Characteristics and outcomes of SARS-CoV-2 infection in Victorian children at a tertiary paediatric hospital.

AIM: Victoria experienced two 'waves' of COVID-19 between March and September 2020 and more cases than any other jurisdiction in Australia. Although world-wide reports of COVID-19 reflect that children are less likely to experience severe disease compared with adults, hospitalisations and deaths have been reported. We report testing and outcomes of children with SARS-CoV-2 infection presenting to a tertiary paediatric hospital in Melbourne. METHODS: We conducted a prospective cohort study at The Royal Children's Hospital (RCH), including all children and adolescents (aged 0-18 years) who presented and were tested for SARS-CoV-2 over a 6-month period, between 21 March 2020, up to the 21 September 2020. Detailed epidemiological and clinical data were recorded. RESULTS: A total of 19 708 tests for SARS-CoV-2 were performed in 14 419 patients. One hundred and eighty patients tested positive for SARS-CoV-2 (1.2%). 110 (61%) were symptomatic, 60 (33%) were asymptomatic and 10 (6%) were pre-symptomatic. Close contacts of a positive case were associated with a higher risk of a testing positive for SARS-CoV-2 (120/2027 (6%) vs. 60/14589 (0.4%), RD 5.5 (95% CI 4.5 to 6.5), P < 0.001). Eighteen (10%) SARS-CoV-2-positive patients were admitted to hospital with one patient requiring intensive care. All patients recovered fully with no deaths. CONCLUSION: In Victorian children presenting to a tertiary hospital, SARS-CoV-2 infection caused predominantly mild or asymptomatic infection, with most children not requiring hospitalisation.

Emergency department utilisation by vulnerable paediatric populations during the COVID-19 pandemic.

OBJECTIVE: To determine if changes to community-based services have effected paediatric ED attendances for mental health issues and neonates during the COVID-19 pandemic. METHODS: Analysis of total presentations, presentations with a mental health diagnoses and presentation of neonates during the early stages of the pandemic compared with the previous year for four Victorian hospitals. RESULTS: There was a 47.2% decrease in total presentations compared with 2019, with a 35% increase in mental health diagnoses and a 2% increase in neonatal presentations. CONCLUSION: Vulnerable paediatric patients are seeking care elsewhere during the pandemic because of the closure of community services.

SARS-CoV-2 testing and outcomes in the first 30 days after the first case of COVID-19 at an Australian children's hospital.

OBJECTIVE: International studies describing COVID-19 in children have shown low proportions of paediatric cases and generally a mild clinical course. We aimed to present early data on children tested for SARS-CoV-2 at a large Australian tertiary children's hospital according to the state health department guidelines, which varied over time. METHODS: We conducted a retrospective cohort study at The Royal Children's Hospital, Melbourne, Australia. It included all paediatric patients (aged 0-18 years) who presented to the ED or the Respiratory Infection Clinic (RIC) and were tested for SARS-CoV-2. The 30-day study period commenced after the first confirmed positive case was detected at the hospital on 21 March 2020, until 19 April 2020. We recorded epidemiological and clinical data. RESULTS: There were 433 patients in whom SARS-CoV-2 testing was performed in ED (331 [76%]) or RIC (102 [24%]). There were four (0.9%) who had positive SARS-CoV-2 detected, none of whom were admitted to hospital or developed severe disease. Of these SARS-CoV-2 positive patients, 1/4 (25%) had a comorbidity, which was asthma. Of the SARS-CoV-2 negative patients, 196/429 (46%) had comorbidities. Risk factors for COVID-19 were identified in 4/4 SARS-CoV-2 positive patients and 47/429 (11%) SARS-CoV-2 negative patients. CONCLUSION: Our study identified a very low rate of SARS-CoV-2 positive cases in children presenting to a tertiary ED or RIC, none of whom were admitted to hospital. A high proportion of patients who were SARS-CoV-2 negative had comorbidities.

Rapid Assessment, Planning, Investigations and Discharge: Piloting the introduction of a senior doctor at triage model in an Australian paediatric emergency department.

