Blogs

CanadiEM Blog: TREKK Series | Multisystem Trauma

September 08, 2016

CanadiEM blog: TREKK Series | Bronchiolitis

July 20, 2016

TREKK and CanadiEM have come together to translate the latest guidelines in pediatric emergency medicine.  First up in this blog series: bronchiolitis.  Join Drs. Ashley Lubberdink and Kaif Pardhan as they translate the TREKK Bottom Line Recommendations and run through the case - a 5 month old male who presents to a community ED with a 4-day history of cough and nasal congestion. 

Read the blog here.

Building a connection: TREKK and NENA

June 30, 2015

The 2015 Annual National Emergency Nurses Association Conference (NENA) was held in Edmonton this year and I had the pleasure of not only attending, but also representing TREKK with a poster display on our first Social Networking Analysis.

As a pediatric emergency nurse (The Children’s Hospital of Winnipeg) and a NENA member, I was quite excited to attend this year’s conference, themed “Prepare for the Unexpected”. Those who work in an emergency department (ED) can attest to the uncertainty and lack of a routine that encompasses the ED. The goal of the conference was to prepare and inform emergency nurses for unpredictable scenarios to increase comfort and make the unfamiliar more familiar. This got me thinking – isn’t this exactly what TREKK is all about? Treating children is unfamiliar to many healthcare professionals working in general EDs and can be stressful. TREKK is connecting pediatric and general EDs and creating resources like our bottom line recommendations, to support our general emergency colleagues in getting quicker access to the latest evidence-based care.

NENA connects emergency nurses across Canada by encouraging networking and promoting engagement. As members, we are able to talk about issues that we have in common, explore solutions and learn from one another’s experiences. Talking to general ED nurses at the conference was really exciting. They shared their stories, discussed opportunities to utilize TREKK and were curious to know who was involved in our network from their community, so that they knew who to reach out to for information on treating children.

During the time I spent at our TREKK poster exhibit, I had nurses approach me who remembered our needs assessment from two years ago, to say, “hey, I did that iPad survey!” It was great opportunity to reconnect with them and provide updates on TREKKs accomplishments since the needs assessment and the many resources now available on trekk.ca. I was able to talk with nurses in remote locations such as northern Yukon, nursing stations and big urban centres. Having the NENA conference as a venue to build camaraderie among emergency nurses is amazing. I received great feedback on our Social Networking Analysis and was able to broaden my connections across the country.  

I encourage all TREKK coordinators to reach out to their provincial NENA representative – this is a critical connection to make so that we can continue to work towards our shared goal of improving emergency care for children across Canada.

Written by: Laura Ebenspanger

Crisis Interventions in the Emergency Department | Cochrane Child Health Twitter Journal Club – #CochraneChild

May 27, 2015

Thanks to everyone for joining the #CochraneChild Twitter journal club on May 27th, 2015 with TREKK's own Dr. Terry Klassen and Dr. Amanda Newton. The archived discussion is at: http://bit.ly/CrisisJC 

What: Twitter journal club on crisis interventions for pediatric mental health in the emergency department

When: Wednesday, May 27th, 1:00pm PT Vancouver | 2:00pm MT Edmonton & Calgary | 3:00pm CT Winnipeg | 4:00pm ET Toronto 

Where: Follow #CochraneChild on Twitter and join in the discussion by including #CochraneChild in all your posts. See these tips for participating in a Twitter chat.

Link to paper: A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research

Questions we will be addressing: 

1. How often do Emergency Department (ED) clinicians see a patient for mental health care? Have visit trends changed over time?

2. Based on the 2010 review, what interventions have been tested for pediatric crisis care in the ED?

3. The studies included in the review were all observational studies. What are the challenges with this? Would other study designs have worked in this context?

4. What care do children and youth currently receiving in EDs for mental health emergencies?

5. Have new studies of ED-based crisis care been published since the 2010 review highlighted today?

Dr Terry Klassen Bio-sketch:

Dr. Klassen graduated from the Faculty of Medicine, University of Manitoba in 1982 and completed his Pediatric Residency training at the University of Manitoba in 1986.  He completed M.Sc. in Epidemiology at McMaster University in 1994.  He has served as CEO and Scientific Director for the Children’s Hospital Research Institute of Manitoba and Associate Dean, Academic in the College of Medicine, Faculty of Health Sciences at the University of Manitoba and Director of the George and Fay Yee Center for Healthcare Innovation since returning to Manitoba in September, 2010.  Since the commencement of his new role as Head of the Department of Pediatrics, he has stepped down from the Associate Dean, Academic position but continues to serve both the Children’s Hospital Research Institute of Manitoba and CHI roles.

From 1999 to 2009 Dr. Klassen was Chair of the Department of Pediatrics, University of Alberta; Director of the Alberta Research Centre for Health Evidence and Director of the Evidence-based Practice Center at the University of Alberta. He is a clinician scientist focused on Pediatric Emergency Medicine, and has been active in Pediatric Emergency Research Canada collaborating on a national research program involving randomized controlled trials, systematic reviews and knowledge translation. He has a consistent record of national and international peer reviewed funding, along with a publication record that has included many articles in the highest impact medical journals.

In 2009, Dr. Klassen co-founded StaR Child Health, an international group aimed at improving the design, conduct and publication of randomized controlled trials in children. In recognition for his lifetime contributions, he was elected into the Institute of Medicine in 2010 in the foreign associate category. He is also a Fellow in the Canadian Academy of Health Sciences. Dr. Klassen’s research has had a large impact on the practice of Pediatric Emergency Medicine, which was recognized when he received a 2011 Canadian Institutes of Health Research – Canadian Medical Association Journal Top Achievements in Health Research Award. In 2011 he was also awarded the Networks of Centres of Excellence (NCE) grant, entitled TRanslating Emergency Knowledge for Kids (TREKK). In 2012 Dr. Klassen was appointed to the Governing Council of the Canadian Institutes of Health Research.

Dr. Amanda Newton Bio-sketch:

Dr. Newton is an Associate Professor in the Department of Pediatrics at the University of Alberta (Edmonton, Alberta, Canada) and clinician scientist affiliated with the Stollery Children’s Hospital in Edmonton. Her research aims to improve mental health care and outcomes for children and youth who are acutely mentally ill.

Crisis Interventions for Pediatric Mental Health Presentations in the Emergency Department

May 20, 2015

May 25, 2015 - This week's post is also available from the Cochrane Child Health blog.

Children’s Mental Health by the Numbers

Every year in Canada, 1.2 million children and youth experience mental health problems and illnesses [1]. Fewer than 20% of them receive appropriate treatment [2]. And from 2006-2007 to 2013-2014, the national rates of visits to the emergency department (ED) for mental disorders among children and youth between the ages of 5 and 24 increased by 45% [3]. 

