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J. Woodman1, M. Pitt1, D. Hodes1, B. Taylor1, R. Gilbert1. 1Institute of Child Health, London, UK; 2Peninsula Technology Assessment Group, Exteter, UK; 3University College London Hospital, London, UK; 4Islington Primary Care Trust, London, UK
IntroductionProtocols used to promote the detection of physical abuse in Accident and Emergency departments state that children at high risk of physical abuse should be assessed by a paediatrician. Children considered to be at high risk are injured infants (under 2 years), particularly with fractures or head injury. RCPCH guidelines state that children who repeatedly attend A&E for injury are also at high risk. In practice, A&E staff see two or three injury attendances a year as potentially worrying.
AimsWe aimed to evaluate the effectiveness of protocols specifying young age, type of injury or repeated attendance for detecting physical abuse in A&E.
MethodsWe did a series of systematic reviews of studies reporting the characteristics of abused and accidentally injured children attending A&E.
ResultsWe scanned 7400 abstracts, retrieved 50 papers and included over 20 unique studies in the reviews. Few studies were based on all injured children attending A&E. Most related to more seriously injured children admitted to hospital from A&E. The one study (from Honolulu) that directly compared abused and non‐abused children attending A&E provided no evidence that infants and preschool children were at increased risk of abuse. Indirect comparison of studies that measured attendance in either abused or non‐abused children, but not both, provided weak evidence for an increased risk of physical abuse in injured infants. Studies of severely injured and admitted children showed a clinically important and statistically significant increased risk of abuse in the infant and preschool age groups, but were are not representative of children in A&E. We found no clear evidence that broad injury types (fracture, head injury, bruise, burn) or repeat attendance were useful indicators of physical abuse. Repeat A&E attendance for injury was common among all A&E attendees (46% of children under 5 years in 5 London A&E departments had more than one injury attendance in a year) and our review found that, when adjusted for social factors, children injured due to physical abuse or accidents had similar rates of re‐attendance.
ConclusionImplementation of existing protocols is not supported by the currently available research evidence and may add to paediatric workload without improving detection of abuse. Studies that compare abused and accidentally injured children attending A&E are needed.
P. Davies1, I. Maconochie2. 1Queen's Medical Centre, Nottingham, UK; 2St Mary's Hospital, London, UK
AimTo describe and quantify the effect that increasing body temperature has on heart rate in children attending an Emergency Department.
MethodsData were collected from attendances to two children's emergency departments in the UK between 2003–6. Triage observations as documented at the time were collated and analysed. These were analysed using quantile regression with Stata v9.
ResultsWe had data on a total of 63857 attendances. Of these 31851 had complete data on pulse, temperature and age. We excluded all children who were not sent home from the emergency department, as we wished to exclude any patients in shock. This left us with a dataset of 21033 patients. We had no method of correcting for the state of agitation of the patient. The 5th, 50th, and 95th percentiles of the pulse rate range can be calculated using the following table. The formula is given by: constant (k) + (age (months)×a) + (age2 (months)×b) + (temperature °C × c). As a rule of thumb, the approximate increase in heart rate per degree centigrade of body temperature is 10 beats per minute.
ConclusionsBody temperature is an independent determinant of heart rate, causing an increase of approximately 10 beats per minute per degree centigrade. This quantification will help in assessment of the hot and unwell child, to determine whether any tachycardia is due solely to fever, or whether there may be an element of concurrent shock.
We thank Paul Silcocks for his statistical advice.
K. Bradman, I. Maconochie. St Mary's Hospital, London, UK
BackgroundThe UK Paediatric Early Warning Score (PEWS) was developed for in‐patients, looking at admission to the HDU and PICU and trying to produce a system which would recognise those children at risk of admission. Since the introduction of the “4‐hour‐wait”, A&E departments have been under increasing strain to assess, treat and admit patients (if required) as quickly as possible. We designed this study with the view of identifying if the PEWS score could be used as a triage tool, to detect those patients who will need admission and therefore speed up the process of admitting children to the ward.
