Pediatric Assessment Triangle Research Articles

Salmonella Bacteremia in Spanish Pediatric Emergency Departments: Uncommon But Not Mild.

Salmonella spp. is an uncommon microorganism in bloodstream infections among pediatric patients in our setting, although in developing countries it is the most common causative organism in blood cultures. We describe the children presenting to pediatric emergency departments and diagnosed with Salmonella bacteremia (SB) and identify clinical and laboratory predictors of poor outcome (ie, complications, sequelae and death) by bivariate analysis. We performed an observational study and subanalysis of a multicenter prospective registry, including patients <18 years of age with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered young age, chronic diseases, immunosuppressive treatment and intestinal flora disruption as risk factors for SB. Of the 55 patients with SB (3.2% of registered bacteremia), 32 (58.2%) had no risk factors for SB, 42 (76.3%) had a normal pediatric assessment triangle and 45 (81.8%) an associated gastrointestinal infection (acute gastroenteritis or enteric fever). Nine (16.4%) had a poor outcome, including 1 death (1.8%). A poor outcome was more common in patients with an abnormal pediatric assessment triangle [odds ratio (OR): 51.6; 95% confidence interval (CI): 9.2-289.5], an altered physical examination (OR: 15.2; 95% CI: 4.4-58.8) and elevated C-reactive protein (OR: 1.01; 95% CI: 1.005-1.03). Most SBs were related to a gastrointestinal infection. One in 6 children had a poor outcome; abnormal pediatric assessment triangle on arrival (25% of patients) was the main risk factor identified.

Red Code Management in a Pediatric Emergency Department: A Retrospective Study.

The "red code" (RC) represents the highest level of emergency in the emergency department (ED). This study retrospectively analyzed RCs in the Regina Margherita Children's Hospital ED, a regional referral center in north Italy, between 1 July 2020 and 30 June 2023. The aim was to describe RC characteristics and to identify significant correlations between presenting complaints and clinical management. The study includes 934 RCs (0.9% of overall ED admissions); 64% were assigned based on the Pediatric Assessment Triangle alteration. Most patients, 86.5%, followed the medical pathway, while 13.5% were surgical cases. Admission complaints were respiratory (46.9%), neuropsychiatric (26.7%), traumatic (11.8%), cardiologic (9.3%), metabolic (3.8%), and surgical (1.5%). Seventy-six percent of patients received vascular access, and intraosseous access was obtained in 2.2% of them. In one-third of RCs, an urgent critical care evaluation was necessary, and 19% of cases required admission to the intensive care unit. The overall mortality rate was 3.4% (0.4% in ED setting). The study identified six distinct diagnostic pathways, each associated with specific characteristics in clinical presentation, management, therapeutic interventions, and outcomes. Our findings underscore the need for a systematic approach in pediatric emergency settings, supported by international and national guidelines but also by clearly defined diagnostic pathways, aiming to enhance the quality of care and patient outcomes.

Assessment of the Value of the PAT as the First Step in the Triage Process in a Pediatric Emergency Room

Background: This study aimed to examine the correlation between the pediatric assessment triangle (PAT) and the rate of hospitalization among pediatric patients. Patients presenting to the pediatric emergency department were categorized based on PAT criteria during the study period, and retrospective data analysis was conducted. The primary outcome measure was the percentage of patients with PAT findings who required hospital admission; however, the secondary outcome measure focused on the association between PAT findings and admission to the pediatric intensive care unit (PICU) and the comparison between hospitalization rates with disrupted PAT versus blood testing as the initial diagnostic step. Methods: In this study, 622 patients were enrolled, and among them, 246 patients (39.5%) had normal findings in the peripheral arterial tonometry (PAT) test. The researchers conducted both univariate and multivariate analyses to investigate the relationship between PAT results and hospitalization. They also examined the association between hospitalization and abnormal findings in more than one component of PAT, presentation at the emergency department, performance of blood tests showing abnormalities in more than one component, and appearance while accounting for potential confounding factors. By adjusting for these confounders, the researchers aimed to assess the independent impact of PAT on hospitalization risk and identify any significant associations. Results: The study revealed a strong association between impaired PAT findings and hospitalization, both in univariate and multivariate analyses. Abnormal findings in &gt;1 component of PAT, appearance in the emergency department, and abnormal findings in &gt;1 component of blood tests were the most significant factors related to hospitalization, even after adjusting for confounders. Conversely, normal PAT findings showed no association with either the primary or secondary outcomes. Furthermore, hospitalization rates differed significantly between patients with impaired PAT and those with normal PAT. Conclusions: Impaired PAT findings, when utilized by pediatricians, are associated with increased hospitalization rates, even during the peak of the coronavirus disease 2019 (COVID-19) pandemic. Moreover, it is crucial to emphasize physician training in utilizing PAT effectively as the initial step in evaluating pediatric patients in the emergency room, potentially reducing the need for additional costly testing and enabling physicians to make more confident decisions.