Beyond the numbers, these statistics describe kids who are battling conditions like depression, harmful and hazardous substance use, and anxiety disorders. Kids who can present to the ED in acute crisis. Kids who often have nowhere else to go.

While ideally, children and youth with mental health needs would receive early intervention and community-based management, this doesn’t always align with service availability or the nature of the treatment need. Sometimes, a crisis can’t be avoided. In all these circumstances, the ED plays an important role in providing care. 

Emergency Department-Based Management Interventions for Mental Health Presentations

A systematic review published in 2010 evaluated the effectiveness of different ED-based management strategies used when children and youth presented with mental health complaints [4]. There were only three studies that focused on pediatric (≤18 years) populations, so nine additional studies in adult populations, or in populations where the age was unknown, were also included. In all cases, patients with a range of mental health conditions were represented.

The authors identified three main categories of interventions: specialized models of pediatric care, patient triage scales, and other ED mental health care.

Specialized Models of Pediatric Care: These interventions included referrals to a specialized psychiatric team, made up of at least a child psychiatrist, and possibly also other psychiatric professionals like a nurse specialist or social worker. In three studies, referrals to these teams were associated with reduced hospital admissions, length of stay in the ED, and a modest cost savings in the ED.

Patient Triage Scales: Five studies evaluated four different triage scales as they were applied to mental health presentations. The outcomes measured across studies were variable, limiting the conclusions that can be made.

Other ED Mental Health Care: While none were evaluated in pediatric populations, three other strategies were described in the systematic review. Changes in legislation allowing psychologists to recommend involuntary patient hospitalization did not lead to significant differences in disposition decisions made by psychologists, or between psychiatrists and psychologists. The use of crisis teams had no impact on patient distress in one study, but reduced hospitalization in another. A computerized reminder system for restraints reduced the time to renewal of restraint orders, as well as time spent in restraints.

Limited evidence on the best strategies to treat children and youth with mental health conditions was available, but this review did find some support for the use of specialized psychiatric teams, and identified gaps in the child health evidence where the adult literature may provide some direction, namely the use of triage scales and developing guidance for restraint.

Dr. Amanda Newton, the senior author of the review, commented “Recent statistics reinforce that addressing emergency mental health care is critical. What is clear from this review is that the pediatric evidence base requires development. Studies that evaluate the quality of care provided and patient reported outcomes are important. Evidence exists outside of this review for specialized care, such as care for intentional self-harm, but a focus on the quality of general emergency mental health care is also important as this is standard care provided in emergency departments.”  

Please join the authors of the systematic review for a live discussion on Twitter this Wednesday May 17 @ 2 pm MT. Check out the journal club announcement here.

References:

1. Mental Health Commission of Canada. (2013). School-based mental health and substance abuse project.

2. Mental Health Commission of Canada. (2015). Topics: Child and Youth.

3. Canadian Institute for Health Information. (2015). Care for Children and Youth with Mental Disorders.

4. Hamm, M. P., Osmond, M., Curran, J., Scott, S., Ali, S., Hartling, L., . . . Newton, A. S. (2010). A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research. Pediatr Emerg Care, 26(12), 952-962. doi: 10.1097/PEC.0b013e3181fe9211

Identifying kids at high risk for diabetic ketoacidosis

May 15, 2015

May 18, 2015 - This week's post is also available from the Cochrane Child Health blog.

I am sure you have heard. Type I diabetes is growing in both prevalence and incidence every year. This year alone, nearly 65,000 children and youth under the age of 15 will be diagnosed with type 1 diabetes worldwide [1]. Next year, there will be a 3% increase in the incidence of diagnosis [2]. Unfortunately, this trend is not expected to change in the near future. 

Upon diagnosis, 10-70% of children will present with diabetic ketoacidosis (DKA) [2]. Characterized by hyperglycemia, acidosis, and ketonuria, DKA is a very serious condition that carries substantial risk for life threatening complications, like cerebral edema. Moreover, in comparison to adults, children are at a high risk for severe complications. Because of this, DKA is the most common cause of diabetes related death in kids [2].

It remains unclear whether presenting in DKA at diagnosis is indicative of a more severe form of type 1 diabetes, or if it is linked to delayed diagnosis. However, we do know that children who present with DKA at diagnosis have a poorer long term prognosis, with diminished glycemic control, less residual β cell function for up to two years after diagnosis, and a decreased incidence of remission [2]. 

The mean duration between the onset of symptoms and development of DKA is 14 days, and over one third of children will have at least one medical consultation in this period prior to diagnosis [2]. This represents an ideal time for identifying and triaging children at high risk for developing DKA. To do this, evidence-based risk factors for the development of DKA in children need to be identified. 

Evidence-based factors associated with DKA at type 1 diabetes diagnosis

Usher-Smith et al. conducted a systematic review, including 46 studies with over 24,000 children and youth (ages 0-21 years) from 31 different countries, to determine factors associated with diabetic ketoacidosis at the diagnosis of type 1 diabetes in children and young adults. Together, 23 different factors were considered in this review. Here is the key evidence you need to know to identify a child at risk for presenting in DKA at type 1 diabetes diagnosis.

Risk factors:

Age: Children less than 2 years old were three times more likely to present in DKA than children 2-5 years old.

Ethnicity: Because the populations included in the studies were too heterogeneous, the frequency of DKA could not be determined for specific ethnic groups. However, 5 studies compared differing pairs of ethnic groups, and consistently found the ethnic minority group experienced an increased risk of DKA.

Body mass index (BMI): Children with lower BMIs were at an increased risk for DKA.

Health insurance status: In the United States, children who had either no health insurance or Medicaid were three times more likely to present in DKA at diagnosis when compared to children with private health insurance.

Family income, parental employment, and social status: Children of low SES were at an increased risk for presenting in DKA.

Diagnostic error: Children who were not diagnosed with type 1 diabetes on their first medical consultation due to diagnostic error were three times more likely to present in DKA at diagnosis. Diagnostic error was significantly more likely in young children. The mean age of children presenting in DKA at diagnosis whose diagnosis was missed on the first medical consultation was 5.4 years, compared to mean age of 8.8 years in children whose diagnosis was not missed.

Delayed treatment and presence of structured diabetes team: One European multicenter study showed a greater than 24 hour delay between diagnosis and treatment led to a small increased risk of presenting in DKA at diagnosis. One Kuwaiti study showed that children diagnosed in hospitals without a structured diabetes team were more likely to present in DKA.

Preceding infection or febrile illness: Having a preceding infection or febrile illness increased the risk of presenting with DKA at diagnosis.

Protective factors:

Family history of diabetes: Children who had a first-degree relative with type 1 diabetes were six times less likely to present in DKA on diagnosis.

