O’Brien S., Borland M. L., Cotterell E., Armstrong D., Babl F., Bauert P., Brabyn C., Garside L., Haskell L., Levitt D., McKay N., Neutze J., Schibler A., Sinn K., Spencer J., Stevens H., Thomas D., Zhang M., Oakley E., and Dalziel S. R., ‘Australasian Bronchiolitis Guideline’, J Paediatr Child Health, 55 (2019) 42-53 DOI 10.1111/jpc.14104. Epub 2018 Jul 15. [link]

O’Brien S, Borland ML, Oakley E. Dalziel S, Babl FE. Letters to the Editor: National guidelines for bronchiolitis. J. Paediatr. Child Health. 2019 June 2. 55(2019) 728–729, PMID: 31155791. DOI: 10.1111/jpc.14463. [link]

Tavender E, Babl FE, Middleton S. Review article: Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction. Emerg Med Australas. 2019 Apr 24. doi: 10.1111/1742-6723.13296. [Epub ahead of print] Review. PMID: 31016861 [link]

Dalziel SR, Borland ML, Furyk J, Bonisch M, Neutze J, Donath S, Francis KL, Sharpe C, Harvey AS, Davidson A, Craig S, Phillips N, George S, Rao A, Cheng N, Zhang M, Kochar A, Brabyn C, Oakley E, Babl FE; PREDICT research network. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial.  Lancet. 2019 Apr 17. pii: S0140-6736(19)30722-6. doi: 10.1016/S0140-6736(19)30722-6. [Epub ahead of print] [link].

Long E, Craig S, Babl FE, Tavender E, Lunny C. Review article: A primer for clinical researchers in the emergency department: Part IX. How to conduct a systematic review in the field of emergency medicine. Emerg Med Australas. 2019 Apr 15. doi: 10.1111/1742-6723.13298. [Epub ahead of print] Review. PMID: 30989835 [link]

Bressan S, Kochar A, Oakley E, Borland M, Phillips N, Dalton S, Lyttle MD, Hearps S, Cheek JA, Furyk J, Neutze J, Dalziel S, Babl FE; Paediatric Research in Emergency Department International Collaborative (PREDICT) group. Traumatic brain injury in young children with isolated scalp haematoma. Arch Dis Child. 2019 Mar 4. pii: archdischild-2018-316066. doi: 10.1136/archdischild-2018-316066. [Epub ahead of print]. [link].

George S, Humphreys S, Williams T, Gelbart B, Chavan A, Rasmussen K, Ganeshalingham A, Erickson S, Ganu SS, Singhal N, Foster K, Gannon B, Gibbons K, Schlapbach LJ, Festa M, Dalziel S, Schibler A; Paediatric Critical Care Research Group (PCCRG), Paediatric Research in Emergency Departments International Collaborative (PREDICT) and the Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG). Transnasal humidified rapid insufflation ventilatory exchange in children requiring emergent intubation (Kids THRIVE): a protocoll for a randomised controlled trial.  BMJ Open. 2019 Feb 20;9(2):e025997. doi: 10.1136/bmjopen-2018-025997 [link].

Lee WH., O’Brien S., Skarin D., Cheek JA., Deitch J., Nataraja R., Craig S., Borland ML., on behalf of PREDICT. Accuracy of clinician gestalt in diagnosing appendicitis in children presenting to the emergency department. Emerg Med Australas. 2019 Jan 21. doi: 10.1111/1742-6723.13220. Epub ahead of print [link].

Borland ML, Dalziel SR, Phillips N, Lyttle MD, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek JA, Neutze J, Gilhotra Y, Dalton S, Babl FE; Paediatric Research in Emergency Department International Collaborative (PREDICT) Group. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study, Ann Emerg Med. 2019 July, 74(1) pii: S0196-0644(18)31485-9. doi: 10.1016/j.annemergmed.2018.11.035. [link]

2019 Presentations (conference proceedings, posters, published abstracts)

Ibrahim L, Hopper S, Donath S, Salvin B, Babl FE, Bryant P. An ASSET for treatment: development and validation of a paediatric cellulitis risk score. International Conference on Emergency Medicine (ICEM), Seoul, South Korea, 12-15 June 2019. (Poster). More information

Aims: There are currently no standardised guidelines for treating cellulitis in children, specifically whether oral or intravenous (IV) antibiotics should be used. This potentially results in over treatment leading to unnecessary hospital admission or under treatment resulting in further complications. This study aimed to derive and validate a cellulitis risk assessment scoring system to guide which patients require IV antibiotics.

