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Krueger C, Nguyen ELV, Mahant S, Borkhoff CM, Cichon J, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds J, Kanani R, Sakran M, Sehgal A, Pullenayegum E, Widjaja E, Reginald A, Wolter N, Parkin P, Gill PJ. Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study. Arch Dis Child 2024:archdischild-2023-326175. [PMID: 38589203 DOI: 10.1136/archdischild-2023-326175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 03/27/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVE To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections. DESIGN Multi-centre observational cohort study using data from 2009 to 2018 clinical records. SETTING Canadian children's hospitals (7) and community hospitals (3). PATIENTS Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections. INTERVENTIONS Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation. MAIN OUTCOME MEASURES Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates. RESULTS Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018. CONCLUSIONS Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.
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Affiliation(s)
| | | | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Cornelia M Borkhoff
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Cichon
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Olivier Drouin
- Division of General Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Gemma Vomiero
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jessica Foulds
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ronik Kanani
- North York General Hospital, Toronto, Ontario, Canada
| | | | - Anupam Sehgal
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Wolter
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Patricia Parkin
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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D'Alessandro M, Fricano C, Abdulsatar F, Bechard N, Brar JS, Drouin O, Foulds JL, Giglia L, Gill PJ, Gupta R, Li P, McConnery J, Metcalf J, Sakran M, Seaton C, Sehgal A, Sirizzotti N, Mbuagbaw L, Wahi G. Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study. BMJ Open 2024; 14:e080197. [PMID: 38326253 PMCID: PMC10860006 DOI: 10.1136/bmjopen-2023-080197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/24/2024] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support. METHODS AND ANALYSIS This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management. ETHICS AND DISSEMINATION Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals.
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Affiliation(s)
| | - Chiara Fricano
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Farah Abdulsatar
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nicole Bechard
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jagraj Singh Brar
- Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Olivier Drouin
- Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Lucia Giglia
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Peter J Gill
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronish Gupta
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Patricia Li
- Pediatrics, McGill University, Montreal, Quebec, Canada
| | | | | | - Mahmoud Sakran
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
- Lakeridge Health Oshawa Hospital, Oshawa, Ontario, Canada
| | - Claire Seaton
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | | | - Lawrence Mbuagbaw
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
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Im JHB, Wahi G, Giglia L, Bayliss A, Kanani R, Pound CM, Sakran M, Schuh S, Gill PJ, Parkin PC, Barrowman N, Mahant S. Oxygen Saturation Targets in Infants Hospitalized With Bronchiolitis: A Multicenter Cohort Study. Hosp Pediatr 2024; 14:67-74. [PMID: 38164101 DOI: 10.1542/hpeds.2023-007301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To examine 2 hospital oxygen saturation target policies and clinical outcomes in infants hospitalized with bronchiolitis. METHODS This multicenter cohort study used data collected from a randomized clinical trial of infants aged 4 weeks to 24 months, hospitalized with bronchiolitis at children's and community hospitals from 2016 to 2019. We modeled the association between hospital oxygen saturation target policy, either 90% while awake and 88% while asleep (90%/88%) or 90% while awake and asleep (90%/90%), and clinical outcomes. RESULTS A total of 162 infants were enrolled at 4 hospitals using a 90%/88% oxygen saturation target and 67 infants at 2 hospitals using a 90%/90% target policy. No significant differences between the 90%/88% group and 90%/90% groups were observed for time to discharge (adjusted hazard ratio, 0.83; 95% confidence interval [CI], 0.61-1.14; P = .25), initiation of supplemental oxygen (adjusted odds ratio [aOR], 0.98; 95% CI, 0.47-2.02; P = .95), time to discontinuation of supplemental oxygen (adjusted hazard ratio, 0.75; 95% CI, 0.44-1.27; P = .28), revisits (aOR, 1.38; 95% CI, 0.52-3.71; P = .52), and parent days missed from work (aOR, 2.41; 95% CI, 0.90-6.41; P = .08). Three infants in the 90%/88% group and none in the 90%/90% group were transferred to the ICU. CONCLUSIONS Among infants hospitalized with bronchiolitis, clinical outcomes were similar between a hospital oxygen saturation target policy of 90% while awake and 88% while asleep compared with 90% while awake and asleep. These findings may inform the design of future trials of oxygen saturation targets in bronchiolitis hospital care.
