The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline.

BACKGROUND: Bronchiolitis is the commonest respiratory infection in children less than 12 months and cause of hospitalisation in infants under 6 months of age in Australasia. Unfortunately there is substantial variation in management, despite high levels of supporting evidence. This paper reports on the process, strengths and challenges of the hybrid approach used to develop the first Australasian management guideline relevant to the local population. METHOD: An adaption of the nine steps recommended by the National Health and Medical Research Council (NHMRC) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology were utilised. Following establishment of the Guideline Development Committee (GDC), we identified the population, intervention, comparator, outcomes and time of interest (PICOt) questions, undertook a systematic literature search and graded the evidence and recommendations using the NHMRC and GRADE processes. Using Nominal Group Techniques (NGT), consensus was sought in formulating the clinical practice recommendations and practice points. Key health professional bodies were consulted to ensure relevance in the Australasian emergency and ward settings. RESULTS: From 33 PICOT questions, clinical recommendations for practice that were deemed relevant to the Australasian population were identified. Specific considerations for the management of Australian and New Zealand indigenous infants in relation to the use of azithromycin and risk factors for more serious illness are included. Using NGT, consensus demonstrated by a median Likert score > 8 for all recommendations was achieved. The guideline presents clinical guidance, followed by the key recommendations and evidence review behind each recommendation. CONCLUSION: Developing evidence-based clinical guidelines is a complex process with considerable challenges. Challenges included having committee members located over two countries and five time zones, large volume of literature and variation of member's knowledge of grading of evidence and recommendations. The GRADE and NHMRC processes provided a systematic and transparent approach ensuring a final structure including bedside interface, and a descriptive summary of the evidence base and tables for each key statement. Involvement of stakeholders who will ultimately be end-users as members of the GDC provided valuable knowledge. Lessons learnt during this guideline development process provide valuable insight for those planning development of evidence-based guidelines.

A randomized controlled trial of 2 methods of immobilizing torus fractures of the distal forearm.

OBJECTIVES: Immobilization of torus fractures of the distal forearm, for 1 to 4 weeks in a slab, cast, or splint, produces good radiological and functional outcomes. This study assesses the pain associated with 2 forms of immobilization used for these injuries. METHODS: A randomized controlled trial comparing fiberglass volar slab and encircling plaster-of-paris cast was conducted at a children's hospital emergency department. Patients presenting with torus fractures of the distal forearm were enrolled and reviewed after 2 weeks of immobilization. A daily questionnaire was used during immobilization to assess pain, satisfaction, and activity state of the child. RESULTS: Adequate data were available for 42 participants in each group. Immobilization in a volar slab was associated with the following: increased duration of pain, with a median of 6.0 days (interquartile range [IQR] 2.0-11.0) versus 3.0 days (2.0-5.0) P = 0.009, and an increased time to resumption of normal activity at 2 weeks 67% versus 95%, P = 0.001. Average daily pain severity was similar in the 2 groups (35 mm on visual analogue scale [VAS] for the cast group vs. 39 mm for the slab group), P = 0.48. Stratified analysis showed pain on enrollment of greater than 50 mm on VAS, which was a strong association for longer duration of pain in both groups, P < 0.001. CONCLUSIONS: Use of a slab may increase the duration of pain, especially in patients who had more severe pain at presentation.

Processes and impediments in moving patients from the emergency department: pilot study.

OBJECTIVE: To assess the impact of an ED-designed interim orders sheet on patient flow through the ED, and the safety of ED-directed admission. METHODS: The flow of patients through the ED and inpatient length of stay (IPLOS) was retrospectively reviewed on 135 patients who were admitted using interim orders and 125 patients who were admitted after inpatient unit review in the ED. RESULTS: The median time to admission to the ward in the non-interim orders group was 5.7 h (interquartile range [IQR]: 3.8-8.5), with a range from 1.2 to 15.9 h, and in the interim orders group was 6.3 h (IQR: 4.8-8.0) with a range from 0.5 to 22 h (P=0.27). The median IPLOS was 4 days (IQR: 2.0-7.0) in the interim orders group, and 4 days (IQR: 2.1-9.0) in the non-interim orders group (P=0.19). CONCLUSION: There was no difference in the time to patient admission, or IPLOS, with the different processes. Almost half of the average ED stay of adults and about one-third of that of paediatric admissions occurred after the decision to admit was made. Transfer of patients to the ward without inpatient review is appropriate and effective.

Priapism as a presentation of T-cell acute lymphoblastic leukaemia in a child.

We report a case of a child who presented to the ED with priapism. This was the initial presentation of T-cell acute lymphoblastic leukaemia (ALL). To our knowledge, this is the first report of a child with T-cell ALL presenting with priapism. This case demonstrates the importance of identifying the underlying cause of priapism, as it directly impacts on both initial and ongoing management.

Improving emergency care for children: a model of collaboration between emergency departments.

OBJECTIVES: To determine whether a partnership between a tertiary paediatric hospital and a hospital with a mixed population of children and adults can improve emergency care for children. To describe the process of creating and maintaining such a partnership. METHODS: A partnership was created and various strategies employed to improve emergency paediatric care. This was evaluated by examination of demographic data, clinical audit, patient satisfaction surveys and staff satisfaction surveys. RESULTS: Paediatric attendances increased by 12% (P = 0.001), with a 33% increase in children under the age of 5 years (P = 0.001). Despite this there was a reduction of 6% in inpatient paediatric bed usage. Staff decision making and documentation improved during paediatric patient care, and parent and staff satisfaction with care of children improved. CONCLUSIONS: This initiative was successful in improving local paediatric facilities and patient care and is a new and innovative means of improving paediatric emergency care.