Predicting the need for topical anesthetic in the pediatric emergency department

Objective. To investigate the potential for pediatric emergency department (ED) triage nurses to apply a topical anesthetic tie, eutectic mixture of l ocal anesthetic) for intravenous catheter (IV) insertion. Methods. Prospective cross-sectional survey over a 2-month period, with pos t hoc application of internally developed prediction rules. Eligible patien ts were children presenting to the ED triage area of all urban children's h ospital. Results. A total of 2596 (86.7% of eligible children) had a triage nursing prediction performed. Nurse prediction of TV insertion had a sensitivity of 72% (95% CI: 66,78), a specificity of 90% (88,91), and a positive predicti ve value (PPV) of 49% (44,54). Objective factors such as high-risk medical history (chronic neurologic,hematologic, cardiac, endocrine, or gastrointes tinal illness) and high-risk chief complaint (gastrointestinal illness, ski n infection, and previous seizure) were incorporated into a predictive scor e used to predict IV insertion independently with a sensitivity of 33% (27, 39) and a PPV of 43% (44,54). Addition of the objective predictors to nursi ng prediction increased the sensitivity to 76% (70,81) with a PPV of 43% (3 8,47). Of the patients, 95% received an IV insertion less than or equal to 45 minutes after triage, 89% less than or equal to 60 minutes after triage, Of the TV insertions, 68% were placed in the dorsum of the hand. Conclusions. The prediction of an experienced triage nurse can identify mos t patients requiring an IV in a pediatric ED. Incorporation of objective cr iteria other than nursing prediction into this decision process can decreas e the amount of wasted product at the expense of less sensitive identificat ion. The timing of IV insertion in our ED would allow for full medication e ffect of the currently marketed topical anesthetics in the majority of ED p atients.