The latest medical research on Paediatric Emergency Medicine

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about paediatric emergency medicine gathered by our medical AI research bot.

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Implementation and analysis of a multifaceted intervention for alcohol use disorder from a single academic urban emergency department.

Academic Emergency Medicine

From 2006 to 2014, alcohol-related visits to the emergency department (ED) increased by 76% in the United States, highlighting the need for improved ED-driven interventions addressing alcohol use disorder (AUD). Naltrexone is an FDA-approved medication for AUD shown to decrease craving and self-administration of alcohol. While oral naltrexone and extended-release naltrexone have been long utilized in primary care and inpatient hospital settings, the use of naltrexone in the ED is limited.

This study implemented and analyzed a multifaceted intervention regarding ED naltrexone prescribing at a large safety net, academic, urban hospital. A baseline assessment of preintervention conditions and perspectives on naltrexone prescribing was conducted through a chart review and standardized interviews with ED providers, respectively. The interview results guided design of interventions that addressed identified barriers. These included provider education, prescribing aids, and zero-cost naltrexone tablets supplied by the ED pharmacy to patients upon discharge.

Between September 1, 2019, and August 31, 2020, of 753 unique patients who had a primary diagnosis or chief complaint containing the word "alcohol," only five (0.66%) were prescribed naltrexone. ED providers identified lack of training regarding naltrexone, lack of a prescribing protocol, and limited patient and provider education materials as barriers to prescribing naltrexone. Following the intervention, among 278 eligible patients, 11 oral naltrexone prescriptions were written (3.96%) between April 13, 2021, and August 1, 2021. This represents a sixfold increase over the preintervention period.

An intervention to increase ED oral naltrexone prescriptions for AUD was successfully implemented, addressing lack of provider education, lack of prescribing resources, and patient barriers to accessing prescribed medications. Longer-term follow-up is needed to assess the efficacy and sustainability of these interventions. Nevertheless, ED clinicians are well positioned to initiate naltrexone prescriptions for patients presenting with AUD.

Earthquake victims in focus: a cross-sectional examination of trauma and management in intensive care unit.

Prehospital Emergency Care

After the Kahramanmaras earthquake of February 6, 2023, the disaster of the century, a significant number of victims were admitted to intensive care units (ICUs). In this study, we aimed to share the characteristics and management of critical earthquake victims and shed light on our experiences as intensivists in future earthquakes.

The study included 62 earthquake victims in two tertiary ICUs. Demographic characteristics, laboratory findings, clinical characteristics, trauma and disease severity scores, treatments administered to patients, and the clinical course of the patients were recorded retrospectively. The patients were divided into two groups, survivors and nonsurvivors, according to 7-day mortality and into two groups according to the duration of their stay under the rubble: those who remained under the rubble for 72 hours or less and those who remained under the rubble for more than 72 hours. A receiver operating characteristic (ROC) curve analysis was used to determine the best cutoff value for the 'Circulation, Respiration, Abdomen, Motor, and Speech' (CRAMS) score.

The median age of the 62 patients included in the study was 35.5 (23-53) years. The median length of stay under the rubble for the patients was 30.5 (12-64.5) hours. The patient was transferred to the ward with a maximum duration of 222 hours under the rubble. The limb (75.8%) was the most common location of trauma in patients admitted to the ICU. Crush syndrome developed in 96.8% of the patients. There was a positive correlation between the development of acute kidney injury (AKI) and myoglobin, serum lactate, and uric acid levels (r = 0.372, p = 0.003; r = 0.307, p = 0.016; r = 0.428, p = 0.001, respectively). The best cutoff of the CRAMS score to predict in-7-day mortality was < 4.5 with 0.94 area under the curve (AUC); application of this threshold resulted in 75% sensitivity and 96.3% specificity.

Search and rescue operations should continue for at least ten days after an earthquake. The CRAMS score can be used to assess trauma severity and predict mortality in critically ill earthquake victims.

