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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.

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.

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.

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.

BACKGROUND: There is increasing evidence that propofol is efficacious and safe for procedural sedation (PS) in the emergency department (ED) setting. However, propofol has a narrow therapeutic window and lacks of a reversal agent. The aim of this review was to cohere the evidence base regarding the efficacy and safety profile of propofol when used in the ED setting for PS. OBJECTIVES: To identify and evaluate all randomized controlled trials (RCTs) comparing propofol with alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE (1950 to September week 2 2013) and EMBASE (1980 to week 2 2013). We searched the Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (September 2013). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction. We re‐ran the search in February 2015. We will deal with the one study awaiting classification when we update the review. SELECTION CRITERIA: RCTs comparing propofol to alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS in participants of all ages. DATA COLLECTION AND ANALYSIS: Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using The Cochrane Collaboration tool for assessing risk of bias. MAIN RESULTS: Ten studies (813 participants) met the inclusion criteria. Two studies only included participants 18 years and younger; six studies only included participants 18 years and older; one study included participants between 16 and 65 years of age and one study included only adults but did not specify the age range. Eight of the included studies had a high risk of bias. The included studies were clinically heterogeneous. We undertook no meta‐analysis. The primary outcome measures of this review were: adverse effects (as defined by the study authors) and participant satisfaction (as defined by the study authors). In one study comparing propofol/fentanyl with ketamine/midazolam, delayed adverse reactions (nightmares and behavioural change) were noted in 10% of the ketamine/midazolam group and none in the propofol/fentanyl group. Seven individual studies reported no evidence of a difference in adverse effects between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. Three individual studies reported no evidence of a difference in pain at the injection site between intravenous propofol and alternative interventions. Four individual studies reported no evidence of a difference in participant satisfaction between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions (ketamine, etomidate, midazolam). All the studies employed propofol without the use of an adjunctive analgesic and all, except one, were small (fewer than 100 participants) studies. The quality of evidence for the adverse effects and participant satisfaction outcomes was very low. Nine included studies (eight comparisons) reported all the secondary outcome measures of the review except mortality. It was not possible to pool the results of the included studies for any of the secondary outcome measures because the comparator interventions were different and the measures were reported in different ways. Seven individual studies reported no evidence of difference in incidence of hypoxia between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. AUTHORS' CONCLUSIONS: No firm conclusions can be drawn concerning the comparative effects of administering intravenous propofol, with or without an adjunctive analgesic agent, with alternative interventions in participants undergoing PS in the ED setting on adverse effects (including pain at the injection site) and participant satisfaction. The review was limited because no two included studies employed the same comparator interventions, and because the number of participants in eight of the included studies were small (fewer than 100 participants).

Aim Fever and febrile illness are some of the most common conditions managed by parents. The aim of this study was to examine the knowledge, attitudes and beliefs of parents around fever in children under five years of age. Methods Between July and August 2014, a convenience sample of parents was invited to participate in this study in Copenhagen, Denmark. Results were analysed thematically using a constant comparison method. Results Twenty-one parents participated in the study. Five themes emerged from the data: parental concern, help-seeking behaviour, parental knowledge, parent fever management practices and initiatives. Parents used a range of information sources to obtain their knowledge on management of fever; however, due to issues of trust with these sources, reassurance was often sought from healthcare practitioners. There was a desire amongst most parents for initiatives to be introduced which provide general information on how to manage fever in children. Conclusion Parents were very concerned when their child was febrile and instigated practices obtained from accessible information sources. This study has identified a need for specific and reliable information initiatives to be introduced as a means of reducing parental concern and ensuring evidence-based strategies for managing a child with fever.

