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The aim of this study was to evaluate the ability of the Irish Paediatric Early Warning Score (PEWS), the Paediatric Observation Priority Score (POPS), and the Irish Children's Triage System (ICTS) to predict patient disposition pathways in an emergency department (ED) setting.Data were prospectively collected on patients aged less than 16 years presenting to an Irish mixed adult/pediatric ED over 3 weeks during December 2018. After calculating a once-off PEWS, POPS, and ICTS, we investigated the ability of the scoring systems to predict admission or discharge from the ED. Primary comparison of the index tests was conducted using receiver operating characteristic (ROC) curves.A total of 550 patients were included in this study. There were 114 admissions (20.7%) and 436 discharges (79.3%). The POPS had an area under the ROC curve of 0.7 [95% confidence interval (CI), 0.65-0.75]. The PEWS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.64). The ICTS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.63).The POPS has greater accuracy as a predictor of admission from the ED than PEWS and ICTS. Possible future implementation of POPS into pediatric EDs as a cognitive prompt before admission decision seems to be merited. Further multicenter validation in Ireland would be helpful.

Study objectiveApproximately 250,000 children undergo pediatric procedural sedation (PPS) in UK & Irish emergency departments (ED) annually. PPS practice in our setting has not been described as fully as in other high income countries. We aimed to evaluate PPS in UK and Irish EDs.MethodsOnline survey distributed through Pediatric Emergency Research in the UK and Ireland (PERUKI) during June 2020. One respondent per ED completed the survey, including questions on agents, fasting, training and governance. Results are presented using descriptive statistics.Results61/72 (85%) sites responded, of which PPS was performed in 50 (82%). Intravenous ketamine was the most common agent (43/50; 86%), followed by variable concentration nitrous oxide (13/50; 26%). Fasting practices varied widely across sites and agents: 24/45 (53.3%) of sites delivering ketamine/es-ketamine PPS required fasting compared to 2/13 (15.4%) before variable concentration nitrous oxide. 49/72 (68.1%) provided complete responses on training; internal training packages existed in under half (22/49, 44.9%). Most had a guideline (43/61; 70.5%) and documentation proforma (39/61; 63.9%). Databases existed in 24/61 (39.3%).ConclusionWe have demonstrated widespread PPS use, but non-standardized practice. This leads to potential issues of risk and variability, highlighting a need for a UK and Ireland sedation package to standardize PPS practice and data collection, informed by international guidance and evidence. We propose development of a prospective ED sedation registry to facilitate data collection to support research within this area.

During the last 3 decades newly formed pediatric emergency medicine (PEM) research networks have been publishing research. A desire of these networks is to produce and disseminate research to improve patient health and outcomes. The aims of the study were to quantitatively analyze and compare the literature by PEM research networks globally through numeric and visual bibliometrics.A bibliometric analysis of articles published from 1994 to 2019 (26 years) by authors from PEM research networks globally were retrieved using PubMed, Web of Science (Thompson Reuters), and accessing individual research network databases. Bibliometric analysis was performed utilizing Web of Science, VOSviewer, and Dimensions. Research was quantified to ascertain the number of articles, related articles, citations, and Altmetric attention score.A total of 493 articles were published across 9 research networks in 3 decades. Pediatric Emergency Care Applied Research Network produced the most articles, citations, and h-index of all networks. We identified 3 main groupings of productive authors across the networks who collaborate globally. The sex of the first author was female in 46% of publications, and the corresponding author(s) was female in 45%. A nonsignificant moderate positive correlation between the number of years publishing and the number of publications was identified. There was nonsignificant moderate negative association between the number of countries in a network and total publications per annum.This study is the first bibliometric analysis of publications from PEM research networks that collaborate globally. Exploring the relationships of numerical bibliometric indicators and visualizations of productivity will benefit the understanding of the generation, reach, and dissemination of PEM research within the global research community.

Comparing observed versus theoretically expected evolutionary responses is important for our understanding of the evolutionary process, and for assessing how species may cope with anthropogenic change. Here, we document directional selection for larger female size in Atlantic salmon, using pedigree-derived estimates of lifetime reproductive success as a fitness measure. We show the trait is heritable and, thus, capable of responding to selection. The Breeder's Equation, which predicts microevolution as the product of phenotypic selection and heritability, predicted evolution of larger size. This was at odds, however, with the observed lack of either phenotypic or genetic temporal trends in body size, a so-called "paradox of stasis." To investigate this paradox, we estimated the additive genetic covariance between trait and fitness, which provides a prediction of evolutionary change according to Robertson's secondary theorem of selection (STS) that is unbiased by missing variables. The STS prediction was consistent with the observed stasis. Decomposition of phenotypic selection gradients into genetic and environmental components revealed a potential upward bias, implying unmeasured factors that covary with trait and fitness. These results showcase the power of pedigreed, wild population studies-which have largely been limited to birds and mammals-to study evolutionary processes on contemporary timescales.

ObjectiveDuring the last three decades newly formed pediatric emergency medicine (PEM) research networks have been publishing research. A desire of these networks is to produce and disseminate research to improve patient health and outcomes. To quantitatively analyze and compare the literature by PEM research networks globally through numeric and visual bibliometrics.MethodsA bibliometric analysis of articles published from 1994 to 2019 (26 years) by authors from PEM research networks globally were retrieved using PubMed®, Web of Science™ (Thompson Reuters) and accessing individual research network databases. Bibliometric analysis was performed utilizing Web of Science™, VOSviewer and Dimensions. Research was quantified to ascertain the number of articles, related articles, citations and Altmetric attention score.ResultsA total of 493 articles were published across nine research networks in three decades. Pediatric Emergency Care Applied Research Network (PECARN) produced the most articles, citations, and h-index of all networks. We identified three main groupings of productive authors across the networks who collaborate globally. The gender of the first author was female in 46% of publications and the corresponding author(s) was female in 45%. A non-significant moderate positive correlation between the number of years publishing and the number of publications was identified. There was non-significant moderate negative association between the number of countries in a network and total publications per annum.ConclusionsThis study is the first bibliometric analysis of publications from PEM research networks that collaborate globally. The gender gap in first authorship compared to high impact medical journals and high impact emergency medicine journals is narrower. Exploring the relationships of numerical bibliometric indicators and visualizations of productivity will benefit the understanding of the generation, reach and dissemination of PEM research within the global research community.