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Affiliation(s)
- James H B Im
- Dalla Lana School of Public Health
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter J Gill
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas Barrowman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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Yama B, Wahi G, Zhou K, Bayliss A, Sakran M, Breen-Reid K, Pound C, Beck C, Friedman J, Arafeh D, Kanani R, Parkin P, Mahant S. De-implementing low-value continuous pulse oximetry practice in infants hospitalized with bronchiolitis: A multicentre qualitative study. J Hosp Med 2023; 18:1092-1101. [PMID: 37932871 DOI: 10.1002/jhm.13236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Clinical trial evidence supports the routine use of intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis. However, continuous pulse oximetry use is common. OBJECTIVE This study aimed to understand the barriers and facilitators to de-implement continuous pulse oximetry and implement intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis. METHODS This multicentre qualitative study interviewed attending pediatricians, residents, nurses, respiratory therapists, and caregivers of infants hospitalized with bronchiolitis at hospitals in Ontario, Canada, to explore beliefs, attitudes, and experiences regarding pulse oximetry use in bronchiolitis management. Data were analyzed using thematic analysis to understand barriers and facilitators to practice change, mapped to the Consolidated Framework for Implementation Research (CFIR) domains. RESULTS Sixty-seven participants from six hospitals were interviewed using individual interviews and focus groups. Healthcare providers emphasized the importance of identifying and understanding who is responsible for bedside pulse oximetry practice (physicians vs. nurses). Clinical experience, knowledge of guidelines, importance versus competing priorities, and the tensions among team members due to practice variation in monitoring, influenced monitoring practice. Nurses believed in the advantages of intermittent monitoring (reduced alarm fatigue, facilitation of timely discharges, and reduced workload). Clinicians identified ways to clarify indications for continuous monitoring (based on patient risk factors), versus indications to transition to intermittent monitoring (established oral feeding, sleeping without desaturations). Caregivers did not express a clear preference for monitoring type; rather, they described the need for clear communication around interpreting monitor readings, management decisions, and care transitions. CONCLUSIONS Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry practice is essential for practice change. These findings may inform hospital quality improvement efforts to de-implement continuous monitoring in bronchiolitis hospital care.
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Affiliation(s)
- Brie Yama
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, Division of General Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Kim Zhou
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queen's University, Kingston, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Carolyn Beck
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeremy Friedman
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dana Arafeh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Patricia Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Sebastian A, Borkhoff CM, Wahi G, Giglia L, Bayliss A, Kanani R, Pound CM, Sakran M, Breen-Reid K, Gill PJ, Parkin PC, Mahant S. A Feeding Adequacy Scale for Children With Bronchiolitis: Prospective Multicenter Study. Hosp Pediatr 2023; 13:895-903. [PMID: 37712130 DOI: 10.1542/hpeds.2023-007339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
OBJECTIVES To determine the measurement properties of the Feeding Adequacy Scale (FAS) in young children hospitalized with bronchiolitis. METHODS Multicenter cohort study of infants hospitalized with bronchiolitis at children's and community hospitals in Ontario, Canada. Caregivers and nurses completed the FAS, a 10-cm visual analog scale anchored by "not feeding at all" (score 0) and "feeding as when healthy" (score 10). The main outcome measures were feasibility, reliability, validity, and responsiveness of the FAS. RESULTS A total of 228 children were included with an average (SD) age of 6.3 (5.4) months. Completing the FAS was feasible for caregivers and nurses, with no floor or ceiling effects. Test-retest reliability was moderate for caregivers (intraclass correlation coefficient [ICC] 2,1 0.73; 95% confidence interval [CI] 0.63-0.80) and good for nurses (ICC 2,1 0.75; 95% CI 0.62-0.83). Interrater reliability between 1 caregiver and 1 nurse was moderate (ICC 1,1 0.55; 95% CI 0.45-0.64). For construct validity, the FAS was negatively associated with length of hospital stay and positively associated with both caregiver and nurse readiness for discharge scores (P values <.0001). The FAS demonstrated clinical improvement from the first FAS score at admission to the last FAS score at discharge, with significant differences between scores for both caregivers and nurses (P values for paired t test <.0001). CONCLUSIONS These results provide evidence of the feasibility, reliability, validity, and responsiveness of caregiver-completed and nurse-completed FAS as a measure of feeding adequacy in children hospitalized with bronchiolitis.