Knowledge, Awareness, and Understanding of Pediatric Triage Among Nursing Officers in India: A Multicenter Study.

Triage is crucial in patient screening within emergency departments (EDs) worldwide. It is one of the essential and standard medical practices in many developed countries. However, in India, there is a need for improvement in triage utilization, as it is predominantly performed by resident doctors or medical officers, leading to an uneven distribution of clinical skills among healthcare providers (HCPs). A comprehensive analysis incorporating literature review and data collection revealed that while mandatory screening is conducted in most Indian EDs, the formal implementation of standardized triage protocols remains limited. Like in developed countries, registered nurses or nursing officers (NOs) can be effectively trained and directed to play the role of dedicated triage personnel in EDs of most of the healthcare facilities in India. This study aimed to examine the current state of triage utilization and its impact on the distribution of responsibilities among HCPs in Indian EDs. Through this online survey, the investigatorsassessed the knowledge and practical understanding of clinical triaging among NOs, working at various hospitals nationwide. The participants included 5,029 NOs working in various parts of India, predominantly nursing graduates (82.52%), the majority being employed in government healthcare settings (84.01%)and most having over five years of cumulative working experience in the ED (70.77%). Nurses showed inadequate knowledge and awareness about the Pediatric Assessment Triangle (PAT) used for quick initial evaluation (62.18%amongall participants). Concerning the complete triage process applicable, especially in pediatric ED settings, they had even less satisfactory knowledge and understanding, e.g., identifying primary (28.27%) and secondary (22.69%) survey components via focused history and examination, properly using temperature assessment (23.32%) and instant blood glucose level assessment (22.95%) in triage, and knowing various types of internationally accepted triage systems for ED-based health facilities such as the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), and Australasian Triage Scale (ATS) (15.87%). ANOVA and post hoc analysis revealed that the intergroup performance of the study participants with maximum correct responses to the knowledge-determining specified subset of the questionnaire depicts the significantly higher role of graduate nursing degree over diploma such as General Nursing and Midwifery (GNM)/Auxiliary Nursing and Midwifery (ANM) qualification, working in government hospital versus private setup, and ED working experience of >5 years over that of <5 years. Of the participants in the study, 50% were not evaluated for cognitive or psychomotor domains during their assessment examinations. The research illuminated a significant disparity in knowledge and proficiency levels among Indian nurses concerning pediatric triage, especially with the ability to effectively apply the PAT for initial patient evaluations, discern components of primary and secondary surveys, and comprehend various triage systems. This study underscores the importance of comprehensive reform in the Indian healthcare system and teaching curriculum by emphasizing clinical triage training and interprofessional collaboration, and establishing guidelines and regulations to ensure consistent and standardized triage practices across all EDs.

Staphylococcus aureus Bacteremia in the Pediatric Emergency Department and Predictors of Poor Outcome.

