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Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children. In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13–15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7–100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4–100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2–99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2–93·4; 125/141) and CHALICE (92·3%, 89·2–94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.

ObjectiveTo determine the feasibility of Fluids in Shock, a randomised controlled trial (RCT) of restricted fluid bolus volume (10 mL/kg) versus recommended practice (20 mL/kg).DesignNine-month pilot RCT with embedded mixed-method perspectives study.Setting13 hospitals in England.PatientsChildren presenting to emergency departments with suspected infection and shock after 20 mL/kg fluid.InterventionsPatients were randomly allocated (1:1) to further 10 or 20 mL/kg fluid boluses every 15 min for up to 4 hours if still in shock.Main outcome measuresThese were based on progression criteria, including recruitment and retention, protocol adherence, separation, potential trial outcome measures, and parent and staff perspectives.ResultsSeventy-five participants were randomised; two were withdrawn. 23 (59%) of 39 in the 10 mL/kg arm and 25 (74%) of 34 in the 20 mL/kg arm required a single trial bolus before the shock resolved. 79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group (mean 14.5 vs 27.5 mL/kg). The Paediatric Index of Mortality-2 score was 2.1 (IQR 1.6–2.7) in the 10 mL/kg group and 2.0 (IQR 1.6–2.5) in the 20 mL/kg group. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days did not differ significantly between the groups. In the perspectives study, the trial was generally supported, although some problems with protocol adherence were described.ConclusionsParticipants were not as unwell as expected. A larger trial is not feasible in its current design in the UK.Trial registration numberISRCTN 15244462.

Background: Parents are a key source of support for children exposed to single-incident/acute traumas and can thereby play a potentially significant role in children's post-trauma psychological adjustment. However, the evidence base examining parental responses to child trauma and child posttraumatic stress symptoms (PTSS) has yielded mixed findings. Objective: We conducted a systematic review examining domains of parental responding in relation to child PTSS outcomes. Method: Studies were included if they (1) assessed children (6-19 years) exposed to a potentially traumatic event, (2) assessed parental responses to a child's trauma, and (3) quantitatively assessed the relationship between parental responses and child PTSS outcomes. A systematic search of three databases (APAPsycNet, PTSDpubs, and Web of Science) yielded 27 manuscripts. Results: Parental overprotection, trauma communication, avoidance of trauma discussion and of trauma reminders, and distraction were consistently related to child PTSS. There was more limited evidence of a role for trauma-related appraisals, harsh parenting, and positive parenting in influencing child outcomes. Significant limitations to the evidence base were identified, including limited longitudinal evidence, single informant bias and small effect sizes. Conclusion: We conclude that key domains of parental responses could be potential intervention targets, but further research must validate the relationship between these parental responses and child PTSS outcomes. Child post-traumatic stress symptoms following acute trauma are consistently related to post-trauma parental overprotection, avoidance of trauma discussion and of trauma reminders, and promotion of distraction from trauma-related thoughts and stimuli. The findings from this review provide a potential rationale for targeting these parental domains in clinical interventions addressing children's post-traumatic stress symptoms. Future research is needed to validate the longitudinal relationship between parental response domains following children's traumatic exposure and child post-traumatic stress symptoms.