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Affiliation(s)
- Agnes Sebastian
- Temerty Faculty of Medicine
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cornelia M Borkhoff
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Gill
- Temerty Faculty of Medicine
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Temerty Faculty of Medicine
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Temerty Faculty of Medicine
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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6
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McKerlie MF, Wolter NE, Mahant S, Cichon J, Widjaja E, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds JL, Kanani R, Sakran M, Sehgal A, Borkhoff CM, Pullenayegum E, Reginald A, Parkin PC, Gill PJ. Abscess volume as a predictor of surgical intervention in children hospitalized with orbital cellulitis: A multicentre cohort study. Int J Pediatr Otorhinolaryngol 2023; 171:111629. [PMID: 37437497 DOI: 10.1016/j.ijporl.2023.111629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 07/14/2023]
Abstract
IMPORTANCE Orbital cellulitis with subperiosteal or orbital abscess can result in serious morbidity and mortality in children. Objective volume criterion measurement on cross-sectional imaging is a useful clinical tool to identify patients with abscess who may require surgical drainage. OBJECTIVE To determine the predictive value of abscess volume and the optimal volume cut-point for surgical intervention. DESIGN We conducted an observational cohort study using medical records from children hospitalized between 2009 and 2018. SETTING Multicentre study using data from 6 children's hospitals. PARTICIPANTS Children were included if they were between 2 months and 18 years of age and hospitalized for an orbital infection with an abscess confirmed on cross-sectional imaging. EXPOSURE Subperiosteal or orbital abscess volume. MAIN OUTCOME AND MEASURES The primary outcome was surgical intervention, defined as subperiosteal and/or orbital abscess drainage. Multivariable logistic regression was performed to assess the association of abscess volume with surgery. To determine the optimal abscess volume cut-point, receiver operating characteristic (ROC) analysis was performed using the Youden Index to optimize sensitivity and specificity. RESULTS Of the 150 participants (mean [SD] age, 8.5 [4.5] years), 68 (45.3%) underwent surgical intervention. On multivariable analysis, larger abscess volume and non-medial abscess location were associated with surgical intervention (abscess volume: adjusted odds ratio [aOR], 1.46; 95% CI, 1.11-1.93; abscess location: aOR, 3.46; 95% CI, 1.4-8.58). ROC analysis demonstrated an optimal abscess volume cut-point of 1.18 mL [AUC: 0.75 (95% CI 0.67-0.83) sensitivity: 66%; specificity: 79%]. CONCLUSIONS AND RELEVANCE: In this multicentre cohort study of 150 children with subperiosteal or orbital abscess, larger abscess volume and non-medial abscess location were significant predictors of surgical intervention. Children with abscesses >1.18 mL should be considered for surgery.
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Affiliation(s)
- Morgyn F McKerlie
- Queens School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Nikolaus E Wolter
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jessica Cichon
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Olivier Drouin
- Department of Pediatrics, Université de Montreal, Montreal, QC, Canada; Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, ON, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Ronik Kanani
- North York General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, ON, Canada; Research, Lakeridge Health, Oshawa, ON, Canada
| | - Anupam Sehgal
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Cornelia M Borkhoff
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, ON, Canada
| | - Patricia C Parkin
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Nguyen ELV, Hersi L, Mahant S, Cichon J, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds JL, Kanani R, Sakran M, Sehgal A, Borkhoff CM, Pullenayegum E, Widjaja E, Reginald A, Wolter NE, Oni S, Anwar R, Louriachi H, Ge Y, Kirolos N, Patel A, Jasani H, Kornelsen E, Chugh A, Gouda S, Akbaroghli S, McKerlie M, Parkin PC, Gill PJ. Variation in the Management of Hospitalized Children With Orbital Cellulitis Over 10 Years. Hosp Pediatr 2023; 13:375-391. [PMID: 37122049 DOI: 10.1542/hpeds.2022-007006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVES No previous study has examined the management of hospitalized children with orbital cellulitis at both children's and community hospitals across multiple sites in Canada. We describe variation and trends over time in diagnostic testing and imaging, adjunctive agents, empiric antibiotics, and surgical intervention in children hospitalized with orbital cellulitis. PATIENTS AND METHODS Multicenter cohort study of 1579 children aged 2 months to 18 years with orbital cellulitis infections admitted to 10 hospitals from 2009 to 2018. We assessed hospital-level variation in the use of diagnostic tests, imaging, antibiotics, adjunctive agents, surgical intervention, and clinical outcomes using X2, Mann-Whitney U, and Kruskal-Wallis tests. The association between clinical management and length of stay was evaluated with median regression analysis with hospital as a fixed effect. RESULTS There were significant differences between children's hospitals in usage of C-reactive protein tests (P < .001), computed tomography scans (P = .004), MRI scans (P = .003), intranasal decongestants (P < .001), intranasal corticosteroids (P < .001), intranasal saline spray (P < .001), and systemic corticosteroids (P < .001). Children's hospital patients had significantly longer length of hospital stay compared with community hospitals (P = .001). After adjustment, diagnostic testing, imaging, and subspecialty consults were associated with longer median length of hospital stay at children's hospitals. From 2009 to 2018, C-reactive protein test usage increased from 28.8% to 73.5% (P < .001), whereas erythrocyte sedimentation rate decreased from 31.5% to 14.1% (P < .001). CONCLUSIONS There was significant variation in diagnostic test usage and treatments, and increases in test usage and medical intervention rates over time despite minimal changes in surgical interventions and length of stay.
