Pediatric Emergency Assessment Research Articles

Telemedicine vs Telephone Consultations and Medication Prescribing Errors Among Referring Physicians

Critically ill children presenting to emergency departments (EDs) in non-children's hospitals are at high risk for experiencing medical errors, including medication errors. Video telemedicine consultations with pediatric specialists have the potential to reduce the risk of medication errors beyond the current standard of care, telephone consultations. To compare the rates of ED physician-related medication errors among critically ill children randomized to receive either video telemedicine or telephone consultations. This cluster randomized, unbalanced crossover trial was conducted at 15 community EDs in northern California between September 2014 and March 2018. Analyses were conducted from May 2022 to January 2023. Participants included acutely ill children younger than 15 years presenting to a participating ED. Participating EDs were randomized to use video telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine to 1 telephone) crossover treatment assignment sequences. Pharmacists reviewed medical records to document physician-related medication errors using a previously validated instrument. Multilevel logistic regression analyses were performed to create models with the medication order as the unit of analysis and adjusting for age, the log-transformed Revised Pediatric Emergency Assessment Tool score, and hospital study period. A total of 696 patient encounters were included in the trial (mean [SD] age, 4.2 [4.6] years; median [IQR] age, 2.1 [0.5-2.1] years; 304 female [43.7%]), with 537 patient encounters (77.2%) assigned to video telemedicine and 159 patient encounters (22.8%) assigned to telephone. At least 1 physician-related medication error occurred for 87 patients (12.5%), including 20 of 159 patients (12.6%) in the telephone cohort and 67 of 537 patients (12.5%) in the telemedicine cohort. Of the 2414 medication orders, errors occurred in 124 cases (5.1%), including 26 of 513 orders (5.1%) in the telephone cohort and 98 of 1901 orders (5.2%) in the telemedicine cohort. In the multivariable analysis, the adjusted odds ratio of experiencing a medication error among those assigned to telemedicine was 0.86 (95% CI, 0.49-1.52; P = .61). This cluster randomized crossover trial found no statistically significant differences in physician-related medication errors between critically ill children assigned to receive telephone consultations vs video telemedicine consultations. ClinicalTrials.gov Identifier: NCT02877810.

Diagnostic Accuracy of the World Health Organization Pediatric Emergency Triage, Assessment and Treatment Tool Plus Among Patients Seeking Care in Nairobi, Kenya: A Cross-sectional Study.

The World Health Organization developed Emergency Triage Assessment and Treatment Plus (ETAT+) guidelines to facilitate pediatric care in resource-limited settings. ETAT+ triages patients as nonurgent, priority, or emergency cases, but there is limited research on the performance of ETAT+ regarding patient-oriented outcomes. This study assessed the diagnostic accuracy of ETAT+ in predicting the need for hospital admission in a pediatric emergency unit at Kenyatta National Hospital in Nairobi, Kenya. This was a secondary analysis of a cross-sectional study of pediatric emergency unit patients enrolled over a 4-week period using fixed random sampling. Diagnostic accuracy of ETAT+ was evaluated using receiver operating curves (ROCs) and respective 95% confidence intervals (CIs) with associated sensitivity and specificity (reference category: nonurgent). The ROC analysis was performed for the overall population and stratified by age group. A total of 323 patients were studied. The most common reasons for presentation were upper respiratory tract disease (32.8%), gastrointestinal disease (15.5%), and lower respiratory tract disease (12.4%). Two hundred twelve participants were triaged as nonurgent (65.6%), 60 as priority (18.6%), and 51 as emergency (15.8%). In the overall study population, the area under the ROC curve was 0.97 (95% CI, 0.95-0.99). The ETAT+ sensitivity was 93.8% (95% CI, 87.0%-99.0%), and the specificity was 82.0% (95% CI, 77.0%-87.0%) for admission of priority group patients. The sensitivity and specificity for the emergency patients were 66.0% (95% CI, 55.0%-77.0%) and 98.0% (95% CI, 97.0%-100.0%), respectively. ETAT+ demonstrated diagnostic accuracy for predicting patient need for hospital admission. This finding supports the utility of ETAT+ to inform emergency care practice. Further research on ETAT+ performance in larger populations and additional patient-oriented outcomes would enhance its generalizability and application in resource-limited settings.