OBJECTIVE: We implemented a senior doctor at triage (SDT) pilot programme at The Royal Children's Hospital, Melbourne. We examined the impact on ED length of stay, seen on time and fail to wait (FTW) rates. METHODS: A SDT model was piloted on Monday and Tuesday afternoons (pilot period) for 10 weeks, and compared with equivalent shifts for the preceding 10 weeks (pre-pilot period). We determined the differences between the proportions of patients seen on time, length of stay in the ED of less than 4 h and FTW rate, as well as the medians of time to clinician and length of stay in ED. RESULTS: A total of 2736 patients presented in the pilot period, and 2889 in the pre-pilot. The percentage of patients who were seen on time improved from 52.3% to 68.7% (absolute difference 16.4%, 95% confidence interval [CI] 13.6-19.2%, P < 0.001), the percentage of patients who had an ED length of stay of <4 h improved from 58.2% to 72.0% (absolute difference 13.8%, 95% CI 11.1-16.5%, P < 0.001) and the FTW rate reduced from 12.5% to 7.1% (absolute difference 5.4%, 95% CI 3.8-7.0%, P < 0.001) when the SDT model was operational. CONCLUSION: Implementation of a SDT model in a tertiary paediatric ED resulted in an increased proportion of patients being seen on time, having shorter length of stays in the ED and reduced the number of patients who FTW. Further studies are required to determine whether these improvements are sustained over time.

Management of retrieval service patients within a paediatric emergency department.

OBJECTIVE: The Victorian Paediatric Emergency Transport Service (PETS) transports critically unwell children to tertiary paediatric hospitals. Children not directly admitted to ICU go to a tertiary ED. These patients might require prolonged and high-level care. In light of the National Emergency Access Target, we describe this cohort, clinical care needs and process measures. METHODS: A retrospective chart review of patients retrieved by PETS to the Royal Children's Hospital (Melbourne, Australia) ED in 2012. Demographics, illness parameters and process measures were extracted. The ED length of stay (LOS) and time to ward suitability (time at which physiological parameters stabilised and high acuity treatments ceased) were related to patient and illness characteristics. Data are presented descriptively and analysed using spss. RESULTS: In 2012, 120 patients were transported to the ED. Conditions included lower respiratory (44), neurological (28), upper respiratory (16) and trauma (14). The median ED LOS was 4.8 h (interquartile range 2.9, 7.7). On arrival, 73 (60.8%) were ward-suitable, but 51 (43%) had LOS less than 4 h. Twenty-five (20.8%) patients stayed longer than 8 h. Administrative delay (principally bed block) is responsible for the bulk of the LOS; however, 25 (20.8%) had markedly abnormal vital signs after 4 h of ED care, mainly patients with lower respiratory tract disease. CONCLUSION: Most patients retrieved to the ED ultimately go to a ward rather than ICU and most have an ED stay in excess of National Emergency Access Target. Several retrieval associated care issues, such as timely and appropriate ward disposition, can be addressed by administrative changes.

Leaving the paediatric emergency department without being seen: understanding the patient and the risks.

AIM: The aim of this study is to examine the left-without-being-seen (LWBS) patient population of a tertiary paediatric emergency department (ED) to provide quality assurance and risk management data. METHODS: This is a prospective observational study of patients who LWBS after presenting to the Royal Children's Hospital Melbourne ED between July and November 2005. Information was collected from electronic databases and follow-up telephone interviews performed by the principal investigator 3-5 days after the presentation. RESULTS: Over the 17-week study period, 7.6% of attendances were recorded as having LWBS. These patients and their presentations resembled the general ED population in many respects. However, there were several significant differences, particularly in relation to age, insurance status, mode of arrival, referral status, arrival time and illness severity. Most families (74%) indicated they would have been equally happy to visit a general practitioner instead had one been available. Prolonged waiting times and recognition that their child's illness was not severe were the most frequent reasons for leaving. Most parents subsequently accessed alternate health care or were planning to do so, and the majority stated their child's illness was improving. Parents maintained a surprisingly positive attitude to their ED presentation. CONCLUSION: The individual risks associated with leaving the ED before a child has been medically assessed are small. However, when multiplied several thousandfold as a function of the frequency of LWBS patients, the chance of serious adverse events becomes real. Potential risk management strategies include decreasing absolute LWBS numbers by addressing ED overcrowding and providing alternate sources for non-urgent care.

Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients.