Aims/Objectives/BackgroundApproximately 250,000 children undergo paediatric procedural sedation (PPS) in UK and Irish emergency departments (ED) annually. In comparison to other countries, PPS practice in our setting has not been described. We therefore aimed to evaluate PPS practice in UK and Irish EDs.Methods/DesignOnline survey distributed through Paediatric Emergency Research in the UK and Ireland (PERUKI) during June 2020. One respondent per ED completed the survey, including questions on indications, agents, staffing and governance. Results are presented using descriptive statistics.Results/Conclusions61/72 (85%) sites responded, of which PPS was performed in 50 (82.0%). Intravenous ketamine was the most common agent (43/50; 86%), followed by fixed concentration nitrous oxide (FCNO, 35/50; 70%), and variable concentration nitrous oxide (VCNO, 13/50; 26%). PPS was mostly performed a few times a week (17/50; 34%) or daily (9/50; 18%). The most frequent indications were wound closure (31/50; 62%), orthopaedic reduction (28/61; 56%) and foreign body removal (17/61; 34%). Required sedationist seniority was highest for propofol and ketamine/es-ketamine (requiring consultant, registrar, or ANP), whilst FCNO was widely delivered by nurses and SHOs. Most sites had a guideline (43/61; 70.5%), documentation proforma (39/61; 63.9%) and equipment (36/61; 59.0%) and patient checklists (41/50; 82%). Explicit discharge criteria were required for ketamine/es-ketamine (40/45; 88.9%), midazolam (9/10; 90%), propofol (7/10; 70%) and VCNO (9/13; 69.2%). Databases existed in 24/61 (39.3%).We have demonstrated wide PPS use, but non-standardised practice, with only two-thirds of sites using a PPS guideline and standardised proforma. This leads to potential issues of risk and variability, highlighting a need for a UK and Ireland sedation package to standardise PPS practice and data collection, informed by international guidance and evidence. We propose development of a prospective ED sedation registry to facilitate data collection to support research within this area.

The release of captive-bred animals into the wild is commonly practised to restore or supplement wild populations but comes with a suite of ecological and genetic consequences. Vast numbers of hatchery-reared fish are released annually, ostensibly to restore/enhance wild populations or provide greater angling returns. While previous studies have shown that captive-bred fish perform poorly in the wild relative to wild-bred conspecifics, few have measured individual lifetime reproductive success (LRS) and how this affects population productivity. Here, we analyse data on Atlantic salmon from an intensely studied catchment into which varying numbers of captive-bred fish have escaped/been released and potentially bred over several decades. Using a molecular pedigree, we demonstrate that, on average, the LRS of captive-bred individuals was only 36% that of wild-bred individuals. A significant LRS difference remained after excluding individuals that left no surviving offspring, some of which might have simply failed to spawn, consistent with transgenerational effects on offspring survival. The annual productivity of the mixed population (wild-bred plus captive-bred) was lower in years where captive-bred fish comprised a greater fraction of potential spawners. These results bolster previous empirical and theoretical findings that intentional stocking, or non-intentional escapees, threaten, rather than enhance, recipient natural populations.

BackgroundWe know that parents require resources which can assist them to improve fever knowledge and management practices. The purpose of this study, using an RCT, was to examine the effectiveness of an information leaflet at increasing parental knowledge of fever, specifically temperature definition.MethodsA prospective, multi-centre, randomised, two-parallel arm, controlled trial with blinded outcome ascertainment was conducted. Parents presenting at purposively selected healthcare facilities who had a child aged ≤5 years of age were invited to participate. An information leaflet for use in the trial was designed based on previous studies with parents. Parents in the intervention arm read an information leaflet on fever and management of fever in children, completed a short questionnaire at Time 1 (T1) and again 2 weeks after randomisation at Time 2 (T2). Parents in the control arm did not receive the fever information leaflet but completed the same questionnaire as the intervention arm at T1 and againat T2. The primary outcome was the correct definition of fever (higher than ≥38 °C).ResultsA total of 100 parents participated in the study at T1. A greater proportion of the intervention group (76%) than the control group (28%) selected the correct temperature (≥38 °C) at T1. 76% of the intervention arm correctly identified “higher than ≥38°C” as the temperature at which a fever is said to be present compared to 28% of the control arm. After 2 weeks, there was an increase of 6% of parents in the intervention arm (increase to 82.4%) who gave the correct temperature compared to just a 2.8% increase in the control arm (increase to 30.8%). Univariate logistic regression showed that parents in the intervention arm were significantly more likely to give the correct answer at both time-points (T1: OR 8.1; CI 95% 3.3–19.9:p p ConclusionsOur RCT of this simple educational intervention has been shown to improve parental understanding of fever knowledge and correct management strategies. Education interventions providing simple, clear information is a key step to decreasing parental mismanagement of fever and febrile illness in children.Trial registrationClinicalTrials.govNCT02903342, September 16, 2016, Retrospectively registered.

