OBJECTIVES:To examine the factors influencing paediatric fever management practices among Australian Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). METHODS:Cross-sectional survey of doctors and nurses across 22 Australian EDs. The survey assessed 8 of the 12 domains from the TDF using 13 questionnaire items. RESULTS:A total of 472 participants [275 (58.3%) doctors, 197 (41.7%) nurses] completed the survey (overall response rate 57.7%). Of these, 286/470 (60.9%, 95% CI: 56.4%-65.2%) were familiar with clinical practice recommendations on antipyretic administration for paediatric fever (TDF domain: Knowledge). Similar proportions indicated they had been trained to ensure antipyretic use solely when febrile children appear distressed [TDF domain: Skills; 285/469 (60.8%, 95% CI: 56.3%-65.1%)] and agreed that only administering antipyretics to febrile children who seemed distressed aligned with their professional responsibilities as ED clinicians [TDF domain: Social/Professional Role and Identity; 294/467 (63.0%, 95% CI: 58.5%-67.2%)]. More than half (268/467, 57.4%, 95% CI: 52.8%-61.8%) of participants felt pressured by parents/caregivers to give antipyretics for fever reduction, irrespective of the child's discomfort level [TDF domain: Social Influences]. Just under one-third of participants (137/470, 29.1%, 95% CI: 25.2%-33.4%) aimed to reduce fever before discharge (TDF domain: Goals). CONCLUSIONS:Overall, ED clinicians showed moderate knowledge, training, and agreement with clinical practice recommendations on antipyretic administration for paediatric fever. Notably, more than half of the respondents surveyed felt pressured by parents/caregivers to use antipyretics outside of guideline recommendations. Our findings highlight the significant emotion attached to fever management and the need for clinicians to foster trust and provide tailored evidence-based information to families.

BACKGROUND:High-flow nasal cannula (HFNC) in bronchiolitis is widely used beyond guideline recommendations. This study developed targeted, theory-informed implementation strategies to improve appropriate HFNC use in regional and rural emergency departments (EDs), to be evaluated in a cluster randomised controlled trial (cRCT). METHODS:A 3-phase process mapping and implementation science approach was embedded in a clinician co-design study involving 12 senior clinicians (5 nurses, 7 doctors) from Australian regional and rural EDs. International and Australian literature informed discussions. Barriers were coded using the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR 2.0) with strategy co-design guided by CFIR-ERIC and TDF-BCT linkages. RESULTS:Five HFNC decision nodes were identified: assessment of hypoxaemia, low-flow oxygen trial and reassessment, escalation to HFNC, weaning and cessation, and escalation of care. Behavioural factors included fear of deterioration, limited confidence in respiratory assessment, and norms favouring early escalation. Contextual factors included limited paediatric expertise, staff turnover, and unclear de-escalation. Findings informed strategies including targeted education, clinical pathways and audit and feedback. CONCLUSIONS:Process mapping identified behavioural and contextual drivers of inappropriate HFNC use informing implementation strategies and offering a practical, scalable approach to translating guidelines into routine ED practice. IMPACT:This study identifies behavioural and contextual drivers of inappropriate high-flow nasal cannula use in infants with bronchiolitis across regional and rural emergency departments. Using structured process mapping and clinician co-design, we mapped decision-making at key clinical nodes and developed targeted, theory-informed implementation strategies to address identified barriers. Findings directly informed educational content and implementation strategies being evaluated in a cluster randomised controlled trial across 30 regional and rural hospitals. This work provides a practical, scalable framework for translating guidelines into routine emergency department practice, with relevance beyond bronchiolitis to other high-variation clinical behaviours in acute care.