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Affiliation(s)
| | - Leo Hersi
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Jessica Cichon
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Drouin
- Departments of Pediatrics and
- Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Mahmoud Sakran
- Department of Paediatrics, Queens University
- Research, Lakeridge Health, Oshawa, Ontario, Canada
| | - Anupam Sehgal
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Cornelia M Borkhoff
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Departments of Pediatrics
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Ophthalmology and Visual Sciences
| | - Nikolaus E Wolter
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Otolaryngology, Head & Neck Surgery
| | - Semipe Oni
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rashid Anwar
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Yipeng Ge
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nardin Kirolos
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Ashaka Patel
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Hardika Jasani
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Emily Kornelsen
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Ashton Chugh
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sandra Gouda
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Morgyn McKerlie
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Patricia C Parkin
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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Moretti ME, Jegathisawaran J, Wahi G, Bayliss A, Kanani R, Pound CM, Sakran M, Parkin PC, Mahant S. Cost-effectiveness of Intermittent vs Continuous Pulse Oximetry Monitoring in Infants Hospitalized With Stabilized Bronchiolitis. JAMA Netw Open 2022; 5:e2243609. [PMID: 36416823 PMCID: PMC9685487 DOI: 10.1001/jamanetworkopen.2022.43609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Pulse oximetry is a noninvasive technology that is integral to the supportive care of hospitalized infants with bronchiolitis. A multicenter, randomized trial comparing the effectiveness of intermittent vs continuous pulse oximetry found similar length of hospital stay and safety outcomes, and greater nursing satisfaction, with intermittent monitoring. OBJECTIVES To evaluate the cost-effectiveness of intermittent vs continuous pulse oximetry in hospitalized infants with stabilized bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation concurrent with a randomized trial in community and tertiary children's hospitals in Ontario, Canada, was conducted using a probabilistic analysis. Patients were enrolled from November 1, 2016, to May 31, 2019. Data included infants aged 4 weeks to 24 months hospitalized with bronchiolitis, with or without supplemental oxygen, after stabilization. The cost-effectiveness analysis adopted a societal and health care system perspective and a time horizon from hospitalization to 15 days post-discharge. Patient level direct health care costs and indirect costs were included. Health resource use, costs, and clinical outcomes were obtained from trial data. Publicly available pricing resources were used to supplement costs. Ranges for sensitivity analysis were based on 95% confidence intervals of the trial data. All costs were reported in 2021 Canadian dollars. INTERVENTIONS Intermittent (every 4 hours) vs continuous pulse oximetry using an oxygen saturation target of 90% or higher. MAIN OUTCOMES AND MEASURES Costs and incremental costs. RESULTS Trial data from 229 infants (median [IQR] age, 4.0 [2.2-8.5] months; 136 boys [59.4%], 93 girls [40.6%]) were included. Mean societal costs per patient were $6879 (95% CI, $3393 to $12 317) in the intermittent and $7428 (95% CI, $1743 to $25 011) in the continuous group with a mean incremental cost of -$548 (95% CI, -$18 486 to $8105). Mean health care system costs per patient were $4195 (95% CI, $1191 to $9461) in the intermittent and $4716 (95% CI, $335 to $22 093) in the continuous group (incremental cost, -$520; 95% CI, -$18 286 to $7358). The mean effect measure of length of stay was similar between the 2 groups: 37.4 hours (95% CI, 1.0 to 137.7 hours) in the intermittent group and 38.5 hours (95% CI, 0 to 237.1 hours) in the continuous group. One-way sensitivity analyses on all variables revealed that the findings were robust and the incremental costs were not sensitive to the uncertainty within the defined ranges. CONCLUSIONS AND RELEVANCE In this prospective economic evaluation study, we found that costs were similar for intermittent and continuous pulse oximetry considering societal and health care perspectives. Given that clinical outcomes between monitoring strategies are comparable and that other practice considerations favor intermittent monitoring, these findings provide additional information that support the use of intermittent monitoring in hospitalized infants with stabilized bronchiolitis.
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Affiliation(s)
- Myla E. Moretti
- Clinical Trials Unit, Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Jathishinie Jegathisawaran
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children’s Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
- Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M. Pound
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston
| | - Patricia C. Parkin
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Sanjay Mahant
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Ontario, Canada
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Moretti ME, Jegathisawaran J, Wahi G, Bayliss P, Kanani R, Sakran M, Pound C, Parkin P, Mahant S. 78 Cost-effectiveness of intermittent vs. continuous pulse oximetry monitoring in infants hospitalized with stabilized bronchiolitis: A multi-centre clinical trial. Paediatr Child Health 2022. [DOI: 10.1093/pch/pxac100.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Pulse oximetry is a non-invasive technology that is integral to the supportive care of hospitalized infants with bronchiolitis. A multi-centre, randomized trial comparing the effectiveness of intermittent vs. continuous pulse oximetry found similar hospital length of stay and safety outcomes, and greater nursing satisfaction with intermittent monitoring.
Objectives
To evaluate the cost-effectiveness of intermittent vs. continuous pulse oximetry in hospitalized infants with stabilized bronchiolitis.