Parental education: High parental education was protective against DKA, however, the definition of “high” education varied depending on the location of data collection in the included study.

Background incidence of type 1 diabetes: Children who lived in an area with a higher background incidence of type 1 diabetes were less likely to present in DKA.

Factors with no or an unclear effect on rate of presentation in DKA at diagnosis:

The following factors had no impact on the rates of presentation in DKA at diagnosis, or their impact could not be adequately assessed due to limitations of the data: sex, parental consanguinity (i.e., blood relation to a parent with type 1 diabetes), family structure, rural or urban residence, delayed diagnosis, and number of medical consultations before diagnosis.

Summarizing the evidence

The authors of the review concluded: “Younger age, diagnostic error, ethnic minority status, lack of health insurance in the US, lower body mass index, preceding infection, and delayed treatment were all associated with an increased risk of diabetic ketoacidosis, while having a first degree relative with type 1 diabetes at the time of diagnosis, higher parental education, and higher background incidence of type 1 diabetes appear to be protective.”

Implications for practicing clinicians

The authors of the review highlight: “As with other serious illnesses in children, differentiating the occasional child with a serious illness from the large number with minor undifferentiated illness is challenging. The relatively easy access to point of care tests for hyperglycemia, ketonemia, and glycosuria, however, means that diagnosis does not require access to specialist diagnostic services but, instead, a high index of suspicion. Our findings suggest that clinicians should be particularly alert for diabetic ketoacidosis in children under 5 years old, those from ethnic minority groups, and those from families with low education level or socioeconomic status.”

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Diabetic Ketoacidosis Bottom Line Recommendations (French & English)

Diabetic Ketoacidosis Evidence Repository

Emergency Medicine Cases - Episode 63: Pediatric DKA

References:

1. Karvonen, M. (2006). Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999. Diabetic Medicine, 23(8), 857-866. doi: 10.1111/j.1464-5491.2006.01925.x

2. Usher-Smith, J. A., Thompson, M. J., Sharp, S. J., & Walter, F. M. (2011). Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: A systematic review. BMJ, 343(7815). doi: 10.1136/bmj.d4092

To CT, or not to CT? Clinical Decision Rules for Concussion

May 08, 2015

May 11, 2015 - This week's post is also available from the Cochrane Child Health blog.

Head trauma. Headache. Nausea. Loss of balance. Dizziness. Difficulty concentrating. Confusion. Behavioural changes. Sleep changes.

It might be a concussion. What next?

With growing attention in research and the media, it is becoming clear that concussions are very serious injuries with sometimes lasting effects. As an emergency physician, the chances are good that you have treated many children with these symptoms – pediatric concussion is considered a silent epidemic [1]. In the US, estimates suggest up to 3.8 million concussions occur every year, resulting in over 700,000 Emergency Department visits [2]. Because of this, head trauma is one of the most common reasons for consultation in the Emergency Department [3]. 

Concussion symptoms typically alleviate within 72 hours, and completely resolve in 7 to 10 days [4]. However, in many cases, children and youth experience ongoing or recurrent headache, behavioural changes, and other physical symptoms, requiring subsequent Emergency Department and primary care physician visits [4]. It was estimated in one Canadian study that 58% of children with concussion remained symptomatic in the first month, 11% at 3 months, and 2% beyond one year [5]. These findings reinforce that concussions are serious injuries that can last over time. 

Considering the significant morbidity of concussion, and its impact on quality of life and school participation, identifying kids at risk for long-term consequences and those in need of neurosurgical intervention is crucial. There is an increasing tendency by physicians to perform early diagnostic imaging through CT scan for suspected concussion because it is linked to better outcomes, lower admission rates, and serves as the diagnostic standard for identifying intracranial injury [6]. However, it isn’t feasible or necessary to conduct this scan with all children presenting with concussion symptoms. This makes a clinical decision rule for CT scans important. With summer around the corner, and team sports ramping up for the season, understanding and using effective and validated clinical decision rules is essential to identify children at risk for intracranial injury. 

When to CT: The evidence

In a recent systematic review, Pickering et al. reviewed evidence from 16 RCTs (representing 14 cohorts and 79,740 patients) to determine which clinical decision tool is most accurate at predicting which pediatric patients will have an intracranial injury on CT or require neurosurgical intervention [6]. Sensitivity and specificity were determined for 11 decision rules: 

The heterogeneity of the rules included in the review prevented any meta-analysis of the data. The authors noted that a shift in practice from identification of any lesion on a CT scan to focusing on clinically significant lesions has made results of studies difficult to compare. The authors suggested: “future research efforts in this field should concentrate on the universal application of definitions for patient populations, inclusion criteria, reference standards, and outcome criteria” [7].

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Concussion Evidence Repository

Emergency Medicine Cases Podcast: Pediatric head injury

References:

1. TREKK Bottom Line Recommendations: Concussion (English Version)

2. McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R., . . . Turner, M. (2013). Consensus statement on Concussion in Sport - The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Phys Ther Sport, 14(2), e1-e13. doi: 10.1016/j.ptsp.2013.03.002

3. Farrell, C. A. (2013). Management of the paediatric patient with acute head trauma. Paediatrics and Child Health (Canada), 18(5), 253-258.

4. Scorza, K. A., Raleigh, M. F., & O'Connor, F. G. (2012). Current concepts in concussion: Evaluation and management. American Family Physician, 85(2), 124-132.

5. Barlow, K. M., Crawford, S., Stevenson, A., Sandhu, S. S., Belanger, F., & Dewey, D. (2010). Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics, 126(2), e374-381. doi: 10.1542/peds.2009-0925

6. Pickering, A., Harnan, S., Fitzgerald, P., Pandor, A., & Goodacre, S. (2011). Clinical decision rules for children with minor head injury: A systematic review. Archives of Disease in Childhood, 96(5), 414-421. doi: 10.1136/adc.2010.202820

7. Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr., Atabaki, S. M., Holubkov, R., . . . Wootton-Gorges, S. L. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet, 374(9696), 1160-1170. doi: 10.1016/s0140-6736(09)61558-0

8. Zemek, R., Duval, S., Dematteo, C. et al. (2014). Guidelines for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation

Does a child's cough sound like a barking seal? Could be croup

May 01, 2015

May 4, 2015 - This week's post is also available from the Cochrane Child Health blog.

"Michael's barky cough startled Valerie from her sleep. For the last few nights, Valerie had not slept well as her two-year-old son was fighting a cold and had been up off and on with a fever and cough...She desperately hoped the coughing would stop...More barky coughing roused her from her thoughts. This time the cough frightened her. As she ran into his room, Michael seemed to be fighting for breath."

Michael's barky cough is a hallmark sign of croup. The cough that often occurs in the middle of the night, rousing parents from their sleep, can be an intense and worrisome event for parents and their young children. However, croup is a well-defined condition with a strong evidence base supporting effective therapeutic management. 