Objectives High quality data is fundamental to using key performance indicators (KPIs) for performance monitoring. However, the resources required to collect high quality data are often significant and should usually be targeted at high priority areas. As part of a study of 11 emergency department (ED) KPIs in Ireland, the primary objective of this study was to estimate the relative cost of collecting the additional minimum data set (MDS) elements for those 11 KPIs. Methods An economic cost analysis focused on 12 EDs in the Republic of Ireland. The resource use data were obtained using two separate focus group interviews. The number of available MDS elements was obtained from a sample of 100 patient records per KPI per participating ED. Unit costs for all resource use were taken at the midpoint of the relevant staff salary scales. Results An ED would need to spend an estimated additional O3561 per month on average to capture all the MDS elements relevant to the 11 KPIs investigated. The additional cost ranges from 14.8 to 39.2%; this range is 13.9-32.3% for small EDs, whereas the range for medium EDs is 11.7-40%. Regional EDs have a higher additional estimated cost to capture all the relevant MDS elements (O3907), compared with urban EDs (O3353). Conclusion The additional cost of data collection, contingent on that already collected, required to capture all the relevant MDS elements for the KPIs examined, ranges from 14.8 to 39.2% per KPI, with variation identified between regional and urban hospitals.

Background: Good-quality data is required for valid and reliable key performance indicators. Little is known of the facilitators and barriers of capturing the required data for emergency department key performance indicators. This study aimed to explore and understand how current emergency department data collection systems relevant to emergency department key performance indicators are integrated into routine service delivery, and to identify the resources required to capture these data elements. Methods: Following pilot testing, we conducted two focus groups with a multi-disciplinary panel of 14 emergency department stakeholders drawn from urban and rural emergency departments, respectively. Focus groups were analyzed using Attride–Stirling’s framework for thematic network analysis. Results: The global theme “Understanding facilitators and barriers for emergency department data collection systems” emerged from three organizing themes: “understanding current emergency department data collection systems”; “achieving the ideal emergency department data capture system for the implementation of emergency department key performance indicators”; and “emergency department data capture systems for performance monitoring purposes within the wider context”. Conclusion: The pathways to improving emergency department data capture systems for emergency department key performance indicators include upgrading emergency department information systems and investment in hardware technology and data managers. Educating stakeholders outside the emergency department regarding the importance of emergency department key performance indicators as hospital-wide performance indicators underpins the successful implementation of valid and reliable emergency department key performance indicators.

Fusobacterium necrophorumis a rare infection most notable for causing Lemierre’s syndrome. This consists of a primary oropharyngeal infection and septic thrombophlebitis, and one or more metastatic focus. Prior to the widespread use of antibiotics, Lemierre’s syndrome commonly followed a rapidly progressing course, with a high mortality. We describe a case of a previously well 18-month-old boy who presented to the emergency department with a 3-week history of progressive, right-sided, painful neck swelling and systemic sepsis. He was initially treated conservatively with intravenous antibiotics, but ultimately required surgical drainage. Lemierre’s syndrome is a rare condition with increasing incidence which can have significant adverse outcomes including death. Early recognition and treatment are essential, but identifying Lemierre’s disease is challenging.

Background Early warning score systems have been widely recommended for use to detect clinical deterioration in patients. The Irish National Emergency Medicine Programme has developed and piloted an emergency department specific early warning score system. The objective of this study was to develop a consensus among frontline healthcare staff, quality and safety staff and health systems researchers regarding evaluation measures for an early warning score system in the Emergency Department. Methods Participatory action research including a modified Delphi consensus building technique with frontline hospital staff, quality and safety staff, health systems researchers, local and national emergency medicine stakeholders was the method employed in this study. In Stage One, a workshop was held with the participatory action research team including frontline hospital staff, quality and safety staff and health systems researchers to gather suggestions regarding the evaluation measures. In Stage Two, an electronic modified-Delphi study was undertaken with a panel consisting of the workshop participants, key local and national emergency medicine stakeholders. Descriptive statistics were used to summarise the characteristics of the panellists who completed the questionnaires in each round. The mean Likert rating, standard deviation and 95% bias-corrected bootstrapped confidence interval for each variable was calculated. Bonferroni corrections were applied to take account of multiple testing. Data were analysed using Stata 14.0 SE. Results Using the Institute for Healthcare Improvement framework, 12 process, outcome and balancing metrics for measuring the effectiveness of an ED-specific early warning score system were developed. Conclusion There are currently no published measures for evaluating the effectiveness of an ED early warning score system. It was possible in this study to develop a suite of evaluation measures using a modified Delphi consensus approach. Using the collective expertise of frontline hospital staff, quality and safety staff and health systems researchers to develop and categorise the initial set of potential measures was an innovative and unique element of this study. Electronic supplementary material The online version of this article (10.1186/s12873-018-0220-3) contains supplementary material, which is available to authorized users.

Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.

Introduction There is extensive literature on paediatric procedural sedation (PPS) and its clinical applications in emergency departments (EDs). While numerous guidance and policy documents exist from international bodies, there remains a lack of uniformity and consistency of PPS practices within EDs. PPS is now gaining traction in the UK and Ireland and this study aimed to describe existing PPS practices and identify any challenges to training and provision of ED-based PPS. Methods A qualitative approach was employed to capture data through a focus group interview. Nine consultants in emergency medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group was audio-recorded, transcribed verbatim and analysed using Attride-Stirling9s framework for thematic network analysis. Results The global theme ‘The Future of PPS in EM—A UK and Ireland Perspective’ emerged from the following three organising themes: (1) training and education of ED staff; (2) current realities of PPS in EDs and (3) PPS and the wider hospital community. The main findings were (1) there is variability in ED PPS practice throughout the UK and Ireland; (2) lack of formal PPS training for trainees is a barrier to its implementation as a standard treatment and (3) there is a lack of recognition of PPS at a College level as a specialised EM skill. Conclusions Establishment of PPS as a standard treatment option in the emergency setting will require implementation of robust training into general and paediatric EM training. This should be supported and enhanced through national and international collaboration in EM-led PPS research and audit.