Design/Methods
Prospective economic evaluation concurrent with a randomized trial (October 2016 to May 2019) using a probabilistic analysis. Infants (n=229) 4 weeks to 24 months hospitalized with bronchiolitis, with or without supplemental oxygen, after stabilization were randomized at six Ontario hospitals (community and children's) to intermittent (every 4 hours) vs. continuous pulse oximetry using an oxygen saturation target of 90% or higher. The main outcome measure for the economic evaluation was cost and incremental costs. The clinical effect measure was length of hospital stay in hours. The cost-effective analysis adopted a societal and health care system perspective and a time horizon from hospitalization to 15 days post-discharge. Patient level direct health care costs and indirect costs were included. Costs, health resource use and clinical outcomes were obtained from trial data. Publicly available pricing resources were used to supplement costs. Ranges for sensitivity analysis were based on 95% confidence intervals of the trial data. All costs were reported in 2020 Canadian dollars. This study was funded by a grant from the Canadian Institutes of Health Research.
Results
Trial data from 229 infants across six hospitals was included. Mean societal costs per patient were lower in the intermittent monitoring group: $6528 (95% CI: $3201, $12058) in the intermittent and $6815 (95% CI: $1454, $26485) in the continuous group with a mean incremental cost of -$287 (95% CI -$20084, $7842). Mean health care system costs per patient were $3992 (95% CI -$1139, $9224) in the intermittent and $4604 (95% CI -$317, $24126) in the continuous group (incremental cost -$613 (95% CI -$20564, $7089). The mean effect measure, length of stay, was also similar between the two groups: 36.3 hours in the intermittent group and 40.2 hours in the continuous group. One-way sensitivity analyses on all variables revealed that the findings were robust and the incremental costs were not sensitive to the uncertainty within the defined ranges.
Conclusion
In a prospective economic evaluation conducted with a clinical trial, we found that intermittent monitoring was less expensive than continuous monitoring, considering societal and health care costs. These findings support recommendations to use intermittent pulse oximetry monitoring in hospitalized infants with stabilized bronchiolitis.
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Affiliation(s)
- Myla E Moretti
- Ontario Child Health Support Unit-Clinical Trials Unit, The Hospital for Sick Children, Toronto, Ontario; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario
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10
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Yama B, Wahi G, Zhou K, Bayliss P, Sakran M, Breen-Reid K, Pound C, Beck C, Friedman J, Arafeh D, Kanani R, Parkin P, Mahant S. 76 Understanding practice change around intermittent versus continuous pulse oximetry in infants hospitalized with bronchiolitis: a multi-centre qualitative study. Paediatr Child Health 2022. [DOI: 10.1093/pch/pxac100.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Abstract
Background
Bronchiolitis is the most common reason for hospitalization in infants and is cumulatively costly for the healthcare system. Trial evidence and national guidelines support the routine use of intermittent pulse oximetry in stabilized (no oxygen supplementation) infants with bronchiolitis. However, continuous pulse oximetry use is common.
Objectives
To understand the barriers and facilitators important to de-implementing continuous pulse oximetry and implementing intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis.
Design/Methods
From December 2018 to January 2020, participants were recruited from six Ontario hospitals (3 community and 3 paediatric hospitals) in a multi-centre qualitative study. Focus groups were conducted with staff paediatricians, paediatric residents, nurses, and respiratory therapists. Interviews were conducted with caregivers of infants recently hospitalized with bronchiolitis. Participants' beliefs, attitudes, and experiences related to pulse oximetry use in bronchiolitis management were explored. Recordings were transcribed and analyzed using thematic analysis via NVivo software to understand barriers and facilitators to practice change. These were then mapped to the domains and the constructs of the Consolidated Framework for Implementation Research (CFIR).
Results
67 individuals from six hospitals participated. Themes relevant to understanding barriers and facilitators to de-implementing continuous and implementing intermittent monitoring were identified. Healthcare professionals emphasized the importance of identifying and understanding who is responsible for bedside monitoring practice (physician vs. nurses). Clinical experience, knowledge of guidelines (international and local practice), importance relative to competing priorities, and the tensions amongst team members due to practice variation all influenced monitoring practice. Nurses held beliefs around the advantages of intermittent monitoring (e.g., reduced alarm fatigue, facilitation of timely discharges and reduced workload). Clinicians identified ways to clarify indications for ongoing continuous monitoring (e.g., based on clinical risk factors such as medical complexity, prematurity, and age), vs. indications to transition to intermittent monitoring (e.g., established oral feeding, sleeping without desaturations, and off supplemental oxygen). Caregivers did not express a clear preference for monitoring type, but described the stress of having a child admitted to hospital with an emphasis on the need for clear communication around the interpretation of monitors, management decisions, and care transitions.
Conclusion
In this multi-centre qualitative study of clinicians and caregivers, we identified barriers and facilitators that are important to de-implementing continuous monitoring and implementing intermittent monitoring. Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry monitoring practices are essential for practice change.