Methods: A prospective cohort study of children presenting to the Emergency Department aged 6 months-18 years diagnosed with cellulitis, from January 2014-August 2017 for the derivation cohort and over a 14-month period from June 2015-August 2017 for the validation cohort. Demographics and clinical features of cellulitis were collected, and patients were divided into two groups based on route of antibiotic at 24 hours (the pre-determined gold standard). A comparison of demographics and clinical features were made between the two groups.  Clinicians were surveyed on which features they used to decide whether to start IV antibiotics. Combinations of differentiating features were plotted on receiver operating characteristic curves.

Results: There were 285 children in the derivation cohort to create the Melbourne ASSET (Area, Systemic features, Swelling, Eye, Tenderness) score out of 7. The area under the curve (AUC) was 0.86 [95% confidence interval (CI) 0.83-0.91]. Using a cutoff score of 4 to start IV antibiotics gave the highest correct classification of 80% of patients (sensitivity 60%, specificity of 93%). This score was validated in 251 children and maintained a robust AUC of 0.83 (95% CI 0.78-0.89), correctly classifying 76% of patients (sensitivity 85%, specificity 63%).

Conclusion: The Melbourne ASSET score is the first risk assessment scoring system for childhood cellulitis proposed to aid clinicians in deciding whether to treat with IV or oral antibiotics. It is simple, easy to use, applicable and reliable.

Singh S, Borland ML, Dalziel S, Neutze J, Hearps S, Donath S, Cheek JA, Kochar A, Gilhotra Y, Lyttle MD, Bressan S, Oakley E, Kuppermann N, Holmes JF, Babl FE. The effect of observation status on cranial computed tomography rates in children with minor head trauma: the Australasian Paediatric Head Injury Rules Study (APHIRST). International Congress on Emergency Medicine (ICEM), Seoul, South Korea. 12-15 June 2019. (free paper session). More information

Aims: 

Methods: 

Results: 

Conclusion: 

Crellin D, Harrison D,  Santamaria N, Babl FE. Procedural pain assessment in infants and young children: a comparison of 3 behavioural scales. International Congress on Emergency Medicine (ICEM), Seoul, South Korea. 12-15 June 2019. (Poster). More information

Aims: Infants and young children frequently experience painful procedures in the emergency department, the management of which is contingent on accurate assessment. The most suitable tool for this purpose is unclear. The aim of this study was to compare the reliability, validity, feasibility and utility of three observational pain scales to quantify procedural pain in infants and young children.

Methods: A convenience sample of twenty-six clinicians used the Face, Legs, Activity, Cry & Consolability (FLACC) scale, the Modified Behavioural Pain Scale (MBPS) and the Visual Analogue Scale applied by an observer (VASobs) to segments of video from 100 children aged six to 42 months undergoing a procedure.

Results: Inter-rater reliability was poorest for VASobs pain scores (ICC – 0.55). VASobs pain scores were lower than FLACC and MBS scores during the procedure but MBPS scores were higher during non-painful phases (p < 0.001). The FLACC scale provided the best sensitivity (94.9%) and specificity (72.5%) for the lowest cut-off score (pain score 2). Correlations between FLACC and VASobs (distress) were strongest (r = 0.89). The FLACC scale resulted in more incomplete scores (p < 0.000) than the other scales. Finally, reviewers liked the VASobs (pain) most, considered it quickest and easiest to apply but all scales were considered of limited use for procedural pain assessment.