Background Abusive head trauma (AHT) in infants is the most common abusive injury in young children, and increased awareness has resulted in the development of prevention programmes. Most research evaluating AHT prevention programmes report parental and carer perspectives. Little is known about barriers and facilitators to adopting, implementing, and maintaining educational programmes from the perspectives of managers and staff delivering the education. ICON is an AHT prevention programme currently being delivered in National Health Service hospital and primary care settings in the United Kingdom. Methods This study evaluated the ICON programme from the perspective of managers and healthcare professionals through the RE-AIM framework using qualitative methods. Fifty-three managers and healthcare professionals across six geographical areas in England participated in individual interviews and focus groups between October 2022 and April 2023. Data collection and analysis were concurrent, systematic, and iterative, using framework analysis as a guide to explore factors impacting ICON’s reach and the key enablers and obstacles to its effectiveness, adoption, implementation, and maintenance. Results Four primary enablers and related challenges to the ICON programme’s impact were identified. Fidelity to the programme’s recommended touchpoints and message impacted ICON’s reach to new parents and carers. Parental receptiveness to the programme was affected by staff individualising their approach. Staff buy-in was related to staff workload and previous experiences with AHT. Managers with strategic leadership responsibility for reducing infant mortality and able to provide governance oversight fostered successful adoption, implementation, and maintenance of the programme. Conclusions Staff are willing and able to deliver the ICON programme, including, where necessary, delivering the key messages in a format acceptable to families varying situations, if given the workload and training to do so. Those in leadership positions influence the likelihood of successful adoption, delivery and longer-term mainstreaming, if they are able to prioritise the programme. Understanding the barriers and facilitators to ICON’s delivery has the potential to inform policy by facilitating the uptake of the programme by settings, enabling delivery of ICON to reach the needs of local families, and ensuring sustainability of the ICON programme.

Background Head-injured children are commonly transported to the Emergency Department (ED) by ambulance. However, most of those conveyed are deemed non-serious and are discharged at triage. Hospital clinicians use clinical decision tools to support their assessment of head-injured children; however, this is generally to determine whether a computed tomography (CT) scan is indicated. Currently, there is no pre-hospital clinical decision tool designed to support paramedics when assessing and managing head-injured children at scene. The aim of this study was to determine consensus amongst experts and stakeholders to inform the development of a new tool to support paramedics in safely assessing and managing children with minor head injury. Methods A consultation process using a modified online Delphi technique comprising two rounds and a consensus meeting was completed between September 2023 and January 2024. A 5-point Likert scale was used to assess consensus, set a-priori at 67%. Free text survey responses arising from the Delphi were studied and concepts were developed. Data were analysed anonymously, and feedback was given after each round. Results An expert stakeholder group comprising 36 participants took part in Round One, and 34 participants in Round Two of the online Delphi. The participants included parents/grandparents/caregivers, paramedics, primary care clinicians, ED doctors, ED nurses and Paediatricians. Consensus was reached in 36 statements following Rounds One and Two. The remaining eight statements were discussed at a consensus meeting, which was attended by 12 stakeholders. Seven of the eight statements reached agreement. Conclusion This Delphi study has established consensus amongst a group of experts and stakeholders on the content and format of a pre-hospital paediatric head injury clinical decision tool, designed for use by paramedics: PATCH (Pre-hospital Assessment Tool for Children with Head injury). Future research should include an evaluation of the acceptability and usability of PATCH by paramedics. Clinical trial number Not applicable.

The aim of this review was to identify factors associated with multiple visits to emergency department (ED) services for mental health care in adolescents. Electronic databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and ProQuest Dissertations & Thesis Global) were searched for evidence that presented an association between risk factors or correlates of multiple visits to the emergency departmental for mental health care by 10–24 year olds. High impact use was defined as at least one return ED visit for mental health care. Primary studies of any quantitative design were included, with no exclusions based on language or country and all possible risk factors were considered. Data were extracted and synthesised using quantitative methods; frequencies of positive, negative and null associations were summarised for categories of potential risk factors. Sixty-five studies were included in the review. Most studies were from North America and reported a wide range of measures of high impact ED use, the most common being a binary indicator of multiple ED visits. Sex/gender and age were the most frequently reported risk factors. Measure of previous or concurrent access to mental health care was consistently positively associated with high impact use. Having private health insurance, compared with public or no insurance, was generally negatively associated with high impact use. Proxy measures of socioeconomic position (SEP) showed associations between lower SEP and more high impact use in a small number of studies. No other factors were consistently or uniformly associated with high impact use. The review identified a substantial evidence base but due to the variability in study design and measurement of both risk factors and outcomes, no consistent risk factors emerged. More research is needed, particularly outside North America, using robust methods and high quality routinely collected data.