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11
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Gill PJ, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds J, Kanani R, Sakran M, Sehgal A, Pullenayegum E, Widjaja E, Reginald A, Wolter NE, Oni S, Anwar R, Cichon J, Louriachi H, Ge Y, Kirolos N, Patel A, Jasani H, Kornelsen E, Chugh A, Gouda S, Akbaroghli S, McKerlie M, Parkin PC, Mahant S. Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections. J Pediatr 2022; 248:66-73.e7. [PMID: 35568061 DOI: 10.1016/j.jpeds.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. STUDY DESIGN We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. RESULTS Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/μL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). CONCLUSIONS In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.
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Affiliation(s)
- Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.
| | - Olivier Drouin
- Department of Pediatrics, Université de Montreal, Montreal, Quebec, Canada; Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jessica Foulds
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ronik Kanani
- North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, Ontario, Canada; Research, Lakeridge Health, Oshawa, Ontario, Canada
| | - Anupam Sehgal
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Eleanor Pullenayegum
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Semipe Oni
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rashid Anwar
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessica Cichon
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hossam Louriachi
- Department of Pediatrics, Université de Montreal, Montreal, Quebec, Canada
| | - Yipeng Ge
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Nardin Kirolos
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Ashaka Patel
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Hardika Jasani
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Emily Kornelsen
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Ashton Chugh
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sandra Gouda
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Susan Akbaroghli
- North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Morgyn McKerlie
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Patricia C Parkin
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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12
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So V, Watts M, Moharir M, Vargas C, Adrian-Gutierrez J, Sakran M, Elmekkawi A, Duong H, Kukreti V. 2-year-old girl with anemia and irritability. Paediatr Child Health 2022; 27:65-67. [DOI: 10.1093/pch/pxab046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Vincent So
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Queen’s School of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Maria Watts
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Mahendranath Moharir
- Pediatric Stroke Program, Division of Neurology, Department of Pediatrics, The Hospital of Sick Children, Toronto, Ontario, Canada
| | - Carolina Vargas
- Pediatric Stroke Program, Division of Neurology, Department of Pediatrics, The Hospital of Sick Children, Toronto, Ontario, Canada
| | - Javier Adrian-Gutierrez
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Amir Elmekkawi
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Heather Duong
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Vinay Kukreti
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
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Kukreti V, Sakran M, Tsimelkas S, MacDonald J, Wadhwa A. 68 COVID-19 in children: A case series. Paediatr Child Health 2021. [PMCID: PMC8689864 DOI: 10.1093/pch/pxab061.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Primary Subject area Community Paediatrics Background The COVID-19 pandemic has had an overwhelming impact worldwide. Studies on pediatric populations remain limited, as the burden of disease in pediatric patients appears to be low at this time. Objectives To further describe clinical characteristics and severity of disease of confirmed pediatric COVID-19 patients seen and evaluated in a community-based hospital. Design/Methods A retrospective chart review of positive COVID-19 patients ≤ 18 years seen in COVID clinic or in the Emergency Department (ED) between April and December 2020 was performed. The results of nasopharyngeal swabs were confirmed using real-time reverse-transcription-polymerase chain reaction (RT-PCR) assays. A descriptive analysis of illness severity, performed via Excel 2019, was based on clinical presentation, laboratory data, and chest x-ray imaging. The categories of illness severity were: asymptomatic, mild, moderate, severe or critical. Results A total of 53 positive COVID-19 patients were enrolled in this study, which consisted of 24 (45.3%) males and 29 (54.7%) females. The median age was 7.5 years (2.4-12.8). The majority of patients presented with mild symptoms (64.2%), with fever and cough being the main symptoms in 20 (37.7%) and 16 (30.2%) cases, respectively. Other symptoms included sore throat (15.1%), diarrhea (13.2%), headache (9.4%), runny nose (7.5%) and abdominal pain (7.5%). The remaining patients (35.8%) were asymptomatic. Of note, one patient (1.9%) presented with COVID toes requiring referral to a tertiary centre, and one (1.9%) was diagnosed with acute appendicitis. A history of contact with a confirmed COVID-19-positive family member was present in 43 (81.1%) patients, and 6 (11.3%) reported a history of recent travel. Laboratory tests were performed in 7 (13.2%) patients, and chest x-rays were performed in 9 (17%). There were no abnormalities detected in either, other than an elevated CRP seen in one patient with appendicitis. Two (3.8%) patients were admitted, including the patient with appendicitis who developed a perforation and was later transferred to a tertiary care centre to undergo an appendectomy. The majority of patients (96.2%) were discharged home. Conclusion All patients either presented with mild symptoms or were asymptomatic. Fever and cough were the most common presenting symptoms. Due to this, the vast majority of patients were discharged home. The infection in the majority of patients could be traced to a positive family contact. Our findings are consistent with what has been observed previously in our centre as well as worldwide. ![]()
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Mahant S, Wahi G, Bayliss A, Giglia L, Kanani R, Pound CM, Sakran M, Kozlowski N, Breen-Reid K, Arafeh D, Moretti ME, Agarwal A, Barrowman N, Willan AR, Schuh S, Parkin PC. Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:466-474. [PMID: 33646286 PMCID: PMC7922227 DOI: 10.1001/jamapediatrics.2020.6141] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis. OBJECTIVE To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada. INTERVENTIONS Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher. MAIN OUTCOMES AND MEASURES The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction. RESULTS Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, -1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02947204.