Staphylococcus aureus has become the leading cause of bacteremia among previously healthy children older than 5 years. We aimed to describe the infants presenting to pediatric emergency departments and diagnosed with S. aureus bacteremia (SAB) and identify predictors (clinical and laboratory variables) of poor outcome (complications, sequelae or death). We performed an observational study and subanalysis of a multicenter prospective registry, including every patient under the age of 18 years with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered chronic diseases, immunosuppressive treatment and the presence of mechanical devices as risk factors for SAB. Of the 229 patients with SAB, 176 (76.9%) were previously healthy, 192 (83.8%) had a normal pediatric assessment triangle and 158 (69.0%) had an associated focal infection (mainly osteoarticular infection, skin and soft tissue infection and pneumonia). Fifty-three patients (23.1%) had 1 or more risk factors for SAB. Thirty-one (13.5%) presented a poor outcome, including 4 deaths (1.7%). A poor outcome was more common in patients with SAB risk factors [odds ratio (OR): 7.0; 95% CI: 3.2-15.4], abnormal PAT (OR: 5.9; 95% CI: 2.6-13.3), elevated procalcitonin (OR: 1.2; 95% CI: 1.05-1.3) and C-reactive protein, the latter being the only independent predictor of poor outcome (OR: 1.01; 95% CI: 1.01-1.02). Overall, children with SAB are previously healthy, appear well, and have an associated focal infection. One out of 7 had a poor outcome, with C-reactive protein being the only predictor identified.

Pediatric infectious emergencies-from febrile seizure to purpura fulminans

Febrile seizures, which are relatively common in young children, are often triggered by an infection and resolve quickly. Prompt presentation to a pediatric department is mandatory after any first seizure and every time for children ≤ 12months. Central nervous system (CNS) diseases in childhood are able to cause seizures or other neurological disorders. Even the slightest suspicion of aseizure with CNS involvement must be promptly treated. In case of doubt, both an antiviral and an antibacterial treatment are started in parallel, which can be stopped after detecting the pathogen. Lumbar puncture is strictly indicated unless there are contraindications. Meningococcal sepsis is asevere clinical feature comprising high fever, chills and disorders of consciousness. The first skin symptoms are petechiae as ared flag sign. With progression, potentially lethal purpura fulminans may develop. Waterhouse-Friderichsen syndrome is asevere complication of acute bacterial meningitis. Lethality rate is 35%. The pediatric assessment triangle and the ABCDE algorithm help to identify critically ill children in a standardized, structured, and rapid manner.

Breathing disorders in children

Breathing disorders in children are one of the most common challenges for both parents and physicians. The first step should always consist of the initial clinical assessment concerning the potentially critically ill patient. Using the pediatric assessment triangle (PAT), the rapid evaluation of airway and breathing is crucial. Although the etiology of pediatric breathing disorders is manifold, we would like to focus on common diagnoses. Based on the three leading symptoms stridor, wheeze, and tachypnea, the most important diseases of pediatric patients are presented and initial treatment steps are discussed. We target crucial, life-saving, basic medical procedures that should be mastered and performed in and also outside of specialized centers or pediatric units.

The Pediatric Education for Prehospital Professionals Course and the Pediatric Assessment Triangle: A 25-Year Retrospective

The American Academy of Pediatrics established the Pediatric Education for Prehospital Professionals (PEPP) Course in 1998. A national PEPP Task Force rolled out the first courses in 2000, and PEPP rapidly became a foundational pediatric knowledge source in prehospital education. The backbone of the PEPP course is the pediatric assessment triangle (PAT), a simple assessment tool to help determine if an infant or child is “sick” or “not sick”, to identify the likely type of pathophysiology, and to gauge the urgency for intervention. The PAT has been validated in multiple studies as a reliable tool for emergency triage and for guiding initial management of children in both prehospital and emergency settings. Over 400,000 emergency medical services clinicians have taken the PEPP course, and the PAT has been integrated into life support courses, emergency pediatrics training, and pediatric assessment protocols worldwide. We describe the creation and successful implementation of the first national prehospital pediatric emergency care course, including the integration and widespread dissemination of an innovative assessment paradigm for pediatric emergency care education and training.

Towards a Clinical Decision Support System for Helping Medical Students in Emergency Call Centers.

