5 results
P126: Utilization and outcomes of children presenting to an emergency department by ambulance
- Z. Cantor, M. Aglipay, A. Plint
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S110
- Print publication:
- May 2020
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Introduction: Children account for a low proportion of paramedic transports. Evidence suggests that many pediatric transports are of low acuity, but there are few studies comparing these patients to those that self-present to the ED. Our primary objective was to determine if illness severity was associated with presentation by ambulance among pediatric patients. Methods: We undertook a single centre, retrospective cohort study at a tertiary care pediatric centre. All patients presenting to the ED in 2015 by any route other than air ambulance were eligible. Patients were divided into two groups based on the route of presentation – ambulance or self-presentation. The primary outcome was disposition decision; the secondary outcome was CTAS level. To determine whether patient discharge disposition or CTAS was associated with the method of arrival, we conducted generalized estimating equations (GEE) to account for correlation within patients with multiple ED visits. Results: Of the 69,092 visits, 69,034 were eligible and analyzed. Of those, 4478 (6.5%) arrived by ambulance, while 64,556 (93.5) self-presented. Those arriving by ambulance had a median age of 10 years [IQR: 2-5 years] vs. 4 years [IQR: 1.75-10 years] in the self-presenting group and were 52.6% male (vs. 52.8%). Two percent of the ambulance cohort were admitted to the ICU (vs. 0.2%), and 16.6% were admitted to the ward (vs. 5%). Patients presenting by ambulance had higher CTAS scores – 5.3% CTAS 1 (vs. 0.3%), 16.4% CTAS 2 (vs. 7.0%), 61.2% CTAS 3 (vs. 45.8%), and 17.1% CTAS 4-5 (vs. 46.9%). The odds of arriving by ambulance were 10.2 x higher for patients admitted to the ICU (OR = 10.2, 95%CI: 7.9 to 13.3) vs. those discharged home. The odds of arriving by ambulance were 64.2 x (OR = 64.2, 95% CI: 48.6 to 84.7) higher for patients CTAS 1 patients vs. CTAS 5 patients. The top 3 complaints among ambulance patients were neurological (22.5%), respiratory (22.7%), and orthopaedic (11.3%). Among self-presenting patients, the top three were general/minor (20.4%), respiratory (16.4%), and gastrointestinal (14.3%). Conclusion: Children presenting to the ED via ambulance are at higher risk for admission to the ward and critical care unit. It is important that paramedics have sufficient training to ensure adequate skills to manage critically ill children. Given the low proportion but higher severity of illness of pediatric transports, further research and consideration must be given to how best to enable paramedics in the management of children.
P016: Utilization and outcomes of children presenting to an emergency department by ambulance
- Z. Cantor, M. Aglipay, A. Plint
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, pp. S68-S69
- Print publication:
- May 2019
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Introduction: Children account for a low proportion of paramedic transports. Evidence suggests that many pediatric transports are of low acuity, but there are few studies comparing these patients to those that self-present to the ED. Our primary objective was to determine if illness severity was associated with presentation by ambulance among pediatric patients. Methods: We undertook a single centre, retrospective cohort study at a tertiary care pediatric centre. All patients presenting to the ED in 2015 by any route other than air ambulance were eligible. Patients were divided into 2 groups based on the route of presentation – ambulance or self-presentation. The primary outcome was disposition decision; the secondary outcome was CTAS level. To determine whether patient discharge disposition or CTAS was associated with method of arrival, we conducted generalized estimating equations (GEE) to account for correlation within patients with multiple ED visits. Results: Of the 69,092 visits, 69,034 were eligible and analyzed. Of those, 4478 arrived by ambulance, while 64,556 self-presented. Those arriving by ambulance had a median age of 10 years [IQR: 2-5 years] vs. 4 years [IQR: 1.75-10 years] in the self-presenting group, and were 52.6% male (vs. 52.8%). Two percent of the ambulance cohort were admitted to the ICU (vs. 0.2%), and 16.6% were admitted to the ward (vs. 5%). Patients presenting by ambulance had higher CTAS scores – 5.3% CTAS 1 (vs. 0.3%), 16.4% CTAS 2 (vs. 7.0% ), 61.2% CTAS 3 (vs. 45.8%), and 17.1% CTAS 4-5 (vs. 46.9%). The odds of arriving by ambulance were 10.2 x higher for patients admitted to the ICU (OR = 10.2, 95%CI: 7.9 to 13.3) vs. those discharged home. The odds of arriving by ambulance was 64.2 x (OR = 64.2, 95% CI: 48.6 to 84.7) higher for patients CTAS 1 patients vs. CTAS 5 patients. The top 3 complaints among ambulance patients were respiratory (22.7%), orthopedic (14.7%), and general/minor (10.3%). Among self-presenting patients, the top three were general/minor (22.5%), respiratory (18.0%), and gastrointestinal (15.7%). Conclusion: Children presenting to the ED via ambulance are at higher risk for admission to the ward and critical care unit. It is important that EMS staff responsible for transporting children be well trained in managing critically ill children. Given the low proportion of pediatric transports, consideration must be given to how best to train EMS services in managing these children.
