their implications for team processes deepen understanding of job‐related diversity in HRTs. Our study contributes to the literature by (1) shining light on managing the double‐edged sword of job‐related diversity in HRTs; (2) opening up insight into differences in diversity management processes between HRTs and traditional teams; and (3) informing debate in the broader teams literature about specific versus generic processes for managing diversity.

Multicultural presentation of chest pain at an emergency department in Australia.

To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non-CALD chest pain (CP) patients presenting to the ED. A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2-week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records. There were 155 (60%) CALD and 103 (40%) non-CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac-specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8). Both CALD and non-CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences.

Mild traumatic brain injury in children with ventricular shunts: a PREDICT study.

Current clinical decision rules (CDRs) guiding the use of CT scanning in pediatric traumatic brain injury (TBI) assessment generally exclude children with ventricular shunts (VSs). There is limited evidence as to the risk of abnormalities found on CT scans or clinically important TBI (ciTBI) in this population. The authors sought to determine the frequency of these outcomes and the presence of CDR predictor variables in children with VSs. The authors undertook a planned secondary analysis on children with VSs included in a prospective external validation of 3 CDRs for TBI in children presenting to 10 emergency departments in Australia and New Zealand. They analyzed differences in presenting features, management and acute outcomes (TBI on CT and ciTBI) between groups with and without VSs, and assessed the presence of CDR predictors in children with a VS. A total of 35 of 20,137 children (0.2%) with TBI had a VS; only 2 had a Glasgow Coma Scale score < 15. Overall, 49% of patients with a VS underwent CT scanning compared with 10% of those without a VS. One patient had a finding of TBI on CT scanning, with positive predictor variables on CDRs. This patient had a ciTBI. No patient required neurosurgery. For children with and without a VS, the frequency of ciTBI was 2.9% (95% CI 0.1%-14.9%) compared with 1.4% (95% CI 1.2%-1.6%) (difference 1.5% [95% CI -4.0% to 7.0%]), and TBI on CT 2.9% (95% CI 0.1%-14.9%) compared with 2.0% (95% CI 1.8%-2.2%) (difference 0.9%, 95% CI -4.6% to 6.4%). The authors' data provide further support that the risk of TBI is similar for children with and without a VS.

Professional Values and Managerialist Practices: Values work by nurses in the emergency department

Interest in values work – the purposeful effort of actors to create, maintain and disrupt the values of organizations, professions and other institutions – is growing among scholars. We ask: How do frontline professionals engage in values work while enacting managerialist practices inside organizations? We investigate this question using a case study of nurses enacting managerialist practices associated with time-efficient work flow in a hospital emergency department in Australia. Our findings show that professionals engage in values work by categorizing the values of the profession and taking actions within the managerialist practice to (1) defend a superordinate value category, (2) contain erosion of a subordinate value category, and (3) integrate a basic value category. Our study brings attention to how multiple values complicate the processes of values work when particular values become implicated in organizational practices. Frontline professionals become motivated and take actions to accomplish values within a relational system of multiple values according to relative importance and relevance to the local context. Our study offers a way forward for understanding the performance of values work within the ‘new normal’ for professions in contemporary organizational contexts.

Managing Diversity in High-Reliability Teams in the Emergency Department

We examine the question of how High-Reliability Teams (HRTs) manage deep-level diversity, with a particular focus on educational diversity, power diversity and functional diversity. To investigate this question, we conduct a qualitative inductive study of a public hospital emergency department in Australia. Our findings reveal a set of six strategies that HRTs in emergency departments use to manage different types of deep-level diversity. Strategies of active explanations and experience-based task assignment manage educational diversity within HRT team processes. Strategies of deferring to a single-leader and balancing delegation and participative leadership manage power diversity. Finally, strategies of sequential specialist involvement and a co-production mindset manage functional diversity. Our theoretical model of these strategies and their implications for effective and ineffective team processes contributes to the literature by offering nuanced insight into deep-level diversity in HRTs and opens up new avenues for future process-based inquiry into HRTs.

