The impact of transport of critically ill pediatric patients on rural emergency departments in Manitoba.

INTRODUCTION: Although the interfacility transport (IFT) of critically ill pediatric patients from rural to tertiary health centres may improve outcomes, the impact of IFTs on the rural referring centre is not known. The purpose of this study was to investigate how the IFT of critically ill children affects staffing and functionality of rural emergency departments (EDs) in Manitoba. METHODS: In 2015, surveys were emailed to the medical directors of all 15 regional EDs within 2 hours' travel time from a tertiary pediatric hospital. The survey consisted of 9 questions that addressed baseline characteristics of the regional EDs and duration of ED staffing changes or closures due to IFT of critically ill pediatric patients. RESULTS: Ten surveys were received (67% response rate); a regional ED catchment population of about 130 000 people was represented. Interfacility transport caused most EDs (60%, with an average catchment population of 15 000) to close or to alter their staffing to a registered nurse only. These temporary changes lasted a cumulative total of 115 hours. CONCLUSION: Interfacility transport of critically ill pediatric patients resulted in ED closures and staffing changes in rural Manitoba. These findings suggest that long-term sustainable solutions are required to improve access to emergency care.

INTRODUCTION: Même si le transfert entre établissements (TEE) des patients pédiatriques gravement malades des centres de santé ruraux vers des centres tertiaires peut améliorer les résultats, l'impact du TEE sur les centres ruraux d'origine est inconnu. Le but de cette étude était d'évaluer dans quelle mesure le TEE des enfants gravement malades affecte la dotation en personnel et la fonctionnalité des services d'urgence ruraux au Manitoba. METHODS: En 2015, des sondages ont été envoyés par courriel aux directeurs médicaux des 15 services d'urgence régionaux se trouvant à 2 heures de distance ou moins d'un hôpital pédiatrique de soins tertiaires. Le sondage comportait 9 questions qui portaient sur les caractéristiques de base des services d'urgence régionaux et la durée des changements de leur dotation en personnel ou leur fermeture en raison du TEE des patients pédiatriques gravement malades. RESULTS: Dix sondages ont été reçus (taux de réponse : 67 %); une population d'environ 130 000 personnes desservies par les services d'urgence régionaux se trouvait représentée. Le transfert entre établissements a entraîné la fermeture ou la modification de la dotation en personnel ramené à une seule infirmière dans la plupart des services d'urgence (60 %, desservant en moyenne une population de 15 000 personnes). Ces changements temporaires ont eu une durée cumulative de 115 heures. CONCLUSION: Le transfert entre établissements des patients pédiatriques gravement malades a entraîné la fermeture des services d'urgence et des modifications de leur dotation en personnel dans les régions manitobaines rurales. Ces observations donnent à penser que des solutions viables à long terme sont nécessaires pour améliorer l'accès aux soins d'urgence.

Serial optic nerve sheath diameter ultrasonography during pediatric diabetic ketoacidosis management: A pilot study.

OBJECTIVE: Intracranial hypertension is an infrequent but serious acute complication of pediatric diabetic ketoacidosis (DKA). Subclinical elevations of intracranial pressures however, may be more common, and can be indirectly evaluated with ultrasonography of the optic nerve sheath diameter (ONSD). In this pilot study, we report serial data on ONSD trajectories from five pediatric patients with DKA to generate hypotheses for future studies. METHODS: Five pediatric patients with type 1 diabetes presented to our emergency department with DKA and enrolled in our study <3h after initiation of treatment. Ultrasonographic evaluation of the ONSD was conducted at presentation, every three hours until resolution of acidosis, and finally 24h post presentation. Following each interval evaluation, a clinical bedside neurologic tool developed for detecting cerebral edema in DKA was utilized. RESULTS: Four of the five patients exhibited a similar "bell" shaped trajectory - an increase of ONSD after initiation of treatment followed by a return to admission baseline. Patients demonstrated peak ONSDs nine and twelve hours after DKA therapy was initiated, at resolution of acidosis, and at admission. No children exhibited clinical signs suggestive of cerebral edema. CONCLUSIONS: Peak ONSDs cannot be reliability determined in children with DKA unless serial investigations are conducted. Practices to mitigate risks for intracranial hypertension may require constant surveillance during DKA management.

Optic Nerve Sheath Diameter Ultrasonography in Pediatric Patients with Diabetic Ketoacidosis.

OBJECTIVES: Subclinical cerebral edema has been reported in pediatric patients with type 1 diabetes and diabetic ketoacidosis (DKA) through magnetic resonance imaging. Ultrasonography of the optic nerve sheath diameter (ONSD) has been used to evaluate intracranial pressure. The objective of this study was to examine the utility of ONSD ultrasonography to evaluate intracranial pressures in children with DKA. METHODS: This prospective cohort evaluated pediatric patients who presented to the emergency department of the Children's Hospital at the University of Manitoba with DKA within 3 hours of initial treatment. A pediatric bedside neurologic evaluation tool for cerebral edema was utilized 1) within the first hour of the intravenous fluid initiation (t=0 hr); 2) 8 hours after initiation of treatment (t=8 hr); and 3) at hours after presentation (t=24 hr). At each time interval, 3 images of the patients' ONSDs were scanned by an 11 MHz linear array transducer. Increased intracranial pressure was considered in all patients whose mean ONSDs were >4.5 mm. RESULTS: We evaluated 7 patients, aged 4 to 17 years. No patients were clinically assessed as having cerebral edema. Overall, no significant differences emerged among the 3 time points (t=0 vs. t=8 hr; t=0 vs. t=24 hr; t=8 vs. t=24 hr) (all p>.216). Effect sizes were small at 0.14 (t=0 vs. t=8 hr); 0.27 (t=8 vs. t=24 hr); and 0.07 (t=0 vs. t=24). CONCLUSIONS: Although not statistically significant, subtle changes in intracranial pressure may have been detected with ONSD ultrasonography in pediatric patients with DKA.