Comparison of Ambulance Usage Characteristics in Children Between the Pre-Pandemic and Pandemic Periods in Turkey

Objective: A pandemic is an epidemic of an infectious disease that has spread across a large region of the world and affects many people. In this study, it was aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on ambulance use by pediatric patients in Ankara Province, Turkey. Material and Methods: This retrospective study was conducted in the spring-summer of 2019 and 2020. The electronic medical records of pediatric patients who were transported to the hospital by ambulance were analyzed. Results: It was determined that 49.6% of the 23.201 patients included in the study were transported during the pandemic period. Male gender was higher in both the pandemic and pre-pandemic periods, there was no difference in terms of average age. The rate of forensic cases and refugee patients increased, while that of emergency patients decreased. Both the arrival at the scene time and intervention time were prolonged. Medical cause was the most common cause of emergency calls in both years, however, it increased significantly in 2020. The decrease in cases of traffic accidents, suicides, and other accidents was statistically significant. In the pandemic period, total rate of COVID-19 infection and suspicion was 29.7%. Most of the patients had been referred to a public hospital. Conclusion: It was found that most of the ambulances were used for transporting patients with minor illnesses that did not require immediate medical attention in pandemic period. (English) [ FROM AUTHOR] Amaç: Pandemi, dünyanın geniş bir bölgesine yayılan ve birçok insanı etkileyen bulaşıcı hastalık salgınıdır. Bu çalışmada, Türkiye'nin Ankara ilinde, 2019 koronavirüs hastalığı (COVÍD-19) pandemisinin çocuk hastaların ambulans kullanımına etkisinin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntemler: Bu retrospektif çalışmada 2019 ve 2020 yıllarının bahar-yaz aylarında ambulans ile hastaneye nakledilen çocuk hastaların elektronik tıbbi kayıtları incelendi. Bulgular: Çalışmaya alınan 23201 hastanın %49.6'sının pandemi döneminde nakledildiği belirlendi. Erkek cinsiyet hem pandemi hem de pandemi öncesi dönemlerde daha yüksekti, yaş ortalamaları açısından fark yoktu. Pandemi döneminde adli vaka ve mülteci hasta oranı artarken, acil hasta oranı azaldı. Hem olay yerine gelme süresi hem de müdahale süresi uzadı. Medikal nedenler her iki yılda da en sık acil çağrı nedeniydi, ancak 2020'de önemli ölçüde arttı. Trafik kazası, özkıyım ve diğer kaza vakalarındaki azalma istatistiksel olarak anlamlıydı. Pandemi döneminde toplam kesin ve şüpheli COVÍD-19 enfeksiyonu oranı %29.7'di. Hastaların çoğu devlet hastanesine sevk edildi. Sonuç: Pandemi döneminde ambulansların çoğunun acil tıbbi müdahale gerektirmeyen hafif hastalığı olan hastaları taşımak için kullanıldığı tespit edildi. (Turkish) [ FROM AUTHOR] Copyright of Journal of Pediatric Disease / Cocuk Hastaliklari Dergisi is the property of Turkish Journal of Pediatric Disease and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Challenges Created by the COVID-19 Pandemic: Pediatric Emergency Medicine and Disaster Management Perspectives.

OBJECTIVE: The coronavirus disease (COVID-19) pandemic has presented unique challenges to pediatric emergency medicine (PEM) departments. The purpose of this study was to identify these challenges and ascertain how centers overcame barriers in creating solutions to continue to provide high-quality care and keep their workforce safe during the early pandemic. METHODS: This is a qualitative study based on semi-structured interviews with physicians in leadership positions who have disaster or emergency management experience. Participants were identified through purposive sampling. Interviews were recorded and transcribed electronically. Themes and codes were extracted from the transcripts by 2 independent coders. Constant comparison analysis was performed until thematic saturation was achieved. Member-checking was completed to ensure trustworthiness. RESULTS: Fourteen PEM-trained physicians participated in this study. Communication, leadership and planning, clinical practice, and personal adaptations were the principal themes identified. Recommendations elicited include improving communication strategies; increasing emergency department (ED) representation within hospital-wide incident command; preparing for a surge and accepting adult patients; personal protective equipment supply and usage; developing testing strategies; and adaptations individuals made to their practice to keep themselves and their families safe. CONCLUSIONS: By sharing COVID-19 experiences and offering solutions to commonly encountered problems, pediatric EDs may be better prepared for future pandemics.

