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Research reviews
Reviews
Research Reviews The papers reviewed for this edition of the journal have a paediatric theme. They are also all from the Academic Emergency Medicine journal which I have found to consistently provide clinically useful research papers.
Smith SR, Baty JD, Hodge D 2002 “Validation of the Pulmonary Score: An Asthma Severity Score for Children” Academic Emergency Medicine 9(2): 99–104 Objectives: To assess the validity of the pulmonary score (PS), an asthma severity score devised by the authors, by comparing it to the peak expiratory flow rate (PEFR) – an accepted standard in emergency units. The PS is measured using three factors – respiratory rate (by age), wheezing and accessory muscle use – each scoring between 0 and 3 (3 the most severe). Methods: Children aged between 5 and 17 years, attending the ED with exacerbation of asthma had their PEFR and PS measured before and after initial treatment. At least two staff members, either doctors or nurses measured all scores. Pre- and post-treatment PEFR and PS scores were compared to establish if the PS is a good indicator of airway obstruction. Correlation between the PEFR and the PS was also measured pre- and post-test. Results: Forty-six children completed the study, with a mean age of 11.5 years. Results showed an improvement after treatment using both the PEFR (20.7%) and the PS (1.5 nurse-scorer, 1.9 doctor-scorer). Correlation between PEFR and PS was significant – as PEFR went up, PS decreased, in both the nursing and physician scores. Comment: A useful paper using explicit methods to measure validity, proving to be significant for this severity score. There is thorough discussion of the need for a user-friendly tool, in contrast to those already available. The mean age of the sample (11.5 years) did not correlate to the mean age of children presenting with asthma – 6.9 years. The limitations of the study are recognised in relation to the under – 5s, a group for which the score has potentially the greatest impact. If a scoring system such as this is to be relevant clinically, it needs to be related to management of the condition. It is a straightforward tool that has potential, but further work obviously needs to be done.
Beckman AW, Sloan BK, Moore GP, Cordell WH, et al. 2002 “Should Parent be Present during Emergency Procedures on Children, and Who Should Make that Decision? A Survey of Emergency Physician and Nurse Attitudes.” Academic Emergency Medicine 9(2): 154–158
° C 2 0 0 2 Published by Elsevier Science Ltd.
Objectives: To ascertain the attitudes of emergency staff to the presence of parents during invasive procedures on their children, and who should make that decision. Methods: Survey of nursing and medical staff in 10 EDs, using six clinical scenarios with different procedures, asking whether a parent should be allowed to be present – peripheral IV access, laceration repair, lumber puncture, conscious sedation, and resuscitation – with and without likelihood of the child’s death. The survey also asked who should make the decision about the parent(s) to be present. Results: 645 staff responded – 306 doctors, and 339 nurses. Most staff were in favour of parents being present for simple procedures – IV access (91.3% doctors, 86.8% nurses) and repair of lacerations (93.3% and 89.6%). This reduced greatly for resuscitation, with nurses more likely to respond positively to the presence of parents. In resuscitation with the likelihood of death, 35.6% of doctors thought parents should be present in contrast to 54.3% of nurses. Most of the medical staff thought they alone should make the decision for parents’ presence (44%), in contrast to nurses who were split between the parents themselves deciding (24.3%), or it being a joint decision between nurse, doctor and parent (27.7%). Comment: I felt this study added little new to the body of evidence on relatives’ participation in patient care. This subject has been discussed and studied widely in both nursing and medical literature, although this is not reflected in this paper. The fear of litigation is always central to this debate, and again is raised here. In methodological terms, surveys are recognised as an effective method to ascertain attitudinal data, especially relating to sensitive subjects. The authors recognise the potential selection bias of those responding, but the most significant concern is the lack of information about the response rate. This is essential as an indicator of the validity of the tool, and although 645 responses seems high, we have no idea what percentage of the total mailed surveys this was.
Karpas A, Hennes H, Walsh-Kelly CM 2002 “Utilization of the Ottawa Ankle Rules by Nurses in a Paediatric Emergency Department” Academic Emergency Medicine 9(2): 130–133 Objectives: To determine the ability of paediatric ED nurses to apply Ottawa Ankle Rules and to determine if the rate of negative radiographs could be reduced by the implementation of OAR within current practice protocols. Methods: All children aged 5–17 years, meeting the criteria set out in the department’s own Practice Protocol (acute injury (< 48 h) and either ankle pain,
Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 1 7 7–1 7 8
177
Research reviews
swelling, deformity or decreased range of movement) were included in the study. Nurses trained in the OAR assessed the patient as either positive or negative, and then all patients were X-rayed. Results: 190 patients included, with a median age of 13 years. OAR was positive in 79% of patients, and 31 patients from the complete sample had fractures identified. 30 of the 31 were Ottawa positive. Use of the OAR instead of their current protocol would lead to a 21% reduction in X-rays. OAR was correctly interpreted by the nurses in 98% of cases, and most found them straightforward to apply (89%). A small sample of 20 patients used to measure interobserver reliability found 100% agreement. Comment: Again this study seems to add little to the body of evidence surrounding Ottawa rules, although it
178
Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 1 7 7 – 1 7 8
may just complete the picture, looking specifically at paediatric nurses. It is important for this department as it shows potential for a significant change in practice. The study itself is straightforward with explicit methodology and results sections. There is thorough discussion of the other studies relating to Ottawa Ankle rules, although these relate only to American research. Heather M. McClelland, RGN, MSc, Practice Development Facilitator, A&E Department, Leeds General Infirmary Great George Street Leeds, LS1, UK doi: 10.1054/aaen.2002.0362, available online at http://www.idealibrary.com on
° C 2 0 0 2 Published by Elsevier Science Ltd.