Paediatric Emergency Triage, Assessment and Treatment (ETAT) – preparedness for implementation at primary care facilities in Malawi

ABSTRACT Background The majority of deaths amongst children under 5 years are still due to preventable infectious causes. Emergency care has been identified as a key health system weakness, and referrals are often challenging. Objective We aimed to establish how prepared frontline facilities in Malawi are to implement WHO Emergency Triage Assessment and Treatment (ETAT) guidelines, to support policy and planning decisions. Methods We conducted a concurrent mixed-methods study, including facility audit; healthcare provider survey; focus group discussions (FGD) and semi-structured interviews with facility staff. The study was conducted in two districts in Malawi, Zomba and Mchinji, between January and May 2019. We included all frontline facilities, including dispensaries, primary health centres, rural and community hospitals. Quantitative data were described using proportions, means and linear regression. Qualitative data was analysed using a framework approach. Data were analysed separately and then triangulated into common themes. Results Forty-seven facilities and 531 healthcare providers were included in the audit and survey; 6 FGDs and 5 interviews were completed. Four common themes emerged: (1) current emergency case management; (2) referral practices; (3) trained staff capacity; (4) opportunities and barriers for ETAT. Triage was conducted in most facilities with various methods described, and 53% reporting all staff are responsible. Referrals were common, but challenging due to issues in transportation. Twelve percent of survey respondents had ETAT training, with clinical officers (41%) reporting this more frequently than other cadres. Training was associated with increased knowledge, independent of cadre. The main barriers to ETAT implementation were the lack of resources, but opportunities to improve quality of care were reported. Conclusions Malawian frontline facilities are already providing a level of emergency paediatric care, but issues in training, drug supplies and equipment were present. To effectively scale-up ETAT, policies need to include supply chain management, maintenance and strengthening referral communication.

Inter-rater reliability of paediatric emergency assessment: physiological and clinical features

ObjectiveThe Paediatric Admission Guidance in the Emergency Department (PAGE) score is an assessment tool currently in development that helps predict hospital admission using components including patient characteristics, vital signs (heart...

Analysis of the implementation and effect of PEARS course in a hospital

The pediatric emergency assessment, recognition and stability (PEARS) courses were launched by American Heart Association in December 2007. The Shanghai Children's Medical Center (SCMC) affiliated to the Medicine School of Shanghai Jiao Tong University implemented the PEARS course training for all pediatric health care staff in batches in 2015 with the purpose of enhancing the capacity of initial judgment and stability and practicing the high-quality cardiopulmonary resuscitation, which achieved good results and better training satisfaction. The PEARS courses are helpful for paramedics to master the pediatric first-aid system evaluation method, and identification, assessment and processing of severe children properly, and meanwhile also emphasize the teamwork. The PEARS courses meet the requirements of the clinical practice of paramedics, and bear strong clinical practicability and maneuverability, furthermore, the training of them is effective in reducing medical errors. Consequently, it is recommended that the training is added into the continuing education and vocational education. Key words: Pediatric staff; Pediatric emergency assessment, recognition and stabilization (PEARS); Training; Effect analysis

Association of Insurance With Use of Emergency Medical Services Among Children.

The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED). In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings. Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results. In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

Appropriateness of Disposition Following Telemedicine Consultations in Rural Emergency Departments

To compare the appropriateness of hospital admission in eight rural emergency departments among a cohort of acutely ill and injured children who receive telemedicine consultations from pediatric critical care physicians to a cohort of similar children who receive telephone consultations from the same group of physicians. Retrospective cohort study between January 2003 and May 2012. Eight rural emergency departments in Northern California. Acutely ill and injured children triaged to the highest-level triage category who received either telemedicine or telephone consultations. Telemedicine and telephone consultations. We compared the overall and stratified observed-to-expected hospital admission ratios between telemedicine and telephone cohorts by calculating the risk of admission using the second generation of Pediatric Risk of Admission score and the Revised Pediatric Emergency Assessment Tool. A total of 138 charts were reviewed; 74 children received telemedicine consultations and 64 received telephone consultations. The telemedicine cohort had fewer hospital admissions compared with the telephone cohort (59.5% vs 87.5%; p < 0.05). Although the telemedicine cohort had lower observed-to-expected admission ratios than the telephone cohort, these differences were not statistically different (Pediatric Risk of Admission II, 2.36 vs 2.58; Revised Pediatric Emergency Assessment Tool, 2.34 vs 2.57). This result did not change when the cohorts were stratified into low (below median) and high (above median) risk of admission cohorts, using either Pediatric Risk of Admission II (low risk, 18.25 vs 22.81; high risk, 1.40 vs 1.54) or Revised Pediatric Emergency Assessment Tool (low risk, 5.35 vs 5.94; high risk, 1.51 vs 1.81). Although the overall admission rate among patients receiving telemedicine consultations was lower than that among patients receiving telephone consultations, there were no statistically significant differences between the observed-to-expected admission ratios using Pediatric Risk of Admission II and Revised Pediatric Emergency Assessment Tool. Our findings may be reassuring in the context of previous research, suggesting that telemedicine specialty consultations can aid in the delivery of more appropriate, safer, and higher quality of care.