A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms.

OBJECTIVE: For the pediatric population, there is no consensus on which triage system to use for mass-casualty incidents (MCI). A scoping review was conducted to identify the most accurate triage system for pediatric patients in MCIs. METHODS: MEDLINE (NLM, Bethesda, MA, USA), Embase (Elsevier Inc., Amsterdam, Netherlands), CINAHL (EBSCO Information Services, Ipswitch, MA, USA), and The Cochrane CENTRAL Register of Controlled Trials (John Wiley & Sons, Hoboken, NJ, USA), as well as Scopus (Elsevier Inc., Amsterdam, Netherlands), Global Health (Centre for Agriculture and Bioscience International, Wallingford, UK), Global Health Archive (Centre for Agriculture and Bioscience International, Wallingford, UK), and Global Index Medicus (World Health Organization, Geneva, Switzerland) were searched for relevant studies that were divided into 3 categories: accuracy of a single system, comparison of 2 or more primary triage system and comparison of secondary triage systems. Grey literature was also searched. RESULTS: 996 studies were identified from which 18 studies were included. Systems studied were found to have poor inter-rater reliability, had a low level of agreement between providers, had missed critically ill patients or were not externally validated. 11 studies compared pediatric MCI triage algorithms using different strategies and the most accurate algorithm was not identified. A recently developed secondary triage system, specifically for pediatric patients, was found to perform better than the comparison triage system. CONCLUSION: Although some algorithms performed better than others, no primary triage algorithm was accurate enough for the pediatric population. However, only 1 secondary triage algorithm was found to be superior to the others.

COVID-19 Management in Pediatric Emergency Medicine

Emergency departments are on the front line in the management of Covid-19 cases. Emergency department personal need to be equipped with appropriate personal protective equipment and trained in its use. Pre-triage screening is necessary to prevent nosocomial infection. The clinical presentation of Covid-19 ranges from non-specific symptoms to acute respiratory distress syndrome. Personal in triage must maintain a high index of suspicion when evaluating all patients, but especially those with fever, cough, dyspnea, or signs of a respiratory illness. Healthcare workers who perform aerosol processing should be carefully. Even though morbidity and mortality are rare in pediatric population, clinicians should be aware that they may infect more vulnerable populations and social distance should be encouraged.

