David W Johnson

The University of Calgary, Calgary, Alberta, Canada

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Publications (64)387.73 Total impact

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    ABSTRACT: Objectives Despite the substantial body of literature on emergency department (ED) crowding, to the best of our knowledge, there is no agreement on the measure or measures that should be used to quantify crowding. The objective of this systematic review was to identify existing measures of ED crowding that have been linked to quality of care as defined by the Institute of Medicine (IOM) quality domains (safe, effective, patient-centered, efficient, timely, and equitable).Methods Six major bibliographic databases were searched from January 1980 to January 2012, and hand searches were conducted of relevant journals and conference proceedings. Observational studies (cross-sectional, cohort, and case-control), quality improvement studies, quasi-experimental (e.g., before/after) studies, and randomized controlled trials were considered for inclusion. Studies that did not provide measures of ED crowding were excluded. Studies that did not provide quantitative data on the link between crowding measures and quality of care were also excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality using the Newcastle-Ottawa Quality Assessment Scale (NOS) for observational studies and a modified version of the NOS for cross-sectional studies.ResultsThe search identified 7,413 articles. Thirty-two articles were included in the review: six cross-sectional, one case-control, 23 cohort, and two retrospective reviews of performance improvement data. Methodologic quality was moderate, with weaknesses in the reporting of study design and methodology. Overall, 15 of the crowding measures studied had quantifiable links to quality of care. The three measures most frequently linked to quality of care were the number of patients in the waiting room, ED occupancy (percentage of overall ED beds filled), and the number of admitted patients in the ED awaiting inpatient beds. None of the articles provided data on the link between crowding measures and the IOM domains reflecting equitable and efficient care.Conclusions The results of this review provide data on the association between ED crowding measures and quality of care. Three simple crowding measures have been linked to quality of care in multiple publications.
    Academic Emergency Medicine 05/2015; 22(6). DOI:10.1111/acem.12682 · 2.20 Impact Factor
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    ABSTRACT: Introduction: Procedural sedation and analgesia have become standard practice in paediatric emergency departments worldwide. Although generally regarded as safe, serious adverse events such as bradycardia, asystole, pulmonary aspiration, permanent neurological injury and death have been reported, but their incidence is unknown due to the infrequency of their occurrence and lack of surveillance of sedation safety. To improve our understanding of the safety, comparative effectiveness and variation in care in paediatric procedural sedation, we are establishing a multicentre patient registry with the goal of conducting regular and ongoing surveillance for adverse events in procedural sedation. Methods: This multicentre, prospective cohort study is enrolling patients under 18 years of age from six paediatric emergency departments across Canada. Data collection is fully integrated into clinical care and is performed electronically in real time by the healthcare professionals caring for the patient. The primary outcome is the proportion of patients who experience a serious adverse event as a result of their sedation. Secondary outcomes include the proportion of patients who experience an adverse event that could lead to a serious adverse event, proportion of patients who receive a significant intervention in response to an adverse event, proportion of patients who experience a successful sedation, and proportion of patients who experience a paradoxical reaction to sedation. There is no predetermined end date for data collection. Ethics and dissemination: Ethics approval has been obtained from participating sites. Results will be disseminated using a multifaceted knowledge translation strategy by presenting at international conferences, publication in peer-reviewed journals, and through established networks.
