There is extensive literature on paediatric procedural sedation (PPS) and its clinical applicatio... more There is extensive literature on paediatric procedural sedation (PPS) and its clinical applications in emergency departments (EDs). While numerous guidance and policy documents exist from international bodies, there remains a lack of uniformity and consistency of PPS practices within EDs. PPS is now gaining traction in the UK and Ireland and this study aimed to describe existing PPS practices and identify any challenges to training and provision of ED-based PPS. A qualitative approach was employed to capture data through a focus group interview. Nine consultants in emergency medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group was audio-recorded, transcribed verbatim and analysed using Attride-Stirling's framework for thematic network analysis. The global theme 'The Future of PPS in EM-A UK and Ireland Perspective' emerged from the follo...
documentation in the paediatric population in the UK. We defined the audit standard as the minimu... more documentation in the paediatric population in the UK. We defined the audit standard as the minimum level of documentation required to satisfy Barts Health NHS trust and local policies. Results Projected results indicate safegaurding documentation may be inadequate in greater than 90% of cases. Conclusions Current standards of safeguarding documentation within our Major Trauma Centre will be significantly below the minimum standard required at a local level. This has implications nationally where analysis would be expected to achieve a similar outcome.
s day. He had occasional episodes of vacant stares and "wanted to go home", when was at home. He ... more s day. He had occasional episodes of vacant stares and "wanted to go home", when was at home. He had gastroenteritis after exposure to snails at nursery and was treated for otitis media by general practitioner. There was no history of fever or foreign travel. He was sleepy with normal neurology and an apthous ulcer over lower lip. He was managed as encephalitis and treated with acyclovir, ceftriaxone and clarithromycin. He had neutrophilia with normal lumbar puncture and viral PCR's. After a week of admission, he deteriorated with generalized pain, bedwetting, ataxia and upper motor neuron signs. MRI scan showed asymmetric, bilateral white matter changes suggestive of acute demyelinating encephalomyelitis (ADEM) or other viral encephalitis. Repeat lumbar puncture showed pleocytosis with neutophilia. Viral PCR's were negative. ASOT was raised. MRI with contrast showed 4 mm high signal focus behind C2 body and C2-3 disk. After completing a 10 day course of acyclovir, he was started on methyl prednisolone for ADEM and drastically improved. He was discharged after 3-4 days of the treatment with follow up.
documentation in the paediatric population in the UK. We defined the audit standard as the minimu... more documentation in the paediatric population in the UK. We defined the audit standard as the minimum level of documentation required to satisfy Barts Health NHS trust and local policies. Results Projected results indicate safegaurding documentation may be inadequate in greater than 90% of cases. Conclusions Current standards of safeguarding documentation within our Major Trauma Centre will be significantly below the minimum standard required at a local level. This has implications nationally where analysis would be expected to achieve a similar outcome.
Background The use of procedural sedation outside the operating theatre has increased in hospital... more Background The use of procedural sedation outside the operating theatre has increased in hospital settings and has gained popularity among non-anesthesiologists. Sedative agents used for procedural pain, although effective, also pose significant risks to the patient if used incorrectly. There is currently no universally accepted program of education for practitioners using or introducing procedural sedation into their practice. There is emerging literature identifying structured procedural sedation programs (PSPs) as a method of ensuring a standardized level of competency among staff and reducing risks to the patient. We hypothesize that programs of education for healthcare professionals using procedural sedation outside the operating theatre are beneficial in improving patient care, safety, practitioner competence and reducing adverse event rates. Methods/Design Electronic databases will be systematically searched for studies (randomized and non-randomized) examining the effectiven...
Children with sickle cell disease (SCD) frequently and unpredictably present to the emergency dep... more Children with sickle cell disease (SCD) frequently and unpredictably present to the emergency department (ED) with pain. The painful event is the hallmark acute clinical manifestation of SCD, characterised by sudden onset and is usually bony in origin. This study aims to establish if 1.5mcg/kg of intranasal fentanyl (INF; administered via a Mucosal Atomiser Device, MAD™) is non-inferior to intravenous morphine 0.1 mg/kg in severe SCD-associated pain. This study is a randomised,double-blind, double-dummy active control trial of children (weighing more than 10 kg) between 1 year and 21 years of age with severe painful sickle cell crisis. Severe pain is defined as rated seven or greater on a 0 to 10 age-appropriate numeric pain scale or equivalent. The trial will be conducted in a single tertiary urban paediatric ED in Dublin, Ireland. Each patient will receive a single active agent and a single placebo via the intravenous and intranasal routes. All clinical and research staff, patient...