BACKGROUND:In 2017, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network conducted a cluster randomised controlled trial (cRCT) at 26 Australian and New Zealand hospitals to improve bronchiolitis care. Findings demonstrated that targeted interventions significantly improved adherence with five evidence-based low-value bronchiolitis practices (no chest radiography, salbutamol, glucocorticoids, antibiotics and epinephrine) in the first 24 hours of hospitalisation (adjusted risk difference, 14.1%; 95% CI: 6.5% to 21.7%; p<0.001). During the intervention year (2017), intervention hospital (n=13) compliance was 85.1% (95% CI: 82.6% to 89.7%). This study aimed to determine if improvements in bronchiolitis management were sustained at intervention hospitals 2 years post-trial completion. METHODS:International, multicentre follow-up study of hospitals in Australia and New Zealand that participated in a cRCT of de-implementation of low-value bronchiolitis practices, 1 year (2018) and 2 years (2019) post-trial completion, obtained retrospectively from medical audits. Sustainability was defined a priori as no more than a <7% decrease to any level of improvement in adherence for all five low-value practices (composite outcome) from the cRCT intervention year. RESULTS:Of the 26 hospitals, 11 intervention and 10 control hospitals agreed to participate in the follow-up study. Data were collected on 3299 infants with bronchiolitis 1 year (intervention and control hospitals) and 1689 infants 2 years post-trial (intervention hospitals). Adherence with no use of the five low-value practices 2 years post-trial completion was 80.9% (adjusted predicted adherence, 80.8%, 95% CI: 77.4% to 84.2%; estimated risk difference from cRCT outcome -3.9%, 95% CI: -8.6% to 0.8%) at intervention hospitals, fulfilling the a priori definition of sustainability. DISCUSSION:Targeted interventions, delivered over one bronchiolitis season, resulted in sustained improvements in bronchiolitis management in infants 2 years later. This follow-up study provides evidence for sustainability in de-implementing low-value care in bronchiolitis management. TRIAL REGISTRATION DETAILS:Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Bronchiolitis is the leading cause of hospital presentation and admission for infants in Australasia. We aimed to synthesise current evidence on the effect of discharge criteria for infants (aged < 12 months) who are presenting to or are admitted to hospital with bronchiolitis, to inform a binational guideline recommendation update. Systematic searches were conducted on MEDLINE, EMBASE, PubMed, Cochrane Library and CINAHL (last search 19 February 2025) for non-randomised studies evaluating hospital discharge criteria in bronchiolitis. The primary outcomes were length of stay (LOS) and readmission rates. The risk of bias (ROBINS-I) and certainty of the evidence (GRADE) were appraised, and findings were narratively synthesised. GRADE evidence-to-decision methodology, expert consensus voting and interest-holder consultation were used to finalise the recommendation update. Two retrospective observational studies were included (N = 2697) (low to very low quality), reporting on unique discharge criteria. In both studies, use of the discharge criteria was associated with a significant reduction in LOS relative to alternative protocols. There was no significant difference in readmission rates observed in either study. There was low to very low certainty evidence across outcomes due to risk of bias, indirectness and imprecision. The review findings informed a recommendation update for safe discharge criteria in the 2025 Australasian Bronchiolitis Guideline update. Updated, prescriptive discharge criteria and flow chart were developed, covering clinical stability, oxygen saturation/support, feeding difficulties, caregiver confidence and education on deterioration, social factors and follow-up. The revised criteria provide clinicians with increased certainty in decision-making in bronchiolitis, albeit with further research needed.

BACKGROUND:The 2017 Paediatric Research in Emergency Departments International Collaborative (PREDICT) Bronchiolitis Knowledge Translation (KT) Study, a cluster randomised trial in 26 Australasian hospitals, found targeted interventions provided over one bronchiolitis season effectively de-implemented five low-value practices (salbutamol, glucocorticoids, chest radiography, antibiotics and epinephrine) by 14.1% (adjusted risk difference, 95% CI 6.5% to 21.7%; p<0.001). A 2-year follow-up study found de-implementation was sustained. This process evaluation aimed to identify factors that influenced sustainability of de-implementation of these five low-value practices in PREDICT Bronchiolitis KT Study intervention hospitals and examine fidelity and/or adaptation of the targeted interventions over 4 years post intervention delivery (sustainment). METHODS:Semistructured qualitative interviews were conducted, over 2021 and 2022, with a purposive sample of emergency department (ED) and paediatric inpatient clinicians. Data were analysed thematically into facilitators and barriers using the Consolidated Framework for Sustainability Constructs in Healthcare (CFSCH). The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies was used to explore fidelity and adaptation. RESULTS:50 clinicians (nurses: n=26; doctors: n=24) from 12 intervention hospitals were interviewed. Eight themes were identified and mapped to three CFSCH domains: (1) organisational setting; (2) initiative design and delivery and (3) people involved. Facilitators were a culture of evidence-based practice, ongoing multimodal education, strong clinical leadership as unofficial champions and the previous effectiveness of the PREDICT Bronchiolitis KT Study interventions. Barriers were lack of paediatric trained ED staff, assumptions by senior clinicians that junior doctors can provide evidence-based bronchiolitis management, bronchiolitis not a current improvement priority and lack of bronchiolitis education sessions. Use of the targeted interventions reduced over time and, when used, was adapted locally. CONCLUSION:This study provides insights into factors influencing the sustainability of de-implementation of low-value care in acute care settings. Fostering an evidence-based practice culture, supported by senior leadership and ongoing multimodal education, supports sustainability of improvements in this setting. TRIAL REGISTRATION NUMBER:Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