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Affiliation(s)
- Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Children’s Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M. Pound
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Queens University, Kingston, Ontario, Canada,Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada
| | | | - Karen Breen-Reid
- Learning Institute, Hospital for Sick Children and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Dana Arafeh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla E. Moretti
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada,Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
| | - Amisha Agarwal
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada ,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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15
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Gill PJ, Parkin PC, Begum N, Drouin O, Foulds J, Pound C, Quet J, Vomiero G, Wahi G, Sakran M, Kozlowski N, Bayliss A, Kanani R, Sehgal A, Pullenayegum EM, Reginald A, Wolter N, Mahant S. Care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis: protocol for a multicentre, retrospective cohort study. BMJ Open 2019; 9:e035206. [PMID: 31871262 PMCID: PMC6937073 DOI: 10.1136/bmjopen-2019-035206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Skin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis. METHOD AND ANALYSIS This is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay. ETHICS AND DISSEMINATION Approval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed.
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Affiliation(s)
- Peter J Gill
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nurshad Begum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Olivier Drouin
- Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Jessica Foulds
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Gita Wahi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queen's University, Oshawa, Ontario, Canada
| | - Natascha Kozlowski
- Research, Lakeridge Health Ajax Pickering Hospital, Ajax, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, University of Toronto, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anupam Sehgal
- Department of Paediatrics, Queen's University, Kingston, Ontario, Canada
| | - Eleanor M Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Arun Reginald
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Wolter
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Otolaryngology, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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16
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Mahant S, Wahi G, Giglia L, Pound C, Kanani R, Bayliss A, Roy M, Sakran M, Kozlowski N, Breen-Reid K, Lavigne M, Premji L, Moretti ME, Willan AR, Schuh S, Parkin PC. Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial. BMJ Open 2018; 8:e022707. [PMID: 29678995 PMCID: PMC5914772 DOI: 10.1136/bmjopen-2018-022707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Bronchiolitis is the most common reason for hospitalisation in infants in developed countries. The main focus of hospital care is on supportive care, such as monitoring for hypoxia and supplemental oxygen administration, as active therapies lack effectiveness. Pulse oximetry is used to monitor hypoxia in hospitalised infants and is used either intermittently or continuously. Observational studies have suggested that continuous pulse oximetry use leads to a longer length of hospital stay in stable infants. The use of continuous pulse oximetry may lead to unnecessary clinical intervention due to readings that are of little clinical significance, false-positive readings and less reliance on the clinical status. There is a lack of high-quality evidence to guide which pulse oximetry monitoring strategy, intermittent or continuous, is superior in infants hospitalised with bronchiolitis with respect to patient and policy-relevant outcomes. METHODS AND ANALYSIS This is a multicentre, pragmatic randomised controlled trial comparing two strategies for pulse oximetry monitoring in infants hospitalised for bronchiolitis. Infants aged 1 month to 2 years presenting to Canadian tertiary and community hospitals will be randomised after stabilisation to receive either intermittent or continuous oxygen saturation monitoring on the inpatient unit until discharge. The primary outcome is length of hospital stay. Secondary outcomes include additional measures of effectiveness, acceptability, safety and cost. We will need to enrol 210 infants in order to detect a 12-hour difference in length of stay with a type 1 error rate of 5% and a power of 90%. ETHICS AND DISSEMINATION Research ethics approval has been obtained for this trial. This trial will provide data to guide hospitals and clinicians on the optimal pulse oximetry monitoring strategy in infants hospitalised with bronchiolitis. We will disseminate the findings of this study through peer-reviewed publication, professional societies and meetings. TRIAL REGISTRATION NUMBER NCT02947204.