A structure and process evaluation of the Geriatric Emergency Department Intervention model

BackgroundThe positive effect of the Geriatric Emergency Department Intervention (GEDI) model, on the outcomes of frail older adults, is established. This study aimed to describe and evaluate the structures and processes required for the effective delivery of the GEDI model to assist in its potential translation into emergency departments in Australia and overseas. MethodsThis was a descriptive qualitative study. Twenty-four semi-structured interviews were conducted with emergency department staff and GEDI doctors and nurses from a regional hospital in Queensland, Australia. An a priori framework guided interview questions and analysis. ResultsStructures required for successful model deployment included having an emergency department physician champion and nurses with gerontology experience, adequate funding, and geriatric specific resources. Processes identified as fundamental to the GEDI model included having a targeted approach to assessment, a patient-centred approach to care, and staff with inter-facility, intra-facility and inter-personal communication skills. ConclusionsThe GEDI model addresses the specific care needs of our aging population. For optimal performance of the model, key structures and processes require identification and acknowledgement. Research involving qualitative methodology is vital for successful translation and integration of emergency department models of care.

Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study.

To characterise the causes, clinical characteristics and short-term outcomes of neonates who presented to paediatric emergency departments with a head injury. Secondary analysis of a prospective data set of paediatric head injuries at 10 emergency departments in Australia and New Zealand. Patients without neuroimaging were followed up by telephone call. We extracted epidemiological information, clinical findings and outcomes in neonates (≤28 days). Of 20 137 children with head injuries, 93 (0.5%) occurred in neonates. These were mostly fall-related (75.2%), commonly from a care giver's arms, or due to being accidentally struck by a person/object (20.4%). There were three cases of non-accidental head injuries (3.2%). Most neonates were asymptomatic (67.7%) and many had no findings on examination (47.3%). Most neonates had a Glasgow Coma Scale 15 (89.2%) or 14 (7.5%). A total of 15.1% presented with vomiting and 5.4% were abnormally drowsy. None had experienced a loss of consciousness. The most common findings on examination were scalp haematoma (28.0%) and possible palpable skull fracture (6.5%); 8.6% underwent computed tomography brain scan and 4.3% received an ultrasound. Five of eight computed tomography scan (5.4% of neonates overall) showed traumatic brain injury and two of four (2.2% overall) had traumatic brain injury on ultrasound. Thirty-seven percent were admitted, one patient was intubated and none had neurosurgery or died. Neonatal head injuries are rare with a mostly benign short-term outcome and are appropriate for observation. However, non-accidental injuries need to be considered.

Imaging and admission practices in paediatric head injury across emergency departments in Australia and New Zealand: A PREDICT study.

Variation in the management of paediatric head injury has been identified worldwide. This prospective study describes imaging and admission practices of children presenting with head injury across 10 hospital EDs in Australia and New Zealand. Prospective observational multicentre study of 20 137 children (under 18 years) as a planned secondary analysis of the Australasian Paediatric Head Injury Rules Study. All presentations with head injury without prior imaging were eligible for inclusion. Variations in rates of computed tomography of the brain (CTB) and admission practices between sites, ED type and country were investigated, as were clinically important traumatic brain injuries (ciTBIs) and abnormal CTBs within CTBs. Among the 20 137 enrolled patients, the site adjusted CTB rate was 11.2% (95% confidence interval [CI] 7.8-14.6); individual sites ranged from 2.6 to 18.6%. ciTBI was found in 0.4-2.2%, with abnormal scans documented in 0.7-6.5%. As a percentage of CTBs undertaken, ciTBIs were found in 12.8% (95% CI 10.8-14.7) with individual site variation of 8.8-16.9%, and no statistically significant difference noted, and traumatic abnormalities in 29.3% (95% CI 26.2-32.3) with individual site variation between 19.4 and 35.6%. Among those under 2 years,traumatic abnormalities were found in greater than 50% of CTBs at 90% of sites. Admission rate overall was 24.0% (site adjusted) with wide variation between sites (5.0-48.9%). Across the 10 largely tertiary EDs included in this study, the overall CTB rate was low with no significant variation between sites when adjusted for ciTBIs.