Impact of contextualized pediatric resuscitation training on pediatric healthcare providers in Botswana

BackgroundWorldwide, 6.6 million children die each year, partly due to a failure to recognize and treat acutely ill children. Programs that improve provider recognition and treatment initiation may improve child survival. ObjectivesDescribe provider characteristics and hospital resources during a contextualized pediatric resuscitation training program in Botswana and determine if training impacts provider knowledge retention. Design/methodsThe American Heart Association's Pediatric Emergency Assessment Recognition and Stabilization (PEARS) course was contextualized to Botswana resources and practice guidelines in this observational study. A cohort of facility-based nurses (FBN) was assessed prior to and 1-month following training. Survey tools assessed provider characteristics, cognitive knowledge and confidence and hospital pediatric resources. Data analysis utilized Fisher's exact, Chi-square, Wilcoxon rank-sum and linear regression where appropriate. Results61 healthcare providers (89% FBNs, 11% physicians) successfully completed PEARS training. Referral facilities had more pediatric specific equipment and high-flow oxygen. Median frequency of pediatric resuscitation was higher in referral compared to district level FBN's (5 [3,10] vs. 2 [1,3] p=0.007). While 50% of FBN's had previous resuscitation training, none was pediatric specific. Median provider confidence improved significantly after training (3.8/5 vs. 4.7/5, p<0.001), as did knowledge of correct management of acute pneumonia and diarrhea (44% vs. 100%, p<0.001, 6% vs. 67%, p<0.001, respectively). ConclusionFBN's in Botswana report frequent resuscitation of ill children but low baseline training. Provider knowledge for recognition and initial treatment of respiratory distress and shock is low. Contextualized training significantly increased FBN provider confidence and knowledge retention 1-month after training.

The Implementation of PEARS Training: Supporting Nurses in Non-Critical Care Settings to Improve Patient Outcomes

Children's Hospital Boston's Life Support Program began offering the newly developed American Heart Association Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) course for nurses working in non-critical care settings in December of 2007. The goal was to provide an appropriate alternative to pediatric advanced life support (PALS) training for clinical staff caring for the general pediatric population. To date, more than 900 nurses have completed the course with feedback from the participants being extremely positive. Even more impressive is a more appropriate use of the hospital's emergency medical response system promoting early intervention and the significant reduction in cardiac arrests on inpatient units. During a 12-month period, nurses involved in activations of the response system were asked to rate their ability to assess, categorize, decide and act after each event. The overwhelming majority agreed they were able to apply the PEARS systematic approach of assessment and early intervention to the situation. This article describes the planning and implementation of PEARS training for non-critical care nursing staff and provides data that demonstrates improved patient outcomes. Supporting activities and strategies promoting early recognition and interventions contributing to the successful reduction of cardiac arrests on inpatient units are also discussed.

Derivation and validation of age and temperature specific reference values and centile charts to predict lower respiratory tract infection in children with fever: prospective observational study

Objectives To develop reference values and centile charts for respiratory rate based on age and body temperature, and to determine how well these reference values can predict the presence of...

Emergency assessment tariff: lessons learned

The cost of emergency assessment unit activities is shown to lie in the region of an outpatient attendance or the higher end of an A&amp;E attendance. Significant economy of scale in cost is demonstrated with the larger units having lower average costs. Acute Trusts make an average profit margin of greater than £300 per zero day (or same day) stay admission. This equates to an overpayment of greater than £300M for these ‘admissions’ and this then creates £300M of compensating errors and distortions across NHS finances. Part two of the series will demonstrate that assessment costs must be added back into the residual A&amp;E costs in order to arrive at a true picture for the overall emergency department costs, whereas part three looks specifically at the costs for paediatric emergency assessment. Both parts will discuss the additional flaws and complexities behind the tariff process relating to the wider emergency department functions.

