Paediatric emergency research in Canada: Using the iterative loop of research as a paradigm for advancing the field

Throughout the 1980s in Canada, paediatric emergency medicine was gaining momentum as a new subspecialty. This occurred because a growing number of physicians were dedicating themselves exclusively to the practice of paediatric emergency medicine and many saw it as an attractive career choice. At the same time, fellowship training programs for paediatric emergency medicine were developed. An interesting phenomenon occured as clinicians dedicated themselves to this area of clinical practice on a full-time basis; they started questioning why certain approaches were being employed for the management of the patients they were assessing. It was apparent that much of standard clinical practice had been established by other subspecialists who did not practice in the paediatric emergency department (ED). Hence, the patient population on whom these approaches had been developed were different than the ones being assessed by paediatric emergency physicians. One early example of this is the management of the febrile infant. Up until the early 1990s, hospital-based neonatologists or inpatient general paediatricians provided the recommendations for the management of febrile infants in emergency rooms. Their view was that febrile infants had a high risk for serious and overwhelming sepsis. Hence, many paediatric EDs followed a policy of complete septic workups, empirical coverage with antibiotics and mandatory hospitalization. However, clinicians in the paediatric ED observed that the large majority of their children had viral illnesses and did very well with outpatient management. They started wondering whether a diagnostic protocol could be developed that would identify infants at low risk for serious bacterial infection. This led to a series of paediatric emergency-based studies that examined the management of infants with fever. As a result, most paediatric EDs now employ a selective diagnostic protocol so that not all febrile infants younger than three months are automatically admitted to hospital and treated with intravenous antibiotics. This is a key example of why research must occur in the context in which patients are being managed and why clinicians who care for the patients in those settings must be involved with the design and implementation of the studies. Over the last two decades, many clinical studies conducted in the paediatric ED have been spawned by asking important and relevant clinical questions. Canadian researchers have played a key role in this area and are arguably world leaders in many areas of paediatric emergency medicine research. The reasons for this might be because clinical research may have fewer impediments in Canada; because there are dedicated research funds in Ontario for emergency medicine research, which allows for more than one fledgling research career to develop; and because there is a tremendous history of cohesiveness between emergency departments, allowing collaborative, multicentre research to flourish in Canada. Pediatric Emergency Research Canada (PERC) was formed in 1995 with the aim of developing collaborative, multicentre research and mentoring young, emerging researchers. The framework for research was the iterative loop of research as described by Tugwell et al (Figure 1) (1,2). In the accompanying “abstract summaries and commentaries” we have chosen ten Canadian paediatric emergency research studies from the past two years. Each study forms part of the iterative loop of research. The iterative loop of research. Adapted from references 1 and 2 Papers were selected according to quality, interest, impact and thematic area. We decided to extend our MEDLINE (1966 to February 2004) search to papers covering the years 2002 and 2003 so as not to miss key papers that made up part of a research theme. Search terms included but were not limited to: research, emergency, critical care, Canada, paediatric, child, teen and elementary school. A full search strategy is available on request to the authors. In addition, we identified Canadian paediatric emergency medicine researchers and performed an author search in PubMed (1966 to February 2004) to incorporate more research; this had the added benefit of making sure we covered the range of geographic areas in the country. This search obtained 128 further articles. Ten papers were selected in the areas of bronchiolitis research, other respiratory work and injury. These three areas were selected because of their importance in paediatric emergency room visits in Canada. This report also draws attention to the value of decision methodology and the high quality and breadth of research being done by Canadians in these three areas of paediatric ED care. Thanks to Ellen Crumley for performing the literature search.

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