Study DesignAll patients who visited A&E from 1 October–16 October were audited. The PEWS scores were collated after the study period.
Results774 children attended A&E during the study period. 316 patients were sent home from triage following nurse‐led treatment or sent to another facility. Of the 458 patients remaining, 424 (93%) were included in the study—the only exclusion criteria was the failure of complete documentation of observations. The sensitivity (the probability of a child being admitted with a score of (n)) and the specificity (the probability of a patient not being admitted with a score of 0) were calculated. For all children aged 0–16 years: A PEWS score of 4 had a sensitivity of 24% and a specificity of 96%. The positive predictive value (PPV) was 50% and the likelihood ratio of admission (LR +ve) was 6. A PEWS score of 2 had a sensitivity of 37% and a specificity of 88%. The PPV was 34% and the LR +ve was 3.
ConclusionPEWS is of limited value in predicting admission (in a triage setting) in a population of undifferentiated disease.
AMohagham Detecting and managing deterioration in children. Paediatric Nursing200517 pp 32-5
G. Verma, B. Mehta, R. Massey. Royal Liverpool Alder Hey Childrens NHS Trust, Liverpool, UK
AimTo assess the usefulness of ultrasound in the management of irritable hips in children.
MethodsRetrospective study of 168 patients with irritable hip (January 2004–December 2005. Right hip: 86 patients and left hip: 85 patients. Bilateral hip: 3 patients. All patients presented with painful hip. Most had pain on internal rotation. Majority had limp lasting 0–3 days. All patients were >1 year. White blood cell count (WBC), C‐reactive protein (CRP) and ultrasound (US) of the hip was performed on all the patients. Temperature and associated medical condition were also recorded. Patients were divided into two groups, Group A who could weight bear (146 patients) and Group B who could not weight bear (22 patients).
ResultsUltrasound showed no effusion in 77 patients (Group A) and 11 patients (Group B). Remaining patients in both groups had hip joint effusion from 2–7 mm. All were treated conservatively. None needed aspirations of the effusion in the hip joint or secondary operative procedure. Group A: 31 patients had mild temperature, normal WBC, CRP and US showed effusion from 0–7 mm. 12/31 patients had upper respiratory tract infection (URTI). Group B: 5 patients had mild temperature with normal WBC, CRP and US showed effusion from 0–6 mm. 1/5 patient had URTI. Remaining 115 patients (Group A) and 17 patients (Group B) had normal WBC and CRP values. Gastroenteritis was noted in 4 patients in group A and 1 patient in group B.
ConclusionUltrasound for irritable hips in weight bearing patients with normal WBC and CRP is of no help. Ultrasound may be considered for non‐weight bearing patients despite normal parameters. Ultrasound is of definite value to surgeon before any operative procedure for the hip joint.
D. Roland1, T. Keil2. 1Derriford Hospital, Plymouth, Devon, UK; 2Princess Margaret Hospital for Children, Perth, Western Australia, Australia
AimsTo determine how often a blood culture influences the management of children diagnosed with pneumonia in a paediatric emergency department and to determine how many of the pathogenic isolates might have been prevented by prior immunisation with conjugate pneumococcal vaccine (7v‐PCV).
MethodsAll blood cultures taken from children with a diagnosis of pneumonia or lower respiratory tract infection (LRTI) without clinical signs of septicaemia in a tertiary paediatric emergency department were reviewed over a one‐year period (prior to widespread implementation of 7v‐PCV). A consultant clinical microbiologist analysed all positive cultures to determine clinical significance. All cases of positive cultures were analysed for organism type, antibiotic use and whether admitted or discharged.
Results880 children (mean age 3.35 years) were diagnosed with pneumonia or LRTI. Blood cultures were taken in 243 (27.6%), of which 18 were positive (7 pathogenic). Of those who had blood cultures taken, 223 (91.8%) patients were admitted. All discharged patients received oral antibiotics. The only pathogenic organisms isolated were Streptococcus pneumoniae (6) and a non‐typable Haemophilus influenzae (1). The pathogenic organism was susceptible to the prescribed antibiotic in all cases. Waiting for a potential contaminant culture to be confirmed as non pathogenic delayed discharge in three cases.
