Emergency Research Networks Research Articles

Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis

BackgroundSerious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and...

Pediatric Anaerobic Blood Culture Practices in Industrialized Countries.

Routine anaerobic blood culture collection in febrile children is controversial, as clinicians try to account for the severe but relative infrequency of anaerobic bacteremia. Furthermore, clinical and laboratory practice variation among institutions may lead to potentially inaccurate epidemiological data. Our goal was to assess blood culture practices in pediatric patients throughout an international network of hospitals in industrialized countries. We conducted a survey of current clinical and laboratory practice patterns in a convenience sample of international institutions participating in 6 pediatric emergency research networks in the US, Canada, Europe, Australia, and New Zealand. A lead clinician at each institution queried institutional practices from the emergency department, pediatric intensive care unit, and oncology medical directors. The microbiology director at each institution completed the laboratory survey. Sixty-five of 160 (41%) invited institutions participated in the survey. Routine anaerobic blood cultures are collected in 30% of emergency departments, 30% of intensive care units, and 48% of oncology wards. Reasons for restricting anaerobic culture collection included concerns regarding blood volume (51%), low pretest probability (22%), and cost-effectiveness (16%). The most common reasons institutions allow for selectively obtaining anaerobic cultures are clinical suspicion (64%) and patients who are immunosuppressed (50%). The microbiology survey showed variation in systems, although most use the BACTEC™ culture system and MALDI-TOF for organism identification. There is broad variation in anaerobic blood culture practices among a network of pediatric hospitals in industrialized countries.

Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes.

Computed tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the use of CT scan guidelines in the management of pediatric trauma. The study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT use before and after CT-guideline implementation. Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis using published criteria from the Pediatric Emergency Care and Research Network. There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age < 15) trauma patients seen in our TC from 2010 to 2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay, readmissions, and mortality. Categorical and continuous variables were analyzed with χ and Wilcoxon rank-sum tests, respectively. p < 0.05 was considered significant. We identified 1,934 patients: 1,106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8%, respectively (p < 0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. Implementation of a pediatric CT guideline significantly decreases CT use, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. Therapeutic study, level IV.

Overcoming the Bronchiolitis Blues: Embracing Global Collaboration and Disease Heterogeneity.

* Abbreviation: RSV — : respiratory syncytial virus Although bronchiolitis is 1 of the most common conditions in infancy, no medicine has been proven to be consistently beneficial. As a result, the primary objective of frontline providers in primary care and emergency medicine is to triage infants to the appropriate level of care (ie, home, hospital ward, or intensive care) for their hydration and respiratory needs.1 However, prospectively validated risk-stratification tools for infants with bronchiolitis do not exist for frontline providers. Freire et al,2 as part of the Pediatric Emergency Research Networks, addressed this knowledge gap by analyzing data that were collected from 38 emergency departments across the globe to develop a bronchiolitis risk score. In the resulting article,2 the authors report that the usual suspects (ie, being ≤2 months of age; having apnea; oxygen saturation of <90%; signs of increased work of breathing [including nasal flaring, grunting, and retractions]; and dehydration and/or poor feeding) were all predictive of escalated care, which is defined as hospitalization with a high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission. Although many clinicians feel comfortable triaging infants with bronchiolitis at either … Address correspondence to Jonathan M. Mansbach, MD, MPH, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, 9 S. 9157, Boston, MA 02115. E-mail: jonathan.mansbach{at}childrens.harvard.edu

Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study.

Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7). More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.

51 Paediatric emergency clinicians are rarely exposed to non-airway critical procedures: a predict/PERN study

BackgroundRecent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how...

Radiologic Safety Events Within a Pediatric Emergency Medicine Network.

The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network. This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based. Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization. We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

A conceptual model for the development process of confirmatory adaptive clinical trials within an emergency research network.