ABSTRACT We will identify and evaluate all randomized controlled trials (RCTs) and quasi-randomiz... more ABSTRACT We will identify and evaluate all randomized controlled trials (RCTs) and quasi-randomized trials comparing the use of INF with any alternative analgesic interventions in children with acute pain, with respect to pain relief and the incidence of adverse events.
Background Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations o... more Background Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß2-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department. Methods/design This is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patien...
Acute non-traumatic limp is a common reason for children to present to the emergency department (... more Acute non-traumatic limp is a common reason for children to present to the emergency department (ED). There is a wide differential diagnosis for these patients, and there are certain serious conditions which cannot be missed. An evidence based guideline for the 'limping child' was designed and the impact of guideline implementation on a number of specific, predefined quantitative outcomes was assessed. An initial retrospective chart review over 3 months was carried out for all patients presenting with acute non-traumatic limp. Following guideline introduction and implementation, information was gathered prospectively for a further 3 month period. Data outcomes between the two patient groups were then compared. 110 patients met the criteria for inclusion: 56 pre-guideline and 54 post-guideline implementation. Baseline characteristics and diagnosis breakdown were similar in both groups. The rate of laboratory investigations was significantly reduced following guideline implementation (68% of patients pre-guideline, vs 48% post-guideline; (χ(2)), p=0.03). The number of x-rays carried out was similar in each group (74 pre- vs 67 post-guideline, mean 1.32 vs 1.28; (χ(2)), p=0.53). Length of time spent in the ED was significantly reduced following guideline implementation (median time 150 min pre- vs 82.5 min post-guideline; (χ(2)), p=0.04). No cases of serious pathology were missed using the guideline. Implementation of an evidence based clinical practice guideline for the limping child in a paediatric ED reduced the overall time patients spent in the ED, reduced the need for unnecessary laboratory investigations and ensured that appropriate investigations were carried out on an individual patient basis.
Aims As medicine becomes more complex, the need for effective communication increases. Changes in... more Aims As medicine becomes more complex, the need for effective communication increases. Changes in acute paediatrics have reduced opportunities for information transfer, with more Paediatric Assessment Units (PAU's) attendances and shorter inpatient stays. However parents still expect clinicians to explain the diagnosis and management. We therefore explored factors predicting effective information transfer to parents of children in a PAU. Methods In a PAU serving 22,000 patients/yr, doctor-parent interactions were observed after consent, noting the child's demographics, presentation variables and information covered. Parents were interviewed 2-4 hours later exploring what they remembered and how their perceptions of the earlier interaction. The study had been approved by the local ethics committee. Results 20 patients, attending between 0900 and 1700 on weekdays were selected. Those not expected to stay after their consultation were excluded. Mean patient age was 7.75 yrs (range 10 months-15 years). 75% were boys. Mean number of items of information was 6.6 (range 4-10) per patient. Parents recalled a mean of 86% of these items (range 33-100%). There was no correlation between numbers of items covered and the number remembered, nor with demographics, interaction time, perceived anxiety or departmental noise. Those with better than mean recall more often had children who had suffered an injury rather than an illness, had overall lower illness severity (PEWS mean 0.91 vs 1.67; p = 0.08) and had shorter overall waiting times before being seen (2.5 vs 3.9 hours; p = 0.08) than those in the lower recall group. Conclusions Despite the stressful PAU environment, we found good recall of given information in our sample group. Unexpectedly, better recall was unrelated to consultation time or items covered, but seemed better with traumatic presentations, when the child was less unwell and with shorter waits. Parents may more readily assimilate information in relation to more obvious or external conditions and when they are less stressed. These findings suggest extra consideration is placed upon information giving when the child is particularly unwell or has an illness rather than trauma. Prevalence anD ManageMent of acute Pain in chilDren attenDing eMergency DePartMentS in irelanD via aMbulance
We sought to review the clinical outcomes of patients referred to our emergency department (ED) v... more We sought to review the clinical outcomes of patients referred to our emergency department (ED) vaccination service for children with a history of allergy or anaphylaxis or in whom there was a concern of a significant adverse reaction. Methods: This was a prospective observational cohort study set in an urban tertiary Paediatric ED. All attendances for any childhood vaccination for a 5-year period (from January 1, 2006 to December 31, 2010) were included. Our primary outcome measure was any adverse reaction as a result of the vaccine administered.
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, Jan 29, 2015
Pain is the most common symptom in the emergency setting and remains one of the most challenging ... more Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency amb...
