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The 60th Bubble Wrap

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With millions upon millions of journal articles being published every year, it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye.

Article 1: Does having paediatric clinicians taking the calls make a difference to the outcomes of NHS 111?

Stilwell PA, Stuttard G, Scott-Jupp R, et al.  Paediatric NHS 111 Clinical Assessment Services Pilot: an observational study. Arch Dis Child 2022;107:e14.

What’s it about? 

This is an observational study looking at the feasibility and impact of having paediatric clinicians working in the Clinical Assessment Services (CAS) within NHS 111. Between May and December 2020, six NHS 111 providers used volunteer paediatric clinicians (paediatric doctors and paediatric Advanced Nurse Practitioners (ANPs)). A data framework was used to evaluate the calls taken by paediatric clinicians (PCs) vs non-paediatric clinicians (NPCs). Patient disposition was subdivided into those who ended up looking after themselves without a referral, those who needed a primary care appointment, those sent to ED and those requiring an emergency ambulance. The duration of the call was also recorded.

In total 70 PCs (66 doctors and 4 ANPs) were recruited split between 5 NHS 111 sites with a local 6th site . There were a total of 2535 calls to PCs vs 137 008 to equivalent NPCs (GPs, ANPs, paramedics, dental nurses, mental health nurses and urgent care practitioners). 69% of calls taken by PCs led to self-care compared to 43% in NPCs.  PCs advised 13% to use primary care (versus 29% NPCs). Paediatric clinicians suggested 13% advised to go to ED (vs 18% in NPCs). 1% of callers were advised to call an ambulance by paediatric clinicians (4% NPCs).

Paediatric clinicians were more likely to have resolved the problem (92% vs 27%).  Response time was also quicker in the paediatric clinician cohort (average 6 mins 18s vs 8 mins 4s).

Why does it matter? 

NHS 111 is a national telephone advice service in the United Kingdom. During the early phases of the COVID-19 pandemic, there was a large increase in the volume of calls to the service. Many of which were about children and young people.

Call handlers may have had little paediatric specific experience. In the NHSE/I (NHS England/Improvement) and UEC (Urgent Emergency Care) long-term plan emphasis has been placed on improving patient outcomes and ensuring that urgent care services are used for those where hospital is the only option.

At a time when purse strings are tight- saving pennies is crucial. Projections from this study suggest that for every 100 calls made to NHS111 the potential cost saving of using paediatric clinicians was £1936. This equated to £106 million per year based on an estimated 5.5 million calls to NHS 111.

The study did not break down the calls taken by non-paediatric clinicians, or the grade of the paediatric clinician giving advice. Neither did it provide granular data around what the presenting complaints were. There is also no way of knowing if the disposition suggested was the final destination of the patient.

Clinically Relevant Bottom Line:

It is important we get things right the first time. Accessing the most appropriate clinician early in the patient journey may result in more patients managed in a primary care setting with appropriate safety net advice and improve the satisfaction of children and parents. This ultimately saves money for the healthcare systems.

Reviewed by: Vicki Currie

Article 2: Let’s debate a classic…

Megged, O., Dorembus, S., Ben-Shalom, E., Heiman, Eyal (2022) Comparing blood culture contamination rates by different sampling methods in a paediatric emergency department, Journal of Paediatric and Child Health, Vol 58 pp 668-673 https://doi.org/10.1111/jpc.15812

What’s it about? 

How many of you were taught to collect a blood culture using a needle and syringe when inserting an intravenous cannula (IVC). It’s the classic paediatric blood collection method! Well, a study has shown this “open” system is associated with higher blood culture contamination methods, in comparison to “closed” systems i.e., intravenous catheter or venepuncture, with a device connected directly to a syringe.

A tertiary paediatric emergency department in Jerusalem, Israel had ethics approval to document patient demographics (hospital ID, age, sex, weight) and procedural details (date, time and method of blood culture collection, proceduralist). The volume of blood collected ranged from 1 – 4mL in infants and up to 10mL in older children. Additional data was collected retrospectively; if a blood culture flagged positive in under 24 hours, the proceduralist could be identified and remember the patient demographics and procedural details. Blood samples were placed into the same aerobic and anaerobic bottles and the laboratory used the same techniques to isolate and identify any pathogens.

The single centre prospective study ran from February 2020 to September 2020, where a total of 512 blood cultures were included. Of these, 327 were collected using a “closed” system and 185 were collected using the “open” system. They found 41 (8%) positive blood cultures, with 33 identified as contaminants and 8 identified as true positives. There was no difference between the groups based on patient demographics or proceduralist. There was a 2.34-fold increased rate of contamination when blood was collected using the “open” system, which was statistically significant. The contaminant pathogens were a mix of skin flora (87%) and oral flora (13%).

Why does it matter? 

Contaminated blood cultures result in children needing repeat blood tests, unnecessary hospitalisations and increased antibiotic use. This adds to stress, the risk of side effects to antibiotics and is costly to the health care system.

Clinically Relevant Bottom Line:

Blood culture collection should be as sterile as possible. Future studies may look at how many children experience harm as a result of a false-positive blood culture, if we opted for a “closed” system collection in EDs.

Reviewed by: Tina Abi Abdallah

Article 3: Is spending time in the emergency department bad for your health?

Jones, S., Moulton, C., Swift, S., Molyneux, P., Black, S., Mason, N., Oakley, R. and Mann, C., 2022. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emergency Medicine Journal.

What’s it all about?