Croup, or laryngotracheobronchitis, is an illness that affects a child's breathing. It is caused by many different viruses and most often occurs in the cooler fall and winter months. Croup occurs most commonly in children between 6 months and 3 years of age, but can occur in children of all ages. Croup is characterized by a barky cough that can start quite suddenly. Often the child will have a hoarse voice and difficulty breathing. You may hear a high pitched sound when the child breathes in (stridor). Croup is worse at night or when the child is lying flat. The symptoms occur predominately at night with improvement during the day. The barky cough and difficulty breathing usually resolve after a few nights, though occasionally they can last up to a week. Viruses that trigger croup symptoms are picked up from others, and usually spread through coughing, sneezing or contact with the mucous on tissues, toys or hands.

Doctors assess the severity of the child's symptoms by simply watching and listening. If children have an occasional barky cough, but no stridor, they have a mild case. If they have a frequent barky cough and easily heard stridor even while calm, they have a moderate case. If a child’s chest caves in as they breathe, in addition to a frequent barky cough and easily heard stridor, they have a severe case. When the child has severe symptoms they are most commonly very distressed and agitated. In most cases, the illness is mild and lasts a short time; however, in the most severe cases, a small number of children may require hospitalization and intubation [1].

Antibiotics do not work on croup because the infection is caused by a virus. However, there are a number of other treatment strategies. An overview of reviews compiled evidence to determine which treatment strategies were most effective. The overview brought together evidence from four systematic reviews that included 54 studies involving 4,710 children. The authors made the following conclusions:

• - Glucocorticoids are effective for treating children with mild croup in terms of reduction in symptoms, hospitalizations, and length of stay. Dexamethasone and budesonide were the most commonly studied and there was no evidence that one was superior to the other.
• - Both nebulized epinephrine and glucocorticoids are effective for children with moderate to severe croup that is accompanied by respiratory distress.
• - There was insufficient evidence to determine the effectiveness of heliox.
• - There is sufficient evidence showing that humidified air is not an effective treatment for croup.
• - Though there are no large scale surveillance studies published which focus on adverse effects from any of these treatments, randomized trials and systematic reviews of glucocorticoids, epinephrine, humidified air and heliox have not reported any significant adverse events. 

Dr. David Johnson of the Alberta Children's Hospital Research Institute has developed bottom line recommendations for treating croup in collaboration with Translating Emergency Knowledge for Kids (TREKK). The recommendations and other resources including clinical practice guidelines are available at trekk.ca. Dr. Johnson suggests: 

“The vast majority of children with croup will resolve their barky cough and difficulty breathing within a few nights. While this will occur regardless of whether their child is treated or not, treatment with glucocorticoids helps reduce both children’s severity and duration of symptoms, allowing parents to relax and return to their normal daily routine sooner than they would otherwise.”

Resources:

TRanslating Emergency Knowledge for Kids (TREKK):

Croup Bottom Line Recommendations (French & English)

Croup Evidence Repository

Croup Cochrane Pediatric Emergency Medicine Reviews

Croup Storybooks for Caregivers:

University of Alberta, Capital Health, Stollery Children's Hospital. (2012). A Resourceful Father and His Internet Connections: Managing Croup at Home - Mild Croup [Brochure]. Edmonton, Canada.

University of Alberta, Capital Health, Stollery Children's Hospital. (2012). A Late Night Trip to the Emergency Department: Was It The Right Thing To Do? - Moderate Croup [Brochure]. Edmonton, Canada.

University of Alberta, Capital Health, Stollery Children's Hospital. (2012). Things We Take for Granted: A Mother’s Account of Her Child’s Struggle with Croup - Severe Croup [Brochure]. Edmonton, Canada.

References:

1. Bjornson C, Russell K, Foisy M, Johnson DW. The Cochrane Library and the treatment of croup in children: an overview of reviews. Evidence-based Child Health: A Cochrane Review Journal 2010;5(4):1555-65.

Evidence-Based Treatments for Acute Otitis Media

April 24, 2015

April 27, 2015 – This week's post is also available from the Cochrane Child Health blog.

Acute otitis media (AOM), or middle ear infection, is one of the most common diseases of childhood. AOM presents most frequently in children under the age of two, with 75% of children having at least one episode before one year of age [1,2]. Although AOM is very common, it can be challenging to accurately diagnose – symptoms of AOM often overlap with acute respiratory illness, visualization of the tympanic membrane can be obscured by cerumen, and slight changes in the tympanic membrane can be hard to detect [1]. 

The Canadian Paediatric Society recommends antibiotics for treatment in all children under the age of six months, and for children who are six months to two years when the diagnosis of AOM is certain [2]. For children older than six months with mild symptoms, the Canadian Paediatric Society recommends a ‘watchful waiting’ approach supported by a topical or oral analgesic [2]. Given the prevalence of AOM in these age groups, antibiotics are being prescribed very frequently. With increasing concern about antibiotic resistance, guidelines need to be created to prevent inappropriate prescription for children who have been misdiagnosed with AOM, and treatments need to be supported by strong evidence to justify their use.

Including six systematic reviews, covering 92 randomized controlled trials with 19,695 participants, a Cochrane overview investigated the available evidence on treatments for AOM in children. Below is the key evidence you need to know when treating a child with AOM.  

Effectiveness of Antibiotics

• Compared to placebo,children treated with antibiotics reported less pain 2-7 days after treatment initiation.
• Children taking antibiotics were more likely to have vomiting, diarrhea, and rash. 

Short-Course Antibiotics

• There is no evidence to support one length of antibiotic treatment over another.

Immediate versus Delayed Antibiotics

• Children who immediately received antibiotics had no difference in pain 3-7 days after treatment initiation compared to children who had a delay in antibiotic receipt.
• Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of delayed start of antibiotic treatment. 

Decongestants and Antihistamines

• There was no evidence in support of the use of decongestants or antihistamines to treat AOM.
• The authors discouraged the use of decongestants and antihistamines in young children because of their potentially harmful side effect profile caused by unintentional overdose [3]. 

Topical Analgesia

• There was some low quality evidence suggesting that topical analgesia may reduce pain after ten minutes of administration in children over five years. However, no adverse events were recorded.
• Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of topical analgesia for AOM.

The authors of the overview concluded:

“The literature to date suggests that antibiotic use in young children with stringently diagnosed AOM appears to be justified, although benefits must be balanced with risk, particularly adverse events and bacterial resistance, and with a role for parental preferences. Improving the accuracy of diagnosis (e.g. training programs for otoscopy and cerumen removal), is thus an important mechanism for reducing inappropriate antibiotic use.”

In 2009, the Canadian Paediatric Society released a position statement with information on treatment and recommendations to guide proper diagnosis of AOM [2].

