A retrospective cohort review study of patients with Primary Immune Deficiency (PID) who have presented to the emergency department (ED) with a fever

Primary Immune Deficiency can develop into frequent and in some cases severe infections, and inflammation. With this cohort of patients being so vulnerable, they should be treated and assessed promptly when presenting to an emergency department with a fever. There remains a critical need in this specific population to optimise strategies aiming to improve the recognition as to which febrile patients require immediate intervention, and to identify if treatment can be withheld/de-escalated safely.

Currently there are limited guidelines and knowledge surrounding this specific population when they present to an ED creating a gap in research. This dissertation will aim to address this via:

1. A scoping Review of global standards and practices of febrile PID children presenting to ED, and
2. A retrospective review, of all paediatric patients with a PID who present to an ED with a fever. Data will include demographics, PID characteristics, ED diagnosis, procedures and disposition.

SPASMS: Study of Paediatric Appendicitis Scores and Management Strategies

Abdominal pain is one of the commonest reasons for children to attend the emergency department (ED), and acute appendicitis is the most common cause of abdominal pain requiring surgery. There are various clinical prediction scores that have been developed to help doctors diagnose appendicitis; however, most scores were developed overseas and are not routinely used in Australian EDs. The aim of this project is to review different published scores and compare them with overall clinician impression in diagnosing acute appendicitis in children presenting to ED.

The project will include all patients presenting to the ED with abdominal pain that are having investigations for possible appendicitis. The treating doctor will be asked to complete a case report form detailing patient history, examination findings, investigation results, as well as their overall clinical impression of the patient’s likelihood of having the diagnosis of appendicitis. Data collected will be analysed by project researchers to determine which scores are the most helpful for clinicians in diagnosing acute appendicitis in children presenting to Australian EDs, with the expectation that this will improve future care provided to children with abdominal pain.

Assessment of emergency presentations, outcomes and departmental impact of patients presenting after COVID-19 immunisation to a tertiary Paediatric Emergency Department.

Since the introduction of COVID-19 immunisations for young people aged 0-16yrs, patients and families have presented to the Emergency Department (ED) with concerns about possible side-effects. There have been rare but potentially serious complications of these immunisations reported worldwide including inflammation of the heart muscle and lining. These patients therefore need careful assessment and investigation in the Emergency Department.

This study will measure the number of patients presenting with these concerns, how they have been cared for and the outcomes of these assessments. It will assess the impact on Emergency Department (ED) resources and whether guidelines for assessment and reporting side effects have been followed. This information will be used to improve care pathways for this group of patients in the future.

Comparison of respiratory supports in the mitigation or exacerbation of environmental droplet contamination following coughing

COVID-19 is an infectious respiratory pathogen with significant capacity to spread within the healthcare environment which has been highlighted by the number of healthcare staff internationally that have died or suffered significant morbidity through transmission while caring for patients. Guidelines recommend distancing between healthcare staff and patients and the need for personal protective equipment (PPE).

The majority of hospitalised and unwell patients with COVID-19 will receive some type of respiratory support, however very little is known in regard to how differing devices mitigate or exacerbate spread of respiratory droplets during coughing. Inadequate information has led to restrictions on certain types of therapies being offered to patients at risk for COVID-19. This study aims to clarify the extent of environmental contamination from droplet spread during coughing and the effect of different types of standard respiratory support on this.

Can assessment of parental concern improve sepsis recognition in children?

Sepsis is devastating infection, leading to organ dysfunction. Sepsis kills more children in Australia than road traffic accidents. One out of three survivors will suffer from long-term health problems. Faster recognition of sepsis can save lives. However, recognising sepsis in children can be difficult, as children with sepsis initially present with symptoms similar to common infections. Currently, the recognition of sepsis is based on physician assessment of patients, and laboratory tests. Sadly, a common finding in Coroner`s investigations of sepsis deaths is that parents represented several times to health-care facilities, stating their concerns that “something is wrong” with their child. There is at present great debate as to what role parental concern should have in sepsis recognition.

We hypothesise that parents as experts of their child provide important information to recognise disease severity in their child. We will perform questionnaires with parents, and with medical and nursing staff when a child is evaluated for sepsis. We will compare the value of measuring parental concern in comparison to healthcare worker assessment, clinical signs and symptoms, and routine infection markers.

Assessing Children’s Head Injury: Variation in CT scan use (APHIRST-Gap)

This study will collect information from the records of 3000 children from 30 hospitals presenting after a head injury in 2016 and will interview staff to look at different factors influencing the care provided. APHIRST-Gap is expected to provide crucial information on scan rates and inform strategies, including national guideline development to standardise and improve the care of children with head injury across Australia and New Zealand.

Head injury is a common reason children present to Emergency Departments in Australia and New Zealand. While most are minor the important issue for emergency clinicians is to determine whether a particular child is at risk of a serious head injury such as a bleed on the brain. A computerised tomography(CT) scan is the investigation of choice to look for these injuries. Its presents risks though, including the risk of sedation, and radiation induced cancer.