    BMJ Open 05/2015; 5(5):e008223. DOI:10.1136/bmjopen-2015-008223 · 2.06 Impact Factor
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    ABSTRACT: This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:
    Pediatrics 10/2014; 134(5). DOI:10.1542/peds.2014-2742 · 5.30 Impact Factor
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    ABSTRACT: Guidance from the American Academy of Pediatrics (AAP) for the use of palivizumab prophylaxis against respiratory syncytial virus (RSV) was first published in a policy statement in 1998. Guidance initially was based on the result from a single randomized, placebo-controlled clinical trial conducted in 1996-1997 describing an overall reduction in RSV hospitalization rate from 10.6% among placebo recipients to 4.8% among children who received prophylaxis. The results of a second randomized, placebo-controlled trial of children with hemodynamically significant heart disease were published in 2003 and revealed a reduction in RSV hospitalization rate from 9.7% in control subjects to 5.3% among prophylaxis recipients. Because no additional controlled trials regarding efficacy were published, AAP guidance has been updated periodically to reflect the most recent literature regarding children at greatest risk of severe disease. Since the last update in 2012, new data have become available regarding the seasonality of RSV circulation, palivizumab pharmacokinetics, the changing incidence of bronchiolitis hospitalizations, the effects of gestational age and other risk factors on RSV hospitalization rates, the mortality of children hospitalized with RSV infection, and the effect of prophylaxis on wheezing and palivizumab-resistant RSV isolates. These data enable further refinement of AAP guidance to most clearly focus on those children at greatest risk.
    Pediatrics 08/2014; 134(2):E620-E638. DOI:10.1542/peds.2014-1666 · 5.30 Impact Factor
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    ABSTRACT: The burden of acute gastroenteritis on children and their families continues to be enormous. Probiotics, defined as viable microbial preparations that have a beneficial effect on the health of the host, represent a rapidly expanding field. Although clinical trials in children with gastroenteritis have been performed, most have significant flaws, and guidelines do not consistently endorse their use.
    Trials 05/2014; 15(1):170. DOI:10.1186/1745-6215-15-170 · 2.12 Impact Factor
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    ABSTRACT: Benzodiazepines are considered first-line therapy for pediatric status epilepticus. Some studies suggest that lorazepam may be more effective or safer than diazepam, but lorazepam is not Food and Drug Administration approved for this indication. To test the hypothesis that lorazepam has better efficacy and safety than diazepam for treating pediatric status epilepticus. This double-blind, randomized clinical trial was conducted from March 1, 2008, to March 14, 2012. Patients aged 3 months to younger than 18 years with convulsive status epilepticus presenting to 1 of 11 US academic pediatric emergency departments were eligible. There were 273 patients; 140 randomized to diazepam and 133 to lorazepam. Patients received either 0.2 mg/kg of diazepam or 0.1 mg/kg of lorazepam intravenously, with half this dose repeated at 5 minutes if necessary. If status epilepticus continued at 12 minutes, fosphenytoin was administered. The primary efficacy outcome was cessation of status epilepticus by 10 minutes without recurrence within 30 minutes. The primary safety outcome was the performance of assisted ventilation. Secondary outcomes included rates of seizure recurrence and sedation and times to cessation of status epilepticus and return to baseline mental status. Outcomes were measured 4 hours after study medication administration. Cessation of status epilepticus for 10 minutes without recurrence within 30 minutes occurred in 101 of 140 (72.1%) in the diazepam group and 97 of 133 (72.9%) in the lorazepam group, with an absolute efficacy difference of 0.8% (95% CI, -11.4% to 9.8%). Twenty-six patients in each group required assisted ventilation (16.0% given diazepam and 17.6% given lorazepam; absolute risk difference, 1.6%; 95% CI, -9.9% to 6.8%). There were no statistically significant differences in secondary outcomes except that lorazepam patients were more likely to be sedated (66.9% vs 50%, respectively; absolute risk difference, 16.9%; 95% CI, 6.1% to 27.7%). Among pediatric patients with convulsive status epilepticus, treatment with lorazepam did not result in improved efficacy or safety compared with diazepam. These findings do not support the preferential use of lorazepam for this condition. clinicaltrials.gov Identifier: NCT00621478.
    JAMA The Journal of the American Medical Association 04/2014; 311(16):1652-60. DOI:10.1001/jama.2014.2625 · 30.39 Impact Factor
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    ABSTRACT: Many children requiring acute care receive suboptimal analgesia.