There is extensive literature on paediatric procedural sedation (PPS) and its clinical applicatio... more There is extensive literature on paediatric procedural sedation (PPS) and its clinical applications in emergency departments (EDs). While numerous guidance and policy documents exist from international bodies, there remains a lack of uniformity and consistency of PPS practices within EDs. PPS is now gaining traction in the UK and Ireland and this study aimed to describe existing PPS practices and identify any challenges to training and provision of ED-based PPS. A qualitative approach was employed to capture data through a focus group interview. Nine consultants in emergency medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group was audio-recorded, transcribed verbatim and analysed using Attride-Stirling's framework for thematic network analysis. The global theme 'The Future of PPS in EM-A UK and Ireland Perspective' emerged from the follo...
documentation in the paediatric population in the UK. We defined the audit standard as the minimu... more documentation in the paediatric population in the UK. We defined the audit standard as the minimum level of documentation required to satisfy Barts Health NHS trust and local policies. Results Projected results indicate safegaurding documentation may be inadequate in greater than 90% of cases. Conclusions Current standards of safeguarding documentation within our Major Trauma Centre will be significantly below the minimum standard required at a local level. This has implications nationally where analysis would be expected to achieve a similar outcome.
s day. He had occasional episodes of vacant stares and "wanted to go home", when was at home. He ... more s day. He had occasional episodes of vacant stares and "wanted to go home", when was at home. He had gastroenteritis after exposure to snails at nursery and was treated for otitis media by general practitioner. There was no history of fever or foreign travel. He was sleepy with normal neurology and an apthous ulcer over lower lip. He was managed as encephalitis and treated with acyclovir, ceftriaxone and clarithromycin. He had neutrophilia with normal lumbar puncture and viral PCR's. After a week of admission, he deteriorated with generalized pain, bedwetting, ataxia and upper motor neuron signs. MRI scan showed asymmetric, bilateral white matter changes suggestive of acute demyelinating encephalomyelitis (ADEM) or other viral encephalitis. Repeat lumbar puncture showed pleocytosis with neutophilia. Viral PCR's were negative. ASOT was raised. MRI with contrast showed 4 mm high signal focus behind C2 body and C2-3 disk. After completing a 10 day course of acyclovir, he was started on methyl prednisolone for ADEM and drastically improved. He was discharged after 3-4 days of the treatment with follow up.
documentation in the paediatric population in the UK. We defined the audit standard as the minimu... more documentation in the paediatric population in the UK. We defined the audit standard as the minimum level of documentation required to satisfy Barts Health NHS trust and local policies. Results Projected results indicate safegaurding documentation may be inadequate in greater than 90% of cases. Conclusions Current standards of safeguarding documentation within our Major Trauma Centre will be significantly below the minimum standard required at a local level. This has implications nationally where analysis would be expected to achieve a similar outcome.
Background The use of procedural sedation outside the operating theatre has increased in hospital... more Background The use of procedural sedation outside the operating theatre has increased in hospital settings and has gained popularity among non-anesthesiologists. Sedative agents used for procedural pain, although effective, also pose significant risks to the patient if used incorrectly. There is currently no universally accepted program of education for practitioners using or introducing procedural sedation into their practice. There is emerging literature identifying structured procedural sedation programs (PSPs) as a method of ensuring a standardized level of competency among staff and reducing risks to the patient. We hypothesize that programs of education for healthcare professionals using procedural sedation outside the operating theatre are beneficial in improving patient care, safety, practitioner competence and reducing adverse event rates. Methods/Design Electronic databases will be systematically searched for studies (randomized and non-randomized) examining the effectiven...
Children with sickle cell disease (SCD) frequently and unpredictably present to the emergency dep... more Children with sickle cell disease (SCD) frequently and unpredictably present to the emergency department (ED) with pain. The painful event is the hallmark acute clinical manifestation of SCD, characterised by sudden onset and is usually bony in origin. This study aims to establish if 1.5mcg/kg of intranasal fentanyl (INF; administered via a Mucosal Atomiser Device, MAD™) is non-inferior to intravenous morphine 0.1 mg/kg in severe SCD-associated pain. This study is a randomised,double-blind, double-dummy active control trial of children (weighing more than 10 kg) between 1 year and 21 years of age with severe painful sickle cell crisis. Severe pain is defined as rated seven or greater on a 0 to 10 age-appropriate numeric pain scale or equivalent. The trial will be conducted in a single tertiary urban paediatric ED in Dublin, Ireland. Each patient will receive a single active agent and a single placebo via the intravenous and intranasal routes. All clinical and research staff, patient...