Several “rules” have been designed to guide doctors in the decision, by weighing up the risk of injury with the risks associated with the scan. The published Australasian APHIRST study examined three of these rules. It found that all three rules performed well, clinicians made sound judgements, and the overall rate of CT scan use was low (10%). APHIRST was limited to 10 large metropolitan, and predominately paediatric hospitals. Most children in Australia are not seen in these hospitals. Further research is required to determine whether there is a large variation in scan use between different hospitals and how best to apply these findings to a broader range of hospitals.

This trial is being run by the PREDICT network and the Principal Investigator is Prof Franz Babl.

Rapid diagnosis of sepsis in acutely ill children

Life threatening bacterial infections such as sepsis are a leading cause of childhood mortality. International authorities recognise the urgent need for better recognition, diagnosis, and management of children with sepsis. Children in regional and remote settings are at particular risk for late or inaccurate diagnosis resulting in worse outcomes.

In this study, the researchers are testing the feasibility, performance, time-to-diagnosis, and cost impact of applying the most advanced genomics-based sepsis diagnostic tools. This could lead to better treatment of infections, reduce unnecessary antibiotic use, shorten hospital length of stay, improve patient outcomes, and allow patients and families to be managed closer to home, with the aim to provide the same care for all children around the state. We are recruiting acutely ill children presenting with suspected sepsis to Emergency Departments, including regional and remote centres in Queensland.

High Flow Nasal Cannula Treatment for Infants and Children with Acute Respiratory Failure – a Pilot Trial

Worldwide, the respiratory distress associated with pneumonia and other causes remains the leading cause of death in children. In Australia 39% of intensive care admissions for children are due to respiratory disease, with bronchiolitis/viral infection representing 17%, asthma 7% and pneumonia 7%. There is an emerging trend to support respiration with methods other than oxygen, particularly in the early stage of disease process aiming to prevent the progression of disease. In under resourced countries children presenting to hospitals with severe pneumonia have a mortality rate between 13-20% and most deaths occur with hypoxemia before therapeutic benefit of antimicrobials. High flow nasal cannula (HFNC) therapy is a new promising mode of respiratory support as an alternative to non-invasive ventilation, which is poorly tolerated by a sick child. HFNC therapy can be used very early in the disease process and requires little cooperation

This study aims to develop a multi-centre trial and to assess which infants and children with acute respiratory failure benefit using HFNC therapy. For this purpose we will perform a randomised controlled trial comparing current best practice (standard oxygen delivery via subnasal prongs, facemask, venturi mask) versus HFNC therapy. With the introduction of this simple to use respiratory system administered earlier in the disease process, we aim to investigate if HFNC therapy has a lower treatment failure rate in comparison to standard oxygen delivery, and to investigate if there is a reduction in the need for transfer of these patients to a tertiary hospital or admission to intensive care.

Children’s Rules for Imaging the Cervical Spine Evaluation Study

In this study, clinicians looked at all children presenting to the ED over a 12 month period for the assessment of possible cervical spine injury to better understand how children are treated in hospital and how further investigation into the use of these rules can be undertaken.

Children rarely break their necks but if they do, they can risk spinal injury or death. Many more children present for assessment of possible cervical spine (neck) injuries than are subsequently diagnosed with cervical spine injury. The challenge for the emergency doctor is to identify the rare cases without subjecting too many children to unnecessary tests.
These tests, x-rays and scans, have risks including exposure to radiation and associated danger of long term cancer development, as well as the possible need for sedation to perform the scan in young children. Awaiting these tests is often a time of prolonged distress for the patient and family as the child needs to be kept lying flat and still without moving their neck. Considerable staff time and Emergency Department costs are associated with these tests. Rules have been proposed to assist doctors in deciding whether tests are needed.

The Australasian Paediatric Head Injury Rules: a prospective validation of 3 international clinical decision rules for acute head injury in children presenting to emergency departments.

Many children sustain head injuries and present to emergency departments for evaluation. Even a seemingly minor incident may lead to serious injury requiring neurosurgery. While head computer tomography (CT) identifies all important injuries, there is an increasing recognition that radiation from CTs can increase the risk of fatal brain cancers, especially in younger children.

Failure to identify a significant intracranial injury quickly may result in catastrophic consequences including long-term neurological disability and or death. A number of evidence-based head injury (HI) clinical decision rules (CDRs) have been developed to help physicians identify patients at risk of having a significant head injury. These CDRs provide recommendations (including CTs) based on the presence of certain features of the history or physical examination. No HI CDRs have been validated outside of their original settings.

The identification of an optimal CDR for implementation would help to minimise risks, both of missing a clinically significant intracranial injury, and of exposure to radiation from cranial CT scans. The results will likely have a major impact on head injury management in children in Australia, New Zealand and worldwide.