Educational intervention does not reduce non-invasive urine contamination rates in children presenting to the emergency department.

AIM: Urinary tract infection is common in children with high contamination rates with non-invasive urine sampling (NIU). Our aims were to evaluate an educational tool for decreasing contamination rates and find factors associated with contamination. METHODS: This was a prospective cohort interventional study with a review of microbiology data and medical records of all NIU specimens collected at a large tertiary children's emergency department (ED) over a 1-year period. The intervention was the provision of a urine collection kit and educational pamphlet and education of staff. NIU contamination was calculated for 6 months pre-intervention and 6 months post-intervention. The association of factors with NIU contamination was evaluated for all cohorts (age, gender, presence of diarrhoea, season, time of day, time to incubation and activity of the ED). RESULTS: A total of 2104 NIU samples were included (median age 3 years, 52% females). There was no difference between periods in contamination rates (29.2% and 31.2%, respectively, P = 0.322). Collectively, high monthly activity of the department, age and female gender were associated with contamination. The highest contamination rates were among children aged 0-3 months and 12 years and older (38.1 and 48.9%, respectively). CONCLUSIONS: The urine collection kit and educational tool did not decrease NIU contamination rates in our ED. Contamination rates were correlated with the monthly activity of our department and female gender and were noticeably high among infants and adolescents. Given the high prevalence of urinary tract infection among these age groups, measures should be taken to reassess indications and methods for urine collection.

Managing adolescent behavioural and mental health problems in the Emergency Department.

Children and young people with behavioural issues frequently present to Emergency Departments. These are complex cases, often with a long preceding history. Caring for them requires a structured approach to ensure safety for the patient and all those involved. The HEADSS assessment is used as a framework. The Emergency Department focuses on treatment of the acute behavioural issues in the least restrictive manner possible. Ongoing behavioural issues are managed with referral to community and specialist resources.

Timing of antibiotics in febrile children meeting sepsis criteria at a paediatric emergency department.

OBJECTIVE: Delay in antibiotic administration in paediatric sepsis is associated with increased mortality and prolonged organ dysfunction. This pre-intervention study evaluated performance in paediatric sepsis management. METHODS: Retrospective cohort study of febrile children admitted through the ED at The Children's Hospital at Westmead, Sydney, between 1 May and 31 July 2017. Participants were children aged 29 days to 60 months excluding children with simple febrile seizures, neonates and children who had received intravenous antibiotics elsewhere. We assessed the timing of antibiotic administration in children meeting local sepsis guidelines. We conducted a survey of clinicians in ED in 2018 to describe contributing factors. RESULTS: There were 160 febrile children admitted and 144 presentations were included in the analysis. Male 53% (n = 76); median age 20.1 months (interquartile range [IQR] 3.9-37 months). Thirty-seven (26%) febrile children met local sepsis criteria. The median time from triage to first dose of intravenous antibiotic was 109 min (IQR 62-183 min). Delay (>60 min) occurred in 26 (76%) children. Reported reasons contributing to delay included high patient load, long waiting times, difficult intravenous access, delayed prescribing, inadequate staffing and difficulty distinguishing between a viral infection and serious bacterial infection. CONCLUSION: There was frequent delay in administering antibiotics in children meeting local sepsis criteria, more commonly in young infants. Reasons contributing to delay were specific to young children along with departmental factors that will require addressing through targeted quality improvement interventions.

Does location of rapid influenza diagnostic testing influence treatment time and ancillary testing in a paediatric emergency department?

OBJECTIVE: Influenza causes a significant burden of disease. Our aim was to assess whether location of rapid influenza diagnostic testing (RIDT) for patients with influenza-like illness (ILI) has an impact on ED treatment time or ancillary testing. METHODS: This was a retrospective observational study in a tertiary paediatric ED during 2017 influenza season. All patients with ILI were included. Some had RIDT performed (ED bedside or at the laboratory). Primary outcome measure was the correlation of RIDT location to treatment time compared to patients with ILI with no RIDT. Secondary outcome measures were the correlation of RIDT location to ancillary testing and treatment with antibiotics. RESULTS: A total of 1451 patients with ILI were included. Eighty patients for whom RIDT was performed at the laboratory had a shorter treatment time in the ED when compared to the 215 patients for whom RIDT was performed bedside (2.8 and 3.4 h, respectively; P < 0.0001). However, treatment time was not statistically different when sub-analysed for admitted and discharged patients separately. Overall, patients with ILI and no RIDT had the shortest treatment time in the ED (1.7 h). There was no difference in ancillary testing and treatment with antibiotics between ILI patients for whom RIDT was performed bedside or at the laboratory regardless of admission. CONCLUSION: Location of RIDT may not have a significant impact on treatment time, ancillary testing and treatment with antibiotics. When RIDT was not performed, patients had the shortest treatment time.