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Acute otitis media Bottom Line Recommendations (French & English)
Acute otitis media Evidence Repository
Acute otitis Media Cochrane Pediatric Emergency Medicine Reviews

References:

1. Oleszczuk, M., Fernandes, R. M., Thomson, D., & Shaikh, N. (2012). The Cochrane Library and acute otitis media in children: an overview of reviews. Evidence‐Based Child Health: A Cochrane Review Journal, 7(2), 393-402.
2. Forgie, S., Zhanel, G., & Robinson, J. (2009). Management of acute otitis media. Paediatrics & Child Health, 14(7), 457-460.
3. Goldman, R. D., & Hazardous Substances Committee. (2011). Treating cough and cold: guidance for caregivers of children and youth. Paediatrics & Child Health, 16(9), 564.

Making Medical Procedures Less Painful for Kids - Evidence for Clinicians

April 17, 2015

April 20, 2015 – This week's post is also available from the Cochrane Child Health blog.

Today we are going to discuss a topic that will be familiar to any parent, or to anyone who’s ever been a kid: the pain from medical procedures.  These can range from immunizations and blood tests through to less common things like lumbar punctures, inserting a catheter or starting an intravenous line.  All of these procedures have an important goal: supporting diagnosis and treatment.  But they can be really stressful for both children and their caregivers.

Doctors used to think that very young children did not experience pain, and, even if they did, did not remember it.  This has been repeatedly disproven over the past twenty years or so, and we now know that inadequate pain treatment can have a lot of negative effects in both the short and long term.

The experience of pain for a child is complex and is usually accompanied by anxiety, fear and behavioural changes. In the case of pain from medical procedures, health care professionals have a range of options for preventing or reducing the negative experience.

The Child Health Field’s journal, Evidence-Based Child Health, has published an overview of Cochrane evidence on reducing and preventing procedural pain for kids.  The kids in the studies included in this synthesis ranged in age from infancy (but not newborns) up to 19 years. The overview found three main conclusions:

1)  Behavioural therapies, such as showing videos to kids to distract them during a procedure, are effective and inexpensive, and should be used.

2)  Sweet-tasting substances have proven pain-reducing effect for procedures in early infancy, but have not been shown to have similar effect in older children.

3)  Amethocaine, a topical anaesthetic, works and should be used.

Dr. Samina Ali, one of the authors of the synthesis, commented that, “Despite our understanding of the importance of pain relief in children, there remains a significant knowledge-practice gap in clinical practice.”  It is our hope that publishing this overview of evidence will help overcome this gap so that receiving care is less painful for kids!

Resources:

Translating Emergency Knowledge for Kids (TREKK):

• Acute Pain Cochrane Pediatric Emergency Reviews
• Procedural Pain Bottom Line Recommendations (French & English)
• Procedural Pain Evidence Repository

Cochrane Community Podcast:

• Check out Dr. Ali's comments on the Cochrane overview in this podcast

Other Resources:

• The Center for Pediatric Pain Research shares suggestions for reducing procedural pain in this video

References:

1. Curtis, S., Wingert, A., & Ali, S. (2012). The Cochrane Library and procedural pain in children: an overview of reviews. Evidence‐Based Child Health: A Cochrane Review Journal, 7(5), 1363-1399. doi: 10.1002/ebch.1864

Treating Gastroenteritis: Evidence for Clinicians

April 10, 2015

April 13, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Fever. Vomiting. Diarrhea.

These are the symptoms that characterize one of the most common pediatric illnesses – Acute Gastroenteritis (AGE). In Canada, AGE accounts for 10% of emergency department visits annually and results in the hospitalization of 1 in 25 children under the age of five, keeping primary care physicians busy as ever [1,2]. Although AGE is not a serious condition in the developed world, it exerts significant economic burden. Estimates suggest Canadian AGE specific costs are $3.7 billion annually [2].

Despite the prevalence of AGE, its cost, and the ubiquity of its symptomatic presentation, there is no unified approach to its management in emergency departments (ED) institutionally, nationally, or internationally. Standardized, clinical decision tools targeting improvement of gastroenteritis care are not routinely used in Canadian EDs, which can result in variation in clinical decisions for key treatment approaches [3]. In effort to bring easily accessible, up-to-date evidence for AGE treatment approaches to one place, a Cochrane overview of systematic reviews provides a cohesive summary of treatment options and their effectiveness to help clinicians in their evidence-based decision making. This overview included four systematic reviews containing 95 randomized controlled trials involving over 12,000 participants. Here is the key evidence you need to know when treating a child with AGE.

Oral Rehydration Therapy (ORT) versus Intravenous (IV) Rehydration Therapy

• ORT is less invasive than IV rehydration and therefore is considered as first line treatment for children with AGE and associated mild-to-moderate dehydration.
• There are no important clinical differences (e.g. length of hospital stay, adverse effects) between children who receive oral rehydration therapy (ORT) and those administered IV rehydration therapy.

Anti-Emetics

• Oral ondansetron is the first line anti-emetic agent for children with dehydration and significant vomiting because it lowers hospital admission and IV rehydration rates.
• IV ondansetron is associated with lower hospital ED admission rates, but should only be used for children who require IV rehydration.

Probiotics

• Probiotics can reduce hospital duration by over 24 hours.
• There are no known interactions between probiotics and other medications.
• Existing evidence favors the use of probiotics as a safe adjunct treatment for AGE, but it is unclear which probiotic should be used, at what dose, and for what duration.
• Current evidence suggests the use of formulations containing Lactobacillus sp or S. boulardii, but optimal dosage and duration of therapy is unknown.

Dr. Moshe Ipp, a pediatrician and academic clinician from Toronto, shares his conclusions about this overview in this Cochrane Community podcast:

 “In summary, oral rehydration therapy is considered to be the first line choice for rehydration in patients with acute gastroenteritis and mild to moderate dehydration. When there is significant vomiting, ondansetron is the recommended anti-emetic of choice. And probiotics have been shown to be safe and effective for hospitalized children.”

However, Dr. Ipp highlights that ondansetron may not be suitable for all children with AGE: “An interesting finding, and a note of caution, is that in 3 randomized controlled trials there was a higher frequency of diarrhea in the ondansetron group compared to placebo, and because of this finding it is suggested that ondansetron might not be the agent of choice when vomiting is associated with a significant amount of diarrhea.”

Resources:

Translating Emergency Knowledge for Kids (TREKK):

• Bottom Line Recommendations: Gastroenteritis
• TREKK Talks: Gastroenteritis, Dr. Stephen Freedman
• Evidence Repository: Gastroenteritis
• Gastroenteritis Podcasts
• Gastroenteritis Cochrane Pediatric Emergency Medicine Reviews

Cochrane Community Podcast:

• Check out Dr. Ipp’s comments on the overview in this podcast

References:

[1] Majowicz, S., McNab, W., Sockett, P., Henson, S., Dore, K., Edge, V., ... & Wilson, J. (2006). Burden and cost of gastroenteritis in a Canadian community. Journal of Food Protection, 69(3), 651-659.

