The quality of a simulation examination using a high-fidelity child manikin.

PURPOSE: Developing quality examinations that measure physicians' clinical performance in simulations is difficult. The goal of this study was to develop a quality simulation examination using a high-fidelity child manikin in evaluating paediatric residents' competence about managing critical cases in a simulated emergency room. Quality was determined by evidence of the reliability, validity and feasibility of the examination. In addition, the participants' responses regarding its realism, effectiveness and value are presented. METHOD: Scenario scripts and rating instruments were carefully developed in this study. Experts were used to validate the case scenarios and provide evidence of construct validity. Eighteen paediatric residents, 'working' as pairs, participated in a manikin-based simulation pre-test, a training session and a post-test. Three independent raters rated the participants' performance on task-specific technical skills, medications used and behaviours displayed. At the end of the simulation, the participants completed an evaluation questionnaire. RESULTS: The manikin-based simulation examination was found to be a realistic, valid and reliable tool. Validity (i.e. face, content and construct) of the test instrument was evident. The level of inter-rater concordance of participants' clinical performance was good to excellent. The item analysis showed good to excellent internal consistency on all the performance scores except the post-test technical score. CONCLUSIONS: With a carefully designed rating instrument and simulation operation, the manikin-based simulation examination was shown to be reliable and valid. However, a further refinement of the test instrument will be required for higher stake examinations.

Critical pediatric equipment availability in Canadian hospital emergency departments.

STUDY OBJECTIVE: Of all child visits to emergency departments, 1% to 5% involve critically ill children who require cardiopulmonary resuscitation. Numerous versions of pediatric equipment lists for EDs have been published. Despite these efforts, many EDs remain unprepared for pediatric emergencies. The objectives of this study were to assess the availability of pediatric resuscitation equipment items in Canadian hospital EDs and to identify risk factors for the unavailability of these items. METHODS: Using the updated database of the Canadian Association of Emergency Physicians (CAEP), a questionnaire survey was sent to 737 Canadian hospital EDs with a maximum of 3 mailings to nonresponders. On-site visits to a selected subset of hospital EDs were completed to validate the results obtained by the mailed questionnaire. RESULTS: The response rate was 88.3% (650/737). Results showed the following overall equipment unavailability: intraosseous needle, 15.9%; pediatric drug dose guidelines, 6.6%; infant blood pressure cuff, 14.8%; pediatric defibrillator paddles, 10.5%; infant warming device, 59.4%; infant bag-valve-mask device, 3.5%; infant laryngoscope blade, 3.5%; 3-mm endotracheal tube, 2.5%; and pediatric pulse oximeter, 18.0%. Low percentage of pediatric visits, lack of an on-call pediatrician for the ED, and lack of a pediatric advanced life support-trained physician on staff were independently associated with equipment unavailability. CONCLUSION: This study demonstrated that essential pediatric resuscitation equipment is unavailable in a disturbingly high number of EDs across Canada and has identified several determinants of this unavailability.

Telelearning in a partnership between a university faculty and a regional health authority: benefits, challenges and strategies.

The University of Calgary's Faculty of Medicine and the Calgary Regional Health Authority understand that telehealth is an evolving field requiring both academic enquiry and operational readiness. Both parties are committed to quality educational programmes--the Faculty through its commitment to excellence and the Authority with its charge to maintain and enhance such programmes. There are shared applications, multi-learner user groups, shared strategies to overcome distances and shared infrastructure--technologies, communication pathways and resources. Having embarked on a joint telelearning venture, we have learned a number of lessons. Central to progress has been an appreciation and respect for unique mandates, a spirit of trust and flexibility, an agreement on a set of principles, ongoing communication between and participation from the users and, at times, redirection. Questions being answered include the following. How well is this collaborative model working? How functional is it at this time of health reform and restructuring? Can one meet complementary telelearning goals within a faculty-health authority relationship? These all have implications for future success.

Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: a Canadian experience.

OBJECTIVES: To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself. METHODS: A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression. RESULTS: One thousand one hundred sixty-four children were included in the study. One hundred seventy-one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan. CONCLUSIONS: Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.

Emergency department utilization and success rates for intraosseous infusion in pediatric resuscitations.

OBJECTIVE: To determine the frequency of use and the success rates of intraosseous (IO) vascular access in the emergency department. DESIGN: A retrospective chart review. SETTING: A tertiary pediatric emergency department (ED) in a large urban centre. METHODS: ED resuscitations (ICD-9 code 996) occurring between Oct. 1, 1989, and Sept. 30, 1995, were identified by searching the ED database, inpatient database, ICU admission log and provincial medical examiner's database. From these, all cases involving IO access were selected and comprised the study sample. Demographics, diagnosis, number of IO attempts, success or failure of IO placement, relevant times and patient outcomes were recorded on standard data forms. Frequency of use, success rates and performance times were reported. RESULTS: IO access was successful in 36 of 42 (86%) patients. In total, there were 68 attempts, or 1.6 attempts per child. All but one child were less than 3 years of age. The median time to successful IO placement was 8 minutes. Two complications, both fractures, occurred in one patient, a 10-day-old neonate. CONCLUSIONS: IO success rates were high despite infrequent use.