In critical situations such as pandemic, medical students are often called to help in emergency call centers. However, they may encounter difficulties in phone triage because of a lack of medical skills. Here, we aim at developing a Clinical Decision Support System for helping medical students in phone call triage of pediatric patients. The system is based on the PAT (Pediatric Assessment Triangle) and local guidelines. It is composed of two interfaces. The first allows a quick assessment of severity signs, and the second provides recommendations and additional elements such as "elements to keep in mind" or "medical advice to give to patient". The system was evaluated by 20 medical students, with two fictive clinical cases. 75% of them found the content useful and clear, and the navigation easy. 65% would feel more reassured to have this system in emergency call centers. Further works are planned to improve the system before implementation in real-life.

Late-onset Group B Streptococcus Bacteremia Evaluated in the Pediatric Emergency Department and Risk Factors for Severe Infection.

To describe the infants presenting to pediatric emergency departments (PEDs) and diagnosed with group B Streptococcus (GBS) late-onset disease (LOD) bacteremia and identify risk factors for severe infection and pediatric intensive care unit (PICU) admission. Observational study and subanalysis of a multicenter prospective registry. Setting: pediatric emergency department. Inclusion criteria: infants between 7 and 89 days of age with positive blood culture for GBS seen between 2011 and 2016 at any of 22 Spanish PEDs. Main outcome: risk factors (clinical and laboratory variables) for severe infection (sepsis/septic shock or meningitis) and PICU admission. Second, the prevalence of poor outcomes (acute complications, sequelae or death). Among 118 patients with LOD, 74 (62.7%) presented a severe infection: 66 sepsis/septic shock (11 with associated meningitis) and 8 meningitis. Thirty-five patients (29.7%) were admitted to a PICU. An altered Pediatric Assessment Triangle (PAT) upon arrival and leukopenia were the only independent risk factors for severe infection [odds ratio (OR): 43.6; 95% confidence interval (CI): 8.1-235.7, P < 0.01] and PICU admission (OR: 11.6; 95% CI: 1.5-91.4; P < 0.019), respectively. Six patients (5.1%) developed a poor outcome, including 2 deaths (1.7%); all had an altered PAT, elevated procalcitonin (range 4.7-100 ng/ml), and were diagnosed with sepsis/septic shock and admitted to a PICU. Four developed leukopenia. Infants with GBS LOD frequently develop sepsis/septic shock and bacterial meningitis, associated with non-negligible morbidity and mortality. Clinical appearance was the only risk factor for severe infection, whereas leukopenia was related to PICU admission.

In-hospital pediatric patient transfers to the pediatric emergency department

Purpose: The aim of this study was to determine whether the clinical features of the cases referred from in-hospital areas to the pediatric emergency department (ED) with “reverse transport” have emergency characteristics and the reasons for the transfer, and to contribute to intra-hospital transfer protocols to be prepared. &#x0D; Materials and Methods: This is a retrospective cohort study. The clinical properties of 120 patients who were sent to the ED from the hospital area were evaluated. &#x0D; Results: 57.5% (69) of the patients were male and the median age was 42 months (0-210 months). 45.8% (55) were referred to the ED because their clinical condition required emergency treatment. 54.8% of these patients were stable according to Pediatric Assessment Triangle (PAT) and 78.6% were category 3, 4, 5 according to Emergency Severity Index (ESI). Only 4 patients received ESI life-saving procedures. 70% (84) were treated in the ED. There was a statistically significant difference between the PAT and ESI and the group of patients whose clinical status needed urgent treatment.&#x0D; Conclusion: Most of the patients sent to PED from other wards within the hospital are stable patients. For the effective use of the PED, the patients who will be transferred to the PED should be carefully evaluated by the relevant physician, priority should be given to the transport of hemodynamically unstable patients to the emergency room, and they should be treated appropriately in short-term follow-up or treatment units. For stable patients, an area independent from the emergency department should be created in line with the facilities of each hospital.