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    ABSTRACT: Given the recent publication of several large trials and systematic reviews, we undertook a study of the current management of bronchiolitis in Canadian pediatric emergency departments (EDs) and explored physicians' rationale for their treatment decisions. The overarching purpose of this study was to assist in planning a future trial of combined epinephrine and dexamethasone for bronchiolitis. Physicians in the Pediatric Emergency Research Canada (PERC) database received an 18-item electronic survey. A modified Dillman method was used. Of the 271 physicians surveyed, 191 (70.1%) responded. The majority (120 of 271; 66.5%) reported ''typically'' giving a bronchodilator trial in the ED, with respondents almost evenly divided between treatment with salbutamol (n=62) and treatment with epinephrine (n=61). Of those who use salbutamol, 77.4% indicated that they prefer it because it can be prescribed for home use. Of those who use epinephrine, 80.3% indicated that they believe the medical literature supports its benefit over salbutamol. Few participants (2.6%) reported ''always'' using steroids, whereas the majority (62.8%) reported ''sometimes'' using them. The most common factor reported to influence steroid use was illness severity (73.3%). The majority (60.5%) reported that if corticosteroids were beneficial in bronchiolitis, they prefered treatment with a single dose in the ED as opposed to a multiday course. Our results indicate that physicians practicing in Canadian pediatric EDs commonly use bronchodilators to manage bronchiolitis but use corticosteroids less commonly. They appear to be uncomfortable using corticosteroids, particularly longer courses, and have a stated preference for a single dose. Any future trial examining the role of corticosteroids in bronchiolitis should carefully consider the issue of steroid dosage.
    Canadian Journal of Emergency Medicine 02/2014; 16:1-8. DOI:10.2310/8000.2013.131325 · 0.66 Impact Factor
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    ABSTRACT: Health professionals frequently recommend fever treatment regimens for children that either combine paracetamol and ibuprofen or alternate them. However, there is uncertainty about whether these regimens are better than the use of single agents, and about the adverse effect profile of combination regimens. To assess the effects and side effects of combining paracetamol and ibuprofen, or alternating them on consecutive treatments, compared with monotherapy for treating fever in children. In September 2013, we searched Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; and International Pharmaceutical Abstracts (2009-2011). We included randomized controlled trials comparing alternating or combined paracetamol and ibuprofen regimens with monotherapy in children with fever. One review author and two assistants independently screened the searches and applied inclusion criteria. Two authors assessed risk of bias and graded the evidence independently. We conducted separate analyses for different comparison groups (combined therapy versus monotherapy, alternating therapy versus monotherapy, combined therapy versus alternating therapy). Six studies, enrolling 915 participants, are included.Compared to giving a single antipyretic alone, giving combined paracetamol and ibuprofen to febrile children can result in a lower mean temperature at one hour after treatment (MD -0.27 °Celsius, 95% CI -0.45 to -0.08, two trials, 163 participants, moderate quality evidence). If no further antipyretics are given, combined treatment probably also results in a lower mean temperature at four hours (MD -0.70 °Celsius, 95% CI -1.05 to -0.35, two trials, 196 participants, moderate quality evidence), and in fewer children remaining or becoming febrile for at least four hours after treatment (RR 0.08, 95% CI 0.02 to 0.42, two trials, 196 participants, moderate quality evidence). Only one trial assessed a measure of child discomfort (fever associated symptoms at 24 hours and 48 hours), but did not find a significant difference in this measure between the treatment regimens (one trial, 156 participants, evidence quality not graded).In practice, caregivers are often advised to initially give a single agent (paracetamol or ibuprofen), and then give a further dose of the alternative if the child's fever fails to resolve or recurs. Giving alternating treatment in this way may result in a lower mean temperature at one hour after the second dose (MD -0.60 °Celsius, 95% CI -0.94 to -0.26, two trials, 78 participants, low quality evidence), and may also result in fewer children remaining or becoming febrile for up to three hours after it is given (RR 0.25, 95% CI 0.11 to 0.55, two trials, 109 participants, low quality evidence). One trial assessed child discomfort (mean pain scores at 24, 48 and 72 hours), finding that these mean scores were lower, with alternating therapy, despite fewer doses of antipyretic being given overall (one trial, 480 participants, low quality evidence)Only one small trial compared alternating therapy with combined therapy. No statistically significant differences were seen in mean temperature, or the number of febrile children at one, four or six hours (one trial, 40 participants, very low quality evidence).There were no serious adverse events in the trials that were directly attributed to the medications used. There is some evidence that both alternating and combined antipyretic therapy may be more effective at reducing temperatures than monotherapy alone. However, the evidence for improvements in measures of child discomfort remains inconclusive. There is insufficient evidence to know which of combined or alternating therapy might be more beneficial.Future research needs to measure child discomfort using standardized tools, and assess the safety of combined and alternating antipyretic therapy.