AIM:To synthesize evidence on the clinical utility of chest X-ray (CXR), laboratory and viral testing in infants with bronchiolitis, including in subgroups with unexpected deterioration or intensive care unit (ICU) admission (severe disease). METHODS:An overview of reviews and systematic review of primary studies were conducted. MEDLINE, EMBASE, PubMed, Cochrane Library, CINAHL were searched (2000 to 19/02/25) for systematic reviews and primary studies evaluating investigations in bronchiolitis management at hospital. Risk of bias (ROBIS, NOS) and certainty of evidence (GRADE) were evaluated. Results were narratively synthesized. RESULTS:Thirty/28,602 publications were included (N = 23,605 infants, N = 59 studies; three systematic reviews [32 studies], 27 observational studies). In typical bronchiolitis: (1) CXR demonstrated insufficient diagnostic accuracy, increased antibiotic prescriptions, and was not associated with ICU length of stay (LOS) (very low quality of evidence); (2) Laboratory test results were not associated with mortality, and were inconsistent for LOS (very low quality of evidence); (3) Viral testing results were not associated with ICU admission, and were inconsistent for hospitalization (very low quality of evidence). In infants with severe disease: serum procalcitonin and c-reactive protein testing at ICU admission had some benefit in predicting bacterial co-infection and/or pneumonia (very low quality evidence). Evidence was lacking for infants with unexpected deterioration. CONCLUSIONS:Very low certainty evidence indicates that CXR, laboratory and viral testing may have limited clinical utility in individual management of typical bronchiolitis, and should not be routinely used in this group. Further research is required in subgroups with unexpected deterioration or severe disease.

ABSTRACT Background The Australasian Bronchiolitis Guideline (ABG) provides evidence‐based recommendations for managing one of the most frequent reasons for infant hospitalisation. As traditional guidelines age, they suffer from lack of relevance when new evidence is available but not incorporated. To address this limitation a guideline, or parts thereof, can be converted into a “living” mode, where new evidence is regularly incorporated into recommendations, enabling faster translation to practice. This study aimed to prioritise ABG recommendations for conversion to a living mode. Method Members of the 2025 ABG Guideline Advisory Group and Guideline Development Committee were invited to participate in an online, modified Delphi study. Panellists ranked 38 recommendations as low, medium, or high priority for conversion to a living mode across two rounds. A consensus threshold of ≥ 75% agreement was used. Data collection ceased once consensus was reached on ≥ 4 recommendations for conversion. Results Twenty‐five of 29 (86%) experts responded in round one and 20/25 (80%) in round two. Panel diversity was maintained throughout voting rounds. At round one, consensus was reached to convert three recommendations to a living format and 11/38 recommendations were excluded. At round two, one additional recommendation was prioritised for conversion and 16/24 were excluded. Consensus was not reached on seven recommendations. Conclusion Four key management recommendations will be converted to a living mode: high‐flow therapy, combined glucocorticoid/adrenaline therapy, oxygen saturation targets, and chest X‐ray in intensive care settings. These recommendations will be regularly updated as new evidence becomes available, supporting a more rapid translation to clinical practice.