ConclusionsThere appears to be little justification for taking blood cultures in children with pneumonia without clinical signs of septicaemia when the choice of antimicrobial chemotherapy is invariably correct and the rate of contamination is so high (albeit similar to previous published rates in other centres). However without organisms isolated from such blood cultures, pneumococcal serotype and antibiotic susceptibility would not be known from a key population group. With the advent of the pneumococcal vaccine it will be even more important to characterise pathogenic organisms in order to assess the changing burden of disease in the community. A balance must be found between the need to protect individual patients from unnecessary investigation while allowing public health officials to obtain adequate epidemiological evidence on the effects of pneumococcal vaccination.
N. Maheshwari. Oxford Deanery, Oxford, UK
AimThis systematic review of literature was undertaken to look at usefulness of C‐reactive protein in detecting occult bacterial infection in young children with fever without apparent focus.
MethodsAn all language literature search of original articles, conference abstracts, and references from 1951–2006 was performed, using six databases. All studies looking at usefulness of CRP in detecting occult bacterial infection in young children without focus were included apart from retrospective case reviews and expert opinions. Studies looking at use of CRP to differentiate between viral and bacterial infection in which children with identifiable focus of infection were included, were excluded. Standardised criteria for study definition, data extraction, and critical appraisal were used.
ResultsOf 58 studies reviewed, 4 exploratory prospective cohort studies were included. The results of these studies are shown in the table.
ConclusionChildren with serious bacterial infections and occult bacteraemia are more likely to have high CRP than children with benign infections (Grade B). A single CRP value gives a probability but never a certainty of presence or absence of serious bacterial infection (Grade B).
V. S. Jones, I. R. Morrison. Barts and the London NHS Trust, London, UK
BackgroundFalls from windows and balconies are the second leading cause of death and leading cause of injury in the paediatric population.
ObjectivesTo determine demographic features and injuries sustained in children following a fall from a window or balcony and to compare with similar data from 1996.
MethodsWe obtained data for children attending Paediatric A&E with a fall from a window or balcony over a five‐year period from the Helicopter Emergency Medical Service database, TARN database and EPR.
ResultsNinety two cases were identified with a male preponderance (39F, 42%; 53M 58%) of whom 3 (3.2%) died. The 0–4 age group accounted for 55% of the incidents, median age was 3.5 years. Falls peaked in the summer with a smaller peak in April corresponding to Easter. Most falls were in the afternoon (65%). The majority of injuries were long bones fractures and head injuries. Pelvic, spine and chest injuries occurred in falls >2 m. The borough in which the fall occurred was recorded and incidence in each borough compared to the Jarman Index for the borough. The four boroughs with the highest incidence were among the top six most deprived boroughs in Britain and conversely the four with the lowest incidence were among the least deprived in London. The data we have collected concur very closely to that obtained in the same population in 1996. There has been no decrease in the incidence of falls and demographic data are similar.
ConclusionsWe feel that this is a neglected public health topic which is a significant cause of morbidity, particularly in deprived populations, and warrants further study.
M. Amadife, R. Ibekwe. Ebonyi State University, Abakaliki, Nigeria, Nigeria
AimTo evaluate the pattern, seasonal variation and outcome of paediatric emergencies in Ebonyi state University Teaching Hospital (EBSUTH), Abakaliki and compare it with findings in other centres.
MethodThis is a 12‐month retrospective study between December 2004 and November 2005. Information required was extracted from the case files of the patients.
ResultA total of 634 children presented during the period. There were 381 males (60.1%) and 253 females (39.9%) giving a male:female ratio of 1.5:1. The most common diseases were malaria 219 (34.5%), pneumonia 94 (14.8%), gastroenteritis 79 (12.5%) and severe anaemia 49 (7.7%). The peak period of presentation was from July to November. 245 (38.6%) patients were referred to the ward, while 307 (48.4%) were discharged home. 23 (3.6%) had surgery. 11 children (1.7%) were discharged against medical advice while 36 died, giving a mortality rate of 5.7%. The most common cause of death was malaria and its complications—mainly severe anaemia, accounting for 36.1% of all the mortality.
