The objective of this study was to describe a population of children admitted to a tertiary care pediatric hospital with severe trauma to identify key areas for injury prevention research, and programming.
Retrospective chart review conducted on all children 0-17 years admitted to the Children's Hospital of Eastern Ontario (CHEO) between April 1, 1996, and March 31, 2000, following acute trauma. Each record was reviewed and assigned an ISS using the AIS 1990 revision. All cases with an ISS > 11 were included in the study.
There were 2610 trauma cases admitted to CHEO over the study period. Of these, 237 (9.1%) had severe trauma (ISS > 11). Sixty-two percent were male. Twenty-nine percent were between the ages of 10 and 14 years, 27% between 5 and 9 years, 16% between 15 and 17 years, 15% between 1 and 4 years, and 13% less than 1 year old. The most common mechanisms of injury were due to motor vehicle traffic (39%), falls (24%), child abuse (8%), and sports (5%). Of those resulting from motor vehicle traffic, 53 (57%) were occupants, 22 (24%) were pedestrians, and 18 (19%) were cyclists. When combining traffic and nontraffic mechanisms, 26 (11% of all severe trauma cases) occurred as a result of cycling incidents. The most severe injury in 65% of patients was to the head and neck body region.
Research efforts and activities to prevent severe pediatric trauma in our region should focus on road safety, protection from head injuries, avoidance of falls, and prevention of child abuse.
The validity of using adult physiologic criteria to triage injured children in the out-of-hospital setting remains unproven. Among children meeting adult field physiologic criteria, we assessed the availability of physiologic information, the incidence of death or prolonged hospitalization, and whether age-specific criteria would improve the specificity of the physiologic triage step.
We analyzed a prospective, out-of-hospital cohort of injured children aged 29 breaths/min, Glasgow Coma Scale (GCS) score 2 days. The decision tree was derived and validated using binary recursive partitioning.
Nine hundred fifty-five children were included in the analysis, of whom 62 (6.5%) died and 117 (12.3%) were hospitalized > 2 days. Missing values were common, ranging from 6% (respiratory rate) to 53% (pulse oximetry), and were associated with younger age and high-risk outcome. The final decision rule included four variables (assisted ventilation, GCS score 96 mmHg), which demonstrated improved specificity (71.7% [95% confidence interval (CI) 66.7-76.6%]) at the expense of missing high-risk children (sensitivity 76.5% [95% CI 66.4-86.6%]).
The incidence of high-risk injured children meeting adult physiologic criteria is relatively low and the findings from this sample do not support using age-specific values to better identify such children. However, the amount and pattern of missing data may compromise the value and practical use of field physiologic information in pediatric triage.
Metered-dose inhalers and spacers (MDI+S) are at least as effective as nebulizers for treating children with mild to moderate asthma exacerbations. Despite advantages in terms of efficacy, side effects, and ease of use, MDI+S are not used in many North American pediatric emergency departments (PEDs).
To survey emergency physicians, emergency nurses, and respirologists in Canadian pediatric teaching hospitals regarding their practices, beliefs, and barriers to change with respect to bronchodilator delivery.
This was a cross-sectional, mailed survey of all emergency physicians, all respirologists, and a random sample of emergency nurses at ten Canadian PEDs.
A total of 291 of 349 health care professionals (83%) responded. Twenty-one percent of emergency physicians use MDI+S in the PED (largely concentrated at two "user sites"). A majority at nonuser sites, and virtually all professionals at user sites, responded that MDI+S are at least as effective as nebulizers, switching to MDI+S is justified by existing research, patient outcomes would be equal or better, and they have the required knowledge and skills to use MDI+S in the emergency department. The largest perceived barriers to MDI+S implementation include concerns regarding safety and costs, related to feasibility of providing and sterilizing spacers, and parental expectations for nebulizers. Other barriers included staff beliefs regarding the effectiveness of MDI+S, changes in nursing workload, and lack of a physician champion for change.
MDI+S are infrequently used to treat patients with acute asthma in Canadian PEDs, despite the fact that most emergency staff believe they are effective. Important barriers to using MDI+S have been identified in this study and should be used to guide future implementation strategies.
The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity.
This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED.
A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted ? score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay.
The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.
Children commonly require sedation and analgesia for procedures in the emergency department. Establishing accurate adverse event and complications rates from the available literature has been difficult because of the difficulty in aggregating results from previous studies that have used varied terminology to describe the same adverse events and outcomes. Further, serious adverse events occur infrequently, necessitating the study of large numbers of children to assess safety. These limitations prevent the establishment of a sufficiently large database on which evidence-based practice guidelines may be based. We assembled a panel of pediatric sedation researchers and experts to develop consensus-based recommendations for standardizing procedural sedation and analgesia terminology and reporting of adverse events. Our goal was to create a uniform reporting mechanism for future studies to facilitate the aggregation and comparison of results.