To synthesise evidence on the efficacy and safety of azithromycin in infants presenting or admitted to hospital with bronchiolitis in an updated systematic review. MEDLINE, EMBASE, PubMed, Cochrane Library and CINAHL were searched (last search 19/02/25) for trials evaluating the efficacy and safety of azithromycin in infants with bronchiolitis. Primary outcomes were hospital length of stay (LOS), intensive care unit (ICU) admission and mechanical ventilation. Risk of bias (RoB2) and the certainty of evidence (GRADE) were evaluated. Data were pooled using fixed-effect meta-analyses. Six RCTs and one pilot RCT were included ( N  = 867). Azithromycin was associated with a significantly shorter LOS in infants with bronchiolitis, compared to placebo (MD –0.30 days (95% CI –0.58 to –0.02), p  = 0.04; low certainty). However, statistical significance was lost in sensitivity analyses. There was no significant difference between the azithromycin and placebo groups in rates of adverse events, ICU admission, mechanical ventilation, readmission within 6 months and in most evaluations of persistent respiratory symptoms. The evidence certainty was low to very low across outcomes. There is insufficient evidence to support the use of azithromycin as part of hospital care for infants with bronchiolitis, with inconclusive findings on its role in reducing LOS. PROSPERO registration number: CRD42023463917

Bronchiolitis is the leading cause of hospitalisation in infants under one year. While evidence-based guidelines exist, including the updated Australasian Bronchiolitis Guidelines (2025), variations in care persist. Improving care in regional and rural hospitals is challenging due to limited access to paediatric expertise and evidence-based resources, contributing to continued use of low-value interventions. This mixed methods study will use a human-centred design approach to co-design and evaluate the usability of the Regional and Rural Translation Bronchiolitis (RART-Bronch) platform, an interactive online tool targeted at non-metropolitan settings. The platform will feature bronchiolitis educational resources, implementation support, a benchmarking and feedback tool, and family education materials. Participants will be regional and rural clinicians and parents of infants hospitalised with bronchiolitis in these settings. Data will be collected through co-design meetings, usability surveys, semi-structured interviews, and think aloud methods. Engagement with the co-design process will also be evaluated. We will develop a user-friendly, evidence-based platform specific to regional and rural contexts that supports bronchiolitis guideline adherence and enhances clinical decision-making. Effectiveness will be evaluated in a future cluster randomised controlled trial and may inform future implementation strategies for improving care, quality and equity across regional and rural healthcare.

OBJECTIVES:To examine variation in practice and adherence to international clinical guidelines for the management of fever among Australian Emergency Department (ED) clinicians. METHODS:Cross-sectional survey across 22 Australian EDs. Clinical vignettes were used to determine compliance with international best practice guidelines (use of antipyretic monotherapy to alleviate fever-associated child distress) for paediatric fever treatment. Comparisons were made between specialist paediatric EDs and general (non-specialist paediatric) EDs, and between medical and nursing staff. RESULTS:Of 539 survey respondents (300 doctors, 239 nurses; overall response rate 65.9%), only 9.3% (50/539, 95% confidence interval [CI] 7.1%-12.0%) adhered to evidence-based practice guidelines. Specialist paediatric ED clinicians demonstrated less than half the adherence of those from general EDs (5.4% [11/204] vs. 12.4% [38/307], difference -7.0%, 95% CI -11.7% to -1.9%). In a febrile settled child with normal hydration, the proportion of respondents who opted for antipyretics more than doubled in the context of elevated vital signs (40.4% [218/539] vs. 83.1% [44/539], difference -42.7%, 95% CI -46.8% to -38.2%). Nearly half of respondents (239/539, 46.8%, 95% CI 42.4%-51.2%) endorsed giving combined antipyretic therapy. In a febrile settled child, most participants would give antipyretics for temperature reduction (453/539, 84.0%, 95% CI 80.7%-86.9%) and for decreased fluid intake (468/539, 87.5%, 95% CI 84.4%-90.0%). Over one-third (192/539, 36.0%, 95% CI 32.1%-40.2%) recommended using antipyretics for febrile convulsion prevention during the current illness. CONCLUSIONS:Fewer than 10% of Australian ED clinicians self-report practice consistent with international consensus recommendations for paediatric fever management.