A Lecture to Teach an Approach and Improve Resident Comfort in Leading Resuscitation of Young Infants in the Emergency Department.

The intended audience of this lecture is emergency medicine residents at all levels of training. It is also appropriate for practicing emergency physicians interested in improving comfort in resuscitating sick young infants, ages 0-60 days. The majority of sick and injured children in the United States are seen and treated in general emergency departments.1 This includes very young infants (0-60 days old) in need of immediate resuscitation. Resuscitation of children in this age group involves use of specific knowledge and skills that residents and emergency physicians in general have fewer opportunities to practice.2,3 Emergency medicine residents and practicing emergency physicians often report this as an area of particular discomfort in practice.4,5 It is important that the inconsistent and infrequent opportunities to resuscitate young infants during emergency medicine residency and beyond are supplemented by residency didactics that focus on improving comfort and skills with this population of sick children. This lecture focuses on a practical approach intended to improve the relevant knowledge, skills, and confidence required to stabilize a critically ill young infant in a general emergency department. By the end of this lecture, participants should be able to:Apply a consistent approach to the initial resuscitation of a critically ill young infant in the emergency department.Select appropriate medications and equipment for use in resuscitation of critically ill young infants.Describe the components of the Pediatric Assessment Triangle,6 which can be used to identify critically ill infants and children.Improve comfort in resuscitating young infants in the emergency department. This is a live lecture format using PowerPoint slides. The lecture emphasizes a practical approach to improve the skills and knowledge required for successful young infant resuscitation. It utilizes a case-based approach, and encourages the audience to determine next steps in care to mimic the real time decision-making required for care of critically ill young infants in the ED. Learners were asked to fill out anonymous pre- and post quizzes immediately prior to and directly after the lecture was given. These surveys included questions to assess resident knowledge as well as resident comfort as it pertained to resuscitation of critically ill young infants. Resident comfort with resuscitation of young infants improved with a mean Standard Deviation (SD) pre-lecture rating of 23.1(14.9) on a 100-point visual analog scale and a mean (SD) post lecture rating of 46.7(14.6). Resident performance on all knowledge base questions improved on the post-lecture quiz for all four questions asked. This lecture was effective in improving emergency medicine resident comfort and practical knowledge pertaining to resuscitation of young infants in the emergency department. The emphasis on a practical approach was well received by the resident audience, and they engaged well with audience participation portions of the lecture. The impact of the lecture can be enhanced by having the lecturer share their own real-world experience of resuscitation of young infants in the emergency department during the discussion portions of the lecture. Neonatal resuscitation, infant resuscitation, pediatric assessment triangle, neonatal sepsis, congenital heart disease, congenital adrenal hyperplasia, non-accidental trauma, malrotation.

The Physiological Diagnosis Missing in the Pediatric Assessment Triangle.

The Physiological Diagnosis Missing in the Pediatric Assessment Triangle.

The accuracy of the pediatric assessment triangle in assessing triage of critically ill patients in emergency pediatric department

BackgroundThe Pediatric Assessment Triangle (PAT) is a rapid evaluation tool that establishes a child’s clinical status and his or her category of illness in order to direct initial management priorities. However, only few studies have examined its accuracy in assessing triage of critically ill patients in the emergency pediatric department (EPD) in China. ObjectiveTo quantitatively validate the accuracy in assessing critically ill medical children and nurses’ acceptance of PAT in the EPD. MethodsThis is a prospective observational study performed at The First People’s Hospital of Kunshan from January to May 2019. Ill children arriving to the EPD were assessed by trained nurses with the PAT and Pediatric early warning score (PEWS) at the same time. The five-level triage system used as the gold standard for comparing the accuracy of PAT was tracked following the triage. PEWS was compared with PAT in terms of assessment time and the degree of nurse’ acceptance. ResultsA total of 1608 subjects were included in this study, of whom 74 were critically ill. The AUROCC to screen out the critical children evaluated by PAT was 0.963. When the cut-off value of PAT score was 1, its sensitivity, specificity, PPV and NPV were 93.24%, 99.15%, 84.15% and 99.67%, respectively. The maximum value of the YI of PAT scored with 1 was 0.924. For the different categories of diseases, PAT had a better performance in assessing non-respiratory critical diseases (vs. respiratory critical diseases), with values of AUROCC of 0.986 vs 0.930, YI of 0.969 vs 0.858, respectively. For the different age of sick children, PAT had a better performance in assessing critical diseases in children aged 1 to 36 months (vs. 3 to 14 years), with values of AUROCC of 0.978 and 0.899, YI of 0.952 and 0.797, respectively. The assessment time of PAT was 13.81 ± 6.41 s, while PEWS score was 37.24 ± 10.29 s (t = 17.27, p < 0.001). The VAS scores of nurses’ acceptance of PAT and PEWS were 9.27 ± 0.87 and 8.57 ± 1.52, respectively. ConclusionsPAT can be used as a rapid and effective assessment tool in emergency triage in China. When a child's PAT score is 1 or more, the child's condition is critical and priority treatment should be arranged.