Gene Expression Profiling in Pediatric Appendicitis.

JAMA Pediatrics

Appendicitis is the most common indication for urgent surgery in the pediatric population, presenting across a range of severity and with variable complications. Differentiating simple appendicitis (SA) and perforated appendicitis (PA) on presentation may help direct further diagnostic workup and appropriate therapy selection, including antibiotic choice and timing of surgery.

To provide a mechanistic understanding of the differences in disease severity of appendicitis with the objective of developing improved diagnostics and treatments, specifically for the pediatric population.

The Gene Expression Profiling of Pediatric Appendicitis (GEPPA) study was a single-center prospective exploratory diagnostic study with transcriptomic profiling of peripheral blood collected from a cohort of children aged 5 to 17 years with abdominal pain and suspected appendicitis between November 2016 and April 2017 at the Alberta Children's Hospital in Calgary, Alberta, Canada, with data analysis reported in August 2023. There was no patient follow-up in this study.

SA, PA, or nonappendicitis abdominal pain.

Blood transcriptomics was used to develop a hypothesis of underlying mechanistic differences between SA and PA to build mechanistic hypotheses and blood-based diagnostics.

Seventy-one children (mean [SD] age, 11.8 [3.0] years; 48 [67.6%] male) presenting to the emergency department with abdominal pain and suspected appendicitis were investigated using whole-blood transcriptomics. A central role for immune system pathways was revealed in PA, including a dampening of major innate interferon responses. Gene expression changes in patients with PA were consistent with downregulation of immune response and inflammation pathways and shared similarities with gene expression signatures derived from patients with sepsis, including the most severe sepsis endotypes. Despite the challenges in identifying early biomarkers of severe appendicitis, a 4-gene signature that was predictive of PA compared to SA, with an accuracy of 85.7% (95% CI, 72.8-94.1) was identified.

This study found that PA was complicated by a dysregulated immune response. This finding should inform improved diagnostics of severity, early management strategies, and prevention of further postsurgical complications.

High-flow nasal cannula oxygen versus noninvasive ventilation for the management of acute cardiogenic pulmonary edema: a randomized controlled pilot study.

European Journal of Emergency Medicine

NCT04971213 (https://clinicaltrials.gov).

To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure.

The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality.

Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P = 0.052] at 60 min. There was a median SpO2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P = 0.60]. PaO2, PaCO2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates.

In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen.

Dynamic monitoring tools for patients admitted to the emergency department with circulatory failure: narrative review with panel-based recommendations.

European Journal of Emergency Medicine

Intravenous fluid therapy is commonly administered in the emergency department (ED). Despite the deleterious potential of over- and under-resuscita...

Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study.

European Journal of Emergency Medicine

Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inap...

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study.

European Journal of Emergency Medicine

Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics.

First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history.

Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests.

Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome (P < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder.

Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients.

Prehospital Emergency Care

Mobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability.

Following a pilot study, we developed a 4-level prehospital mobility score based of the question"How much help did the patient need to be mobilized to the ambulance trolley". Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020-May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics.

We included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1). Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86).

We developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study.

Prehospital Emergency Care

Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients.

A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round.

Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management.

Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Identifying quality indicators to measure workplace violence in healthcare settings: a rapid review.

Prehospital Emergency Care

Workplace violence (WPV) in healthcare is a growing challenge posing significant risks to patient care and employee well-being. Existing metrics to measure WPV in healthcare settings often fail to provide decision-makers with an adequate reflection of WPV due to the complexity of the issue. This increases the difficulty for decision-makers to evaluate WPV in healthcare settings and implement interventions that can produce sustained improvements.

This study aims to identify and compile a list of quality indicators that have previously been utilized to measure WPV in healthcare settings. The identified quality indicators serve as tools, providing leadership with the necessary information on the state of WPV within their organization or the impact of WPV prevention interventions. This information provides leadership with a foundation for planning and decision making related to addressing WPV.