BACKGROUND:Bronchiolitis is the most common reason for hospital admission in infants in Australia and Aotearoa New Zealand (AoNZ), with care historically affected by practice variation, including use of ineffective therapies. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) developed the first Australasian (Australia, AoNZ) bronchiolitis guideline in 2016, providing evidence-based guidance on the management of infants (< 12 months of age), presenting or admitted to hospital with bronchiolitis. In 2022, PREDICT initiated a guideline update to include new evidence and expand the scope to include intensive care (up to intubation), management of SARS-CoV-2 co-infection, and respiratory syncytial virus prevention. AIM:This article outlines the methodology used in the guideline update, following AGREE and CheckUp reporting standards. METHODS:A Guideline Advisory Group and Guideline Development Committee, consisting of 29 clinical and methodological experts from Australasia, developed the guideline with consumer input. Forty-one scoping questions on 25 topics were investigated. Systematic searches were performed by a subject librarian across five electronic databases (last search 24/01/24). Screening of 13,932 new articles occurred independently, in duplicate in two stages. The results of 431 articles were synthesized narratively and quantitatively where appropriate, per topic. Risk of bias was evaluated using appropriate tools. GRADE methodology was used to assess evidence quality and develop the recommendations, which were finalised through consensus voting across three guideline development meetings. RESULTS:The update produced 41 recommendations (33 evidence-based, 8 consensus-based; including 11 new and 7 with key revisions), covering bronchiolitis investigations, management and RSV prevention. Interest-holder groups consulted on the recommendations. CONCLUSION:The Australasian Bronchiolitis Guideline was updated and expanded according to AGREE and CheckUp reporting standards.

AIM:Bronchiolitis is the leading cause of hospital admission in Australasian infants. Infants with risk factors for severe disease may have a greater likelihood of prolonged hospitalisation and intensive care admission. This study aimed to synthesise the literature on risk factors for severe bronchiolitis in Australasian infants. METHODS:Systematic review including observational studies of risk factors for severe bronchiolitis in Australasian infants (< 12 months), published from 2000. Databases were searched (24 January 2024): MEDLINE, EMBASE, PubMed, Cochrane Library and CINAHL. Risk of bias (RoB) was assessed using the Newcastle-Ottawa Scale for cohort studies, and evidence quality was evaluated using GRADE. Results were narratively synthesised. RESULTS:Ten out of 26 467 articles were included (N = 895 276; 12 cohorts, prospective = 5, retrospective = 7). Studies were mostly rated low RoB. There was evidence for the following risk factors: younger chronological age, prematurity, plural birth, comorbidity (chronic lung disease, congenital heart disease, chronic neurological disease, any genetic disorder, any comorbidity), Indigenous ethnicity, economic disadvantage, tobacco smoke exposure and timing of illness onset at presentation. Most risk factors had moderate-quality evidence (range high to very low). Evidence was lacking for the following risk factors present in international literature: breastfeeding exposure and faltering growth. The following risk factors have not been reported in Australasian infants: trisomy-21, congenital diaphragmatic hernia and environmental pollutants. CONCLUSIONS:Risk factors for severe bronchiolitis in Australasian infants are largely consistent with the international literature, although evidence is lacking for some. Knowledge of these risk factors is highly relevant to those assessing infants with bronchiolitis, and in guiding targeted delivery of respiratory syncytial virus immunisation and other preventative programmes. TRIAL REGISTRATION:PROSPERO (CRD42023463917).

AIM:To synthesise evidence on the efficacy and safety of azithromycin in infants presenting or admitted to hospital with bronchiolitis in an updated systematic review. METHODS:MEDLINE, EMBASE, PubMed, Cochrane Library and CINAHL were searched (last search 19/02/25) for trials evaluating the efficacy and safety of azithromycin in infants with bronchiolitis. Primary outcomes were hospital length of stay (LOS), intensive care unit (ICU) admission and mechanical ventilation. Risk of bias (RoB2) and the certainty of evidence (GRADE) were evaluated. Data were pooled using fixed-effect meta-analyses. RESULTS:Six RCTs and one pilot RCT were included (N = 867). Azithromycin was associated with a significantly shorter LOS in infants with bronchiolitis, compared to placebo (MD -0.30 days (95% CI -0.58 to -0.02), p = 0.04; low certainty). However, statistical significance was lost in sensitivity analyses. There was no significant difference between the azithromycin and placebo groups in rates of adverse events, ICU admission, mechanical ventilation, readmission within 6 months and in most evaluations of persistent respiratory symptoms. The evidence certainty was low to very low across outcomes. CONCLUSIONS:There is insufficient evidence to support the use of azithromycin as part of hospital care for infants with bronchiolitis, with inconclusive findings on its role in reducing LOS. REGISTRATION:PROSPERO registration number: CRD42023463917.