    Cochrane database of systematic reviews (Online) 10/2013; 10(10):CD009572. DOI:10.1002/14651858.CD009572.pub2 · 5.94 Impact Factor
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    ABSTRACT: Introduction: Stories may be an effective tool to communicate with patients because of their ability to engage the reader. Our objective was to evaluate the effectiveness of story booklets compared to standard information sheets for parents of children attending the emergency department (ED) with a child with croup. Methods: Parents were randomized to receive story booklets (n=208) or standard information sheets (n=205) during their ED visit. The primary outcome was change in anxiety between triage to ED discharge as measured by the State-Trait Anxiety Inventory. Follow-up telephone interviews were conducted at 1 and 3 days after discharge, then every other day until 9 days (or until resolution of symptoms), and at 1 year. Secondary outcomes included: expected future anxiety, event impact, parental knowledge, satisfaction, decision regret, healthcare utilization, time to symptom resolution. Results: There was no significant difference in the primary outcome of change in parental anxiety between recruitment and ED discharge (change of 5 points for the story group vs. 6 points for the comparison group, p=0.78). The story group showed significantly greater decision regret regarding their decision to go to the ED (p<0.001): 6.7% of the story group vs. 1.5% of the comparison group strongly disagreed with the statement "I would go for the same choice if I had to do it over again". The story group reported shorter time to resolution of symptoms (mean 3.7 days story group vs. 4.0 days comparison group, median 3 days both groups; log rank test, p=0.04). No other outcomes were different between study groups. Conclusions: Stories about parent experiences managing a child with croup did not reduce parental anxiety. The story group showed significantly greater decision regret and quicker time to resolution of symptoms. Further research is needed to better understand whether stories can be effective in improving patient-important outcomes.
    PLoS ONE 10/2013; 8(10):e77800. DOI:10.1371/journal.pone.0077800 · 3.53 Impact Factor
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    ABSTRACT: OBJECTIVE:Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen.METHODS:A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED.RESULTS:The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators.CONCLUSIONS:A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.
    PEDIATRICS 09/2013; 132(4). DOI:10.1542/peds.2013-0854 · 5.30 Impact Factor
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    ABSTRACT: OBJECTIVE: To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness. DESIGN: Multicentre retrospective case-control study. SETTING: 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries. PARTICIPANTS: 265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control. MAIN OUTCOME MEASURES: Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios. RESULTS: 151 (57%) of the 265 cases were male, the median age was 6 (interquartile range 2.3-10.0) years, and 27 (10%) died. Six factors were associated with severe outcomes in children presenting with influenza-like illness: history of chronic lung disease (odds ratio 10.3, 95% confidence interval 1.5 to 69.8), history of cerebral palsy/developmental delay (10.2, 2.0 to 51.4), signs of chest retractions (9.6, 3.2 to 29.0), signs of dehydration (8.8, 1.6 to 49.3), requirement for oxygen (5.8, 2.0 to 16.2), and tachycardia relative to age). CONCLUSION: These independent risk factors may alert clinicians to children at risk of severe outcomes when presenting with influenza-like illness during future pandemics.