[2] Alberta Provincial Pediatric Enteric Infection Team. APPETITE seminar series [PDF document]. Retrieved from: Got Gastro Online Website

[3] Kinlin, L., Bahm, A., Guttmann, A., & Freedman, S. (2013). A survey of emergency department resources and strategies employed in the treatment of pediatric gastroenteritis. Academic Emergency Medicine, 20(4), 361-366. doi: 10.1111/acem.12108

[4] Freedman, S., Ali, S., Oleszczuk, M., Gouin, S., & Hartling, L. (2013). Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evidence‐Based Child Health: A Cochrane Review Journal, 8(4), 1123-1137. doi: 10.1002/ebch.1932

Bicycle helmets – now that’s using your head!

April 02, 2015

April 6, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Head injuries due to bicycle crashes are a common reason that children present to the emergency department. Bicycle helmets were designed to decrease head injuries. Different approaches to encourage bicycle helmet use have been evaluated. These range from legislation where individuals are required by law to wear a helmet when cycling to media campaigns and other health promotion activities, such as promoting the use of bicycle helmets in schools or offering free helmets through community-based programs.

An overview of Cochrane systematic reviews [1] was conducted in order to bring together evidence from reviews that focused on different aspects of the topic of bicycle helmet use. The reviewers identified three systematic reviews [2-4] that included 35 studies involving children. The reviews looked at:

• the use of helmets for preventing head and facial injuries in bicyclists
• bicycle helmet legislation to increase the uptake of helmet use and prevent head injuries
• nonlegislative interventions to promote use of bicycle helmets in children (these included health education programs, subsidized or free helmets, and media campaigns)

Some of the key findings:

• helmet use in children decreased medically reported head injuries by 63%
• helmet use decreased brain injuries by 86%
• mandatory helmet laws for children decreased the odds of head injury hospitalizations by 45%
• after helmet legislation, the odds of traumatic brain injuries decreased by 18%
• legislation resulted in an increase in the number of children wearing a helmet
• nonlegislative helmet promotion activities also resulted in an increase in the number of children wearing a helmet
• there were no risks involved with using bicycle helmets

The authors concluded that bicycle helmets are effective in reducing head injuries in children. They also concluded that both legislative and non-legislative interventions are helpful in reducing injuries and promoting helmet use. However, the authors noted that there are some who oppose helmet legislation. The main reasons are that they feel that this may encourage people to cycle more recklessly or less frequently.

Dr. Tony Woodward, Chief of Emergency Medicine at Seattle Children's Hospital states that "there's no question that the best way to protect your child when they're on a bike, scooter, or skates is to wear an appropriately sized helmet. In the emergency department, the children we see who are the most seriously injured are the ones that don't have helmets or have helmets that are inappropriately sized or inappropriately worn."

Finally, check out the TREKK resources on severe head injury. Helmets prevent injury, but accidents still happen! 

References:

[1] Russell, K., Foisy, M., Parkin, P., & Macpherson, A. (2011). The promotion of bicycle helmet use in children and youth: an overview of reviews. Evidence-Based Child Health: A Cochrane Review Journal, 6(6), 1780-1789. doi: 10.1002/ebch.901

[2] Owen, R., Kendrick, D., Mulvaney, C., Coleman, T., & Royal, S. (2011). Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD003985.pub3

[3] Macpherson, A., & Spinks, A. (2008). Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews, (3). doi:10.1002/14651858.CD005401.pub3

[4] Thompson D., Rivara, F., & Thompson, R. (1999). Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews, (4). doi:10.1002/14651858.CD001855

More Information:

TREKK (Translating Emergency Knowledge for Kids) Resources:

• Valani, R., & Riley, J. (2010). Emergency Medicine Cases Podcast: Pediatric Head Injury. [Podcast]
• TREKK (Translating Emergency Knowledge for Kids). (2015). Severe Head Injury: Evidence Repository.

ChildSafetyLink. (2014). Keep Kids Safe: A Parent's Guide to Helmet and Recreation Safety.

Government of Manitoba. (2013). Bike Helmet Safety Video.

TREKKing Through Friendly Manitoba

May 23, 2014

Welcome to the prairies!

Our names are Laura Ebenspanger and Angela Matwick and we have the pleasure of sharing the TREKK coordinator role for Manitoba. We work in the Children’s Emergency Department (ED) of The Children’s Hospital of Winnipeg (PERC site) and coordinate three incredible, yet very different, EDs across Manitoba. Each of these sites enthusiastically participated in the TREKK Needs Assessment and contributed invaluable insight into providing emergency care to children.

“Friendly Manitoba” is known as a province with strong relationships and a small-town feel, despite its vast geography. People work closely across disciplines and decades and TREKK is no exception. Dr. Terry Klassen (TREKK Director) has his roots in Steinbach, Manitoba and Dr. Shannon Scott (TREKK Co-Director & Principal Investigator for TREKK Needs Assessment), hails originally from Neepawa, Manitoba and attended the University of Manitoba Faculty of Nursing with Lisa Knisley (Network Manager), and Christy Seniuk (Nurse Practitioner, TREKK rep for Bethesda Regional Health Centre). Dr. Darcy Beer is the PERC Site Representative for Children’s Hospital, where he works as a pediatric emergency physician.  Dr. Beer attended the University of Manitoba along with Dr. Shannon Scott, Lisa Knisely and Christy Seniuk. Dr. Beer provides an amazing connection between all 3 of our sites as he is involved in a multitude of educational and professional development resources.

Our TREKK Sites

Seven Oaks General Hospital, Winnipeg- is a 304 bed, in-patient facility, nestled in the northwest corner of Winnipeg, with the second busiest emergency department in the city. Our needs assessment visits to the site found an amazing staff. We were welcomed with open arms, laughter and an honest interest in the TREKK project.

Portage District General Hospital, Portage la Prairie- is located in a small city of 13,000 people along the Trans-Canada highway, west of Winnipeg. Centrally located, the hospital is an 88 bed facility serving approximately 50,000 people. The staff of this ED was instrumental in providing quality data on the needs of their emergency practitioners.

Bethesda Regional Health Centre, Steinbach- located just southeast of Winnipeg, Steinbach houses about 14,000 residents. Although Bethesda dates back to 1929, its emergency department is in the midst of getting a brand new facility. Bethesda emergency staff welcomed us into their temporary department excited by the prospect of TREKK.