AIM:To provide updated evidence-based clinical guidance in the management of infants with bronchiolitis presenting to emergency departments (EDs), general paediatric, or intensive care units (ICUs) in Australia and Aotearoa New Zealand (AoNZ) following the first publication in 2016. METHOD:The Paediatric Research in Emergency Departments International Collaborative (PREDICT) network guideline working group appraised, summarised, and updated evidence from 1 January 2000 to 24 January 2024 addressing 41 questions (30 from the 2016 guideline and 11 new questions for 2025). Recommendations were developed using GRADE methodology and revised after a period of external consultation. RESULTS:The literature search identified 26 467 citations with 431 included in 41 recommendations providing 11 new and 7 key updates. The key changes included: (i) refinement of the clinical features of bronchiolitis, (ii) addition of new risk factors for severity of illness, (iii) advice on the role of biomarkers for unexpected deterioration or admission to ICU, (iv) guidance on glucocorticoids in SARS-CoV-2 co-infection, (v) guidance on combined glucocorticoids/inhaled epinephrine in severe bronchiolitis requiring ICU level care, (vi) refinement of oxygen saturation targets, (vii) guidance on humidified high flow therapy and continuous positive airway pressure, (viii) recommendation on use of RSV prevention therapies/immunisations for babies and mothers. CONCLUSION:The updated Australasian Bronchiolitis Guideline provides clinicians across Australasian settings with the latest evidence-based guidance on the management of the commonest condition in infancy requiring hospital admission.

The Paediatric Research in Emergency Departments International Collaborative (PREDICT) has operated as an emergency research network in Australia and Aotearoa New Zealand for 20 years. A focus on both knowledge generation and, over the last decade, knowledge translation research has produced more than 200 network publications. Active research sites have increased from the original 12 sites to 47, with enhanced representation of where children with acute illness present in both countries. We outline ongoing challenges across the network, which will be relevant for those providing acute paediatric care and to other emergency clinicians interested in multicentre research collaboration.

To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. Quantitative and qualitative analysis of clinical ‘real-world’ adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

Conducting research in ED is important and necessary to improve emergency care. Effective recruitment is an essential ingredient for the success of a research project and must be carefully monitored. Research coordinators are focused on optimising recruitment to research studies while also ensuring that the needs of participants and their families are met, and the research is acceptable to ED staff. In this paper, a group of experienced research coordinators from Australia and New Zealand have shared their strategies to engage staff and enhance recruitment of participants in emergency research. Although this paper is from a paediatric research network, the findings are applicable for EDs in general, both in Australasia and elsewhere.

AIM:To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments.METHODS:A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made.RESULTS:Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation.CONCLUSION:Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

OBJECTIVES:To determine the prevalence of eczema among children in New Zealand. METHODS:Population-based retrospective observational study utilising national pharmaceutical dispensing records for topical corticosteroids and emollients for all New Zealand children aged 0-14 years from 1st January 2006 to 31st December 2019. Data are reported using descriptive statistics, with comparisons between ethnicities and socioeconomic quintiles undertaken with rate ratios. RESULTS:Based on dispensing data, the prevalence of eczema for New Zealand children aged 0-14 years in 2018 was 14.0% (95% CI 14.0%-14.1%), with prevalence decreasing in older age groups (children aged <1 year 26.0% (25.6%-26.4%); children aged 10-14 years 8.8% (8.7%-8.9%)). Prevalence was higher in Pacific children (23.6% (23.3%-24.0%)), but slightly lower in Māori children (13.2% (13.0%-13.3%)). CONCLUSION:Eczema is a common condition affecting a considerable proportion of children in New Zealand. This study provides nationwide paediatric prevalence data for New Zealand, and highlights the increased burden of eczema in Pacific children. Inequity in dispensing of topical corticosteroids is postulated to explain the reduced rates found for Māori children compared to previous studies. These results support the need for further research to determine factors contributing to differing eczema prevalence rates in New Zealand.