LO25: How safe are our pediatric emergency departments? A multicentre, prospective cohort study
- A. Plint, L. Calder, Z. Cantor, M. Aglipay, A.S. Stang, A.S. Newton, S. Gouin, K. Boutis, G. Joubert, Q. Doan, A. Dixon, R. Porter, S. Sawyer, M. Bhatt, K. Farion, T. Crawford, D. Dalgleish, D.W. Johnson, T. Klassen, N. Barrowman, for Pediatric Emergency Research Canada
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, p. S36
- Print publication:
- May 2017
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Introduction: Data regarding adverse events (AEs) (unintended harm to the patient from health care provided) among children seen in the emergency department (ED) are scarce despite the high risk setting and population. The objective of our study was to estimate the risk and type of AEs, and their preventability and severity, among children treated in pediatric EDs. Methods: Our prospective cohort study enrolled children <18 years of age presenting for care during 21 randomized 8 hr-shifts at 9 pediatric EDs from Nov 2014 to October 2015. Exclusion criteria included unavailability for follow-up or insurmountable language barrier. RAs collected demographic, medical history, ED course, and systems level data. At day 7, 14, and 21 a RA administered a structured telephone interview to all patients to identify flagged outcomes (e.g. repeat ED visits, worsening/new symptoms, etc). A validated trigger tool was used to screen admitted patients’ health records. For any patients with a flagged outcome or trigger, 3 ED physicians independently determined if an AE occurred. Primary outcome was the proportion of patients with an AE related to ED care within 3 weeks of their ED visit. Results: We enrolled 6377 (72.0%) of 8855 eligible patients; 545 (8.5%) were lost to follow-up. Median age was 4.4 years (range 3 months to 17.9 yrs). Eight hundred and seventy seven (13.8%) were triaged as CTAS 1 or 2, 2638 (41.4%) as CTAS 3, and 2839 (44.7%) as CTAS 4 or 5. Top entrance complaints were fever (11.2%) and cough (8.8%). Flagged outcomes/triggers were identified for 2047 (32.1%) patients. While 252 (4.0%) patients suffered at least one AE within 3 weeks of ED visit, 163 (2.6%) suffered an AE related to ED care. In total, patients suffered 286 AEs, most (67.9%) being preventable. The most common AE types were management issues (32.5%) and procedural complications (21.9%). The need for a medical intervention (33.9%) and another ED visit (33.9%) were the most frequent clinical consequences. In univariate analysis, older age, chronic conditions, hospital admission, initial location in high acuity area of the ED, having >1 ED MD or a consultant involved in care, (all p<0.001) and longer length of stay (p<0.01) were associated with AEs. Conclusion: While our multicentre study found a lower risk of AEs among pediatric ED patients than reported among pediatric inpatients and adult ED patients, a high proportion of these AEs were preventable.