Conclusion: This study supported the reliability and sensitivity of the FLACC and MBPS. There were practical concerns for application of the FLACC scale and the MBPS and doubt about the capacity of both scales to differentiate between pain- and non-pain related distress exist. The VASobs, although practical, was less reliable than either the FLACC scale or the MBPS. The results of this study demonstrated that the FLACC scale may be best suited for procedural pain assessment.

Wilson CL, Tavender E, Phillips N, Oakley E, O’Brien S, Dalziel SR, Babl FE, for PREDICT.. Variation in Head Computed Tomography Use for Paediatric Head Injury Across Different Types of Emergency Departments: Do We Have a Problem? International Congress on Emergency Medicine (ICEM), Seoul, South Korea. 12-15 June 2019. (Poster).  More information

Aims: Computed tomography of the brain (CTB) for paediatric head injury is used at low rates at tertiary paediatric Emergency Departments (EDs) in Australia and New Zealand. However, most paediatric patients are seen in mixed, non-tertiary EDs. International studies have found large variation in CTB rates across hospital types. We aimed to assess variation in CTB use for paediatric head injury in Australia and New Zealand across tertiary, urban/suburban and regional/rural EDs.

Methods: A retrospective observational study of medical and neuroimaging records of presentations to 30 tertiary, urban/suburban and regional/rural EDs in Australia and New Zealand in 2016.  Case inclusion criteria; 1) Primary ED diagnosis of head injury; 2)Age <16 years. Data extraction was undertaken on 100 sequential eligible cases per site for head injury severity by Glasgow Coma Scale (GCS) scores, CTB rate and clinical management.

Results: 2472 eligible presentations from 25 of 32 EDs recruited have been analysed, 9 tertiary (n=900), 9 urban/suburban (n=872) and 7 regional/rural EDs (n=700). Proportion of children <2 years; tertiary 54.6%; urban/suburban 42.9%; regional/rural 36%, p<.001. Proportion of children presenting with a known GCS of 15/14/13/12-9/3-8; tertiary 95.2%/2.4%/0.4%/0.6%/0.22%, urban/suburban 93.7%/4.6%/0.57%/0.8%/0.1%, regional/rural 93.6%/2.57%/0.3%/0.71%/0.1%, p=0.001. CTB imaging rates were; tertiary 8.2%, urban/suburban 7.2%, regional/rural 4.14%, p=0.004. Median length of stay was; tertiary 2.6 hours, urban/suburban 2.7 hours, regional/rural 1.7 hours, p=<0.001. Full data are expected to be analysed by January 2019, when severity weighted analysis will occur.

Conclusion: Neuroimaging rates for paediatric head injury in Australia and New Zealand are not higher in mixed urban/suburban or regional/rural EDs when compared with tertiary paediatric EDs.  Lower imaging rates do not seem to be offset by increased length of observation.  Assessing variation in CTB rates across hospital types is an important consideration in strategies to improve care.

Haskell L, Tavender EJ, Wilson C, O’Brien S, Borland ML, Cotterell E, Babl FE, Orsini F, Schembri R, Sheridan N, Johnson D, Oakley E, Dalziel SR, for PREDICT. Improving the management of infants with bronchiolitis: a cluster randomised controlled trial of tailored knowledge translation in paediatric acute care. International Congress on Emergency Medicine (ICEM), Seoul, South Korea. 12-15 June 2019. (Poster). More information

Aims: Bronchiolitis is the most common reason for infants to be hospitalised following presentation to emergency departments (EDs). Management is supportive with high-level evidence of no efficacy for salbutamol, glucocorticoids, chest x-rays, antibiotics, or adrenaline. Despite all international guidelines recommending against the use of these therapies, significant practice variation exists, with the use of inappropriate therapy a worldwide problem. Knowledge translation (KT) interventions that are tailored to the factors that influence practice can improve care; however there is little high-level evidence in acute paediatrics. The primary objective was to establish whether tailored, theory informed KT interventions, compared to passive guideline dissemination, reduces the use of salbutamol, glucocorticoids, chest x-rays, antibiotics, and adrenaline, in infants. 