Ovid databases were used to identify articles relevant to violence in healthcare settings, from which 43 publications were included for data extraction. Data extraction produced a total of 229 quality indicators that were sorted into three indicator categories using the Donabedian model: structure, process, and outcome.

A majority of the articles (93%) contained at least 1 quality indicator that possessed the potential to be operationalized at an organizational level. In addition, several articles (40%) contained valuable questionnaires or survey instruments for measuring WPV. In total, the rapid review process identified 84 structural quality indicators, 121 process quality indicators, 24 outcome quality indicators, 57 survey-type questions and 17 survey instruments.

This study provides a foundation for healthcare organizations to address WPV through systematic approaches informed by quality indicators. The utilization of indicators showed promise for characterizing WPV and measuring the efficacy of interventions. Caution must be exercised to ensure indicators are not discriminatory and are suited to specific organizational needs. While the findings of this review are promising, further investigation is needed to rigorously evaluate existing literature to expand the list of quality indicators for WPV.

A qualitative assessment of emergency physicians' experiences with robust emergency department buprenorphine bridge programs.

Academic Emergency Medicine

Emergency departments (EDs) are a critical point of entry into treatment for patients struggling with opioid use disorder (OUD). When initiated in the ED, buprenorphine is associated with increased addiction treatment engagement at 30 days when initiated. Despite this association, it has had slow adoption. The barriers to ED buprenorphine utilization are well documented; however, the benefits of prescribing buprenorphine for emergency physicians (EPs) have not been explored. This study utilized semistructured interviews to explore and understand how EPs perceive their experiences working in EDs that have successfully implemented ED bridge programs (EDBPs) for patients with OUD.

Semistructured interviews were conducted with EPs from four geographically diverse academic hospitals with established EDBPs. Interviews were recorded and transcribed, and emergent themes were identified using codebook thematic analysis. Analysis credibility and transparency were confirmed with peer debriefing.

Twenty-two interviews were conducted across the four sites. Three key themes were constructed during the analyses: (1) provided EPs agency; (2) transformed EPs' emotions, attitudes, and behaviors related to treating patients with OUD; and (3) improved EPs' professional quality of life.

Participants in this study reported several common themes related to participation in their hospital's BP. Overall our results suggest that physicians who participate in EDBPs may feel a renewed sense of fulfillment and purpose in their personal and professional lives. These positive changes may lead to increased job satisfaction in hospitals that have successfully launched EDBP.

Missed nursing care in emergency departments: a cross-sectional descriptive study.

Prehospital Emergency Care

Missed care refers to the omission or delay in performing any aspect of patient's care (either a part of the care or the entire care). Currently, missed care has become a growing concern at the international level, which threatens the quality and safety of care and cases many unwanted consequences. This study aims to investigate the frequency and types of missed nursing care in the emergency departments of selected hospitals affiliated to Tehran University of Medical Sciences.

This is a cross-sectional and descriptive- observational study that was conducted with the aim of determining the frequency and types of missed nursing care in the emergency departments of selected hospitals affiliated to Tehran University of Medical Sciences from January 2020 to June 2020. The research community included all nursing care offered in the designated areas, as well as all nurses working in the emergency departments of selected hospitals. Finally, 146 nurses were selected by census method. The information was collected by self-reporting method and the researcher's observation. Demographic information questionnaire, a researcher-made checklist were used to determine the frequency and types of missed nursing care. 384 observations were made for each item. Descriptive statistics methods were used to analyze the data.

The area of checking equipment and emergency trolley(mean = 81.80) had the lowest and the area of patient communication(mean = 55.72) had the highest level of missed care.

The level of missed nursing care in the emergency departments of selected hospitals affiliated to Tehran University of Medical Sciences was found to be high and the highest amount was related to the field of communication with the patient. Therefore, it is recommended that the details of missed nursing care in each area should be considered by nursing managers.