Background: Although caregivers are important in the management of frail, community-dwelling older adults, the influence of different caregiver network types on the risk of adverse healthcare outcomes is unknown. Objective: To examine the association between caregiver type and the caregiver network subtest of The Risk Instrument for Screening in the Community (RISC), a five point Likert scale scored from one (“can manage”) to five (“absent/liability”). To measure the association between caregiver network scores and the one-year incidence of institutionalisation, hospitalisation and death. Design: Observational cohort study. Setting and Participants: Community-dwelling adults, aged >65,attending health centres in Ireland,(n=779). Procedure and Measurements: The caregiver network subtest of the RISC was scored by public health nurses. Caregivers were grouped dichotomously into low-risk (score of one) or high-risk (scores two-five). Results: The majority of patients had a primary caregiver (582/779;75%), most often their child (200/582;34%). Caregiver network scores were highest, indicating greatest risk, when patients had no recognised primary caregiver and lowest when only a spouse or child was available. Despite this, patients with a caregiver were significantly more likely to be institutionalised than those where none was required or identified (11.5% versus 6.5%,p=0.047). The highest one-year incidence of adverse outcomes occurred when state provided care was the sole support; the lowest when private care was the sole support. Significantly more patients whose caregiver networks were scored high-risk required institutionalisation than low-risk networks; this association was strongest for perceived difficulty managing medical domain issues, odds ratio (OR) 3.87:(2.22-6.76). Only perceived difficulty managing ADL was significantly associated with death, OR 1.72:(1.06-2.79). There was no association between caregiver network scores and risk of hospitalisation. Conclusion: This study operationalizes a simple method to evaluate caregiver networks. Networks consisting of close family (spouse/children) and those reflecting greater socioeconomic privilege (private supports) were associated with lower incidence of adverse outcomes. Caregiver network scores better predicted institutionalisation than hospitalisation or death.

Objectives The primary study objective was to describe the development of a data dictionary for a feasibility analysis of 11 emergency department (ED) key performance indicators (KPIs). The secondary objective was to internally validate the data dictionary by measuring the inter-observer agreement between data abstractors at participating study sites. Methods A list of data variables based on the minimum data set elements relevant to the KPIs was developed by a panel of emergency medicine (EM) specialists and from the EM literature. A summit involving the relevant stakeholders, including ED frontline staff, a health economist, an ED clinical data manager and a health care informatician, was convened. For the feasibility analysis project, each data abstractor was furnished with a copy of the data dictionary and attended a one-hour training session prior to commencing data abstraction. Data was independently abstracted for each KPI by two abstractors at each of 12 participating EDs. Inter-rater agreement between abstractors was calculated using Cohen’s kappa and results were reported using the Landis and Koch criteria. Results A data dictionary was developed by creating clear definitions and establishing abstraction instructions for each variable. A total of 43 data variables were included in the study data dictionary: 4 on patient demographics; 19 time variables; 5 outcome variables; 8 ED service and staffing units and 7 medical definitions. A clear definition and a set of data abstraction instructions including data sources were developed for each variable to aid data abstraction during the feasibility analysis. Overall 9,276 ED patient records were used for data abstraction to internally validate the data dictionary. The median Cohen kappa score ranged between 0.56 to 0.81. Conclusion There is a continued need to standardize definitions of KPIs for the purpose of comparing ED performance and for research purposes. This is a necessary first step in the implementation of valid and reliable ED performance measures. This study successfully developed an internally valid data dictionary that can be used for day-to-day ED operations and for research purposes.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: The objective of this review is to identify and evaluate all RCTs comparing premedication for paediatric endotracheal intubation with the use of atropine to paediatric endotracheal intubation without the use of atropine, and to quantify the effect of using atropine as a premedication in paediatric endotracheal intubation on adverse clinical outcomes.

Few case-finding instruments are available to community healthcare professionals. This review aims to identify short, valid instruments that detect older community-dwellers risk of four adverse outcomes: hospitalisation, functional-decline, institutionalisation and death. Data sources included PubMed and the Cochrane library. Data on outcome measures, patient and instrument characteristics, and trial quality (using the Quality In Prognosis Studies [QUIPS] tool), were double-extracted for derivation-validation studies in community-dwelling older adults (>50 years). Forty-six publications, representing 23 unique instruments, were included. Only five were externally validated. Mean patient age range was 64.2–84.6 years. Most instruments n = 18, (78%) were derived in North America from secondary analysis of survey data. The majority n = 12, (52%), measured more than one outcome with hospitalisation and the Probability of Repeated Admission score the most studied outcome and instrument respectively. All instruments incorporated multiple predictors. Activities of daily living n = 16, (70%), was included most often. Accuracy varied according to instruments and outcomes; area under the curve of 0.60–0.73 for hospitalisation, 0.63–0.78 for functional decline, 0.70–0.74 for institutionalisation and 0.56–0.82 for death. The QUIPS tool showed that 5/23 instruments had low potential for bias across all domains. This review highlights the present need to develop short, reliable, valid instruments to case-find older adults at risk in the community.

Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (

Aims Fever, despite being one of the most common childhood symptoms, causes undue concern for parents. The aim of this study was to describe parental knowledge, attitudes and beliefs regarding fever in children aged five years of age and younger. Methods Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals prior to starting the study. Data for this study were collected at purposively selected primary schools in Cork, Ireland using a paper-based survey. Further data were collected from a cross-sectional web-based study using a convenience sample of parents via websites and web pages previously identified in an interview study. The questionnaire administered in this study was developed and used in previous research. Respondent’s answers were entered into a data file and analysed using SPSS version 22.0 (SPSS, Inc., Chicago IL). Results Overall 1104 parents contributed to this research. Almost two thirds of parents (60.4%, n=667) were worried about the consequences of fever in general, while only 27.2% of parents (n=301) were of the opinion that fever may be beneficial to their child’s health. Almost two thirds of parents (63.1%, n=695) identified temperatures at which they define fever that were either below or above correct definition of temperature (38OC). Logistic regression analysis showed no apparent associations between reporting the correct definition of fever temperature and years of parenting experience or key socio-demographic factors. Nearly two thirds of parents (64.6%, n=714/1011) alternate between fever reducing medications. Most parents (94.9% n=971) believed that the majority of children with a fever did not need an antibiotic, correspondingly, 71.6% (n=732) believed that there was not always an infection in all fever cases. Conclusion Parental knowledge concerning fever as a symptom and fever management was found to be deficient. Opportunities to engage with parents when attending healthcare professionals must be used to elucidate what parents already know and to provide parents with relevant and timely information on how to manage the symptom. This could decrease unnecessary presentation at urgent and emergency care services.

Background: Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED). Methods: A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of ‘Plan Do Study Act’ (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed. Discussion: Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

During a prospective 10-week assessment period, 3238 children aged 1-16 years presented with acute wheeze to Paediatric Emergency Research in the UK and Ireland centres. 110 (3.3%) received intravenous bronchodilators. Intravenous magnesium sulfate (MgSO4) was used in 67 (60.9%), salbutamol in 61 (55.5%) and aminophylline in 52 (47.3%) of cases. In 35 cases (31.8%), two drugs were used together, and in 18 cases (16.4%), all three drugs were administered. When used sequentially the most common order was salbutamol, then MgSO4, then aminophylline. Overall, 30 different intravenous treatment regimens were used varying in drugs, dose, rate and duration.

Objective National clinical guidelines for childhood wheeze exist, yet despite being one of the most common reasons for childhood emergency department (ED) attendance, significant variation in practice occurs in other settings. We, therefore, evaluated practice variations of ED clinicians in the UK and Ireland. Design Two-stage survey undertaken in March 2013. Stage one examined department practice and stage two assessed ED consultant practice in acute childhood wheeze. Questions interrogated pharmacological and other management strategies, including inhaled and intravenous therapies. Setting and participants Member departments of Paediatric Emergency Research in the United Kingdom and Ireland and ED consultants treating children with acute wheeze. Results 30 EDs and 183 (81%) clinicians responded. 29 (97%) EDs had wheeze guidelines and 12 (40%) had care pathways. Variation existed between clinicians in dose, timing and frequency of inhaled bronchodilators across severities. When escalating to intravenous bronchodilators, 99 (54%) preferred salbutamol first line, 52 (28%) magnesium sulfate (MgSO4) and 27 (15%) aminophylline. 87 (48%) administered intravenous bronchodilators sequentially and 30 (16%) concurrently, with others basing approach on case severity. 146 (80%) continued inhaled therapy after commencing intravenous bronchodilators. Of 170 who used intravenous salbutamol, 146 (86%) gave rapid boluses, 21 (12%) a longer loading dose and 164 (97%) an ongoing infusion, each with a range of doses and durations. Of 173 who used intravenous MgSO4, all used a bolus only. 41 (24%) used non-invasive ventilation. Conclusions Significant variation in ED consultant management of childhood wheeze exists despite the presence of national guidance. This reflects the lack of evidence in key areas of childhood wheeze and emphasises the need for further robust multicentre research studies.

Background: Flucloxacillin either alone or combined with penicillin V is still the first-line antibiotic drug of choice for the treatment of cellulitis in emergency departments (EDs) in Ireland. The rationale for this antibiotic regimen is their anti-staphylococcal and anti-streptococcal activity. Objective: To determine the clinical efficacy, tolerability and safety of oral flucloxacillin alone (monotherapy) compared with a combination of flucloxacillin with penicillin V (dual therapy) in the ED-directed outpatient treatment of cellulitis. Methods: We searched the following electronic databases: MEDLINE (1950 to August 2011), EMBASE (1980 to August 2011), Cochrane Central Register of Controlled Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue), OpenGrey, Current Controlled Trials metaRegister of Clinical Trials (August 2011) and reference lists and websites of potential trials. We performed cross-referencing from the reference lists of major articles on the subject. We imposed no language restriction. Results: Despite a comprehensive literature search to identify relevant studies, no randomized-controlled trials that fulfilled the inclusion criteria were found. Conclusions: Despite its common use, there are no published randomized-controlled trials comparing flucloxacillin monotherapy with a combination of flucloxacillin and penicillin V in the ED management of cellulitis. We discuss existing European and North American prescribing rationale and current guidelines.

Introduction Effective pain management in the prehospital setting is gaining momentum as a potential key performance indicator by many emergency medical service systems, but historically has been shown to be inadequate, particularly in the paediatric population. This study aimed to identify the barriers, as perceived by a national cohort of advanced paramedics (APs), to achieving optimal prehospital management of acute pain in children. Methods A qualitative approach was employed to capture data through two focus group interviews. Sixteen APs were invited to participate in this study. Both focus groups were audio recorded, transcribed and analysed using Attride–Stirling9s framework for thematic network analysis. Results The global theme ‘Understanding Barriers to the Prehospital Management of Acute Pain in Children’ emerged from three organising themes as follows: AP education and training; current clinical practice guidelines for paediatric pain management; realities of prehospital practice. Limited exposure to children in the prehospital setting, difficulty assessing pain intensity in small children, and challenges in administering oral or inhaled analgesic agents to distressed and uncooperative children were highlighted by participants. Short transfer times to the emergency department, and a ‘medical’ cause of pain were also implicated as examples of when children are less likely to receive analgesia from practitioners. Conclusions The pathway to improving care must include an emphasis on improvements in practitioner education and training, offering alternatives to assessing pain in preverbal children, exploring the intranasal route of drug delivery in managing acute severe pain, and robustly developed evidence-based guidelines that are practitioner friendly and patient-focused.