Methods: Tailored KT interventions were developed, following qualitative interviews using the Theoretical Domains Framework, to target key identified factors influencing bronchiolitis management. We then compared the tailored KT interventions versus passive dissemination in a cluster randomised controlled trial of 26 hospitals in Australia and New Zealand during the 2017 Australasian bronchiolitis season. The primary outcome was compliance with the Australasian Bronchiolitis Guideline during the first 24 hours of care (no use of salbutamol, glucocorticoids, chest x-rays, antibiotics, or adrenaline). Secondary outcomes included length of stay, median medication doses, health costs and process evaluation.

Results: Data was collected on 3,727 infants. Compliance with the Australasian Bronchiolitis Guideline was 86.1% (95%CI 82.6-89.7%) in the intervention sites and 72.0% (95%CI 65.3-78.8%) in the control sites, risk difference 14.1% (95%CI 6.5%-21.7%), p<0.0001.

Conclusion: The use of tailored KT interventions substantially reduces the use of inappropriate therapies in the management of infants with bronchiolitis. As bronchiolitis is the most common reason for infants to be admitted to hospital this study has important implications for future management of bronchiolitis and for KT in general in EDs.

Wilson CL, Tavender E, Phillips N, Oakley E, O’Brien S, Dalziel SR, Babl FE, for PREDICT.. Variation in Head Computed Tomography Use for Paediatric Head Injury Across Different Types of Emergency Departments: Do We Have a Problem? Pediatric Academic Societies Meeting 2019 (PAS), Baltimore, USA. April 24-May 1 2019. (Poster).  More information

Aims: Computed tomography of the brain (CTB) for paediatric head injury is used at low rates at tertiary paediatric Emergency Departments (EDs) in Australia and New Zealand. However, most paediatric patients are seen in mixed, non-tertiary EDs. International studies have found large variation in CTB rates across hospital types. We aimed to assess variation in CTB use for paediatric head injury in Australia and New Zealand across tertiary, urban/suburban and regional/rural EDs.

Methods: A retrospective observational study of medical and neuroimaging records of presentations to 30 tertiary, urban/suburban and regional/rural EDs in Australia and New Zealand in 2016.  Case inclusion criteria; 1) Primary ED diagnosis of head injury; 2)Age <16 years. Data extraction was undertaken on 100 sequential eligible cases per site for head injury severity by Glasgow Coma Scale (GCS) scores, CTB rate and clinical management.

Results: 2472 eligible presentations from 25 of 32 EDs recruited have been analysed, 9 tertiary (n=900), 9 urban/suburban (n=872) and 7 regional/rural EDs (n=700). Proportion of children <2 years; tertiary 54.6%; urban/suburban 42.9%; regional/rural 36%, p<.001. Proportion of children presenting with a known GCS of 15/14/13/12-9/3-8; tertiary 95.2%/2.4%/0.4%/0.6%/0.22%, urban/suburban 93.7%/4.6%/0.57%/0.8%/0.1%, regional/rural 93.6%/2.57%/0.3%/0.71%/0.1%, p=0.001. CTB imaging rates were; tertiary 8.2%, urban/suburban 7.2%, regional/rural 4.14%, p=0.004. Median length of stay was; tertiary 2.6 hours, urban/suburban 2.7 hours, regional/rural 1.7 hours, p=<0.001. Full data are expected to be analysed by January 2019, when severity weighted analysis will occur.

Conclusion: Neuroimaging rates for paediatric head injury in Australia and New Zealand are not higher in mixed urban/suburban or regional/rural EDs when compared with tertiary paediatric EDs.  Lower imaging rates do not seem to be offset by increased length of observation.  Assessing variation in CTB rates across hospital types is an important consideration in strategies to improve care.

Teo SSS, Oakley E, Stanford J, Cichero J.  Paediatric acute care: Highlights from the Paediatric Acute Care-Advanced Paediatric Life Support Conference, Hobart, 2018.  Emerg Med Australas. 2019 Mar 27. doi: 10.1111/1742-6723.13285. [Epub ahead of print] [link].