LO063: Adverse events in a pediatric emergency department: a prospective, cohort study
- A. Plint, D. Dalgleish, M. Aglipay, N. Barrowman, L.A. Calder
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S52
- Print publication:
- May 2016
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Introduction: Data regarding adverse events (AEs) (unintended harm to a patient related to health care provided) among children treated in the emergency department (ED) have not been collected despite identification of the setting and population as high risk. The objective of our study was to estimate the risk and type of AEs, as well as their preventability and severity, for children seen in a pediatric ED. Methods: This prospective cohort study examined outcomes of patients presenting to a paediatric ED. Research assistants (RA) recruited patients < 18 yrs old during 28 randomized 8-hr shifts (over 1 yr). Exclusion criteria included unavailability for follow-up and insurmountable language barrier. RAs collected demographics, medical history, ED course, and systems level data. A RA administered a structured telephone interview to all patients at day 7, 14, and 21 to identify flagged outcomes (such as repeat ED visits, worsening/new symptoms, etc). Admitted patients' health records were screened with a validated trigger tool. A RA created narrative summaries for patients with flagged outcomes/triggers. Three ED physicians independently reviewed summaries to determine if an AE occurred. Primary outcome was the proportion of patients with an AE within 3 weeks of their ED visit. Results: We enrolled 1367 (70.3%) of 1945 eligible patients. Median age was 4.3 yrs (range 2 months-17.95 yrs); 676 (49.5%) were female. Most (n= 1279; 93.9%) were discharged. Top entrance complaints were fever (n=206,15.1%), cough (n=135, 9.9%), and difficulty breathing (n=108, 7.9%). Eight eighty (6.5%) patients were triaged as CTAS 1 or 2, 689 (50.6%) as CTAS 3, and 585 (42.9%) as CTAS 4 or 5. Only 44 (3.2%) were lost to follow-up. Flagged outcomes/triggers were identified for 498 (36.4%) patients. Thirty three (2.4%) patients suffered at least one AE within 3 weeks of ED visit; 30 (90.9%) AEs were related to ED care. Most AEs (n= 28; 84.8%) were preventable. Management (n=18, 54.5%) and diagnostic issues (n=15, 45.5%) were the most common AE types. The most frequent clinical consequences were need for medical intervention (n=15;45.5%) and another ED visit (n=13,39.4%). In univariate analysis, age (p=0.005) and weekday presentation (p=0.02) were associated with AEs. Conclusion: We found a lower risk of AEs than that reported among inpatient paediatric and adult ED studies utilizing similar methodology. A high proportion of AEs were preventable.
LO057: Association between metoclopramide treatment in the ED for concussion and persistent post-concussion headaches: a propensity score matching analysis
- N. Bresee, M. Aglipay, N. Barrowman, F. Momoli, A. Dubrovsky, R. Zemek
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S50
- Print publication:
- May 2016
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Introduction: There is a paucity of pediatric literature regarding effective treatment for post-concussion headache. The objective of this study was to assess whether metoclopramide treatment in the Emergency Department (ED) within 48 hours of injury was associated with reduced persistent headache symptoms post-concussion at 1-week and 1-month post-injury. Methods: Children aged 8-18 years with acute concussion were enrolled across 9 EDs of the Pediatric Emergency Research Canada network in a prospective cohort study [Predicting and Preventing Post-concussive Problems in Paediatrics (5P)] from August 2013 to June 2015. Treatments administered in ED (including metoclopramide) were collected using standardized forms. Self-report symptom questionnaires were rated at baseline, at 7 and 28 days follow-up using the validated Post-Concussion Symptom Inventory (PCSI). Propensity scores for treatment with metoclopramide were calculated using a multivariate logistic regression model including confounders. Intervention and control groups were matched 1:4 on the logit of the propensity scores using a greedy algorithm and nearest-neighbour approach. The primary outcome was headache persistence at one-month. Results: 2095 patients met inclusion criteria and completed baseline assessment. At 1 and 4 weeks respectively, 54% (963/1808) and 26% (456/1780) of participants completing follow-up had persistent headache symptoms. 50 metoclopramide treated participants were propensity score matched to 234 controls (1:4 matching). At 4 weeks, no statistically significant difference in persistent headache symptoms was observed between the treatment and propensity score matched control groups (OR: 0.67; 95% CI: 0.33-1.36, p=0.26). There was also no statistically significant difference between the groups at 1-week post-concussion (OR 0.58; 95% CI: 0.32-1.05, p=0.07). Conclusion: This secondary analysis was unable to detect a statistically significant association between acute ED treatment with metoclopramide and reduced medium and long-term headache symptoms post-concussion. Nevertheless, the 1-week results hold promise, but require a well-powered RCT to fully address confounding issues to determine the benefit of metoclopramide post-concussion.