Not all shortness of breath and throat pain is COVID

Case Report: A previously, healthy 18-year-old female presents to a Pediatric Emergency Medicine Department with shortness of breath, fever, and worsening throat and abdominal pain for 3 days. She had a sick contact, a teacher that tested positive for COVID-19 2 weeks prior to presentation. She denies runny/stuffy nose, cough, loss of taste/smell, or rashes/lesions. She denies any significant past medical history including allergies, as well as any history of smoking or any illicit drug use. Upon arrival to the ED, the patient was noted to be tachycardic, hypotensive and febrile. There were no desaturations. Initial physical examination revealed a generally uncomfortable female that was alert and oriented, with noted tenderness over the right anterior neck region, diffuse cervical lymphadenopathy, and painful neck range of motion. Her pharynx was noted to be erythematous without exudates or any unilateral tonsillar swelling. In the ED patient received IV fluid resuscitation and was started on norepinephrine drip, broad spectrum antibiotics. Initial lab workup revealed an anion gap metabolic acidosis, likely secondary to uremia or lactic acidosis from poor perfusion in setting of sepsis and hypovolemia. BUN and creatinine were elevated, likely due to an acute kidney injury (AKI) secondary to hypovolemia. The patient was also found to have an elevated LDH, fibrinogen, and mild elevation of AST. D-Dimer was elevated at 29 000. Covid PCR, Rapid Strep, and respiratory PCR panel were negative. Her chest X-ray (CXR) was negative and ECG showed sinus tachycardia. Given the patient's history of throat and neck pain with shortness of breath, in the setting of a septic picture, a CT scan of neck, chest, abdomen was ordered prior to transferring the patient to the PICU. CT scan of the chest revealed small patches of consolidation with ground glass opacities in the right lung apex, as well as an nearly occlusive, acute thrombosis of the anterior right facial vein. The patient's initial blood cultures grew gram negative bacilli which later were revealed to be Fusobacterium necrophorum. These findings are consistent with Lemierre's syndrome. The patient was treated in the PICU on vasopressors, heparin anticoagulation, and antibiotics for 6 days and discharged with a course of Augmentin. Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein. First described by Andre Lemierre in 1936, it begins as a bacterial pharyngitis, generally developing into a peritonsillar abscess or other deep space neck infection with progressive erosion into the internal jugular vein. Diagnostic criteria for Lemierre's syndrome includes radiographically evidence of thrombophlebitis of the internal vein and positive blood cultures. CT and MRI can help make the diagnosis, but are not always required. Treatment is prompt intravenous antibiotics with beta-lactamase penicillins, metronidazole, clindamycin, and third generation cephalosporins. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

Impact of COVID-19 on the associated complications of high-risk conditions in a statewide pediatric emergency network.

Background: The COVID-19 pandemic affected the volume and epidemiology of pediatric emergency department (ED) visits. We aimed to determine the rate of associated complications for 16 high-risk conditions in a Michigan statewide network of academic and community EDs during the pandemic. Methods: We conducted a cross-sectional study of pediatric ED visits among a network of 5 Michigan health systems during the pre-pandemic (March 1, 2019-March 10, 2020) and pandemic (March 11, 2020-March 31, 2021) periods. Data were collected from the medical record and included patient demographics, ED visit characteristics, procedure codes, and final International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. Selection of codes for 16 high-risk conditions and diagnostic complications were identified using previously described methods. Characteristics of ED visits were compared before versus during the pandemic using χ2 and Fisher's exact tests. We used multilevel logistic regression to analyze covariates and potential confounders for being diagnosed with a high-risk condition or a complication of a high-risk condition. Results: A total of 417,038 pediatric ED visits were analyzed. The proportion of patients presenting with 10 of 16 high-risk conditions (including appendicitis, sepsis, and stroke) was higher in the pandemic period compared with pre-pandemic (P < 0.01). Despite this, there was no significant increase in the frequency of complications for any of the 16 high-risk conditions during the pandemic. The adjusted odds of being diagnosed with appendicitis (pre-pandemic 0.23% vs pandemic 0.52%; odds ratio [OR], 1.19 [95% confidence interval, CI, 1.00-1.41]), diabetic ketoacidosis (pre-pandemic 0.16% vs pandemic 0.52%; OR, 2.40 [95% CI, 2.07-2.78]), intussusception (pre-pandemic 0.05% vs pandemic 0.07%; OR, 1.64 [95% CI, 1.22-2.21)], and testicular torsion (pre-pandemic 0.10% vs pandemic 0.14%; OR, 1.64 [95% CI, 1.18-2.28]) was higher during the pandemic. Conclusions: Despite a higher proportion of ED visits attributed to high-risk conditions, there was no increase in complications, suggesting minimal impact of the pandemic on outcomes of pediatric ED visits.

Development of Simple and Advanced Adult Proximal Tibia Simulators for a Decentralized Simulation-Based Education Model to Teach Paramedics-in-Training the Intraosseous Infusion Procedure.