New Opportunity to Improve Pediatric Emergency Preparedness: Pediatric Emergency Assessment, Recognition, and Stabilization Course

The ideal first response to a life-threatening pediatric emergency includes early recognition of the emergency, activation of the appropriate emergency response system, performance of basic life support (cardiopulmonary resuscitation/automated external defibrillator treatment), and initiation of advanced life support, but the extent of resuscitation training among health care providers likely to be first at the side of a critically ill or injured child is often deficient. In the past, resuscitation courses beyond basic life support focused on training advanced providers. The Pediatric Emergency Assessment, Recognition, and Stabilization course was developed by the American Heart Association to target a broad range of health care providers who are likely to be first at the side of a child requiring resuscitation. It is hoped that training of health care providers through the Pediatric Emergency Assessment, Recognition, and Stabilization course will translate into early recognition of life-threatening pediatric emergencies and greater resuscitation success, but results will depend on the availability of instruction and the maintenance of skills.

Ascertaining GP demand for a full-time paediatric emergency assessment unit

Changes in the general practitioner (GP) contract have led to the development of a variety of models for managing children who become sick outside of GP surgery hours. One such model is the hospital-based 24-hour paediatric emergency assessment unit (PEAU). This study sought to assess the demand for such a service in one English regional health authority. The opinions of general practitioners (GPs) regarding the service were sought via a fax survey, and a retrospective analysis of out-of-hour admissions staying less than 24 hours, over two discrete three-month periods. Differences in GP referral outcomes were also examined. GPs using the current PEAU (N=431) were invited to participate. GP’s responses, and analysis of PEAU out-of-hours throughput and admission trajectories were obtained. Results indicate that 83.9% of respondent GPs strongly agreed or agreed that the unit should provide a 24-hour PEAU service. 987 sick children were admitted to hospital out of PEAU opening hours, of which 404 had a stay of less than 24 hours. There was widespread approval by GPs to implement a 24-hour PEAU service, however, analysis of the hospital data showed that there were currently insufficient out-of-hours admissions to warrant changes in service delivery.

Revised Pediatric Emergency Assessment Tool (RePEAT): A Severity Index for Pediatric Emergency Care

To develop and validate a multivariable model, using information available at the time of patient triage, to predict the level of care provided to pediatric emergency patients for use as a severity of illness measure. This was a retrospective cohort study of 5,521 children 18 years of age or younger treated at four emergency departments (EDs) over a 12-month period. Data were obtained from abstraction of patient records. Logistic regression was used to develop (75% of sample) and validate (25% of sample) models to predict any nonroutine diagnostic or therapeutic intervention in the ED and admission to the hospital. Data on ED length of stay and hospital costs were also obtained. Eight predictor variables were included in the final models: presenting complaint, age, triage acuity category, arrival by emergency medical services, current use of prescription medications, and three triage vital signs (heart rate, respiratory rate, and temperature). The resulting models had adequate goodness of fit in both derivation and validation samples. The area under the receiver operating characteristic curve was 0.73 for the ED intervention model and 0.85 for the admission model. The Revised Pediatric Emergency Assessment Tool (RePEAT) score was then calculated as the sum of the predicted probability of receiving intervention and twice the predicted probability of admission. The RePEAT score had a significant univariate association with ED costs (r = 0.44) and with ED length of stay (r = 0.27) and contributed significantly to the fit of multivariable models comparing these outcomes across sites. The RePEAT score accurately predicts level of care provided for pediatric emergency patients and may provide a useful means of risk adjustment when benchmarking outcomes

Revised Pediatric Emergency Assessment Tool (RePEAT): A Severity Index for Pediatric Emergency Care

Revised Pediatric Emergency Assessment Tool (RePEAT): A Severity Index for Pediatric Emergency Care

411: Comparison of Pediatric Emergency Department Severity of Illness Models: The Pediatric Risk of Admission (PRISA) II and the Revised Pediatric Emergency Assessment (rePEAT) Tools

411: Comparison of Pediatric Emergency Department Severity of Illness Models: The Pediatric Risk of Admission (PRISA) II and the Revised Pediatric Emergency Assessment (rePEAT) Tools

Parental satisfaction with a nurse-led emergency assessment unit

Parents of children dischared from the paediatric emergency assessment unit of a large regional children's unit were surveyed to discover their perceptions of the care experience and post discharge support. Data from 40 parents revealed that the family journey through the unit was generally positive, although not without problems. The majority of children were referred from their general practitioner, and most were seen by a paediatrician within an hour of arrival. Morning-after phone calls and 24-hour access after discharge increased satisfaction. However, nearly a third of families reported they were not shown the facilities of the unit and just under half mentioned lack of privacy as a concern. An action plan to address these issues has been subsequently implemented and will be evaluated periodically.