OBJECTIVE: To perform a multicenter study examining the presentations and emergency management of children with convulsive status epilepticus (CSE) to sites within the Paediatric Research in Emergency Departments International Collaborative. METHODS: Retrospective review of children presenting to emergency departments (EDs) with convulsive seizures of at least 10 minutes' duration. Eight sites within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand participated. Patients were identified through a search of ED electronic records for the period January 2000 to December 2004. RESULTS: Data were obtained from 542 eligible episodes of CSE. Demographics and seizure history were similar across all sites. One third of children with CSE presented with their first seizure. A preexisting diagnosis that predisposed to seizures was present in 59%. Median duration of seizures before hospitalization was 45 minutes, and median duration of treatment in ED before termination was 30 minutes. Prehospital duration did not seem to influence the timing of key ED interventions such as the administration of second-line anticonvulsants or progression to rapid sequence induction (RSI) of anesthesia and intubation. Convulsive status epilepticus was terminated after first-line treatment in 42%, second-line treatment in 35%, and RSI in 22%. One third of the patients had persistent seizure activity beyond 40 minutes of ED treatment. Marked variation in the use of RSI for refractory seizures was observed between sites. CONCLUSIONS: Convulsive status epilepticus is an important neurological emergency, with many children experiencing prolonged seizures in both the prehospital and hospital phases. Persistent seizure activity beyond 40 minutes contrasts with current published guidelines. There is a need to adopt a widely accepted approach to the management of children who fail to respond to standard anticonvulsant therapy.

Vaccination-related adverse events.

Vaccine-related adverse events are uncommon and typically mild. Children may experience conditions such as rashes, fevers, syncope, protracted crying, or seizures shortly after receiving their routine immunizations. When children are brought to the emergency department or clinic to be evaluated for one of these conditions, the health care provider may be called upon to determine the likelihood that it was caused by a recently administered set of vaccines. This determination has substantial implications for medical care, including the safety of administering future vaccines. This article reviews the current understanding of vaccine-related adverse events. Using this information, clinicians should be able to identify those events likely to be related to vaccine administration and those that are not. The appropriate management of vaccine-related adverse events is also discussed.

When benzodiazepines fail: how effective is second line therapy for status epilepticus in children?

OBJECTIVES: To define the characteristics and management of children presenting to the ED of a major tertiary paediatric hospital with convulsive status epilepticus (CSE). To determine the timing and efficacy of therapeutic interventions in this group and to identify factors that influence the effectiveness of treatment. METHOD: A retrospective audit of all children who presented to an ED of a tertiary paediatric hospital in CSE over a 3 year period. RESULTS: Thirty-seven cases were identified. Prehospital treatment had been administered in 51%. Uncomplicated seizure control was achieved in 30% with the combination of first and second line therapy. Rapid sequence induction (RSI) of anaesthesia was required in 70% for the control of ongoing seizure activity (21 cases) or to support severe respiratory depression (five cases). This requirement for RSI was increased to 85% in those with seizure duration in excess of 30 min and 89% of those who received prehospital treatment. Of those who required RSI, 35% were treated for periods in excess of 60 min before this intervention was performed. CONCLUSIONS: Standard second line anticonvulsant treatment was relatively ineffective in terminating seizures in children who presented in CSE not responsive to benzodiazepines. Failure to respond to prehospital treatment and prolonged seizure duration at presentation both predict poor therapeutic response. Third line treatment with RSI of anaesthesia is often delayed while waiting for second line treatment to work.

Infective endocarditis: experience of a paediatric emergency department.

OBJECTIVES: To determine the clinical features at presentation of children with infective endocarditis to a tertiary centre and review the role of the emergency department in these cases. The subsequent course and outcomes are briefly discussed. METHODS: Retrospective audit of children with endocarditis presenting to a tertiary children's hospital over a 16-year period. RESULTS: Twenty-three cases of infective endocarditis were identified. Initial presentation via the paediatric emergency department occurred in 78% of cases and was associated with the least delay to commencement of appropriate treatment. The average duration of illness at the time of presentation was 6 days. Prior medical care had been sought in 65% of the cases, with antibiotics prescribed for an alternate diagnosis in 73%. Children with and without cardiac anomalies were equally represented. Of the group with normal cardiac anatomy, 45% presented without a murmur. Staphylococcus aureus was the most frequent causative organism (43%) and accounted for 64% of cases in children with no pre-existing cardiac abnormalities. Permanent sequelae were more likely to occur with S. aureus. The overall mortality rate was 9%. CONCLUSIONS: Infective endocarditis is a rare illness in children and represents a diagnostic challenge. The majority of cases will present via the paediatric emergency department with a non-specific febrile illness, having frequently commenced antibiotics for an alternate diagnosis. Specific expertise in paediatric emergency care can assist in early diagnosis and management. Morbidity remains significant, particularly in cases caused by S. aureus.