    BMJ Clinical Research 08/2013; 347(7921). DOI:10.1136/bmj.f4836. · 14.09 Impact Factor
  • Candice L Bjornson, David W Johnson
    Canadian Medical Association Journal 08/2013; 185(15). DOI:10.1503/cmaj.121645 · 5.81 Impact Factor
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    ABSTRACT: BACKGROUND: Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches. OBJECTIVES: To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 12), MEDLINE (1950 to January week 2, 2013), EMBASE (1980 to January 2013), LILACS (1982 to January 2013), Scopus® (1823 to January 2013) and IRAN MedEx (1998 to November 2009). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children under 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. We meta-analysed inpatient and outpatient results separately using random-effects models. We pre-specified subgroup analyses, including the combined use of bronchodilators used in a protocol. MAIN RESULTS: We included 17 trials (2596 participants); three had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% confidence interval (CI) 0.78 to 1.08 and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65; 95% CI 0.44 to 0.95; number needed to treat 11; 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes. AUTHORS' CONCLUSIONS: Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalisation. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.
    Cochrane database of systematic reviews (Online) 06/2013; 6(6):CD004878. DOI:10.1002/14651858.CD004878.pub4 · 5.94 Impact Factor
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    ABSTRACT: BackgroundThe clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.Design/methodsWe will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma—the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis—the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.DiscussionThis study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.Trial registrationClinicalTrials.gov: NCT01815710
    Implementation Science 05/2013; 8(1):55. DOI:10.1186/1748-5908-8-55 · 3.47 Impact Factor
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    ABSTRACT: Objectives:To describe pediatric emergency medicine (PEM) physicians' reported pain management practices across Canada and explore factors that facilitate or hinder pain management.Methods:This study was a prospective survey of Canadian pediatric emergency physicians. The Pediatric Emergency Research Canada physician database was used to identify participants, and a modified Dillman's Total Design Survey Method was used for recruitment.Results:The survey response rate was 68% (139 of 206). Most physicians were 31 to 50 years old (82%) with PEM training (56%) and had been in practice for less than 10 years (55%). Almost all pain screening in emergency departments (EDs) occurred at triage (97%). Twenty-four percent of physicians noted institutionally mandated pain score documentation. Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain (88% and 83%, respectively). Over half of urinary catheterizations (60%) and intravenous (53%) starts were performed without any analgesia. The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively. Training background and gender of physicians affected the likelihood of using nonpharmacologic interventions. Physicians noted time restraints to be the greatest barrier to optimal pain management (55%) and desired improved access to pain medications (32%), better policies and procedures (30%), and further education (25%).Conclusions:When analgesia was reported as provided, ibuprofen and acetaminophen were most commonly used. Both procedural and presenting pain remained suboptimally managed. There is a substantial evidence practice gap in children's ED pain management, highlighting the need for further knowledge translation strategies and policies to support optimal treatment.
    Canadian Journal of Emergency Medicine 01/2013; 15:1-9. DOI:10.2310/8000.2013.131261 · 0.66 Impact Factor
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    ABSTRACT: ACADEMIC EMERGENCY MEDICINE 2012; 19:1019-1026 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:  The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. Methods:  This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. Results:  The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4). Conclusions:  The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.