Adaptive clinical trials use accumulating data from enrolled subjects to alter trial conduct in pre-specified ways based on quantitative decision rules. In this research, we sought to characterize the perspectives of key stakeholders during the development process of confirmatory-phase adaptive clinical trials within an emergency clinical trials network and to build a model to guide future development of adaptive clinical trials. We used an ethnographic, qualitative approach to evaluate key stakeholders' views about the adaptive clinical trial development process. Stakeholders participated in a series of multidisciplinary meetings during the development of five adaptive clinical trials and completed a Strengths-Weaknesses-Opportunities-Threats questionnaire. In the analysis, we elucidated overarching themes across the stakeholders' responses to develop a conceptual model. Four major overarching themes emerged during the analysis of stakeholders' responses to questioning: the perceived statistical complexity of adaptive clinical trials and the roles of collaboration, communication, and time during the development process. Frequent and open communication and collaboration were viewed by stakeholders as critical during the development process, as were the careful management of time and logistical issues related to the complexity of planning adaptive clinical trials. The Adaptive Design Development Model illustrates how statistical complexity, time, communication, and collaboration are moderating factors in the adaptive design development process. The intensity and iterative nature of this process underscores the need for funding mechanisms for the development of novel trial proposals in academic settings.

A national survey of emergency pharmacy practice in the United States

The results of a survey to characterize pharmacy practice in emergency department (ED) settings are reported. An electronic survey was sent to all members of the American Society of Health-System Pharmacists' Emergency Medicine Connect group and the American College of Clinical Pharmacy's Emergency Medicine Practice and Research Network. Approximately 400 nontrainee pharmacy practitioners were invited to participate in the survey, which was open for 30 days. Descriptive statistics were used for all analyses. Two hundred thirty-three responses to the survey that were at least partially completed were received. After the removal of duplicate responses and null records, 187 survey responses were retained. The majority of respondents were from community hospitals (59.6%) or academic medical centers (36.1%). A pharmacist's presence in the ED of more than eight hours per day on weekdays and weekends was commonly reported (68.7% of respondents); 49.4% of institutions provided more than eight hours of coverage daily. Nearly one in three institutions (34.8%) provided no weekend ED staffing. The most frequently reported hours of coverage were during the 1 p.m.-midnight time frame. The distribution of ED pharmacist activities, by category, was as follows (data are median reported time commitments): clinical, 25% (interquartile range [IQR], 15-40%); emergency response, 15% (IQR, 10-20%); order processing, 15% (IQR, 5-25%); medication reconciliation/history-taking, 10% (IQR, 5-25%); teaching, 10% (IQR, 5-15%); administrative, 5% (IQR, 3-10%); and scholarly endeavors, 0% (IQR, 0-5%). Pharmacists from academic and community EDs perform a variety of clinical, educational, and administrative activities.

Near misses and unsafe conditions reported in a Pediatric Emergency Research Network

ObjectivePatient safety may be enhanced by using reports from front-line staff of near misses and unsafe conditions to identify latent safety events. We describe paediatric emergency department (ED) near-miss events...

Febrile Young Infants With Altered Urinalysis at Low Risk for Invasive Bacterial Infection. A Spanish Pediatric Emergency Research Network’s Study

Febrile Young Infants With Altered Urinalysis at Low Risk for Invasive Bacterial Infection. A Spanish Pediatric Emergency Research Network’s Study

RNA transcriptional biosignature analysis for identifying febrile infants with serious bacterial infections in the emergency department: a feasibility study.