Validation of Songklanagarind Pediatric Triage Model in the Emergency Department; a Cross-Sectional Study.

Introduction:An effective triage needs to consider many factors, such as good triage protocol, experienced triage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage (SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associated with triage appropriateness. Methods:This study was done in two phases. In the first phase, a team of emergency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT model by considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), Pediatric Canadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of the hospital as the core concept. In the second phase, a prospective observational study was conducted in the ED of Songklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to October 2019 to evaluate the accuracy of the developed triage model. Results: A total of 520 pediatric patients met the inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%, respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction of death, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triage were 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage were underlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75‒9.23), fever (OR = 0.60, 95%CI: 0.41‒0.88), dyspnea (OR: 6.38, 95%CI: 2.51‒16.22), diarrhea (OR = 0.26, 95%CI: 0.09‒0.73), oxygen saturation <95% (OR = 3.18, 95%CI: 1.09‒9.27), accessory muscle use during breathing (OR = 3.67, 95%CI: 1.09‒12.41), and wheezing or rhonchi (OR = 6.96, 95%CI: 3.14‒15.43). Conclusion:SPT showed good correlation of hospital admission rates and resource utilization with pediatric triage level of urgency. However, further efforts are needed to decrease the rates of over- and under-triage.

Evaluation of Patients with Suspicion of COVID-19 in Pediatric Emergency Department.

Objectives:Coronavirus disease 2019 (COVID-19) have different clinical presentations in children. Most symptomatic children with suspicion of COVID-19 have fever and respiratory symptoms. In this retrospective study, we aimed to describe demographic features, clinical characteristics, and outcomes of confirmed and probable COVID-19 patients admitted to our pediatric emergency department (ED).Methods:We identified 135 children (aged 1 month-18 years) with suspicion of the COVID-19 who were admitted to our ED between March 11 and May 12, 2020. The urgency of patients was evaluated according to their Pediatric Assessment Triangle (PAT) and Emergency Severity Index (ESI) scores. Patients were divided into two groups as confirmed cases (Group 1) and probable cases (Group 2). Clinical, laboratory, radiologic features, and the disease severity of patients were analyzed.Results:According to PAT evaluation, 82 patients (65.6%) were non-urgent. The most frequent ESI triage category level was 3 (n=102, 76.1%). Forty-one (30.4%) patients were identified as laboratory-confirmed cases. Fifty-five (40.7%) patients were between 28 days and 4 years of age. Fever with cough was the most frequent symptoms at the onset of illness in COVID-19 positive patients (n=16, 39%). Sixty-four (47.4%) patients had mild disease and 40 (29.6%) patients had comorbidities. In Group 1, neutropenia was significantly higher than Group 2 (p=0.024). Mean procalcitonin and erythrocyte sedimentation rate levels of Group 2 were significantly higher than Group 1 (p=0.012 and p=0.028, respectively). Twenty-eight of 51 patients had chest computed tomography findings which were compatible with COVID-19. Fifty-one (37.8%) patients were discharged from ED, 81 (60%) were admitted to the ward, and 3 (2.2%) were admitted to the pediatric intensive care unit.Conclusion:During our study, we confirmed the diagnosis of 45 of 135 probable cases with the SARS-CoV-2 polymerase chain reaction test. Among confirmed COVID-19 cases, most of our patients had mild or moderate disease. The clinic of only confirmed three patients was classified as severe disease, and we had no critically ill patient.