Febrile infants 90 days and younger are at risk of invasive bacterial infections (bacteraemia and meningitis) and urinary tract infections. Together this is previously termed serious bacterial infection with an incidence of approximately 10-20%. The National Institute for Health and Care Excellence guidance advocates a cautious approach with most infants requiring septic screening, parenteral broad-spectrum antibiotics and hospital admission. Internationally, variations exist in the approach to febrile infants, with European and North American guidance advocating a tailored approach based on clinical features and biomarker testing. None of the available international clinical decision aids (CDAs) has been validated in the UK and Irish cohorts. The aim of the Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study is to prospectively validate a range of CDAs in a UK and Irish population including CDAs that use procalcitonin testing. The FIDO Study is a prospective multicentre mixed-methods cohort study conducted in UK and Irish hospitals. All infants aged 90 days and younger presenting with fever or history of fever (≥38°C) are eligible for inclusion. Infants will receive standard emergency clinical care without delay. Clinical data and blood samples will be collected, and consent will be obtained at the earliest appropriate opportunity using research without prior consent methodology. The performance and cost-effectiveness of CDAs will be assessed. An embedded qualitative study will explore clinician and caregiver views on different approaches to care and perceptions of risk. This study was reviewed and approved by the Office for Research Ethics Committees Northern Ireland-Health and Social Care Research Ethics Committee B, Public Benefit and Privacy Panel for Health and Social Care Scotland, and Children's Health Ireland Research and Ethics Committee Ireland. The results of this study will be presented at academic conferences and in peer-reviewed publications. NCT05259683.

This study explores clinician leaders understanding and perception at site level towards machine learning (ML) decision support tools for paediatric related emergency care across the UK and Ireland, essential in guiding safe and effective frontline implementation. A cross-sectional online survey was distributed via Paediatric Emergency Research United Kingdom and Ireland (PERUKI) to the lead for digital systems or PERUKI site lead, with one response sought per site. Survey development was in REDCap, and descriptive analysis (counts, percentages) was primarily performed. The response rate was 86.7% (65/75), mostly from England (83.1%). While 80.0% understood ‘Artificial Intelligence’, fewer understood advanced concepts such as ‘Deep Learning’ (32.3%). Most clinicians believed ML will support decision making (83.1%), would be willing to use (87.7%), and the future of decision making is a combination of human and ML (83.1%). Barriers included concerns about bias (61.5%), ML accuracy (56.9%), and inadequate information technology infrastructure (67.7%). Digital leads were more concerned about ML accuracy than non-digital (68.2% vs. 51.2%). Among potential applications, antimicrobial stewardship ranked highest (90.8%), and diagnosis of mental health conditions lowest (24.6%). Strong interest in ML tools for decision support in paediatric emergency care was evident, though concerns about bias, accuracy, and infrastructure must be addressed. Ongoing co-design with clinicians is critical in ensuring these tools are trusted, useful and suited to paediatric emergency care. Targeted education, digital leadership, and strategic investment in infrastructure and governance are essential for the successful adoption and integration of ML in clinical workflows.

The early post-trauma period is a key time to provide psychological support to acutely injured children. This is often when they present to emergency departments (EDs) with their families. However, there is limited understanding of the feasibility of implementing psychological support for children and their families in EDs. The aim of this study was to explore UK and Irish ED clinicians' perspectives on developing and implementing psychosocial care which educates families on their children's post-trauma psychological recovery. Semi-structured individual and group interviews were conducted with 24 UK and Irish ED clinicians recruited via a paediatric emergency research network. Clinicians expressed that there is value in offering psychological support for injured children and their families; however, there are barriers which can prevent this from being effectively implemented. Namely, the prioritisation of physical health, time constraints, understaffing, and a lack of training. Therefore, a potential intervention would need to be brief and accessible, and all staff should be empowered to deliver it to all families. Overall, participants' views are consistent with trauma-informed approaches where a psychosocial intervention should be able to be implemented into the existing ED system and culture. These findings can inform implementation strategies and intervention development to facilitate the development and delivery of an accessible digital intervention for acutely injured children and their families.