Telemedicine in paediatric emergency care: A systematic review

Introduction The impact of telemedicine on the access and quality of paediatric emergency care remains largely unexplored because most studies to date are focused on adult emergency care. We performed a systematic review of the literature to determine if telemedicine is effective in improving quality of paediatric emergency care with regards to access, process measures of care, appropriate disposition, patient-centred outcomes and cost-related outcomes. Methods We developed a systematic review protocol in accordance with PRISMA (Preferred Reporting Items for Systematic Review) guidelines. We included studies that evaluated the impact of synchronous and asynchronous forms of telemedicine on patient outcomes and process measures in the paediatric emergency care setting. Inclusion criteria were study setting, study design, intervention type, age, outcome measures, publication year and language. Results Overall, 1.9% (28/1434) studies met study inclusion and exclusion criteria. These studies revealed that telemedicine increased accuracy of patient assessment in the pre-clinical setting, improved time-to disposition, guided referring emergency department (ED) physicians in performing appropriate life-saving procedures and led to cost savings when compared to regular care. Studies focused on telepsychiatry demonstrated decreased length of stay (LOS), transfer rates and improved patient satisfaction scores. Discussion Our comprehensive review revealed that telemedicine enhances paediatric emergency care, enhances therapeutic decision-making and improves diagnostic accuracy, and reduces costs. Specifically, telemedicine has its most significant impact on LOS, access to specialized care, cost savings and patient satisfaction. However, there was a relative lack of randomized control trials, and more studies are needed to substantiate its impact on morbidity and mortality.

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

BackgroundClinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population.MethodsA single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.Results1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%).ConclusionCSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

A survey of mHealth use from a physician perspective in paediatric emergency care in the UK and Ireland

There has been a drive towards increased digitalisation in healthcare. The aim was to provide a snapshot of current apps, instant messaging, and smartphone photography use in paediatric emergency care. A web-based self-report questionnaire was performed. Individual physicians working in paediatric emergency care recorded their personal practice. One hundred ninety-eight medical doctors completed the survey. Eight percent of respondents had access to institutional mobile devices to run medical apps. Eighty-six percent of respondents used medical apps on their personal mobile device, with 78% using Apple iOS devices. Forty-seven percent of respondents used formulary apps daily. Forty-nine percent of respondents had between 1–5 medical apps on their personal mobile device. Respondents who used medical apps had a total of 845 medical apps installed on their personal device, accounted for by 56 specific apps. The British National Formulary (BNF/BNFc) app was installed on the personal mobile device of 96% of respondents that use medical apps. Forty percent of respondents had patient confidentiality concerns when using medical apps. Thirty-eight percent of respondents have used consumer instant messaging services, 6% secure specialist messaging services, and 29% smartphone photography when seeking patient management advice. Conclusion App use on the personal mobile devices, in the absence of access to institutional devices, was widespread, especially the use of a national formulary app. Instant messaging and smartphone photography were less common. A strategic decision has to be made to either provide staff with institutional devices or use software solutions to address data governance concerns when using personal devices. What is Known:• mHealth use by junior doctors and medical students is widespread.• Clinicians’ use of instant messaging apps such as WhatsApp is the widespread in the UK and Ireland, in the absence of alternatives. What is New:• Personal mobile device use was widespread in the absence of alternatives, with the British National Formulary nearly universally downloaded to physicians’ personal mobile devices.• A third of respondents used instant messaging and smartphone photography on their personal mobile device when seeking patient management advice from other teams in the absence of alternatives.

Paediatric emergencies and related mortality in Nicaragua: results from a multi-site paediatric emergency registry

BackgroundWe aim to describe the characteristics and outcomes of the severe spectrum of paediatric emergency visits using a multi-site registry developed as part of an international cooperation project.MethodsThis observational registry-based study presented descriptive statistics of clinical and outcome data on urgent-emergency paediatric visits from 7 Nicaraguan hospitals, including the national referral paediatric hospital, between January and December 2017. Extensive piloting to ensure data collection feasibility, sustainability and accuracy was carried out in 2016 with substantial input and feedback from local stakeholders.ResultsOverall, 3521 visits of patients <15 years of age, of whom two-thirds <5 years, met predefined inclusion criteria of urgent-emergency visits. Respiratory (1619/3498; 46%), gastrointestinal (407/3498; 12%) and neurological (368/3498; 11%) complaints were the most common symptoms. Malnutrition was reported in 18% (610/3448) of presentations. Mortality was 7% (233/3521); 52% (120/233) of deaths occurred in the <1-year subgroup; 32% (71/3521) of deaths occurred within the first 24 hours of presentation. The most common immediate causes of death were septic shock (99/233; 43%), respiratory failure (58/233; 25%) and raised intracranial pressure (24/233; 10%).ConclusionsThe mortality rate of urgent-emergency paediatric visits in Nicaragua is high, with younger children being most at risk and the majority of deaths being eventually caused by septic shock or respiratory failure. Our data provide useful information for the development of a Paediatric Emergency Care network to help direct training efforts, resources and logistic/organisational interventions to improve children’s health in an emergency setting in Nicaragua.