Evaluation and Impact of the "Advanced Pediatric Life Support" Course in the Care of Pediatric Emergencies in Spain.

The Advanced Pediatric Life Support (APLS) course was introduced in the training of professionals who care for pediatric emergencies in Spain in 2005. To analyze the impact of the APLS course in the current clinical practice in Spanish PEDs. The directors of APLS courses were asked about information regarding the courses given to date, especially on the results of the satisfaction survey completed by students at the end of the course. Furthermore, in December 2014, a survey was conducted through Google Drive, specifically asking APLS students about the usefulness of the APLS course in their current clinical practice. In the last 10 years since the APLS course was introduced in Spain, there have been 40 courses in 6 different venues. They involved a total of 1520 students, of whom 958 (63.0%) felt that the course was very useful for daily clinical practice. The survey was sent to 1,200 students and answered by 402 (33.5%). The respondent group most represented was pediatricians, 223 (55.5%), of whom 61 (27.3%) were pediatric emergency physicians, followed by pediatric residents, 122 (30.3%). One hundred three (25.6%) respondents had more than 10 years of professional practice and 291 (72.4%) had completed the course in the preceding four years. Three hundred forty-one of the respondents (84.9%: 95% confidence interval [CI], 81.9-87.9) said that they always use the pediatric assessment triangle (PAT) and 131 (32.6%: 95% CI, 28-37.1) reported that their organization has introduced this tool into their protocols. Two hundred twenty-three (55.5%: 95% CI, 50.6-60.3) believed that management of critically ill patients has improved, 328 (81.6%: 95% CI, 77.8-85.3) said that the PAT and the systematic approach, ABCDE, help to establish a diagnosis, and 315 (78.4%: 95% CI, 74.3-82.4) reported that the overall number of treatments has increased but that these treatments are beneficial for patients. Hospital professionals (191; 47.5%) include the PAT in their protocols more frequently than pre-hospital professionals (68.5% vs 55.4%; p <0.01) and consider PAT useful in the management of patients (60.2% vs 51.1%; p <0.05). Neither the time elapsed since the completion of the course, nor category and years of professional experience had any influence on the views expressed about the impact of the APLS course in clinical practice. Most health professionals who have received the APLS course, especially those working in the hospital setting, think that the application of the systematic methods learned, the PAT and ABCDE, has a major impact on clinical practice.

Initial Asthma Severity Assessment Tools as Predictors of Hospitalization

BackgroundAssessment tools to classify and prioritize patients, such as systems of triage, and indicators of severity, such as clinical respiratory scores, are helpful in guiding the flow of asthmatic patients in the emergency department. ObjectiveOur aim was to assess the performance of the Pediatric Assessment Triangle (PAT), triage level (TL), Pulmonary Score (PS), and initial O2 saturation (O2 sat), in predicting hospitalization in pediatric acute asthma exacerbations. Study DesignRetrospective study evaluating PAT, TL, and PS at presentation, and initial O2 sat of asthmatic children in the pediatric emergency department (PED). The primary outcome measure was the rate of hospitalization. Secondary outcomes were length of stay (LOS) in the PED and admission to the pediatric intensive care unit (PICU). ResultsPAT, TL, PS, and initial O2 sat were recorded in 14,953 asthmatic children. Multivariate analysis yielded the following results: Abnormal PAT and more severe TLs (I–II) were independent risk factors for hospitalization (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4–1.8; OR 3.4, 95% CI 2.6–4.3, respectively) and longer LOS (OR 1.5, 95% CI 1.3–1.7; OR 2.6, 95% CI 2–3.3, respectively). PS > 3 showed a strong association with hospitalization (OR 8.1, 95% CI 7–9.4), PICU admission (OR 9.6, 95% CI 3–30.9) and longer LOS (OR 6.2, 95% CI 5.6–6.9). O2 sat < 94% was an independent predictor of admission (OR 5.2, 95% CI 4.6–5.9), PICU admission (OR 4.6, 95% CI 4.5–4.6), and longer LOS (OR 4.6, 95% CI 4.1–5.2). ConclusionsPAT, TL, PS, and initial O2 sat are good predictors of hospitalization in pediatric acute asthma exacerbations.

