Paediatric ultrasound-guided vascular access: Experiences and outcomes from an emergency department educational intervention.

AIM: This quality assurance project aims to describe the provision of an ultrasound-guided vascular access education package to paediatric emergency department staff. It subsequently aims to measure clinician and departmental responses to this educational intervention to support future effective education provision. METHODS: Participants were opt-in emergency department staff. Staff were required to be approved to insert intravenous cannulae in the department. A minimum of 50% were non-rotational staff. The educational package consisted of a theory phase (pre-learning video, information document), a practical phase (intensive 90-120 minute individualised session using a mix of live subjects/training equipment), and an embedding phase (education group available for procedural supervision). Data collection was via de-identified, encoded self-reported survey data and logbooks. RESULTS: Twenty-three staff were enrolled for training. Sixteen (69.9%) were non-rotational. Prior to the education intervention, 18 trainees (78.3%) had placed no successful ultrasound-guided peripherally inserted venous cannulae. By 15 weeks following training, six participants (28.6%) had achieved a predetermined competency benchmark; 61.9% had placed at least one successful ultrasound-guided cannula. Difficult intravenous (IV) access predictors were present in 46.3% of patients throughout the data collection period, with infants overrepresented in this group (64.9% with difficult IV access predictors). IV access attempts by staff with prior ultrasound experience increased from 11.0 to 81.8% post-education intervention. CONCLUSIONS: A low-resource brief educational intervention around ultrasound-guided vascular access is achievable. Several barriers to education uptake were presented. Targeting the group of trainees with a high degree of motivation led to the highest yield of benchmark competency acquisition.

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort.

BACKGROUND: Clinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population. METHODS: A single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc. RESULTS: 1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%). CONCLUSION: CSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

Point-of-care ultrasound in paediatric emergency medicine.

Point-of-care ultrasound (POC US) is an adjunct to clinical paediatric emergency medicine practice that is rapidly evolving, improving the outcomes of procedural techniques such as vascular access, nerve blocks and fluid aspiration and showing the potential to fast-track diagnostic streaming in a range of presenting complaints and conditions, from shock and respiratory distress to skeletal trauma. This article reviews the procedural and diagnostic uses, both established and emerging, and provides an overview of the necessary components of quality assurance during this introductory phase.