ABSTRACT We will identify and evaluate all randomized controlled trials (RCTs) and quasi-randomiz... more ABSTRACT We will identify and evaluate all randomized controlled trials (RCTs) and quasi-randomized trials comparing the use of INF with any alternative analgesic interventions in children with acute pain, with respect to pain relief and the incidence of adverse events.
Background Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations o... more Background Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß2-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department. Methods/design This is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patien...
Acute non-traumatic limp is a common reason for children to present to the emergency department (... more Acute non-traumatic limp is a common reason for children to present to the emergency department (ED). There is a wide differential diagnosis for these patients, and there are certain serious conditions which cannot be missed. An evidence based guideline for the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;limping child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; was designed and the impact of guideline implementation on a number of specific, predefined quantitative outcomes was assessed. An initial retrospective chart review over 3 months was carried out for all patients presenting with acute non-traumatic limp. Following guideline introduction and implementation, information was gathered prospectively for a further 3 month period. Data outcomes between the two patient groups were then compared. 110 patients met the criteria for inclusion: 56 pre-guideline and 54 post-guideline implementation. Baseline characteristics and diagnosis breakdown were similar in both groups. The rate of laboratory investigations was significantly reduced following guideline implementation (68% of patients pre-guideline, vs 48% post-guideline; (χ(2)), p=0.03). The number of x-rays carried out was similar in each group (74 pre- vs 67 post-guideline, mean 1.32 vs 1.28; (χ(2)), p=0.53). Length of time spent in the ED was significantly reduced following guideline implementation (median time 150 min pre- vs 82.5 min post-guideline; (χ(2)), p=0.04). No cases of serious pathology were missed using the guideline. Implementation of an evidence based clinical practice guideline for the limping child in a paediatric ED reduced the overall time patients spent in the ED, reduced the need for unnecessary laboratory investigations and ensured that appropriate investigations were carried out on an individual patient basis.
Aims As medicine becomes more complex, the need for effective communication increases. Changes in... more Aims As medicine becomes more complex, the need for effective communication increases. Changes in acute paediatrics have reduced opportunities for information transfer, with more Paediatric Assessment Units (PAU's) attendances and shorter inpatient stays. However parents still expect clinicians to explain the diagnosis and management. We therefore explored factors predicting effective information transfer to parents of children in a PAU. Methods In a PAU serving 22,000 patients/yr, doctor-parent interactions were observed after consent, noting the child's demographics, presentation variables and information covered. Parents were interviewed 2-4 hours later exploring what they remembered and how their perceptions of the earlier interaction. The study had been approved by the local ethics committee. Results 20 patients, attending between 0900 and 1700 on weekdays were selected. Those not expected to stay after their consultation were excluded. Mean patient age was 7.75 yrs (range 10 months-15 years). 75% were boys. Mean number of items of information was 6.6 (range 4-10) per patient. Parents recalled a mean of 86% of these items (range 33-100%). There was no correlation between numbers of items covered and the number remembered, nor with demographics, interaction time, perceived anxiety or departmental noise. Those with better than mean recall more often had children who had suffered an injury rather than an illness, had overall lower illness severity (PEWS mean 0.91 vs 1.67; p = 0.08) and had shorter overall waiting times before being seen (2.5 vs 3.9 hours; p = 0.08) than those in the lower recall group. Conclusions Despite the stressful PAU environment, we found good recall of given information in our sample group. Unexpectedly, better recall was unrelated to consultation time or items covered, but seemed better with traumatic presentations, when the child was less unwell and with shorter waits. Parents may more readily assimilate information in relation to more obvious or external conditions and when they are less stressed. These findings suggest extra consideration is placed upon information giving when the child is particularly unwell or has an illness rather than trauma. Prevalence anD ManageMent of acute Pain in chilDren attenDing eMergency DePartMentS in irelanD via aMbulance
We sought to review the clinical outcomes of patients referred to our emergency department (ED) v... more We sought to review the clinical outcomes of patients referred to our emergency department (ED) vaccination service for children with a history of allergy or anaphylaxis or in whom there was a concern of a significant adverse reaction. Methods: This was a prospective observational cohort study set in an urban tertiary Paediatric ED. All attendances for any childhood vaccination for a 5-year period (from January 1, 2006 to December 31, 2010) were included. Our primary outcome measure was any adverse reaction as a result of the vaccine administered.
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, Jan 29, 2015
Pain is the most common symptom in the emergency setting and remains one of the most challenging ... more Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency amb...
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Papers by Siobhán McCoy