Objective To report on the presence and use of social media by speakers and attendees at the International Conference on Emergency Medicine (ICEM) 2012, and describe the increasing use of online technologies such as Twitter and podcasts in publicising conferences and sharing research findings, and for clinical teaching. Methods Speakers were identified through the organising committee and a database constructed using the internet to determine the presence and activity of speakers on social media platforms. We also examined the use of Twitter by attendees and non-attendees using an online archiving system. Researchers tracked and reviewed every tweet produced with the hashtag #ICEM2012. Tweets were then reviewed and classified by three separate authors into different categories. Results Of the 212 speakers at ICEM 2012, 41.5% had a LinkedIn account and 15.6% were on Twitter. Less than 1% were active on Google+ and less than 10% had an active website or blog. There were over 4500 tweets about ICEM 2012. Over 400 people produced tweets about the conference, yet only 34% were physically present at the conference. Of the original tweets produced, 74.4% were directly related to the clinical and research material of the conference. Conclusions ICEM 2012 was the most tweeted emergency medicine conference on record. Tweeting by participants was common; a large number of original tweets regarding clinical material at the conference were produced. There was also a large virtual participation in the conference as multiple people not attending the conference discussed the material on Twitter.

Young children frequently undergo diagnostic and therapeutic procedures in the emergency department (ED). Although developed and validated for postoperative pain, Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scores have been recommended and used for the assessment of procedural pain as well. We set out to assess if FLACC scores can differentiate pain and distress and establish a hierarchy of FLACC scores experienced during common ED procedures.Prospective observational study at an urban tertiary children's hospital ED. We aimed to recruit 30 children each aged 6 to 42 months undergoing intravenous cannula (IV) insertion, nasogastric tube (NGT) insertion, metered dose inhaler (MDI) use and oxygen saturation (SpO(2)) measurement. Based on videotapes, 2 independent observers assessed pain and distress using FLACC scores during all procedural phases.A total of 125 patients were recruited and filmed for IV (33), NGT (30), MDI (34), and SpO2 (28). Median FLACC scores were as follows: NGT, 10 (interquartile range [IQR] 8.75-10); IV, 6.5 (IQR, 4.5-9.75); MDI, 6.5 (IQR, 0-9); and SpO(2), 0 (IQR, 0-0.5). The FLACC scores increased during each of the 3 phases, before the procedure, during restraint, and during the procedure. Procedural distress decreased with age except for NGT insertions, which remained very high irrespective of age.FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children. This study identified substantial levels of pain and distress in young children by FLACC during commonly performed ED procedures, with nasogastric tube insertion having very high and intravenous cannulation/venepuncture and MDI having high FLACC scores.

Nonpurulent cellulitis is an acute bacterial infection of the dermal and subdermal tissues that is not associated with purulent drainage, discharge or abscess. The objectives of this systematic review and meta-analysis were to identify and appraise all controlled observational studies that have examined risk factors for the development of nonpurulent cellulitis of the leg (NPLC). A systematic literature search of electronic databases and grey literature sources was performed in July 2015. The Newcastle-Ottawa Scale (NOS) was used to assess methodological quality of included studies. Of 3059 potentially eligible studies retrieved and screened, six case-control studies were included. An increased risk of developing NPLC was associated with previous cellulitis [odds ratio (OR) 40·3, 95% confidence interval (CI) 22·6-72·0], wound (OR 19·1, 95% CI 9·1-40·0), current leg ulcers (OR 13·7, 95% CI 7·9-23·6), lymphoedema/chronic leg oedema (OR 6·8, 95% CI 3·5-13·3), excoriating skin diseases (OR 4·4, 95% CI 2·7-7·1), tinea pedis (OR 3·2, 95% CI 1·9-5·3) and body mass index > 30 kg m-2 (OR 2·4, 95% CI 1·4-4·0). Diabetes, smoking and alcohol consumption were not associated with NPLC. Although diabetics may have been underrepresented in the included studies, local risk factors appear to play a more significant role in the development of NPLC than do systemic risk factors. Clinicians should consider the treatment of modifiable risk factors including leg oedema, wounds, ulcers, areas of skin breakdown and toe-web intertrigo while administering antibiotic treatment for NPLC.

Predicting risk of adverse healthcare outcomes is important to enable targeted delivery of interventions. The Risk Instrument for Screening in the Community (RISC), designed for use by public health nurses (PHNs), measures the 1-year risk of hospitalisation, institutionalisation and death in community-dwelling older adults according to a five-point global risk score: from low (score 1,2) to medium (3) to high (4,5). We examined the inter-rater reliability (IRR) of the RISC between student PHNs (n=32) and expert raters using six cases (two low, medium and high-risk), scored before and after RISC training. Correlations increased for each adverse outcome, statistically significantly for institutionalisation (r=0.72 to 0.80, p=0.04) and hospitalisation (r=0.51 to 0.71, p

Background Fever is one of the most common childhood symptoms. It causes significant worry and concern for parents. Every year there are numerous cases of over- and under-dosing with antipyretics. Caregivers seek reassurance from a variety of sources including healthcare practitioners. The aim of this study was to describe parental knowledge, attitudes and beliefs regarding management of childhood fever in children aged 5 years and under. Method Semi-structured interviews were conducted with 23 parents at six ante-natal clinics in the south west of Ireland during March and April 2015. The Francis method was used to detect data saturation and thereby identify sample size. Thematic analysis was used to analyse the data. Results Twenty-three parents participated in the study. Five themes emerged from the data: assessing and managing the fever; parental knowledge and beliefs regarding fever; knowledge source; pharmaceutical products; initiatives. Parents illustrated a good knowledge of fever as a symptom. However, management practices varied between participants. Parents revealed a reluctance to use medication in the form of suppositories. There was a desire for more accessible, consistent information to be made available for use by parents when their child had a fever or febrile illness. Conclusion Parents indicated that further initiatives are required to provide trustworthy information on the management of fever and febrile illness in children. Healthcare professionals should play a significant role in educating parents in how to manage fever and febrile illnesses in their children. The accessible nature and location of pharmacies could provide useful support for both parents and General Practitioners.