Background Key performance indicators (KPIs) are used to identify where organisational performance is meeting desired standards and where performance requires improvement. Valid and reliable KPIs depend on the availability of high-quality data, specifically the relevant minimum data set ((MDS) the core data identified as the minimum required to measure performance for a KPI) elements. However, the feasibility of collecting the relevant MDS elements is always a limitation of performance monitoring using KPIs. Preferably, data should be integrated into service delivery, and, where additional data are required that are not currently collected as part of routine service delivery, there should be an economic evaluation to determine the cost of data collection. The aim of this systematic review was to synthesise the evidence base concerning the costs of data collection in hospitals for performance monitoring using KPI, and to identify hospital data collection systems that have proven to be cost minimising. Methods We searched MEDLINE (1946 to May week 4 2014), Embase (1974 to May week 2 2014), and CINAHL (1937 to date). The database searches were supplemented by searching for grey literature through the OpenGrey database. Data was extracted, tabulated, and summarised as part of a narrative synthesis. Results The searches yielded a total of 1,135 publications. After assessing each identified study against specific inclusion exclusion criteria only eight studies were deemed as relevant for this review. The studies attempt to evaluate different types of data collection interventions including the installation of information communication technology (ICT), improvements to current ICT systems, and how different analysis techniques may be used to monitor performance. The evaluation methods used to measure the costs and benefits of data collection interventions are inconsistent across the identified literature. Overall, the results weakly indicate that collection of hospital data and improvements in data recording can be cost-saving. Conclusions Given the limitations of this systematic review, it is difficult to conclude whether improvements in data collection systems can save money, increase quality of care, and assist performance monitoring of hospitals. With that said, the results are positive and suggest that data collection improvements may lead to cost savings and aid quality of care. Systematic review registration PROSPERO CRD42014007450.

Introduction Key performance indicators (KPIs) are used to monitor and evaluate critical areas of clinical and support functions that influence patient outcome. Traditional prehospital emergency care performance monitoring has focused solely on response time metrics. The landscape of emergency care delivery in Ireland is in the process of significant national reconfiguration. The development of KPIs is therefore considered one of the key priorities in prehospital research. Aims The aim of this study was to develop a suite of KPIs for prehospital emergency care in Ireland. Methods A systematic literature review of prehospital care performance measurement was undertaken followed by a three-round Delphi consensus process facilitated by a broad-based multidisciplinary group of panellists. The consensus process was conducted between June 2012 and October 2013. Each candidate indicator on the Delphi survey questionnaire was rated using a 5-point Likert-type rating scale. Agreement was defined as at least 70% of responders rating an indicator as ‘agree’ or ‘strongly agree’ on the rating scale. Data were analysed using descriptive statistics. Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. Results Of the 78 citations identified by the systematic review, 5 relevant publications were used to select candidate indicators for the Delphi round 1 questionnaire. Response rates in Delphi rounds 1 and 2 were 89% and 83%, respectively. Following the consensus development conference, 101 KPIs reached consensus. Based on the Donabedian framework for quality-of-care indicators, 7 of the KPIs which reached agreement were structure KPIs, 74 were process KPIs and 20 were outcome KPIs. The highest ranked indicator was a process KPI (‘Direct transport of ST-elevation myocardial infarction patients to a primary percutaneous intervention (PCI)-capable facility for ECG to PCI time Conclusion Improving the quality of prehospital care requires the development and implementation of performance measurement using scientifically valid and reliable KPIs. Employing a Delphi panel of key multidisciplinary Emergency Medical Service stakeholders, it was feasible to develop a suite of 101 KPIs for performance monitoring of prehospital emergency care in Ireland. This suite of KPIs may contribute to a framework for achieving safer, better care in the prehospital environment.

Background Many parents consider fever a disease in itself and feel disempowered when their child is ill. Numerous guidelines have been produced; however, their target audience remains healthcare professionals and not carers of children in general. A reliable source of information will decrease worry in parents and carers when managing a febrile child. Methods/Design A systematic search will be conducted in nine electronic databases. Articles published in English, or with an abstract published in English, will be eligible for inclusion in the review. Unpublished literature, grey literature and consultation with experts in the area will be used to supplement database searching. Titles and abstracts of studies will be screened for inclusion in the study by two independent reviewers against pre-determined inclusion and exclusion criteria. A data extraction form will be designed and data will be extracted to provide detail of the included studies by a further two reviewers. Quality assessment of studies will be conducted by two additional independent reviewers and results will be used to moderate included studies. All disagreements will be resolved through discussion until consensus is reached. Thematic synthesis will be used to analyse results. Discussion Correct management of fever in children is not well understood in the general population. Although carers can identify fever and febrile illness in children, determination of the severity of fever proves challenging. Research is needed to cohere existing evidence and identify knowledge gaps. It is envisaged that results of this review will contribute to the development of trustworthy, accessible guidelines for parents and carers of children with fever or febrile illness. Systematic review registration PROSPERO CRD42014009812

