Paediatrics (RCH) - Theses
Permanent URI for this collection
Search Results
1 - 2 of 2
-
ItemUrinary tract infection in children – changing the management paradigm so more children can be treated at home( 2023-07)Urinary tract infections (UTI) are a common reason for paediatric emergency department (ED) presentations. Although most children are successfully treated with oral antibiotics, approximately one-third receive intravenous (IV) antibiotics and hospital admission. However, there is limited evidence supporting these decisions, and consequently an opportunity to approach antibiotic use differently to potentially treat more children out of hospital. Guidelines recommend most patients can be treated with oral antibiotics, but the studies used to support these guidelines excluded several cohorts. The aims of this thesis were to investigate current UTI management, particularly use of antibiotics and Hospital-in-the-Home (HITH), to define which children actually need IV antibiotics, and to explore the feasibility of using shorter IV antibiotic durations. The initial study focused on use of HITH for IV antibiotics for UTI. The study found that 90% of patients successfully completed treatment without readmission to hospital, and none became severely unwell at home. However, HITH was underused, with only 8% of patients on IV antibiotics using this model. The study supports home IV antibiotics for selected UTI management. The next study used a wider lens, examining all current UTI management in ED and found little variation in antibiotic route, choice, and duration for lower UTIs and uncomplicated upper UTIs. However, complicated upper UTIs, where there is less evidence, showed more variation. No single feature reliably predicted use of IV antibiotics, but multiple complicating factors were associated with their initiation, suggesting they represent ‘red flags’ for clinicians. In the following study, clinicians were asked why they used IV antibiotics for UTI and admitted children to hospital. Although they had defined reasons for using IV, objective clinical evidence did not always support their reasons. The study hypothesised that multiple features lead to the decision to prescribe IV antibiotics and that these features may group together. Given the finding that multiple but not always the same features led to IV antibiotic initiation, the next study aimed to develop a clinical score to determine which children need IV antibiotics. The Melbourne RUPERT score was successfully developed and tested on patients with confirmed and probable UTI. Using six clinical features, the score is straightforward, easily attainable, reproducible and aids consistent stratification of patients to determine route of initial antibiotic treatment. Finally, using outcomes and learnings from the preceding studies, a randomised control trial protocol was developed. This trial aims to investigate whether an ultra-short IV duration (1 day) is non-inferior to the standard duration for children requiring IV antibiotics. If a single daily dose of IV antibiotics followed by oral antibiotics proves sufficient, patients could be discharged home from the ED on oral antibiotics, eliminating the need for hospital admission. In questioning whether more children with UTI could be treated out of hospital, this thesis found that indeed they can, through delivering IV antibiotics at home, treating more children with oral antibiotics, and investigating an identified practice of earlier switch from IV to oral. This has the potential for major impacts on patient care and hospital sustainability.
-
ItemNovel technology for the measurement of newborn and infant heart rate( 2017)Background: Monitoring heart rate in newborns and infants is crucially important in guiding resuscitation and medical care. Established methods for heart rate assessment of these children have inherent drawbacks. In recent years, novel methods for assessing neonatal and infant heart rate have been developed, with varying levels of evaluation conducted. Digital stethoscopes may provide a better means of heart rate assessment for newborns and infants. Aim: The aim of this thesis was to comprehensively review existing established and novel technologies used to monitor newborn and infant heart rate, and compare new digital stethoscope technology with the gold standard, electrocardiogram (ECG). Methods: This thesis (a) outlines the definition and importance of heart rate in medicine, presented in the context of a review of cardiac anatomy and physiology relevant to understanding this vital sign and aspects of its measurement in neonates and infants; (b) presents a narrative review of established methods for monitoring heart rate; (c) expands the scope of this review from established to emerging methods for monitoring heart rate with a systematic literature review of novel methods for newborn and infant heart rate assessment; (d) describes original research using a prototype digital stethoscope attached to a smart device containing software for detecting and displaying heart rate in real-time that was conducted on infants in the neonatal intensive and special care setting, as well in the delivery room setting using an improved version of the device and software. Results: A review of the literature analysing methods of assessing neonatal and infant heart rate found strengths as well as significant weaknesses in the various methods in clinical use or in development. In the neonatal unit, a prototype digital stethoscope and smartphone device for assessing heart rate had a mean difference (±2 standard deviations) of 7.4 (48.5) beats per minute (bpm) when compared to the gold standard of electrocardiography. The mean (interquartile range) time to first digital stethoscope heart rate display was 4.8 (1 to 7) seconds, and the device failed in 12.3% of use attempts. Repeating the comparison in the delivery room setting using an updated algorithm and new hardware, Bland-Altman analysis revealed a smaller mean difference (±2 standard deviations) between the digital stethoscope and electrocardiography of 0.2 (-18 to +18) bpm including crying periods (Figure 23), and 1.0 (-11 to +12) bpm excluding crying periods. The improved digital stethoscope took a median (interquartile range) of 7 (5 to 11.5) seconds after application to display a heart rate. It failed to detect heart rate in 37% of cases, all of which were in crying infants. Conclusion: A digital stethoscope and smart device with software can rapidly detect neonatal and infant heart rate. In the delivery room, device failure primarily occurred during infant crying, with improved accuracy during non-crying periods.