Acute pain is the most common symptom in the emergency setting and its optimal management continues to challenge prehospital emergency care practitioners, particularly in the paediatric population. Difficulty in establishing vascular access and fear of opiate administration to small children are recognized reasons for oligoanalgesia. Intranasal fentanyl (INF) has been shown to be as safe and effective as intravenous morphine in the treatment of severe pain in children in the Emergency Department setting. This study aimed to describe the clinical efficacy and safety of INF when administered by advanced paramedics in the prehospital treatment of acute severe pain in children. A 1-year prospective cross-sectional study was carried out of children (>1 year

Background: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.

Background Fever is one of the most common childhood symptoms and accounts for numerous consultations with healthcare practitioners. It causes much anxiety amongst parents as many struggle with managing a feverish child and find it difficult to assess fever severity. Over- and under-dosing of antipyretics has been reported. Aim of the review The aim of this review was to synthesise qualitative and quantitative evidence on the knowledge, attitudes and beliefs of parents regarding fever and febrile illness in children. Method A systematic search was conducted in ten bibliographic databases from database inception to June 2014. Citation lists of studies and consultation with experts were used as secondary sources to identify further relevant studies. Titles and abstracts were screened for inclusion according to pre-defined inclusion and exclusion criteria. Quantitative studies using a questionnaire were analysed using narrative synthesis. Qualitative studies with a semi-structured interview or focus group methodology were analysed thematically. Results Of the 1565 studies which were screened for inclusion in the review, the final review comprised of 14 studies (three qualitative and 11 quantitative). Three categories emerged from the narrative synthesis of quantitative studies: (i) parental practices; (ii) knowledge; (iii) expectations and information seeking. A further three analytical themes emerged from the qualitative studies: (i) control; (ii) impact on family; (iii) experiences. Conclusion Our review identifies the multifaceted nature of the factors which impact on how parents manage fever and febrile illness in children. A coherent approach to the management of fever and febrile illness needs to be implemented so a consistent message is communicated to parents. Healthcare professionals including pharmacists regularly advise parents on fever management. Information given to parents needs to be timely, consistent and accurate so that inappropriate fever management is reduced or eliminated. This review is a necessary foundation for further research in this area.

Objective To examine emergency department (ED) staff's knowledge of traumatic stress in children, attitudes toward providing psychosocial care, and confidence in doing so, and also to examine differences in these outcomes according to demographic, professional, and organizational characteristics, and training preferences. Study design We conducted an online survey among staff in ED and equivalent hospital departments, based on the Psychological First Aid and Distress-Emotional Support-Family protocols. Main analyses involved descriptive statistics and multiple regressions. Respondents were 2648 ED staff from 87 countries (62.2% physicians and 37.8% nurses; mean years of experience in emergency care was 9.5 years with an SD of 7.5 years; 25.2% worked in a low- or middle-income country). Results Of the respondents, 1.2% correctly answered all 7 knowledge questions, with 24.7% providing at least 4 correct answers. Almost all respondents (90.1%) saw all 18 identified aspects of psychosocial care as part of their job. Knowledge and confidence scores were associated with respondent characteristics (eg, years of experience, low/middle vs high-income country), although these explained no more than 11%-18% of the variance. Almost all respondents (93.1%) wished to receive training, predominantly through an interactive website or one-off group training. A small minority (11.1%) had previously received training. Conclusions More education of ED staff regarding child traumatic stress and psychosocial care appears needed and would be welcomed. Universal education packages that are readily available can be modified for use in the ED.

Aim: We sought to review the clinical outcomes of patients referred to our emergency department (ED) vaccination service for children with a history of allergy or anaphylaxis or in whom there was a concern of a significant adverse reaction. Methods: This was a prospective observational cohort study set in an urban tertiary Paediatric ED. All attendances for any childhood vaccination for a 5-year period (from January 1, 2006 to December 31, 2010) were included. Our primary outcome measure was any adverse reaction as a result of the vaccine administered. Results: A total of 446 vaccines were administered during the study period in 374 patients. Of these vaccinations, 310 (69.5%) were Measles, Mumps, Rubella (MMR). The majority of patients (348, 93%) were referred from the community. Suspected egg allergy was the reason for the majority of referrals for MMR (261/310 (84.2%)). Only six patients (1.3%) experienced an immediate reaction to a vaccination. All reactions were minor. Conclusion: This is one of the largest studies looking at childhood vaccinations performed in a hospital setting for children who are ‘at risk’ of allergy, anaphylaxis or hypersensitivity. A significant number of referrals were unwarranted and the majority could have been safely managed in the community.