Objectives There is a lack of evidence to guide the management of cellulitis in the emergency department (ED). The primary aim of this study was to characterize antibiotic-prescribing practices for the treatment of cellulitis in Irish EDs. Secondary aims were to identify patient variables associated with the prescription of intravenous (i.v.) antibiotics and to describe the utility of three published guidelines for the management of cellulitis in the ED. Methods This was a multicentre, prospective, observational cross-sectional study of consecutive patients presenting to six EDs in Ireland over a 1-month period (June 2012). Results In total, 117 patients were enrolled. Fifty-five percent of all patients (n=65) were referred from primary care, and emergency physicians prescribed i.v. therapy in 50% of patients (n=59) overall. Nonpurulent cellulitis accounted for 96.5% of cases (n=113). Flucloxacillin, either alone or with penicillin V, is the most commonly prescribed oral antibiotic in patients both referred from primary care and discharged from the ED. Flucloxacillin with benzylpenicillin is the most commonly prescribed i.v. Treatment Fever, increasing diameter of infection, and tinea pedis were associated with prescription of i.v. antibiotics by emergency physicians. The three guidelines examined in this study recommended oral antibiotic treatment for between 33-44% of patients who were treated with i.v. antibiotics by emergency physicians. Conclusion In Ireland, current prescribing practices for CREST 1 and modified CREST 1 and 2 patients are poorly adherent to guideline recommendations.

Objective Paediatric Emergency Research in the UK and Ireland (PERUKI) is a collaborative clinical studies group established in August 2012. It consists of a network of 43 centres from England, Ireland, Northern Ireland, Scotland and Wales, and aims to improve the emergency care of children through the performance of robust collaborative multicentre research within emergency departments. A study was conducted regarding the research priorities of PERUKI, to establish the research agenda for paediatric emergency medicine in the UK and Ireland. Methods A two-stage modified Delphi survey was conducted of PERUKI members via an online survey platform. Stage 1 allowed each member to submit up to 12 individual questions that they identified as priorities for future research. In stage 2, the shortlisted questions were each rated on a seven-point Likert scale of relative importance. Participants Members of PERUKI, including clinical specialists, academics, trainees and research nurses. Results Stage 1 surveys were submitted by 46/91 PERUKI members (51%). A total of 249 research questions were generated and, following the removal of duplicate questions and shortlisting, 60 questions were carried forward for stage 2 ranking. Stage 2 survey responses were submitted by 58/95 members (61%). For the 60 research questions that were rated, the mean score of ‘relative degree of importance’ was 4.70 (range 3.36–5.62, SD 0.55). After ranking, the top 10 research priorities included questions on biomarkers for serious bacterial illness, major trauma, intravenous bronchodilators for asthma and decision rules for fever with petechiae, head injury and atraumatic limp. Conclusions Research priorities of PERUKI members have been identified. By sharing these results with clinicians, academics and funding bodies, future research efforts can be focused to the areas of greatest need.

Study objective In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for s 2 -agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day 4. Methods We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of s 2 -agonist–responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days. Results There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI –0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner. Conclusion In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4.