Introduction During the COVID-19 pandemic, public health had advised practicing social distancing which led to the temporary shutdown of simulation laboratories or centralized simulation-based education model, shared spaces that healthcare workers such as paramedics use to train on important hands-on clinical skills for the job. One such skill is intraosseous (IO) access and infusion, the delivery of fluids and medication through the marrow or medullary cavity of the bone which provides fast and direct entry into the central venous system. This skill is critical in emergencies when peripheral access is not immediately available. To continue the training of paramedics in life-saving skills like IO infusion in the post-pandemic era, a decentralized simulation-based education (De-SBE) model was proposed. The De-SBE relies on the availability of inexpensive and flexible simulators that can be used by learners outside of the simulation laboratory. However, to date, there is a paucity of simulation design methods that stimulate creativity and ideation, and at the same time, provide evidence of validity for these simulators. Our exploratory research aimed to test a novel approach that combines components of development-related constraints, ideation, and consensus (CIC) approach to develop and provide content validity for simulators to be used in a De-SBE model. Materials and methods The development of the IO simulators was constrained to follow a design-to-cost approach. First, a modified design thinking session was conducted with three informants from paramedicine and medicine to gather ideas for the development of two IO simulators (simple and advanced). Next, to sort through, refine, and generate early evidence of the content validity of the simulators, the initial ideas were integrated into a two-round, modified Delphi process driven by seven informants from paramedicine and medicine. In addition, we surveyed the participants on how well they liked the CIC approach. Results The CIC approach generated a list of mandatory and optional features that could be added to the IO simulators. Specifically, six features (one mandatory and four optional) for the existing simple IO simulator and eight (three mandatories and five optional) for the advanced IO simulators were identified. Following a design-to-cost approach, the features classified as mandatory for the simple and advanced IO simulators were integrated into the final designs to maintain the feasibility of production for training purposes. The surveys with the participants showed that the CIC approach worked well in the group setting by allowing for various perspectives to be shared freely and ending with a list of features for IO simulator designs that could be used in the future. Some improvements to the approach included flagging for potential users to determine what works best concerning the mode of delivery (online or in person), and duration of the stages to allow for more idea generation.  Conclusion The CIC approach led to the manufacturing of simple and advanced IO simulators that would suit a training plan catered to teach the IO access and infusion procedure decentrally to paramedics-in-training. Specifically, they have been designed in a manner that allows them to be made easily accessible to the trainees i.e., low costs and high mobility, and work cohesively with online learning management systems which further facilitates the use of a De-SBE model.

Development and Implementation of a Novel Global Health Track in Pediatric Gastroenterology, Hepatology, and Nutrition Fellowship