When we were informed that Bethesda was chosen as one of sites across Canada to provide additional, qualitative data for the TREKK Needs Assessment, we were excited and honoured to help facilitate this step. Capitalizing on the timing of the TREKK annual meeting in Winnipeg last October, Lauren Albrecht and Dr. Shannon Scott travelled to Bethesda to conduct 2 facilitative discussions. Leaving in the early morning hours, we traveled the 1 hour out to Steinbach, thankful that Manitoba had held off on delivering an early winter. When we arrived, we found a great turn out of staff that were ready to engage and share.

Lesson Learned

As nurses in the Children’s ED of Winnipeg, it was enlightening and eye opening to hear the perspectives of the Bethesda staff. Our department accepts all of the pediatric transfers from Steinbach and the connection between pediatric and general emergency departments is crucial to delivering the best care possible. When a child is transferred from Bethesda to Children’s ED the outcome of the child is never reported back to the initial care team in Steinbach and this was an important focus group discussion. As nurses in Children’s Emergency it is important for us to recognize and support the care given as well as appreciate the challenges working in a rural tertiary general care centre. Now having visited Bethesda Emergency Department we are more cognizant of the impact that the receiving facility can have on the initial care team. Improving our communication and mutual support and respect for one another is crucial in providing the best care. The difference that TREKK can make to everyday practice through linking practitioners and developing connections across the country is truly amazing.

Gratitude

An enormous thank-you to our TREKK sites, Seven Oaks Emergency, Portage District General Hospital and Bethesda Regional Health Centre for welcoming us into your departments and being so willing and excited to participate. We are grateful for your participation in the TREKK Needs Assessment and excited about your ongoing involvement as TREKK moves forward. Thank-you to our TREKK site representatives, without you the success of TREKK would not be possible. Also, a special thank-you to the nurse managers and Clinical Resource Nurses for your help promoting TREKK and facilitating the participation of your staff. It is wonderful to be part of such a team that is working so hard towards improving emergency care for children.

Laura Ebenspanger and Angela Matwick 

A qualitative ‘TREKK’ across Newfoundland

October 29, 2013

My name is Debbie Harnum and I have been a pediatric nurse for 26 years. Most of my career has been as a pediatric emergency department (ED) nurse at the Janeway Children’s Health and Rehabilitation Centre in St. John's, apart from a three year period on the pediatric ward at Credit Valley Hospital in Mississauga, Ontario. I am currently employed by Memorial University as the PERC Coordinator for the Janeway and part of this role includes being the TREKK coordinator for two fantastic sites - Western Memorial Hospital and Carbonear General Hospital. I have had the honour of visiting these unique facilities since March 2013.

Western Memorial Regional Hospital is nestled in the heart of the spectacularly scenic town of Corner Brook on the West Coast of Newfoundland. It is a 192 bed facility that was built in 1951, providing care and services to approximately 80,000 people from surrounding areas. The busy ED treats about 90-150 patients per day with varying levels of acuity and has a walk-in clinic within the ED which is open on evenings and weekends. They are a super friendly, proactive, highly motivated group of individuals working in aged but reasonably spacious environment.

Carbonear General Hospital stands tall in the beautiful seaside town of Carbonear on the East Coast of Newfoundland in Conception Bay North. It is a 70 bed facility that was built in the seventies and serves 40,000 people in surrounding communities. The ED staff is a very warm, hardworking and caring group who treat about 21,500 patients a year.  

They have both kindly opened their doors and welcomed me in. Each visit has been a pleasure and I always walk out with a smile on my face because at the end of every day I have made genuine human connections, a pathway of communication per se. It has brought my career full circle. I now see how hard these individuals work to care for children in emergency situations with the resources they have and to deliver them to the Janeway via air or road ambulance. It was truly humbling and eye opening for me. Sometimes that piece gets lost in the larger pediatric receiving institutions.

In April my sites were chosen to take part in the qualitative portion of the Needs Assessment. Panic initially set in! How was I going to recruit for one hour focus groups in these busy EDs? How would this work? What time would be best suited and would anyone show up? Would anyone come in on their days off or would anyone stay after working a night shift?

I discovered recruitment can be challenging especially with short notice, limited time for visits, along with it being the time of year for graduations and vacations. What would work?  Despite a few sleepless nights and a couple of panic emails to Lauren Albrecht (Needs Assessment Coordinator), I tried to remain upbeat and positive. In the end what worked were the human connections made on previous visits.

The Needs Assessment team flew out from Edmonton in June and we had an amazing TREKK journey across Newfoundland in such a short space of time. Our hard work paid off. We had many great conversations and took in significant amounts of information. We ended the journey with great focus groups - some large and some small. But as we discovered along the way, it is not about the numbers – it’s about the communication that takes place and the connections made.

During a camping vacation with my family in Terra Nova Park in Newfoundland, I was reminded of TREKK as I crossed over a wooden plank boardwalk to get to my morning shower. As I carefully stepped on each wooden plank, it occurred to me how essential each plank is to form a pathway over boggy ground. In many ways TREKK has been about building a boardwalk across uncertain terrain as connections, contacts, and the exchange of ideas bridge pediatric and general hospitals. TREKK is exciting – it has the potential to change pediatric emergency care across this vast and great country. Each piece of the boardwalk is equally important to keep the knowledge flowing as we get vital information on needs and preferences while building crucial relationships to assist in the dissemination of knowledge to all involved.

Huge thanks go out to the amazing pioneers, my TREKK sites Western Memorial and Carbonear General, for opening their doors and welcoming me in. Thank you to the TREKK site representatives, the Western and Eastern Research Managers for helping bring the TREKK project to fruition, the super Nurse Managers for your great interest and help with promotion of the project and finally all of the individual ED staff members for your kindness, time and patience. You have opened the information highway, laying down the first pieces of boardwalk in the East linking us with other Emergency Departments across Canada. You are all amazing individuals who are doing a great job in improving the emergency care for the children of Newfoundland and Labrador.

What a great journey and as we say here on the rock, “Yesb'y.”

A Bird in the Hand is Better than Two in the Bush: Observations about Data Collection

July 22, 2013

As the TREKK Needs Assessment Coordinator since October 2011, I have gained a considerable amount of experience teaching people HOW to collect survey data and HOW to recruit survey participants, but until recently, I had no experience DOING the recruitment in the TREKK sites. In June 2013, I had the pleasure of conducting my first site visits to Western Memorial Hospital in Corner Brook, Newfoundland and Carbonear General Hospital in Carbonear, Newfoundland. The purpose of this trip was to complete survey data collection and begin small-scale qualitative data collection. It was a highly successful trip and I learned a lot - including how difficult recruitment is. Luckily, we had a guide.