Waiting times in ED departments have been increasing. We know that delayed admission from ED to the ward is detrimental to patient care. This paper looks at whether a delay to admission results in an increased risk of death. This was a cross-sectional, retrospective, observational study on patients admitted following from every type 1 ED (major NHS departments that are open 24 hours a day under the supervision of consultants in emergency medicine.) in England between April 2016 – March 2018 with death from all causes within 30 days of admission as the primary outcome. Only the first admission within the study period was included. A logistic regression model was used to predict 30-day mortality, this attempted to control for factors such as ED overcrowding.  Authors concluded that delays to admission of greater than 5 hours from the time of arrival are associated with an increase in mortality with a predictable dose-response effect for delays between 5-12 hours. For every 82 admitted patients whose time to transfer to an inpatient bed is 6-8 hours, there is one extra death. The authors proposed the following as possible mechanisms for this mortality increase, delay in treatments such as antibiotics due to ED overcrowding, accommodation in suboptimal areas, exacerbation of delirium, increased risk of hospital-acquired infection and nighttime admission to wards when staffing levels are lowest.

Why does it matter?

Although the study is not limited to paediatric patients (in whom mortality is far lower) it seems likely that some of the factors would also affect the paediatric population. Paediatric ED’s are not immune from delays to admission or overcrowding.

The Bottom Line:

Prolonged waits in the ED are not just bad for the patient experience, they increase mortality as well.

Reviewed by: Sarah Reynolds

Article 4: How exactly does HFNC help patients with bronchiolitis?

GuglielmoRD, Hotz JC, Ross PA et al.High-Flow Nasal Cannula Reduces Effort of Breathing but Not Consistently via Positive End-Expiratory Pressure. Chest2022 Mar 16;S0012-3692(22)00441-X.

What’s it about?

High Flow Nasal Cannula (HFNC) has become the mainstay therapy for paediatric patients with bronchiolitis, especially in the PICU setting. Studies have shown that HFNC reduces the effort of breathing, risk of PICU admission and risk of intubation (Ed. note. Or does it?). However, the exact mechanism of action of HFNC remains unknown.

This was a prospective, single-centre study of 22 paediatric patients, ≤3 years old admitted with bronchiolitis in an American Paediatric ICU from January 2020 through March 2021. The flow was titrated between 0.5 and 2 L/kg/min.

Electrical impedance tomography (EIT) was used as a surrogate measure for end-expiratory lung volume (EELV) and tidal volume (VT). Oesophagal manometry was used to measure oesophageal pressure (Pes) change (ΔPes), end-expiratory pressure via Pes (PesPEEP) and respiratory rate via Pes (RRPes).

There were no significant changes in VT with increasing HFNC flow rates. At higher ‘doses’ (up to 2L/kg) there was a consistent decrease in the effort of breathing.  There was minimal change in ΔPes and PesPEEP regardless of HFNC flow rate.

This was a single-centre trial with a small sample size (enrollment was halted due to the COVID-19 pandemic). Moreover, technical difficulties may have impacted results although each patient served as their own control in order to reduce variability.

Why does it matter?

HFNC is an effective therapy option for paediatric patients hospitalised with bronchiolitis. The exact mechanism of action remains unknown. This study corroborates findings from previous studies that HFNC reduces respiratory effort without having a direct effect on PEEP.

The bottom line

Results of this study showed that increasing HFNC rates in paediatric patients with bronchiolitis lead to a consistent reduction of breathing effort. However, the primary mechanism of action of HFNC in bronchiolitis is unlikely to be related to the application of PEEP.

Reviewed by: Spyridon Karageorgos

Article 5: What are we using point of care testing for in Paediatrics?

 Pandey, M., Lyttle, M.D., Cathie, K. et al. Point-of-care testing in Paediatric settings in the UK and Ireland: a cross-sectional study. BMC Emerg Med 22, 6 (2022). https://doi.org/10.1186/s12873-021-00556-7

What’s it about?

 

An online cross-sectional survey study was distributed to sites across the UK. All were members of PERUKI (Paediatric Emergency Research in the UK and Ireland) and GAPRUKI (General Adolescent and Paediatric Research UK and Ireland) with one response requested from each network site. POCT (Point Of Care Testing) was defined as a test that would give a result in 30 mins AND that aided clinical decision making at the time taken and interpreted. The authors wanted to know what testing eas currently being undertaken. Data was also collected around who performed/interpreted the tests and the governance surrounding the testing.

The most common tests performed were blood sugar analysis in 98% of the sites, urinalysis (96%) and blood gas analysis (95%). Around one-third of sites had RSV and influenza testing. Other less common tests were; CRP (9%), Group A streptococcus (3%) and procalcitonin (1%). The lab team took full responsibility at 33% of sites. Data was stored as a handwritten note (35%). The commonest barrier to POCT use was lack of funding (45%).

There is a range of testing in the UK and Ireland. The study did attain a wide reach with good response rate reducing some biases.

Why does it matter?

Making quick and accurate decisions is important. When laboratory-based tests are used, waiting for results can result in delays, not just for the patient in question but the system as a whole.

Without much guidance, a lack of funding and a standardised approach there is marked variation in usage.

Clinically Relevant Bottom Line:

With POCT becoming more common, the development of a standardised framework for use and implementation is crucial. POCT will increasingly play a vital role in centres aiming to provide emergency care.

Reviewed by: Vicki Currie

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

All articles reviewed and edited by Vicki Currie

About the authors

  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

KEEP READING

High flow therapy – when and how?

Chest compressions in traumatic cardiac arrest

Searching for sepsis

The missing link? Children and transmission of SARS-CoV-2

Don’t Forget the Brain Busters – Round 2

An evidence summary of Paediatric COVID-19 literature

Urticaria

The fidget spinner craze – the good, the bad and the ugly

Parenteral Nutrition

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