To develop the infrastructure and demonstrate the feasibility of conducting microarray-based RNA transcriptional profile analyses for the diagnosis of serious bacterial infections in febrile infants 60 days and younger in a multicenter pediatric emergency research network. We designed a prospective multicenter cohort study with the aim of enrolling more than 4000 febrile infants 60 days and younger. To ensure success of conducting complex genomic studies in emergency department (ED) settings, we established an infrastructure within the Pediatric Emergency Care Applied Research Network, including 21 sites, to evaluate RNA transcriptional profiles in young febrile infants. We developed a comprehensive manual of operations and trained site investigators to obtain and process blood samples for RNA extraction and genomic analyses. We created standard operating procedures for blood sample collection, processing, storage, shipping, and analyses. We planned to prospectively identify, enroll, and collect 1 mL blood samples for genomic analyses from eligible patients to identify logistical issues with study procedures. Finally, we planned to batch blood samples and determined RNA quantity and quality at the central microarray laboratory and organized data analysis with the Pediatric Emergency Care Applied Research Network data coordinating center. Below we report on establishment of the infrastructure and the feasibility success in the first year based on the enrollment of a limited number of patients. We successfully established the infrastructure at 21 EDs. Over the first 5 months we enrolled 79% (74 of 94) of eligible febrile infants. We were able to obtain and ship 1 mL of blood from 74% (55 of 74) of enrolled participants, with at least 1 sample per participating ED. The 55 samples were shipped and evaluated at the microarray laboratory, and 95% (52 of 55) of blood samples were of adequate quality and contained sufficient RNA for expression analysis. It is possible to create a robust infrastructure to conduct genomic studies in young febrile infants in the context of a multicenter pediatric ED research setting. The sufficient quantity and high quality of RNA obtained suggests that whole blood transcriptional profile analysis for the diagnostic evaluation of young febrile infants can be successfully performed in this setting.

Febrile young infants with altered urinalysis at low risk for invasive bacterial infection. a Spanish Pediatric Emergency Research Network's Study.

Urinary tract infection (UTI) is the most common serious bacterial infection (SBI) in infants younger than 90 days of age. Many physicians admit infants younger than 90 days old because of their greater risk of developing invasive bacterial infections (IBIs), secondary to UTI. The primary objective of this study was to design a prediction model to identify febrile infants younger than 90 days old with an altered urinalysis who were at low risk for IBI and suitable for outpatient management : Prospective multicenter study included 19 hospitals that are members of the Spanish Pediatric Emergency Research Group of the Spanish Society of Pediatric Emergencies. Febrile infants younger than 90 days old with altered urinalysis were included. A total of 766 (22.5%) infants with altered urine dipstick were analyzed. Fifty (6.5%) of them developed IBI, 39 (78.0%) secondary to UTI. Patients were at low risk for IBI if they were well appearing at arrival to the emergency department, were older than 21 days and had procalcitonin and C-reactive protein (CRP) blood values lower than 0.5 ng/mL and 20 mg/L, respectively. These factors were used to create a prediction model for IBI secondary to UTI, with a sensitivity of 100% (95% CI: 89.3-100) and a negative predictive value of 100% (95% CI: 97.5-100). We have derived a highly accurate prediction model for IBI in febrile infants with altered urinalysis. Given these results, outpatient management might be suitable for 1 of each 4 infants diagnosed, with a considerable improvement in resource utilization.

How safe are our paediatric emergency departments? Protocol for a national prospective cohort study

IntroductionAdverse events (AEs), defined as unintended patient harm related to healthcare provided rather than an underlying medical condition, represent a significant threat to patient safety and public health. The emergency...

Acute Trauma and Resuscitation Preceptorship

Acute Trauma and Resuscitation Preceptorship

Risk factors for severe H1N1 infection

Risk factors for severe H1N1 infection

Predictors of Severe H1N1 Infection in Children

Using data from patients who presented to 79 Pediatric Emergency Research Networks (PERN) emergency departments (EDs) in 12 countries during the 2009

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study

Objective To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness.Design Multicentre retrospective case-control study.Setting 79 emergency departments of...

Reported medication events in a paediatric emergency research network: sharing to improve patient safety

ObjectiveMedication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little...

Continuing Professional Development: Diagnosis and management of minor head injury in the UK

Overview Head injury accounts for a large amount of emergency services work in the UK. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. These studies included a review of current practice in the management of minor head injured patients (GCS 13–15) by way of a survey of UK emergency departments. We also performed a systematic review of the head injury literature to identify the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Paediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. This review helped to identify the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. Learning Outcomes After completing this module you will: • Have an understanding of the significant clinical characteristics following head injury • Understand potential pathological problems following head injury • Be able to assess the relevant clinical features of all patients following head injury • Be familiar with key clinical decision rules for patients with head injury • Be able to provide the appropriate pre-hospital management for all head injured patients.