GP views of nurse-led telephone referral for paediatric assessment

Following the introduction of a new nurse-led telephone referral service to a dedicated paediatric emergency assessment unit (PEAU), a study was conducted to determine the views of general practitioners (GPs) who use the service. The PEAU operates between 10 am and 10 pm on weekdays and between 10 am and 6 pm at weekends. The unit has four beds and treatment and stabilization areas, plus associated services in a dedicated area of a regional child health unit. The design utilized a faxed questionnaire over a 1-month period to all consenting GPs using the PEAU with a postal questionnaire follow-up. Non-parametric Likert scores and qualitative data were used to determine levels of satisfaction with the service and the subsequent management of the referred children. Sixty-nine GPs referred 80 children to the PEAU via the service over a period of 1 month. All consented to participate and were sent a faxed questionnaire, which generated 39 (57%) responses. A follow-up questionnaire sent to the 39 respondents achieved a return of 25 (64%) responses. Thirty-four GPs agreed that referral via the dedicated nurse service was easier than the previous senior house officer referral system. Of the 25 GP respondents to the follow-up postal survey, the majority (17) agreed that the follow-up morning after discharge telephone call to parents by the PEAU nurses was helpful. Four GPs indicated that the 24-hour open access system, offered by the nursing staff, in which a parent may attend PEAU with a discharged child causing concern without a previous appointment, does not always work. This study has shown that a nurse-led telephone referral system to a PEAU for GPs and the subsequent management of the children has been favourably received.

Quadrennial review of a paediatric emergency assessment unit.

The primary aim of this article is to report on one aspect of a quadrennial study designed to explore the appropriateness and impact of the development of a paediatric emergency assessment unit (PEAU) as a response to increases in paediatric emergencies presenting to a south-western regional child health unit. In particular, this article will present the findings of a prospective audit of admissions to the PEAU over a 1-month period during the latter part of 2002. The primary method of data collection utilized a structured survey instrument developed using a design and automatic data computer software package, completed by the nursing staff. Anonymized descriptive data were obtained from 223 children admitted to the PEAU during one calendar moth and authorized by the appropriate clinical directorate audit committee as part of its ongoing commitment to the full implementation of clinical governance. The data presented primarily relate to children admitted during the official opening times of the PEAU, and those presenting out of hours. The data analysis demonstrates a reduction in the number of children staying overnight in hospital since the opening of the PEAU, with the majority of children being referred by their own family doctor. Only one child in the sample was readmitted to the PEAU within 24 hours, and two within 24 hours of discharge as inpatients. Although thought to be pertinent, only one child admitted after official closing of the PEAU and out of hours was described as being admitted for social reasons. The International Classification of Diagnosis (ICD) 10 (World Health Organization (WHO), 1994) classifications of the children admitted to the PEAU reflect those found in other similar studies. Overall, the results of this investigation demonstrate that a PEAU can offer an efficient service to GPs, families and others as a route of referral, thus mitigating unnecessary overnight stays for individual children.

Pediatric emergency assessment tool (PEAT): a risk-adjustment measure for pediatric emergency patients.

To develop a multivariable model predicting the level of care required by pediatric patients for use as a risk-adjustment tool in the evaluation of emergency medical services for children. A random 10% sample of records of all visits over a 12-month period to a suburban, university-affiliated pediatric emergency department (PED) was selected and abstracted. The outcome variable, level of care received, was categorized in three levels: routine care only (R); diagnostic or therapeutic procedures performed in the ED but patient not admitted (EDT); and admission to hospital (ADM). Predictor variables included information routinely elicited and recorded at the time of triage. Using multinomial logistic regression, a predictive model was derived from a subset of 70% of the selected visits, and was validated in the remaining 30%. The total sample included 2,287 visits. The overall rate of each outcome was R-37%, EDT-53%, and ADM-10%. The final regression model included the following predictors significantly associated with the outcome: age, past medical history, temperature, abnormal respiratory rate or pulse oximetry in triage, chief complaint, and triage level (model likelihood ratio chi-square, 14 df = 332, p < 0.00001, R(2) = 0.14). The number of outcomes was well predicted by the model in both subsamples. Analysis of variance showed a significant association between Pediatric Emergency Assessment Tool (PEAT) score (weighted sum of the predicted probabilities of EDT and ADM) and both ED charges and time spent in the ED (p < 0.001). A model based on easily and routinely measured variables can accurately predict the level of care rendered in the PED. The predicted probabilities from such a model correlate well with other outcomes of care and may be useful in adjusting for differences in risk when evaluating quality of care.