The Validity of the Pediatric Assessment Triangle as the First Step in the Triage Process in a Pediatric Emergency Department.

This study aimed to assess the association between pediatric assessment triangle (PAT) findings during triage and markers of severity in a pediatric emergency department (PED). During the study period, patients arriving to the PED were classified by trained nurses with the Pediatric Canadian Triage and Acuity Scale using a computer system, from which data were obtained and analyzed retrospectively. The primary outcome measure was the percentage of children hospitalized related with PAT findings. The secondary outcome measures were the admission to the intensive care unit (%), PED length of stay, and performance of blood tests (%). Among the 302,103 episodes included, there were abnormal PAT findings in 24,120 cases (7.9%). Multivariate analysis adjusted for age confirmed that PAT findings and triage level were independent risk factors for admission (odds ratio [OR], 2.21; 95% confidence interval [CI], 2.13-2.29; OR, 6.01; 95% CI, 5.79-6.24, respectively). Abnormal findings in appearance or in more than 1 PAT component were even more strongly associated with admission (3.99; 95% CI, 3.63-4.38; 14.99, 95% CI, 11.99-18.74, respectively). When adjusted for triage level and age, abnormal PAT findings were also an independent risk factor for intensive care unit admission (OR, 4.44; 95% CI, 3.77-5.24) and a longer stay in the PED (OR, 1.78; 95% CI, 1.72-1.84). Abnormal findings in the PAT applied by trained nurses at triage identify patients with a higher risk of hospitalization. The PAT seems to be a valid tool for identifying the most severe patients as a first step in the triage process.

Predictors of Outcome in Children with Status Epilepticus during Resuscitation in Pediatric Emergency Department: A Retrospective Observational Study.

Objectives:To study the clinical profile and predictors of outcome in children with status epilepticus (SE) during resuscitation in pediatric emergency department.Materials and Methods:This retrospective study was carried out in a tertiary care teaching hospital. Admission and resuscitation data of children, aged between 1 month and 12 years, treated for SE, between September 2013 and August 2014, were extracted using a standard data collection form. Our SE management protocol had employed a modified pediatric assessment triangle to recognize and treat acute respiratory failure, cardiovascular dysfunction (CD), and subtle SE until all parameters resolved. Continuous positive airway pressure, fluid boluses based on shock etiology, inotropes, and cardiac safe anticonvulsants were the other modifications. Risk factors predicting mortality during resuscitation were analyzed using univariate and penalized logistic regression.Results:Among 610 who were enrolled, 582 (95.4%) survived and 28 (4.6%) succumbed. Grunt odds ratio (OR): 3.747 (95% confidence interval [CI]: 1.035−13.560), retractions OR: 2.429 (95% CI: 1.036−5.698), rales OR: 10.145 (95% CI: 4.027−25.560), prolonged capillary refill time OR: 3.352 (95% CI: 1.339−8.388), and shock requiring >60 mL/kg fluids OR: 2.439 (95% CI 1.040−5.721) were associated with 2−3 times rise in mortality. Inappropriate prehospital treatment and CD were the significant predictors of mortality OR: 7.82 (95% CI 2.10−29.06) and 738.71 (95% CI: 97.11−999), respectively. Resolution of CD was associated with improved survival OR: 0.02 (95% CI: 0.003−0.17).Conclusion:Appropriate prehospital management and treatment protocol targeting resolution of CD during resuscitation could reduce mortality in children with SE.