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Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study.

ABSTRACT: Background:Paediatric clavicle fractures are commonly seen in the emergency department (ED), and the current standard of care is to obtain a radiograph for all suspected clavicle fractures. We are yet to determine whether radiographs add valuable information to clinicians' assessment and therefore if they are necessary in the management of paediatric clavicle fractures. Objective:To determine whether clinicians can manage paediatric clavicle fractures without radiographs, first by determining the accuracy of clinicians in identifying the presence of a clavicle fracture, and second by evaluating the level of agreement (kappa (?)) between the ultimate management of children with suspected clavicle fractures and clinicians' blinded prediction prior to the radiograph. Methods:This prospective study enrolled patients presenting to a paediatric ED with a suspected clavicle fracture. Prior to requesting a radiograph, clinicians completed a standardised form, where they predicted the presence of a fracture and their ultimate management based on their clinical findings, and rated their confidence. Results:Of the 50 patients aged 7.2±3.9 years included, 40 (80%) had a radiologically proven clavicle fracture, and clinicians were able to accurately identify them (sensitivity 93%, positive predictive value 88%). There were five (50%) patients without a radiological fracture that were treated with broad arm sling. Clinicians' prediction of ultimate management had the highest agreement with the ultimate management of the patient on leaving the ED, compared with clinicians' prediction of the presence of fracture and the final radiograph findings: ? of 0.88 (95% CI 0.64 to 1), 0.67 (95% CI 0.36 to 0.98) and 0.62 (95% CI 0.30 to 0.94), respectively. Thirty-six (72%) of the clinicians felt comfortable treating without radiographs, and this was dependent on their level of training. Conclusions:Clinicians can identify the presence of a fracture and tend to be overconservative in their management. Despite negative radiological findings, some patients were treated as though they had a fracture, based on clinical judgement. This adds evidence that radiographs are not routinely required for uncomplicated paediatric clavicle fractures.

SUBMITTER: Lirette MP

PROVIDER: S-EPMC6089283 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study.

Lirette Marie-Pier MP Bailey Benoit B Grant Samuel S Jackson Michael M Leonard Paul P

BMJ paediatrics open 20180810 1

<h4>Background</h4>Paediatric clavicle fractures are commonly seen in the emergency department (ED), and the current standard of care is to obtain a radiograph for all suspected clavicle fractures. We are yet to determine whether radiographs add valuable information to clinicians' assessment and therefore if they are necessary in the management of paediatric clavicle fractures.<h4>Objective</h4>To determine whether clinicians can manage paediatric clavicle fractures without radiographs, first by ...[more]

PMID: 30116792

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Project description:ObjectivesTo describe clinical characteristics and management of acute lymphadenitis and to identify risk factors for complications.MethodsHealth record review of children ≤17 years with acute lymphadenitis (≤2 weeks) in a tertiary paediatric emergency department (2009-2014); 10% of charts were reviewed by a blinded second reviewer. Multivariate logistic regression identified factors associated with intravenous antibiotic treatment, unplanned return visits warranting intervention, and surgical drainage.ResultsOf 1,023 health records, 567 participants with acute lymphadenitis were analyzed. The median age = 4 years (interquartile range [IQR]: 2 to 8 years), and median duration of symptoms = 1.0 day (IQR: 0.5 to 3.0 days). Cervical lymphadenitis was most common. Antibiotics were prescribed in 73.5% of initial visits; 86.9% of participants were discharged home. 29.0% received intravenous antibiotics, 19.3% had unplanned emergency department return visits, and 7.4% underwent surgical drainage. On multivariate analysis, factors associated with intravenous antibiotic use included history of fever (odds ratio [OR]=2.07, 95% confidence interval [CI]: 1.11 to 3.92), size (OR=1.74 per cm, 95% CI: 1.44 to 2.14), age (OR=0.84 per year, 95% CI: 0.76 to 0.92), and prior antibiotic use (OR=4.45, 95% CI: 2.03 to 9.88). The factors associated with unplanned return visit warranting intervention was size (OR=1.30 per cm, 95% CI: 1.06 to 1.59) and age (OR=0.89, 95% CI: 0.80 to 0.97). Factors associated with surgical drainage were age (OR=0.68 per year, 95% CI: 0.53 to 0.83) and size (OR=1.80 per cm, 95% CI: 1.41 to 2.36).ConclusionsThe vast majority of children with acute lymphadenitis were managed with outpatient oral antibiotics and did not require return emergency department visits or surgical drainage. Larger lymph node size and younger age were associated with increased intravenous antibiotic initiation, unplanned return visits warranting intervention and surgical drainage.

Project description:BackgroundQuality improvement systems are needed to overcome the 'Quality Gap' - difference between evidence-based guidelines and the care delivered. While there are a large array of potential quality assurance measures exists in the Paediatric Emergency Department, parent's/carer's perception of these is unknown. This study aimed to identify what 'quality of care' means to parents/carers of Paediatric Emergency Department (PED) patients, further determine which aspects of these are most important to them. Also, to identify which of the existing PED quality measures are most important to parents/carers, and their preferred method of providing feedback.MethodsA Modified Rand-Delphi study was performed with parents/carers as the expert group and consensus was obtained from them via three web-based surveys. All parents/carers of children attending a tertiary paediatric hospital during six-week in winter were eligible- no exclusions. Quality measures scoring at least 7 on a 9-point Likert scale during the final survey were considered "very important", while those scoring at least an 8 were considered "extremely important".ResultsOne hundred four parents/carers responded from a total of 1095 participants. Parents/carers generated 527 free text entries, to the initial survey on what 'quality of care' means. These were mapped to 48 quality measure which they ranked on subsequent surveys. Eighteen quality measures were considered very important by at least 90% of respondents. Of these, six were considered extremely important by at least 70% of respondents: 'Thorough medical assessment' (84%); 'A triage system' (84%); 'Experienced and knowledgeable staff that are skilled in paediatrics' (77%); 'Resources and equipment available to provide care' (72%); and 'Clear follow up plans and reviews that are communicated and scheduled' (72%). Parents/carers considered existing quality measures as important with 'timely treatment of a critical condition' as the most important. Most participants preferred to provide anonymous feedback (N = 69, 66%), online (N = 77, 72%) after discharge (N = 82, 70%).ConclusionWe have elicited what 'quality of care' means to parents/carers, and which aspects are most important to them. Parents/carers consider commonly used PED quality measure as very important. However, they are less important than outcomes generated by themselves. Further parents/carers in this study preferred to provide feedback that was anonymous and electronically distributed after they leave the ED.

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Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study.

Publications

Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study.

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