Background Global health interest continues to rise among pediatric trainees including those entering pediatric fellowships. While global health opportunities are being incorporated into many pediatric fellowship programs, there remains a paucity of global health training in pediatric gastroenterology, hepatology, and nutrition (GHN) fellowships. In a 2014 survey by Jirapinyo et al. only 17% of responding GHN fellowships offered global health training activities. A 2018 survey by Crouse et al. showed that 34% of responding GHN fellowships offered global health electives, and none had formal global health tracks. We believe that creating a formalized global health track for GHN fellows will not only appeal to the increasing interest among applicants, but also provide a firm knowledge base on GHN topics specific to a more global level, build international collaborations, and contribute a unique perspective in our field. We aim to describe our experience with the development and implementation of a novel global health track in a pediatric GHN fellowship. Methods Planning commenced January 2021. A multidisciplinary team was assembled bringing together experts in different areas including those in other subspecialties involved in global health fellowship training. The team involved in development included GHN program director, GHN division chief, pediatric emergency medicine global health fellowship director, director of the pediatric infectious disease fellowship tropical and global medicine track, and Baylor international pediatric AIDS initiative (BIPAI) chief medical officer. Input was also received on certain aspects of the curriculum from the pediatric viral hepatitis program director, dieticians, a radiologist, an ultrasound technologist, and the pediatric point-of-care ultrasound fellowship program director. Existing clinical niche track curriculum developed within the GHN department at Texas Children's Hospital were used as a guide for the structure and different aspects to be incorporated into the track including, but not limited to, clinical activities, procedural opportunities, research, education, and teaching. Results A comprehensive, multifaceted global health curriculum was developed, and implementation began in July 2021. Clinical activities include participation in pediatric and adult viral hepatitis clinics, nutrition focused clinics, and tropical medicine clinic. Global health electives abroad were explored but deferred given travel restrictions during the COVID-19 pandemic. For procedural opportunities an ultrasound curriculum was developed including point of care ultrasound training as well as more focused training in liver, biliary, and gastrointestinal disease. A fellowship research project was developed in conjunction with the Baylor International Pediatric AIDS Initiative (BIPAI) network in sub-Saharan Africa with mentorship both from faculty in the GHN department as well as the BIPAI network locally and abroad. The project is public health focused examining hepatitis B screening rates and prevalence among people living with HIV in sub-Saharan Africa. Education includes attendance of lectures given in different departments as well as cross departmental within the institution, and global lectures attended virtually. Other educational activities include review of a global health focused GHN topics and assembly of a library of resources including recent seminal papers for current and future fellows to use for review. Last, completion of the Diploma in Tropical Medicine and the Certificate of knowledge in Clinical Tropical Medicine and Travelers' Health Examination. Teaching opportunities include involvement in general global health education for US-based medical students and residents interested in pursuing careers in global health, and teaching residents and faculty on topics such as viral hepatitis, malnutrition, and diarrhea. Conclusion We have developed to our knowledge the first formal global health track in pediatric GHN fellowship that is feasible to integrate into the 2nd and 3rd year and omplete in the available time frame. Participation in the global health track by the first fellow is still in process and improvements are being made based on experience. A multidisciplinary team including support within the fellowship program and experts in global health training is essential to the success of a pediatric GHN global health track. International relationships either previously established by the fellow, within the department, or the institution are also necessary for the success of the track. We believe that this track will help to equip future gastroenterologists to pursue a career with a focus in global health. Future directions include recruiting future fellows to complete the curriculum within our institution, formal evaluation by fellows participating in the curriculum, and securing ongoing funding. We also hope to incorporate global health electives abroad when feasible.

Student Medical Summit - 2022

The proceedings contain 29 papers. The topics discussed include: targeting mutant p53 for the treatment of triple negative breast cancer: a pre-clinical study;senior sign-off in an Irish emergency department: is it feasible?;microfluidic-microwave platforms for real-time, non-invasive and sensitive monitoring of bacteria and antibiotic susceptibility testing;cancer diagnosis using imaging and artificial intelligence applications;enhancing the management of long covid in general practice: a scoping review;feasibility of using a hand-held device to characterize tendon tissue biomechanics;cross sectional study of wristband compliance in St Vincent's University Hospital;man vs machine: do mechanical chest compression devices improve survival outcomes in patients with out-of-hospital cardiac arrest - a systematic review;and investigating the necessity of pediatric emergency medicine in resource limited settings.

Implementation of an Institutional Simulation Curriculum to Teach Team Leadership Skills, Management of Critically Ill Patients, and Emergent Procedures to Pediatric Residents