Background Children frequently undergo diagnostic and therapeutic procedures while in hospital. To conduct these procedures safely, preverbal and early-verbal children in particular are often restrained. However, the literature on procedural restraint use is very limited. We set out to describe the extent of restraint use in 4 common procedures. Methods In this prospective observational study at an urban tertiary children's hospital emergency department, children aged 6 to 42 months undergoing 4 commonly performed procedures (intravenous insertion [IV], nasogastric tube [NGT] insertion, metered-dose inhaler [MDI] use, and oxygen saturation [O2 sat] measurement) were recruited. An independent observer assessed the extent and forcefulness of restraint use. Results were analyzed descriptively by age and procedure. Results One hundred twenty-four patients were recruited. All successful procedures (n = 123) were completed in 3 or fewer attempts, with 102 (82%) successful on the first attempt. Physical restraint was used in 89 (72%) of 124 patients overall. All patients undergoing IV (n = 33) and NGT insertion (n = 30), 64% of children requiring MDI (21/33), and only 18% of children requiring O2 sat measurements (5/28) were restrained. Twenty-three (79%) of the NGT insertions and 16 (48%) of IV insertions required moderate or forceful restraint. No or gentle restraint was used for 24 (73%) of MDI use and 100% of saturation measurements. Overall, 41 (87%) of 47 children 6 to 18 months old required restraint use as compared with 28 (68%) of 41 of 18- to 30-month-olds and 20 (57%) of 35 of 30- to 42-month-olds. Conclusions Procedural restraint use in preverbal and early-verbal children is extensive, and significant amounts of force are used, which vary by procedure. Restraint use diminishes with age. A scoring system for restraint use is suggested based on the number of body parts restrained.

OBJECTIVES. Nasogastric tube insertion is a common procedure in children that is very painful and distressing. Although nebulized lidocaine has been shown to be effective in reducing the pain and discomfort of nasogastric tube insertion in adults, there have been no similar studies in children. We set out to investigate the role of nebulized lidocaine in reducing pain and distress of nasogastric tube insertion in young children. METHODS. We conducted a randomized, double-blind, placebo-controlled trial of nebulized 2% lidocaine at 4 mg/kg versus saline placebo during nasogastric tube insertion at a tertiary urban pediatric emergency department. Patients were eligible if they were aged from 1 to 5 years with no comorbid disease and a clinical indication for a nasogastric tube. Nebulization occurred for 5 minutes, 5 minutes before nasogastric tube insertion. Video recordings before, during, and after the procedure were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) pain and distress assessment tool (primary outcome measure) and pain and distress visual analog scale scores (secondary outcome measures). Difficulty of insertion and adverse events were also assessed. RESULTS. Eighteen participants were nebulized with 2% lidocaine and 18 participants with normal saline. Nebulization was found to be highly distressing. FLACC scores during nasogastric tube insertion were very high in both groups. There was a trend in the post–nasogastric tube insertion period toward lower FLACC scores in the lidocaine group. Visual analog scale scores for this postinsertion period were significantly lower in the lidocaine arm for pain and distress. There were no significant differences between groups in terms of difficulty of insertion and the number of minor adverse events. The study was terminated early because of the distress and treatment delay associated with nebulization. CONCLUSIONS. Nasogastric tube insertion results in very high FLACC scores irrespective of lidocaine use. Nebulized lidocaine cannot be recommended as pain relief for nasogastric tube insertion in children. The delay and distress of nebulization likely outweigh a possible benefit in the postinsertion period.

Summary Introduction: Currently there is no comparison of pain and distress experienced by young children undergoing a range of procedures. This would be important when considering choices between alternative management approaches and to facilitate development of measures to reduce procedural pain and distress. We set out to determine staff perceptions of pain and distress across a range of common emergency procedures. Methods: Standardised survey of medical and nursing staff in the emergency department (ED) of a large urban tertiary children’s hospital. Staff perceptions of pain and distress of common ED procedures were measured using a 10 cm visual analogue scale. It included 15 common ED procedures, ranging from suprapubic aspiration (SPA) to measurement of oxygen saturation when performed in a child aged 12–18 months. It included four trauma related procedures. Respondents were stratified by their experience level with the procedures (50 procedures or less = less experienced, greater than 50 procedures = more experienced). Results: Ninety-two of 150 medical and nursing staff in the ED (61%) responded including almost all full time staff. Twenty-one percent of respondents were senior nurses, 17% senior physicians. The procedure considered the most painful was SPA [5.7 (4.0–7.2)cm]; as well as intramuscular injection (IMI) and lumbar puncture (LP). The procedures considered the most distressing were nasogastric tube (NGT) insertion [7.8(6.6–8.7)cm] as well as i.v. insertion and LP. All procedures were rated overall as more distressing than painful. Pain and distress were overall rated similarly regardless of staff experience level. Conclusions: SPA, IMI and LP are perceived by emergency staff as most painful and NGT insertion, i.v. insertion and LP are perceived as most distressing. These findings are important for clinicians when choosing alternative treatment strategies and for researchers in planning future investigations to reduce procedural pain and distress.

Background: Spontaneous pneumothorax (SP) management varies. Clinical effectiveness of simple aspiration compared to intercostal tube drainage needs to be systematically evaluated to produce evidence to underpin consistent best clinical practice. Aim: To compare the clinically efficacy, including hospital use and safety of, simple aspiration compared to intercostal tube drainage in the management of primary SP. Method: Two independent researchers screened Medline, CENTRAL, EMBASE, and other resources and bibliographies of randomised controlled studies, up until December 2014, in adults 18 years and older with primary SP. Data abstraction was conducted by two independent researchers. Results: Four studies from 1093 citations met the inclusion criteria (one ongoing). Immediate success rate of procedure (defined by study authors) and early failure rate of procedure (incomplete lung expansion after procedure) did not significantly differ between groups (risk ratio 0.85; 95%CI 0.69-1.06; 245 subjects) and (RR 1.24; 95%CI 0.87-1.75; 245 subjects) respectively. However, statistically significant benefits were observed in favour of aspiration for reducing hospitalisation (RR 0.44; 95%CI 0.34-0.57; p Conclusion: Available studies found no significant difference in treatment efficacy between simple aspiration and intercostal tube drainage with respect to immediate success of procedure. However, aspiration was associated with reduced hospitalisation. Methodologically rigorous trials are needed to address outcomes including complications, patient satisfaction and cost.