Procedural sedation programme minimising adverse events: a 3-year experience from a tertiary paediatric emergency department.

INTRODUCTION: A well-developed procedural sedation programme in the paediatric emergency department can minimise adverse events. We examined how adherence to current best evidence ensures safe delivery of paediatric sedation in a newly established tertiary paediatric hospital. METHODS: Our sedation service uses a robust provider training and privileging system, standardised policy and procedures and rigorous data collection all within an evidence-based clinical governance process. We examined sedation data from the first 3 years of operation. RESULTS: From July 2018 to May 2022, ketamine was used in 3388 of the 3405 sedations. The mean age of sedated children was 5.5 years (range 6 months to 17.8 years) and common indications were closed reduction of fractures and laceration repairs. A total of 148 (4.37%, 95% CI 3.68% to 5.06%) adverse events were documented, including 88 (2.59%, 95% CI 2.06% to 3.13%) cases of vomiting, 50 (1.48%, 95% CI 1.07% to 1.88%) cases related to airway and breathing with 40 (1.18%, 95% CI 0.82% to 1.54%) cases of oxygen desaturation, 6 (0.18%, 95% CI 0.04% to 0.32%) cases of laryngospasm, 4 (0.12%, 95% CI 0% to 0.23%) cases of apnoea. CONCLUSION: This study presents a large single-centre dataset on the use of intravenous ketamine in paediatric procedural sedation. Adhering to international standards and benchmarks for provider skills and training, drug administration and monitoring facilities, with a strict clinical governance process, optimizes patient safety.

Variability in the management and imaging use in paediatric minor head trauma in European emergency departments. A Research in European Pediatric Emergency Medicine study.

OBJECTIVE: The objective of the study was to assess the variability in the management of paediatric MHT in European emergency departments (EDs). METHODS: This was a multicentre retrospective study of children ≤18 years old with minor head trauma (MHT) (Glasgow Coma Scale ≥14) who presented to 15 European EDs between 1 January 2013 and 31 December 31. Data on clinical characteristics, imaging tests, and disposition of included patients were collected at each hospital over a 3-year period. RESULTS: We included 11 212 patients. Skull radiography was performed in 3416 (30.5%) patients, range 0.4-92.3%. A computed tomography (CT) was obtained in 696 (6.2%) patients, range 1.6-42.8%. The rate of admission varied from 0 to 48.2%. CONCLUSION: We found great variability in terms of the type of imaging and rate of CT scan obtained. Our study suggests opportunity for improvement in the area of paediatric head injury and the need for targeted individualised ED interventions to improve management of MHT.

An Evaluation of the Accuracy and Necessity of Fracture Clinic Referrals in a Busy Pediatric Emergency Department.

OBJECTIVES: Injuries account for approximately 18% of all pediatric emergency department presentations. Of these, a significant amount will have fractures that will require orthopedic management usually in the orthopedic fracture clinic. Our aim was to assess the accuracy and necessity of fracture clinic referrals from our emergency department and to suggest an approach that might safely reduce the referral numbers. METHODS: All fracture clinic referrals from Temple Street Emergency Department in August 2013 were retrospectively audited. RESULTS: There were 339 fracture clinic referrals in August 2013. Of these, 213 (63%) had fractures as reported by a consultant radiologist. One hundred twenty-six (37%) had no fracture confirmed, and of these, 24 (19%) had no fracture seen in the emergency department but were referred as clinically fractured. Thirty-three (10%) of the 339 were buckle fractures of the wrist. There were 21 (6.2%) finger injuries referred. Of ankle injuries referred to fracture clinic (n = 43), 14 (33%) were confirmed Salter-Harris 1 or 2 or avulsion fractures of the lateral malleolus and 16 (37%) were suspected Salter-Harris 1 or 2 fractures of the lateral malleolus. CONCLUSIONS: Through education and policy change such as the establishment of an Advanced Nurse Practioner (ANP)-led clinic or a virtual clinic within our emergency department, we could safely and efficiently reduce orthopedic fracture clinic referrals by more than 30%.

Evaluation of Safety and Cost-Effectiveness of the Low Risk Ankle Rule in One of Europe's Busiest Pediatric Emergency Departments.

OBJECTIVES: Low Risk Ankle Rule (LRAR) has 100% sensitivity for identifying clinically important pediatric ankle fractures (high-risk injuries) and has the potential to safely reduce imaging by approximately 60%. This study investigates the safety and cost-effectiveness of this rule in our institution. METHODS: All patients triaged during July and August 2013 with an "ankle injury" had a retrospective clinical notes and radiology report review. Data were recorded using Excel and tests of significance, χ test. RESULTS: One hundred twenty-one patients were included. Of these, 65 were female and 56 were male (no significant difference in sex, P = 0.41). Mean age was 9.95 years. Seventy-eight (64%) had LRAR positive examinations. Of these, 77 (98.7%) had an x-ray and 12 (15%) had fractures. Of those with fractures, none had high-risk injuries.Eighteen (100%) of the doctors in our ED felt that a clinical decision rule would be of use within the department. Only 8 (44%) had heard of the LRAR, and of these, only 4 (50%) would be confident to implement the LRAR. Forty-four (88%) of parents felt that an x-ray is required in the diagnosis of ankle injuries in children, and 41 (82%) would want to know whether their child had an ankle sprain or a low-risk fracture even if the management was not different. CONCLUSIONS: By implementing the LRAR in our institution, we could reduce ankle x-rays by 64%. This would offer a significant reduction in radiation exposure to a radiosensitive population. Estimated costs of an ankle x-ray and interpretation are Euro 47 ($65), thus with more than 800 carried out per year in The Children's University Hospital, a potential annual saving is Euro 25,000 ($34,500).

Development of a Caregiver Gastroenteritis Knowledge Questionnaire.

OBJECTIVE: Because caregiver knowledge deficiencies are associated with the development of dehydration and nonurgent emergency department visits, we sought to develop and describe the characteristics of a Caregiver Gastroenteritis Knowledge Questionnaire. METHODS: We conducted a cross-sectional, associational analysis with a questionnaire consisting of 38 true/false questions covering signs of dehydration, indications to see a physician, oral rehydration therapy, solid intake and refeeding, medication use, and disease transmission. After completing initial validation procedures, 80 caregivers of children with gastroenteritis, 25 nurses, and 22 pediatric emergency medicine physicians completed the questionnaire. RESULTS: Content validity was confirmed qualitatively. Construct validity was demonstrated by incremental increases (P < .001) in mean total scores from caregivers to nurses to physicians. Multiple regression analysis revealed the reported number of prior visits for gastroenteritis was inversely associated with overall caregiver score (beta coefficient, -0.26; 95% confidence interval, -3.04, -0.28; P = .02). Internal consistency was demonstrated with a Cronbach's alpha of 0.67 at time 0. CONCLUSIONS: The Caregiver Gastroenteritis Knowledge Questionnaire may have application in identifying knowledge gaps in gastroenteritis management and measuring improvement following educational interventions. Future uses may focus on individual knowledge deficits or serve to document larger community educational needs.