Debbie Harnum, the Newfoundland TREKK Coordinator, was our key contact in both sites. When we arrived, it was immediately obvious that she had spent a significant amount of time building relationships with the staff and the managers in both hospitals. Her bubbly personality, her passion for people, her pediatric nursing background, and her interest in research ignited and fostered relationships that resulted in excellent survey response rates. These relationships also allowed us, virtual strangers from Edmonton, to successfully conduct focus groups and observations over short four day visits to each site. 

Throughout this process, I was struck by the feeling that it was never enough – that there were always more people to meet, to talk to about TREKK, and to include in our mission of mobilizing knowledge. While this urge to be inclusive and to maximize our participants lead us to meet some wonderful individuals and to have some fantastic conversations, it also gave us feelings of disappointment when individuals weren’t interested in the Needs Assessment or in research, period. As a team, we had great discussions about balancing resources to achieve our recruitment goals while at the same time staying within our ethical and financial boundaries. We debated how to reduce and even eliminate barriers to participation, while at the same time respecting individuals’ right to refuse to participate and even withdraw if they so chose. We were also able to talk personally about how we, as part of the Needs Assessment team, can get caught up in our passion for the project and our desire to achieve our targets – and we can forget to be thankful for the people we have met, the rich data we have collected, and ultimately the experiences we’ve gained, in pursuit of getting one more survey completed or one more participant for the focus group. It’s a fine line to walk.

But the beauty of building relationships, rather than focusing on numbers, is that the connection to these sites will last beyond the survey, beyond the focus group, and beyond the Needs Assessment phase. This is the true mission of our work – to create sustainable, long-term relationships that will facilitate knowledge mobilization and ultimately result in better outcomes for kids. And it is thanks to the hard work of all the TREKK Coordinators and Research Assistants over the course of the Needs Assessment phase that this mission is possible.

TREKK Team rescues lost pet cockatiel in Bay Roberts, Newfoundland

When we weren’t busy at the hospital collecting data, we were rescuing lost birds! We found ‘Peaches’ on the side of the road one day (surrounded by crows), so we took her in and made her a home while we tracked down her owner. We successfully returned the bird to her family on the last day of our visit to Bay Roberts. Who says research is boring?!?!

 Click on the pictures below to see how we met our friend Peaches.

A summer project to find online resources

June 24, 2013

Hello, my name is Alexandra Dionisopoulos. I’m working on a summer project with Dr Eddy Lang in Calgary to identify online resources for the emergency care of children. I recently graduated with a Bachelor of Science in Psychology from McGill University and will be starting medical school in the fall, hoping to pursue a career in pediatrics.

The overall objective of the project is to develop and evaluate an online library of high quality, evidence-based resources that can support health care providers caring for children in community emergency departments. The TREKK Needs Assessment is identifying the knowledge needs of health care providers working in general emergency departments across Canada. This Needs Assessment, along with the work from the prioritization committee, is guiding which online resources to search for. 

The evaluation will consist of a screening process, drawn from the Health On the Net quality assessment tool.  I will then be gathering feedback from clinicians in the TREKK network on how useful the resources are.

 I look forward to working with the TREKK team. If you have any comments or questions about the project, feel free to get in touch at trekk@mich.ca 

For more information about TREKK visit http://trekk.ca/about

View from the north - David Pontin

May 11, 2013

David Pontin, TREKK site lead at Stanton Territorial Hospital in the Northwest Territories

Hello from North of 60!

My name is Dr. David Pontin; I am an emergency physician working in Yellowknife and an enthusiastic supporter of the TREKK initiative. 

In the NWT, we have a small population spread across an enormous geographic area, a basic fact that makes providing timely and effective healthcare to our patients extremely challenging. 

Very few of our communities have road access so many of our patients rely on air links to fly them from their homes to the ER at Stanton Hospital in Yellowknife.  As a result, our medivac and medical travel costs are the largest part of our healthcare budget. Much of my job consists of talking with nurses who staff health centers in these small communities to whom I provide medical advice, transportation decisions and moral support. 

Our population is also very young.  I trained in large centers in southern Canada where seeing a pediatric patient could be a rare and often anxiety provoking experience.  In the north I often feel like I work in a pediatric ER where most of my sickest patients are kids.

My colleagues and I are hopeful that the TREKK initiative will help bridge the gap between the remote periphery and the large urban center. There are many very dedicated nurses and physicians working all across Canada’s North who have many of the tools but lack the cutting edge knowledge that may be available in the large urban centers. 

In the NWT, even the smallest most isolated communities now have access to the Internet.  We’re hoping that TREKK will support not only our Yellowknife ER staff but also the health center nurse working alone and caring for sick children in these small remote communities.

Looking forward to what lays ahead.

Dave

TREKK update from Terry Klassen

March 21, 2013

TREKK has had a very eventful first year --- challenges but also some real highlights. I don’t think any of us envisaged how difficult it would be to go into each of our TREKK emergency departments (ED) with iPads to determine the knowledge needs of our health care providers and consumers. But we have persevered, and whether it was ethics or operational approval, funding agreements or other obstacles we have made great strides with over 1100 responses from providers and 350 from consumers. The prioritization committee is already starting to examine these responses for patterns and to get a sense of how best to organize the next phase of getting knowledge tools in these EDs to improve care.

Part of our success of the first year is directly tied into the quality of our team that we have been building. Having TREKK/PERC coordinators do the front end work of creating the relationship with these EDs guided by the needs assessment team in Edmonton. Our nodal leaders, PERC site leads and steering committee have provided great advice and wisdom. Our central administrative team has now been recruited and is first rate – with Lisa Knisley as knowledge broker/network manager and Christa Kruck as the research coordinator. Of course, most importantly are the TREKK sites that have generously opened their doors and allowed us to get to know them better and helped champion this important project.

We are now actively collating the refined knowledge tools that are out there – be they systematic reviews, clinical practice guidelines, pathways or preprinted order forms we will try to find them if they are of sufficient quality and relevant to the care of children in a general ED. We will look at the results of the needs survey to get a sense of how best to provide them to the TREKK sites. Do people still like paper or is the internet the way to go? Maybe everyone has a smartphone and that is the preferred method. We are open and flexible.

Telling the TREKK story, although still in its early chapters, is always very exciting for me. To have 12 PERC sites and 35 TREKK sites come together as a network in such a short time is amazing. We need to work further on strengthening and developing this network. It has been exciting to present TREKK at CAEP in Niagara Falls and CCYHC in Vancouver in 2012. On March 25, I have been invited to present TREKK at Evidence Live 2013 at Oxford University (http://www.evidencelive.org/) and they are already blogging about it (http://doc2doc.bmj.com/forums/bmj_evidence-2011_trekk-evidence-based-medicine-emergency-paediatrics).

I think what most excites me about TREKK is when I reflect on the children and their families that visit our general EDs. The possibility that we can have an impact and improve some of their outcomes is truly motivating. Together we can do so.