Comment In: Ann Emerg Med. 2009 Apr;53(4):436-819097672
To determine etiology of pediatric OHCA in a population-based sample from autopsy and coroner's diagnosis.
As part of the Ontario Pre-hospital Advanced Life Support (OPALS) study, we conducted a prospective cohort study including children below age 19 years with OHCA in an 11-year period. Deaths were matched with provincial coroner's office records and autopsies and investigation notes were reviewed.
From 1992 to 2002, there were 474 cardiac arrests in children below 19 years of age giving an annual incidence of 59.7 per million children. Mean age was 5.8 (S.D. 6.3), 43.0% were
We sought to identify barriers and facilitators to ambulance communications officers' (ACOs') recognition of abnormal breathing and administration of cardiopulmonary resuscitation (CPR) instructions.
We conducted semistructured qualitative interviews based on the constructs of the Theory of Planned Behavior to elicit salient attitudes, social influences, and behavioral controls potentially influencing ACOs' intent to recognize abnormal breathing as a symptom of cardiac arrest and administer CPR instructions over the phone. We conducted interviews until achieving data saturation. We recorded interviews and transcribed them verbatim. Two independent reviewers performed inductive analyses to identify emerging themes.
We interviewed 24 ACOs from four Canadian provinces (67% female, median 9.5 years of experience, 33% with paramedic training). We identified eight behavioral, 14 subjective normative, and 22 control beliefs. Important attitudes were as follows: 1) CPR instructions may help the patient and are likely to be beneficial for the caller; 2) abnormal breathing is an early sign of cardiac arrest; and 3) dispatch-assisted CPR instructions can improve survival. The leading social influence was management/quality assurance staff. Behavioral control was the construct most associated with ACOs' ability to recognize abnormal breathing, including 1) adherence to mandatory scripted protocol, 2) poor caller description of breathing pattern, and 3) ACO training on abnormal breathing.
This qualitative study found that control beliefs are most influential on ACOs' intention to recognize abnormal breathing and provide CPR instructions over the phone. Training and policy changes should target these beliefs to increase the frequency of ACO-administered CPR instructions to callers reporting a patient in cardiac arrest.
There is uncertainty around the types of interventions that are provided by emergency medical services (EMS) to children during prehospital transport. We describe the patient characteristics, events, interventions provided and outcomes of a cohort of children transported by EMS.
This prospective cohort study was conducted in a city of 750 000 people with a 2-tiered EMS system. All children
We systematically summarize pediatric out-of-hospital cardiac arrest epidemiology and assess knowledge of effects of specific out-of-hospital interventions.
We conducted a comprehensive review of published articles from 1966 to 2004, available through MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EmBase, and the Cochrane Registry, describing outcomes of children younger than 18 years with an out-of-hospital cardiac arrest. Patient characteristics, process of care, and outcomes were compared using pediatric Utstein outcome report guidelines. Effects of out-of-hospital care processes on survival outcomes were summarized.
Forty-one studies met inclusion criteria; 8 complied with Utstein reporting guidelines. Included in the review were 5,363 patients: 12.1% survived to hospital discharge, and 4% survived neurologically intact. Trauma patients (n=2,299) had greater overall survival (21.9%, 6.8% intact); a separate examination of studies with more rigorous cardiac arrest definition showed poorer survival (1.1% overall, 0.3% neurologically intact). Submersion injury-associated arrests (n=442) had greater overall survival (22.7%, 6% intact). Pooled data analysis of bystander cardiopulmonary resuscitation and witnessed arrest status showed increased likelihood of survival (relative risk 1.99, 95% confidence interval 1.54 to 2.57) for witnessed arrests. The effect of bystander cardiopulmonary resuscitation is difficult to determine because of study heterogeneity.
Outcomes from out-of-hospital pediatric cardiac arrest are generally poor. Variability may exist in survival by patient subgroups, but differences are hard to accurately characterize. Conformity with Utstein guidelines for reporting and research design is incomplete. Witnessed arrest status remains associated with improved survival. The need for prospective controlled trials remains a high priority.
Comment In: Ann Emerg Med. 2006 Aug;48(2):21916857476
Comment In: Ann Emerg Med. 2005 Dec;46(6):523-416308067
We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs).
This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category.
A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay.
The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.
Comment In: Ann Emerg Med. 2013 Mar;61(3):372-323433024
Comment In: Ann Emerg Med. 2013 Jan;61(1):33-422883682