Is it a Tie at This Point in the Game? Efficacy of Levetiracetam and Phenytoin for the Second-Line Treatment of Convulsive Status Epilepticus.

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Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments. We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge. Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50). Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis. None.

Family needs during critical illness in the Emergency Department: A retrospective factor analysis of data from three countries.

To examine underlying factor structure of the Critical Care Family Needs Inventory-Emergency Department across three countries to identify similarities and differences. Understanding family needs assists nurses to provide family-centred care to deliver optimal outcomes for critically ill patients and their families in Emergency Departments. Retrospective secondary analyses of data collected in three cross-sectional surveys. Convenience samples involved recruitment of family members accompanying a critically ill relative into four Emergency Departments in Australia (2), South Africa (1) and Taiwan (1). Item-matched raw data from 374 responses to 40 items from the surveys were collated and analysed using confirmatory factor analysis methods. Reporting adhered to an adapted STROBE checklist. The factor structure of the 40-item Critical Care Family Needs Inventory-Emergency Department differed between countries. Analyses of the Australian data revealed a four-factor solution comprised of 18 items across four categories of family need (support, communication, participation and comfort); the Taiwanese data also demonstrated a four-factor solution comprised of 13 items (support, communication, participation and comfort); alternatively, the South African data revealed a two-factor solution comprised of nine items (communication and participation). Fifteen items did not match across the countries. However, loading for four items common across all three countries was related to family participation (3) and communication (1). The findings suggest family members from different countries responded to Critical Care Family Needs Inventory-Emergency Department items in different ways. Consistent with concepts of family-centred care, the study identified participation and communication needs that were common across the countries. The outcomes illustrate the challenge of providing appropriate care for family members during critical illness of a relative in the ED. Family perceptions of important needs during critical illness in the Emergency Department differ across countries; hence, the Critical Care Family Needs Inventory-Emergency Department has limited utility. Participation and communication needs emerged as common family needs.

Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial

Phenytoin is the current standard of care for second-line treatment of paediatric convulsive status epilepticus after failure of first-line benzodiazepines, but is only effective in 60% of cases and is associated with considerable adverse effects. A newer anticonvulsant, levetiracetam, can be given more quickly, is potentially more efficacious, and has a more tolerable adverse effect profile. We aimed to determine whether phenytoin or levetiracetam is the superior second-line treatment for paediatric convulsive status epilepticus. ConSEPT was an open-label, multicentre, randomised controlled trial conducted in 13 emergency departments in Australia and New Zealand. Children aged between 3 months and 16 years, with convulsive status epilepticus that failed first-line benzodiazepine treatment, were randomly assigned (1:1) using a computer-generated permuted block (block sizes 2 and 4) randomisation sequence, stratified by site and age (≤5 years, >5 years), to receive 20 mg/kg phenytoin (intravenous or intraosseous infusion over 20 min) or 40 mg/kg levetiracetam (intravenous or intraosseous infusion over 5 min). The primary outcome was clinical cessation of seizure activity 5 min after the completion of infusion of the study drug. Analysis was by intention to treat. This trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12615000129583. Between March 19, 2015, and Nov 29, 2017, 639 children presented to participating emergency departments with convulsive status epilepticus; 127 were missed, and 278 did not meet eligibility criteria. The parents of one child declined to give consent, leaving 233 children (114 assigned to phenytoin and 119 assigned to levetiracetam) in the intention-to-treat population. Clinical cessation of seizure activity 5 min after completion of infusion of study drug occurred in 68 (60%) patients in the phenytoin group and 60 (50%) patients in the levetiracetam group (risk difference -9·2% [95% CI -21·9 to 3·5]; p=0·16). One participant in the phenytoin group died at 27 days because of haemorrhagic encephalitis; this death was not thought to be due to the study drug. There were no other serious adverse events. Levetiracetam is not superior to phenytoin for second-line management of paediatric convulsive status epilepticus. Health Research Council of New Zealand, A+ Trust, Emergency Medicine Foundation, Townsville Hospital Private Practice Fund, Eric Ormond Baker Charitable Fund, and Princess Margaret Hospital Foundation.