Research Reviews The papers reviewed for this edition of the journal have a paediatric theme. They are also all from the Academic Emergency Medicine journal which I have found to consistently provide clinically useful research papers.
Smith SR, Baty JD, Hodge D 2002 “Validation of the Pulmonary Score: An Asthma Severity Score for Children” Academic Emergency Medicine 9(2): 99–104 Objectives: To assess the validity of the pulmonary score (PS), an asthma severity score devised by the authors, by comparing it to the peak expiratory flow rate (PEFR) – an accepted standard in emergency units. The PS is measured using three factors – respiratory rate (by age), wheezing and accessory muscle use – each scoring between 0 and 3 (3 the most severe). Methods: Children aged between 5 and 17 years, attending the ED with exacerbation of asthma had their PEFR and PS measured before and after initial treatment. At least two staff members, either doctors or nurses measured all scores. Pre- and post-treatment PEFR and PS scores were compared to establish if the PS is a good indicator of airway obstruction. Correlation between the PEFR and the PS was also measured pre- and post-test. Results: Forty-six children completed the study, with a mean age of 11.5 years. Results showed an improvement after treatment using both the PEFR (20.7%) and the PS (1.5 nurse-scorer, 1.9 doctor-scorer). Correlation between PEFR and PS was significant – as PEFR went up, PS decreased, in both the nursing and physician scores. Comment: A useful paper using explicit methods to measure validity, proving to be significant for this severity score. There is thorough discussion of the need for a user-friendly tool, in contrast to those already available. The mean age of the sample (11.5 years) did not correlate to the mean age of children presenting with asthma – 6.9 years. The limitations of the study are recognised in relation to the under – 5s, a group for which the score has potentially the greatest impact. If a scoring system such as this is to be relevant clinically, it needs to be related to management of the condition. It is a straightforward tool that has potential, but further work obviously needs to be done.
Beckman AW, Sloan BK, Moore GP, Cordell WH, et al. 2002 “Should Parent be Present during Emergency Procedures on Children, and Who Should Make that Decision? A Survey of Emergency Physician and Nurse Attitudes.” Academic Emergency Medicine 9(2): 154–158
° C 2 0 0 2 Published by Elsevier Science Ltd.
Objectives: To ascertain the attitudes of emergency staff to the presence of parents during invasive procedures on their children, and who should make that decision. Methods: Survey of nursing and medical staff in 10 EDs, using six clinical scenarios with different procedures, asking whether a parent should be allowed to be present – peripheral IV access, laceration repair, lumber puncture, conscious sedation, and resuscitation – with and without likelihood of the child’s death. The survey also asked who should make the decision about the parent(s) to be present. Results: 645 staff responded – 306 doctors, and 339 nurses. Most staff were in favour of parents being present for simple procedures – IV access (91.3% doctors, 86.8% nurses) and repair of lacerations (93.3% and 89.6%). This reduced greatly for resuscitation, with nurses more likely to respond positively to the presence of parents. In resuscitation with the likelihood of death, 35.6% of doctors thought parents should be present in contrast to 54.3% of nurses. Most of the medical staff thought they alone should make the decision for parents’ presence (44%), in contrast to nurses who were split between the parents themselves deciding (24.3%), or it being a joint decision between nurse, doctor and parent (27.7%). Comment: I felt this study added little new to the body of evidence on relatives’ participation in patient care. This subject has been discussed and studied widely in both nursing and medical literature, although this is not reflected in this paper. The fear of litigation is always central to this debate, and again is raised here. In methodological terms, surveys are recognised as an effective method to ascertain attitudinal data, especially relating to sensitive subjects. The authors recognise the potential selection bias of those responding, but the most significant concern is the lack of information about the response rate. This is essential as an indicator of the validity of the tool, and although 645 responses seems high, we have no idea what percentage of the total mailed surveys this was.
Karpas A, Hennes H, Walsh-Kelly CM 2002 “Utilization of the Ottawa Ankle Rules by Nurses in a Paediatric Emergency Department” Academic Emergency Medicine 9(2): 130–133 Objectives: To determine the ability of paediatric ED nurses to apply Ottawa Ankle Rules and to determine if the rate of negative radiographs could be reduced by the implementation of OAR within current practice protocols. Methods: All children aged 5–17 years, meeting the criteria set out in the department’s own Practice Protocol (acute injury (< 48 h) and either ankle pain,
Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 1 7 7–1 7 8
177
Research reviews
swelling, deformity or decreased range of movement) were included in the study. Nurses trained in the OAR assessed the patient as either positive or negative, and then all patients were X-rayed. Results: 190 patients included, with a median age of 13 years. OAR was positive in 79% of patients, and 31 patients from the complete sample had fractures identified. 30 of the 31 were Ottawa positive. Use of the OAR instead of their current protocol would lead to a 21% reduction in X-rays. OAR was correctly interpreted by the nurses in 98% of cases, and most found them straightforward to apply (89%). A small sample of 20 patients used to measure interobserver reliability found 100% agreement. Comment: Again this study seems to add little to the body of evidence surrounding Ottawa rules, although it
178
Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 1 7 7 – 1 7 8
may just complete the picture, looking specifically at paediatric nurses. It is important for this department as it shows potential for a significant change in practice. The study itself is straightforward with explicit methodology and results sections. There is thorough discussion of the other studies relating to Ottawa Ankle rules, although these relate only to American research. Heather M. McClelland, RGN, MSc, Practice Development Facilitator, A&E Department, Leeds General Infirmary Great George Street Leeds, LS1, UK doi: 10.1054/aaen.2002.0362, available online at http://www.idealibrary.com on
° C 2 0 0 2 Published by Elsevier Science Ltd.