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 local anesthetic) for intravenous catheter (IV) insertion. Methods. Prospective cross-sectional survey over a 2-month period, with post hoc application of internally developed prediction rules. Eligible patients were children presenting to the ED triage area of all urban children's hospital. 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 predictive value (PPV) of 49% (44,54). Objective factors such as high-risk medical history (chronic neurologic,hematologic, cardiac, endocrine, or gastrointestinal illness) and high-risk chief complaint (gastrointestinal illness, skin infection, and previous seizure) were incorporated into a predictive score 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 nursing prediction increased the sensitivity to 76% (70,81) with a PPV of 43% (38,47). 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 most patients requiring an IV in a pediatric ED. Incorporation of objective criteria other than nursing prediction into this decision process can decrease the amount of wasted product at the expense of less sensitive identification. The timing of IV insertion in our ED would allow for full medication effect of the currently marketed topical anesthetics in the majority of ED patients.