Pediatric travelers presenting to an Australian emergency department (2014-2015): A retrospective, cross-sectional analysis.

BACKGROUND: Epidemiological data on pediatric travelers are lacking, especially from Oceania. We aimed to evaluate travelers presenting to a pediatric emergency department in Sydney during a time of heightened travel surveillance. METHOD: Cases between December 2014 and February 2015 were ascertained by screening medical records for key terms and visa status, as well as laboratory data for malaria testing. Cases were restricted to communicable diseases and evidence of travel within 21 days. RESULTS: 104 children were identified. 82 children were Australian-resident travelers returning from abroad, 11 were visitors to Australia, 8 were recent migrants/refugees and 3 were medical transfers. Travel and behavioral patterns were characterized by exposures to low-income countries in the Asia-Pacific, visiting families and relatives, prolonged exposure periods and limited uptake of prophylaxis. Intrinsic vulnerabilities included extremes of age (median: 3.3 years) and pre-existing co-morbidities (6.7%). Common syndromes were respiratory (38.5%), systemic febrile illness (19.2%), acute diarrhea (17.3%) and dermatological conditions (9.6%). A minority were diagnosed with tropical infections: four typhoid or paratyphoid fever, two dengue and one tropical ulcer. CONCLUSIONS: Young travelers are a heterogeneous group who present with a broad spectrum of diseases, from the benign to the life-threatening. Our data may be used to inform diagnostic approaches, empiric therapies and contribute towards public health strategies.

Adverse events and risk factors during emergency intubation in a tertiary paediatric emergency department.

BACKGROUND: Rapid sequence intubation and emergency intubation in the emergency department (ED) can be life-saving procedures, but require the appropriate skills, experience and preparation to avoid complications ranging from simple trauma to life-threatening desaturation. Only scarce data exist in the published literature on complications following emergency intubation in children and most guidelines are extrapolated from the adult population. PATIENTS AND METHODS: We reviewed all emergency intubations of patients in our tertiary paediatric ED within a 2-year period to estimate the incidence of complications and to analyse the risk factors associated with this procedure. RESULTS: Seventy-two children were intubated; complications occurred in one in four and repeated attempts at intubation in 17/23 children. The median age of the children was 2 years (range: 0 days-6 years). The most common reason for intubation was altered level of consciousness and the most frequent diagnosis at the time of intubation was seizure/status epilepticus. Complications were related to desaturation (n=7), equipment failure (n=3), intravenous access (n=2) and hypotension (n=2), erroneous or insufficient drug preparation (n=1) and other reasons (n=3). There was no significant association of complications with the child's age or weight, time of arrival to ED, preintubation hypotension or combination of drugs used. CONCLUSION: Complications of rapid sequence intubation, a relatively low-frequency procedure in the paediatric ED, occurred in one of four children and repeat attempts at intubation were made in another 24%. We suggest that the use of an intubation checklist including the preparation of equipment and recommendations for drug use would minimize the occurrence of adverse events of intubation in children.

Serious injury is associated with suboptimal restraint use in child motor vehicle occupants.

AIM: To investigate the relationship between restraint usage and injury outcome in child motor vehicle occupants aged 2-8 years. METHODS: Retrospective case review of all child occupants presenting at the Children's Hospital at Westmead between July 2002 and January 2005 subsequent to a motor vehicle crash. Injury severity was assessed in terms of the Abbreviated Injury Scale (AIS), by age and type of restraint. RESULTS: Data were collected for 152 child occupants aged 2 and 8 years. While nearly all children (94%) used some restraint, most (82%) used a suboptimal form of restraint. Injury severity between optimally restrained children and suboptimally restrained children differed significantly (Fisher's exact test, P<0.001), with suboptimally restrained children receiving a greater proportion of moderate to severe (AIS 2+) injuries. No optimally restrained child sustained an AIS 2+ injury. CONCLUSION: A total of 82% of child occupants aged 2-8 years involved in crashes were suboptimally restrained. All children who sustained serious injuries were suboptimally restrained. There is a need to encourage correct use of the most appropriate restraint for child motor vehicle occupants in order to reduce the number and severity of injuries in these road users.