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines.

Procedural sedation and analgesia are core skills in emergency medicine. Various specialty societies have developed guidelines for procedural sedation, each reflecting the perspective of the specialty group. Emergency practitioners are most likely to embrace guidelines developed by people who understand emergency department (ED) skills, procedures, conditions, and case mix. Recognizing this, the Canadian Association of Emergency Physicians (CAEP) determined the need to establish guidelines for procedural sedation in the ED. In March, 1996, a national emergency medicine (EM) working committee, representing adult and pediatric emergency physicians, was established. This committee teleconferenced with representatives of the Canadian Anesthetic Society (CAS) to identify problems, perspectives, and controversial issues, and to define a process for guideline development. The EM committee subsequently reviewed existing literature, determined levels of evidence, and developed the document, which evolved based on feedback from the CAS and CAEP Standards Committees. The final version was approved by the CAEP Standards Committee and the CAEP Board of Directors, then submitted for peer review. These guidelines discuss the goals, definitions, and principles of ED sedation, and make recommendations for pre-sedation preparation, patient fasting, physician skills, equipment and monitoring requirements, and post-sedation care. The guidelines are aimed at non-anesthesiologists practicing part-time or full-time emergency medicine. They are applicable to ED patients receiving parenteral analgesia or sedation for painful or anxiety-provoking procedures. They are intended to increase the safety of procedural sedation in the ED.

Predictors and outcome of admission for invasive Streptococcus pneumoniae infections at a Canadian children's hospital.

Rates of admission for invasive Streptococcus pneumoniae infection in children vary considerably between institutions. We performed a retrospective study to investigate factors used in the decision to admit patients with invasive S. pneumoniae infection to Alberta Children's Hospital. Of 254 patients who were initially assessed in the emergency department, 38.2% were admitted to the hospital. Significant risk factors for admission as determined by a logistic regression model included murmur (odds ratio [OR], 18.98; 95% confidence interval [CI], 4.08-88.23), focal infection (OR, 11.41; 95% CI, 5.07-25.67), and older age (OR, 2.72; 95% CI, 1.03-7.17). Higher hemoglobin level (OR, 0.96; 95% CI, 0.93-0.99) and temperature of > 38.5 degrees C (OR, 0.39; 95% CI, 0.18-0.85) were associated with a lower risk of admission. Two patients died (case-fatality rate, 0.7%). Despite the low rate of admission for invasive S. pneumoniae infections at our hospital, the mortality rate was comparable with those at institutions with higher rates of admission, thus suggesting that the factors we identified may be useful in deciding whether to admit patients with (or who are at high risk for) invasive S. pneumoniae infections.

Can oral rehydration solution be safely flavored at home?

OBJECTIVE: To determine the concentration of sodium, potassium, glucose, and osmolality of oral rehydration solutions (ORS) which have been flavored with varying amounts of unsweetened Kool-Aid powder, Jell-O powder, apple juice, or orange juice. DESIGN: Descriptive. SETTING: Alberta Children's Hospital Chemistry Laboratory. PATIENTS: None. INTERVENTIONS: Addition of varying amounts of flavoring easily available in all households to commercially available unsweetened ORS. MAIN OUTCOME MEASURES: Concentrations of electrolytes, glucose, and osmolality. RESULTS: Addition of fruit juices or flavor powders to commercially produced ORS does alter the electrolyte content and osmolality. When limited amounts of flavoring or juice is added, the osmolality of the solution approaches iso-osmolality. CONCLUSIONS: Small amounts of unsweetened Kool-Aid powder, Jell-O powder, and apple or orange juice can be added to oral rehydration solutions without significantly altering electrolyte composition and osmolality.

Epiglottitis in Canada: A multiregional review.

Epiglottitis is an acute, life threatening infection usually caused by Haemophilus influenzae type b. Although antibiotic therapy is an important part of management, the optimal route and duration is unknown. A multicentre retrospective review of 305 children with epiglottitis was carried out in order to relate antibiotic therapy to hospital course and outcome, as well as to examine regional variation in patient demographics, clinical presentation and course of disease. A standardized form was used to extract data from hospital records. Although management varied significantly among the six centres in terms of mean duration of intubation (46 to 81 h), intravenous antibiotic therapy (3.8 to 5.7 days) and hospital stay (5.3 to 8.4 days), there were no significant centre-related differences in epidemiology, clinical course or outcome of epiglottitis. An extraepiglottic focus of infection was present in 15% of patients and included three with septic arthritis and one with meningitis. The duration of fever in hospital and maximum recorded temperature in hospital were significantly greater for children with extraepiglottic infection compared to those with epiglottitis alone. The data presented in this review suggest that most children with epiglottitis have an uncomplicated course and respond rapidly to antimicrobial therapy following airway securement. A short period of intravenous and oral antibiotic therapy is likely adequate for most children with epiglottitis. A well designed multicentre prospective trial is still needed to determine the optimal duration of antibiotic therapy.