    Academic Emergency Medicine 09/2012; 19(9):E1019-E1026. DOI:10.1111/j.1553-2712.2012.01433.x · 2.20 Impact Factor
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    ABSTRACT: Background Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation.Objectives To evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup.Search methodsWe searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010).Selection criteriaRandomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L-epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects.Data collection and analysisTwo authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses.Main resultsEight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I2 statistic = 0%). This effect was not significant two and six hours post-treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42).Authors' conclusionsNE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization.Plain Language SummaryNebulized epinephrine for croup in childrenCroup is a common childhood illness that is usually caused by a viral infection. Symptoms of croup include a hoarse voice, a 'barking' cough and noisy breathing. These symptoms are the result of swelling that occurs in the area of the windpipe (trachea) just below the voice box (larynx). Although most cases of croup are mild and resolve on their own, occasionally the swelling can be severe enough to cause difficulty in breathing. In these children, epinephrine (also called adrenaline) is a medication that is inhaled as a mist to temporarily shrink the swollen area in the trachea.This review looked at trials of inhaled epinephrine for the treatment of children with croup. Compared to no medication, inhaled epinephrine improved croup symptoms in children at 30 minutes following treatment (three studies, 94 children). This treatment effect disappeared two hours after treatment (one study, 20 children). However, children's symptoms did not become worse than prior to treatment. No study measured adverse events. This review is comprised of only eight studies and the number of included children was small (225). Few studies examined similar outcomes, therefore data could often not be pooled and conclusions are based on one or few studies.
    Evidence-Based Child Health A Cochrane Review Journal 07/2012; 7(4). DOI:10.1002/ebch.1856
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    Candice L. Bjornson, David W. Johnson
    Evidence-Based Child Health A Cochrane Review Journal 05/2012; 7(3). DOI:10.1002/ebch.1842
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    ABSTRACT: To examine the use of intravenous magnesium in Canadian pediatric emergency departments (EDs) in children requiring hospitalization for acute asthma and association of administration of frequent albuterol/ipratropium and timely corticosteroids with hospitalization. Retrospective medical record review at 6 EDs of otherwise healthy children 2 to 17 years of age with acute asthma. Data were extracted on history, disease severity, and timing of ED stabilization treatments with inhaled albuterol, ipratropium, corticosteroids, and magnesium. Primary outcome was the proportion of hospitalized children given magnesium in the ED. Secondary outcome was the ED use of "intensive therapy" in hospitalized children, defined as 3 albuterol inhalations with ipratropium and corticosteroids within 1 hour of triage. A total of 19 (12.3%) of 154 hospitalized children received magnesium (95% confidence interval 7.1, 17.5) versus 2 of 962 discharged patients. Children given magnesium were more likely to have been previously admitted to ICU (odds ratio [OR] 11.2), hospitalized within the past year (OR 3.8), received corticosteroids before arrival (OR 4.0), presented with severe exacerbation (OR 6.1), and to have been treated at 1 particular center (OR 14.9). Forty-two (53%) of 90 hospitalized children were not given "intensive therapy." Children receiving "intensive therapy" were more likely to present with severe disease to EDs by using asthma guidelines (ORs 8.9, 3.0). Differences in the frequencies of all stabilization treatments were significant across centers. Magnesium is used infrequently in Canadian pediatric EDs in acute asthma requiring hospitalization. Many of these children also do not receive frequent albuterol and ipratropium, or early corticosteroids. Significant variability in the use of these interventions was detected.
    PEDIATRICS 04/2012; 129(5):852-9. DOI:10.1542/peds.2011-2202 · 5.30 Impact Factor

Publication Stats

845 Citations
387.73 Total Impact Points

Institutions

  • 2002–2014
    • The University of Calgary
      • • Department of Paediatrics
      • • Faculty of Medicine
      • • Department of Psychiatry
      Calgary, Alberta, Canada
  • 2013
    • Starship Children's Hospital
      Окленд, Auckland, New Zealand
  • 2012
    • IWK Health Centre
      Halifax, Nova Scotia, Canada
  • 2010
    • Alberta Health Services
      Calgary, Alberta, Canada
    • McGill University
      • Department of Pediatrics
      Montréal, Quebec, Canada
  • 2009
    • University of Alberta
      • Department of Pediatrics
      Edmonton, Alberta, Canada
    • Children's Hospital of Eastern Ontario
      • Department of Pediatrics
      Ottawa, Ontario, Canada
  • 2005
    • Queen's University
      • Department of Emergency Medicine
      Kingston, Ontario, Canada