ConclusionPaediatric emergencies in Abakaliki follow a pattern similar to that observed in other centres in Nigeria. In view of the high number of anaemia‐related deaths there is a need to improve the blood transfusion services. Also, because of the persisting scourge of malaria, malaria control strategies such as roll back malaria should be intensified.
P. de Keyser. Institute of Child Health, London, UK
BackgroundThe configuration of Urgent Care paediatric services, at the interface of both primary and secondary providers, is an area of current focus for PCTs and Acute Trusts.
ObjectivesThe study examined whether outcomes of presentations to an inner city emergency department (ED) are associated with the level of deprivation of the electoral ward in which the child lives, particularly with regard to the timing of the attendance and whether the presentation could be regarded as primary care based, and thus potentially dealt with in an alternative setting to the ED.
MethodsA retrospective departmental database analysis of 7810 presentations of children from the ED's local Borough in the year to 31 October 2005. Deprivation status of electoral wards assessed by Index of Multiple Deprivation 2004. Outcome measures included clinical problem, mode of transport to ED, time of presentation, ability to give named GP, triage score, duration of stay in ED, investigations performed, in patient admission and return to ED. Comparison made with use of the hospital's same day Urgent Referral Clinic.
ResultsMedical conditions represented 53% of presentations. The greater the area of deprivation, the less likely is the child to have a named GP (χ2 6.87, p<0.05), the less likely to receive investigations in ED (χ2 12.6, p<0.01), the less likely to be sent by the GP to the Urgent Referral Clinic (χ2 12.4, p<0.001) and the more likely to come by public transport (χ2 3.99, p<0.05). Differences in admission rates and return rates to ED between areas of high and low deprivation did not reach significance levels. Lacking a named GP is associated with early discharge from ED (χ2 5.08, p<0.025). 44.2% of all presentations, and 49.7% of medical presentations took place out of hours (6:00 pm to 8:00 am). A child attending out of hours is more likely to be triaged to the two most urgent categories (χ2 38.6, p<0.001), but time of attendance was not associated with deprivation or probability of admission.
ConclusionThere is a demand for paediatric primary care services within the ED, especially for children from areas of greater deprivation, both during the daytime and out of hours. Managing this demand may require innovative models of care jointly developed by the ED and local PCT.
G. Geelhoed2, D. Roland1, E. Geelhoed3. 1Derriford Hospital, Plymouth, UK; 2Princess Margaret Hospital, Perth, Australia; 3UWA, Perth, Australia
AimsPaediatric Emergency Medicine is a relatively new discipline with many departments relatively understaffed with appropriately trained consultants. The increased presence of such consultants should theoretically lead to increased efficiencies and improved outcomes. A significant increase of medical staff in five years, largely at consultant level, in one tertiary paediatric emergency department was studied to examine this hypothesis.
MethodsA retrospective observational study was conducted in a tertiary paediatric emergency department over a nine‐year period (1997 to 2005) documenting trends in percentage of children admitted, complaints to the department, average waiting times and associated costs. Consultant numbers increased 240% from 2.6 to 6.2 (full‐time equivalents) between 2000 and 2004. Nursing and clerical staffing numbers during this period were largely unchanged as was the annual attendance of approximately 43000 children. The number of beds in the hospital remained at around 220 during this period.
ResultsAll parameters improved coincident with increasing consultant numbers. The percentage of children admitted decreased 23% (from 26% admitted to 20% admitted); complaints fell 38% from 34 per year to 21 per year and the average waiting time by 17% or 12 minutes. The cost of extra consultant staff was more than offset by the savings of reduced admissions.
ConclusionsThe provision of additional consultant medical staff in a paediatric emergency department coincided with a decrease in the percentage of children admitted, complaints to the department and average waiting times.