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Affiliation(s)
- Sanjay Mahant
- Division of Paediatric Medicine, Paediatric Outcomes Research Team (PORT), Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Hamilton, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Catherine Pound
- Department of Paediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Ronik Kanani
- Department of Paediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Madan Roy
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, Ontario, Canada
| | | | - Karen Breen-Reid
- Interprofessional Education, Learning Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mollie Lavigne
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Laila Premji
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla E Moretti
- Clinical Trials Unit-Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, Ontario Child Health Support Unit, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Division of Emergency Medicine, Department of Paediatrics, University of Toronto Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Division of Paediatric Medicine, Paediatric Outcomes Research Team (PORT), Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Hamilton, Ontario, Canada
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Abstract
OBJECTIVE Determine whether dexamethasone treatment added to salbutamol reduces time to readiness for discharge in patients with bronchiolitis and possible asthma. METHODS We compared efficacy and safety of dexamethasone, 1 mg/kg, then 0.6 mg/kg for 4 more days, with placebo for acute bronchiolitis in patients with asthma risk, as determined by eczema or a family history of asthma in a first-degree relative. All patients received inhaled salbutamol. Time to readiness for discharge was the primary efficacy outcome. RESULTS Two hundred previously healthy infants diagnosed with bronchiolitis, median age 3.5 months, were enrolled. Five placebo recipients needed admission to intensive care unit during infirmary treatment (P = .02). Among 100 dexamethasone recipients, geometric mean time to readiness for discharge was 18.6 hours (95% confidence interval [CI], 14.9 to 23.1 hours); among 90 control patients, 27.1 hours (95% CI, 21.8 to 33.8 hours). The ratio, 0.69 (95% CI, 0.51 to 0.93), revealed a mean 31% shortening of duration to readiness for discharge favoring dexamethasone (P = .015). Twenty-two dexamethasone and 19 control patients were readmitted to the short stay infirmary in the week after discharge (P = .9). No hospitalizations or side effects were reported during 7 days of surveillance. CONCLUSIONS Dexamethasone with salbutamol shortened time to readiness for infirmary discharge during bronchiolitis episodes in patients with eczema or a family history of asthma in a first-degree relative. Infirmary and clinic visits in the subsequent week occurred similarly for the 2 groups.
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Affiliation(s)
- Khalid Alansari
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar.
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Abstract
To analyze the epidemiological and clinical characteristic of a measles outbreak in Qatar in 2007, the records of 21 2 confirmed cases of measles were analyzed retrospectively, confirmation being based on clinical suspicion of the disease with a positive measles IgM (170 cases) and /or exposure to a laboratory confirmed measles case during the infectious period (42 cases; epidemiologic link). Eighty five percent of the cases occurred between April and July. Seventeen percent were in infants < 1 year of age, 47% in children between 1-5 years of age, 24% in school age children < 10 year of age and 1 2% in children >10 years old. Vaccinations were up to date in 60% of cases, second dose missed in 30% and no vaccination in 10% because of travel outside the country, concurrent illness, or lack of transportation. Thirty one percent of the cases required admission, with a mean hospital stay of four days. Cases were reported predominantly in Pakistani and Qatari patients, living mainly in three areas within the capital, Abu Hammour, Al Rayyan, and Al Mamuora.
Conclusion: Status of vaccination in Qatar needs careful analysis and the vaccination schedule should be reviewed. Early administration of vaccine, increasing community awareness, a well-coordinated school-based immunization program and immunization campaigns are required to prevent future outbreaks.
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Affiliation(s)
- K. Ibrahim
- Pediatric Emergency Center, Pediatrics Department, Hamad Medical Corporation, Doha, Qatar
| | - O. Al Gibali
- Pediatric Emergency Center, Pediatrics Department, Hamad Medical Corporation, Doha, Qatar
| | - M. Sakran
- Pediatric Emergency Center, Pediatrics Department, Hamad Medical Corporation, Doha, Qatar
| | - K. Al Ansari
- Pediatric Emergency Center, Pediatrics Department, Hamad Medical Corporation, Doha, Qatar
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Al-Ansari K, Sakran M, Davidson BL, El Sayyed R, Mahjoub H, Ibrahim K. Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in infants. J Pediatr 2010; 157:630-4, 634.e1. [PMID: 20646715 DOI: 10.1016/j.jpeds.2010.04.074] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 02/22/2010] [Accepted: 04/29/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in the prehospital setting. STUDY DESIGN This was a double-blind trial including consecutive infants aged <18 months treated in an urban urgent care setting. A total of 165 patients were randomized to receive nebulized 5%, 3%, or 0.9% (normal) saline with epinephrine every 4 hours. The primary efficacy outcome was bronchiolitis severity score improvement at 48 hours (chi2 analysis). Scores and oxygen saturation immediately before and after each treatment were recorded to assess safety. RESULTS A total of 187 previously healthy infants (median age, 3.1 months) diagnosed with bronchiolitis were enrolled. Positivity for respiratory syncytial virus was similar in the 3 treatment groups (mean, 56%). At 48 hours, the mean severity score for the 5% saline group was 3.69+/-1.09, and that for the 0.9% saline group was 4.12+/-1.11 (P=.04; difference, 0.43, 95% confidence interval for the difference, 0.02-0.88). The mean severity score for the 3% saline group was intermediate at 4.00+/-1.22. Revisit rates after discharge were similar in the 3 treatment groups. No adverse reactions or other safety concerns were identified. CONCLUSIONS Nebulization with 5% hypertonic saline is safe, can be widely generalizable, and may be superior to current treatment for early outpatient treatment of bronchiolitis.
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Affiliation(s)
- Khalid Al-Ansari
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
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