Variation in CT use for paediatric head injuries across different types of emergency departments in Australia and New Zealand.

OBJECTIVES: CT of the brain (CTB) for paediatric head injury is used less frequently at tertiary paediatric emergency departments (EDs) in Australia and New Zealand than in North America. In preparation for release of a national head injury guideline and given the high variation in CTB use found in North America, we aimed to assess variation in CTB use for paediatric head injury across hospitals types. METHODS: Multicentre retrospective review of presentations to tertiary, urban/suburban and regional/rural EDs in Australia and New Zealand in 2016. Children aged <16 years, with a primary ED diagnosis of head injury were included and data extracted from 100 eligible cases per site. Primary outcome was CTB use adjusted for severity (Glasgow Coma Scale) with 95% CIs; secondary outcomes included hospital length of stay and admission rate. RESULTS: There were 3072 head injury presentations at 31 EDs: 9 tertiary (n=900), 11 urban/suburban (n=1072) and 11 regional/rural EDs (n=1100). The proportion of children with Glasgow Coma Score ≤13 was 1.3% in each type of hospital. Among all presentations, CTB was performed for 8.2% (95% CI 6.4 to 10.0) in tertiary hospitals, 6.6% (95% CI 5.1 to 8.1) in urban/suburban hospitals and 6.1% (95% CI 4.7 to 7.5) in regional/rural. Intragroup variation of CTB use ranged from 0% to 14%. The regional/rural hospitals admitted fewer patients (14.6%, 95% CI 12.6% to 16.9%, p<0.001) than tertiary and urban/suburban hospitals (28.1%, 95% CI 25.2% to 31.2%; 27.3%, 95% CI 24.7% to 30.1%). CONCLUSIONS: In Australia and New Zealand, there was no difference in CTB use for paediatric patients with head injuries across tertiary, urban/suburban and regional/rural EDs with similar intragroup variation. This information can inform a binational head injury guideline.

Development and implementation of an education and credentialing programme to provide safe paediatric procedural sedation in emergency departments.

OBJECTIVE: In the conduct of paediatric procedural sedation (PPS) within the ED the combination of powerful drugs, variable competency levels and high staff turnover carry the potential for sedation-associated adverse events. Yet, currently, there is no set programme for education and accreditation of ED staff in PPS. We set out to develop such a programme. METHODS: We outline the development process of a comprehensive multidisciplinary PPS programme and present its key educational elements (sedation manual, lecture, treatment order form and checklist, parent information handout) and credentialing through multiple-choice questions and competency assessments. We describe issues associated with the implementation of the programme at a metropolitan mixed ED and the ED of a major tertiary paediatric centre. RESULTS: Since its inception a total of 294 emergency staff have either completed or have partially completed the programme. Staff feedback showed that the majority of staff scored the elements of the programme as very good to excellent, and felt that their sedation skills had improved and their practice was safer. The development and implementation of the PPS programme raised many issues and posed a number of challenges. We describe the strategies we used to overcome such challenges and barriers. CONCLUSION: We present the development and implementation of a comprehensive PPS programme for emergency staff. As a result of the multicentre development process involving a community and a tertiary paediatric ED the programme will likely have broad applicability in different types of ED caring for children.

Evaluation of the impact of a paediatric procedural sedation credentialing programme on quality of care.

OBJECTIVES: The aim of the present study is to describe changes in documentation, risk assessment and patient care resulting from implementation of a credentialing process for medical and nursing staff in paediatric procedural sedation (PPS) in two EDs - one an urban mixed ED and the other a specialist paediatric ED. METHODS: Chart review of 100 patients undergoing PPS prior to and 100 patients following introduction of the PPS programme. Information was extracted from medical records and sedation checklists. Demographics, drugs used, procedure performed and elements of the pre-procedural, intra-procedural and post-procedural care were compared pre- and post implementation of the PPS programme. RESULTS: Significant improvements in the post-implementation period compared with pre-implementation were seen in: frequency of documentation of informed consent (87 vs 15%, P < 0.0001); evidence of performance of a pre-procedural risk assessment (87 vs 1%, P < 0.0001); and appropriate recording of vital signs (58 vs 27%, P < 0.0001). Improvements were also noted in documentation of weight, allergies, fasting status and recording of drug orders. There were no adverse events recorded in the pre-programme period and 6 recorded in the post-programme period. CONCLUSION: The implementation of a PPS credentialing programme into these two EDs resulted in significant improvements in risk assessment, monitoring and documentation of important information related to safe PPS. These improvements should result in improved quality and safety of PPS.

Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis.

OBJECTIVE: To compare the efficacy of 2 nasogastric rehydration regimens for children with acute viral gastroenteritis. METHODS: Children 6 to 72 months of age with acute viral gastroenteritis and moderate dehydration were recruited from emergency departments (EDs) at 2 metropolitan, pediatric, teaching hospitals. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either standard nasogastric rehydration (SNR) over 24 hours in the hospital ward or rapid nasogastric rehydration (RNR) over 4 hours in the ED. Primary (>2% weight loss, compared with the admission weight) and secondary treatment failures were assessed. RESULTS: Of 9331 children with acute gastroenteritis who were screened, 254 children were assigned randomly to receive either RNR (n = 132 [52.0%]) or SNR (n = 122 [48.0%]). Baseline characteristics for the 2 groups were similar. All patients made a full recovery without severe adverse events. The primary failure rates were similar for RNR (11.8% [95% confidence interval [CI]: 6.0%-17.6%]) and SNR (9.2% [95% CI: 3.7%-14.7%]; P = .52). Secondary treatment failure was more common in the SNR group (44% [95% CI: 34.6%-53.4%]) than in the RNR group (30.3% [95% CI: 22.5%-38.8%]; P = .03). Discharge from the ED after RNR failed for 27 patients (22.7%), and another 9 (7.6%) were readmitted to the hospital within 24 hours. CONCLUSIONS: Primary treatment failure and clinical outcomes were similar for RNR and SNR. Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients.

Application of topical local anesthetic at triage reduces treatment time for children with lacerations: a randomized controlled trial.

STUDY OBJECTIVES: We determine whether application of topical local anesthetic at triage reduces total treatment time for children with simple lacerations. METHODS: This prospective, randomized, double-blind, controlled trial was conducted in an urban pediatric emergency department (ED). Participants were children who were aged 1 to 10 years and had simple lacerations. Exclusions were wounds to digits, ears, penis, nose, or mucous membranes; wounds close to the eye; deep wounds involving bone, cartilage, tendon, or vessels; wounds older than 6 hours; allergy or previous reaction to local anesthetics; trivial wounds unlikely to require any intervention; previous anesthesia to area before presentation; and failure to obtain consent. Participants were randomized to application of adrenaline 1:1,000, lignocaine (lidocaine) 4%, and amethocaine 0.5% (ALA) or placebo (adrenaline 1:1,000 solution) at triage. The primary outcome measure was total treatment time (triage time to discharge time). Secondary outcomes were the proportion of children from each group who required sedation and subgroup analysis by mode of wound closure. Analysis was by Mann-Whitney U test comparing times and chi(2) test comparing sedation rate. RESULTS: One hundred sixty-one patients were eligible for analysis (84 ALA, 77 control). Sixty-five patients were sutured, 84 were treated with glue, 6 were treated with Steristrips, and 6 were not provided with formal closure. The median treatment time for the ALA group was 77 minutes compared with 108 minutes for the control group (effect size 31 minutes; 95% confidence interval 15 to 47 minutes; P =.0019). There was no difference in requirement for sedation between the groups. CONCLUSION: The application of ALA at triage significantly reduces total treatment time for children with simple lacerations.