Objectives Fever is a common symptom of mostly benign illness in young children, yet concerning for parents. The aim of this study was to describe parental knowledge, attitudes and beliefs regarding fever in children aged ≤5 years of age. Design A cross-sectional study using a previously validated questionnaire. Results were analysed using descriptive statistics and multivariable logistic regression. Setting Purposively selected primary schools (n=8) in Cork, Ireland, using a paper-based questionnaire. Data were collected from a cross-sectional internet-based questionnaire with a convenience sample of parents via websites and web pages (n=10) previously identified in an interview study. Participants Parents with at least one child aged ≤5 years were invited to participate in the study. Main outcome measures Parental knowledge, attitudes and beliefs when managing fever in children. Results One thousand one hundred and four parents contributed to this research (121 parents from schools and 983 parents through an online questionnaire). Almost two-thirds of parents (63.1%) identified temperatures at which they define fever that were either below or above the recognised definition of temperature (38°C). Nearly two of every three parents (64.6%) alternate between two fever-reducing medications when managing a child’s fever. Among parents, years of parenting experience, age, sex, educational status or marital status did not predict being able to correctly identify a fever, neither did they predict if the parent alternated between fever-reducing medications. Conclusions Parental knowledge of fever and fever management was found to be deficient which concurs with existing literature. Parental experience and other sociodemographic factors were generally not helpful in identifying parents with high or low levels of knowledge. Resources to help parents when managing a febrile illness need to be introduced to help all parents provide effective care.

Background: Quality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards.Methods: A questionnaire measuring Staff Perception of their patient’s End of Life Experience (SPELE) was developed. Content Validity (CVI) was assessed by a panel of experts and piloting was conducted with dyads of healthcare assistants (n=15) and nurses (n=15).Results: The SPELE captures facets of the quality of the death and dying experience from healthcare staff’s perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain.Conclusion: Further testing of the questionnaire is underway in a large multi-centre randomised control trial in Ireland. To date the tool is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL.

Background Key performance indicators (KPIs) are used to identify where organisational performance is meeting desired standards and where performance requires improvement. Valid and reliable KPIs depend on the availability of high-quality data, specifically, the relevant minimum data set (MDS; the core data identified as the minimum required to measure performance for a KPI) elements. However, the feasibility of collecting the relevant MDS elements is always a limitation of performance monitoring using KPIs. Preferably, data should be integrated into service delivery, and where additional data are required that are not currently collected as part of routine service delivery, there should be an economic evaluation to determine the cost of data collection. The aim of this systematic review is to synthesise the evidence base concerning the costs of data collection in hospitals for performance monitoring using KPIs, and to identify hospital data collection systems that have proven to be cost minimising. Methods/Design Electronic databases will be systematically searched for publications in English that examine the cost of data collection within a hospital context. The database searches will be supplemented by searching through citations and references. Screening of both titles and abstracts will be done by two independent reviewers. All disagreements will be resolved by an independent third reviewer. Data analysis will be completed and reported in a narrative review. Discussion This review will cohere the evidence base regarding cost-minimising hospital data collections systems for performance monitoring and if these are associated with potential benefits for patients. Systematic review registration PROSPERO CRD42014007450

BackgroundThe use of procedural sedation outside the operating theatre has increased in hospital settings and has gained popularity among non-anesthesiologists. Sedative agents used for procedural pain, although effective, also pose significant risks to the patient if used incorrectly. There is currently no universally accepted program of education for practitioners using or introducing procedural sedation into their practice. There is emerging literature identifying structured procedural sedation programs (PSPs) as a method of ensuring a standardized level of competency among staff and reducing risks to the patient. We hypothesize that programs of education for healthcare professionals using procedural sedation outside the operating theatre are beneficial in improving patient care, safety, practitioner competence and reducing adverse event rates.Methods/DesignElectronic databases will be systematically searched for studies (randomized and non-randomized) examining the effectiveness of structured PSPs from 1966 to present. Database searches will be supplemented by contact with experts, reference and citation checking, and a grey literature search. No language restriction will be imposed. Screening of titles and abstracts, and data extraction will be performed by two independent reviewers. All disagreements will be resolved by discussion with an independent third party. Data analysis will be completed adhering to procedures outlined in theCochrane Handbook of Systematic Reviews of Interventions. If the data allows, a meta-analysis will be performed.DiscussionThis review will cohere evidence on the effectiveness of structured PSPs on sedation events and patient outcomes within the hospital and other acute care settings. In addition, it will examine key components identified within a PSP associated with patient safety and improved patient outcomes.Systematic review registrationPROSPERO registration number:CRD42013003851