Background: Simulation in medical training is effective at increasing clinical knowledge, improving comfort with procedures, and teaching crisis resource management skills. Uniquely, simulation can also expose trainees to standardized cases independent of available clinical experience. This is especially important at a time when the COVID-19 pandemic has paradoxically led to decreased emergency department visits and hospitalizations, and, consequentially, decreased clinical opportunities for trainees. We developed and piloted a formal, longitudinal, high-fidelity simulation curriculum for pediatric residents, led by pediatric emergency medicine fellows in a unique, near-peer training program. The project goal was to assess the efficacy of this curriculum at increasing resident selfreported comfort in leading a team, managing critically ill patients, and performing essential emergent procedures. Methods: Six cases were designed by pediatric residents and emergency medicine fellows for the curriculum. Cases were reviewed by faculty members, focused on a critically ill pediatric patient, and included an associated emergent procedure. Three of the cases were used for the study, which was conducted over a four-month period in the 2021 academic year. Study participation was voluntary, and 27 pediatric residents participated, completing up to three cases each. Data was collected as self-reported Likert scales for questions regarding leadership, individual medical knowledge, and comfort with procedures. Surveys were completed prior to the curriculum implementation, following each case, and at study conclusion. To account for expected improvements during traditional residency training, data was also collected for two control cases not used in the study. Wilcoxon Signed-Rank test was used to compare pre- and post-intervention assessments. For significant results, the Dwass-Steel-Chritchlow-Fligner method was used to examine pair-wise comparisons by trainee post-graduate year. Results: Results are summarized in Table 1 and Table 2. There was a significant improvement in self-reported ability to function as team leader, identify and designate roles, effectively organize and minimize noise in the room, effectively use closed loop communication, and access additional resources. There was also an increase in self-reported comfort level with both medical knowledge and performing emergent procedures. There was no significant difference between responses based on trainee year. As expected, residents also reported an improvement in medical knowledge about control cases, although the improvement was less than with the implemented cases. When the size of this effect was compared between implemented and control cases, there was a trend towards significance favoring the simulated cases, suggesting that statistical significance may be achieved with a larger sample size. Conclusion: The implementation of a simulation curriculum can lead to improvements in pediatric resident's self-reported comfort with crisis resource management, team leadership, clinical knowledge, and emergent procedures. The effect on medical knowledge and comfort with procedures may be significantly different than the gains expected naturally over time in pediatric residency training.

Challenges Created by the COVID-19 Pandemic: Pediatric Emergency Medicine and Disaster Management Perspective

Background: The COVID-19 pandemic presented unique challenges to pediatric emergency medicine (PEM) departments nationwide. The purpose of this study was to identify these challenges and ascertain how centers overcame barriers in creating solutions to continue to provide high-quality care while keeping their workforce safe. Methods: This is a qualitative study based on semi-structured interviews with PEM physicians in leadership positions within their institution's COVID-19 response or emergency/disaster management departments. Participants were identified through convenient purposive sampling. Demographic data was captured in a pre-interview survey. Interviews were recorded and transcribed electronically. Themes and codes were extracted from the transcripts by two independent coders. Constant comparison analysis was performed until thematic saturation was achieved. Member checking was completed to ensure trustworthiness of the results. Results: Fourteen PEM-trained physicians participated in this study. Eleven of the participants received specialized disaster management training, and ten are directors of their institutions' emergency/disaster management departments. Communication, leadership and planning, clinical practice, and personal adaptations were the principal themes identified. Within these themes, participants discussed challenges and offered examples as to how they overcame them within their department and their larger institution. To improve communication and disseminate new information, departments might consider shift huddles, town hall meetings, limiting the number of daily emails, and highlighting the newest changes. During traumas and resuscitations, “gatekeepers” oversee who goes into the trauma bay, and technology should be utilized to communicate with the team outside. For leadership and planning, the emergency department should appoint leaders to summarize updates and attend incident command meetings. Institutions should consider developing containment units and having multiple vendors for key supplies as part of their pandemic plans. Business continuity plans should be updated regularly as part of pandemic preparedness. Hospitals should be prepared to utilize telehealth and accept adult patients if pediatric volumes drop. Recommendations regarding adjusting clinical practice include having clear guidelines for what constitutes an aerosol-generating procedure, drive-through testing sites to alleviate pressure on emergency centers, and performing triage in the patient's room if possible. Personal protective equipment (PPE) should be safely re-purposed if supplies are insufficient. Staff must be trained on the proper donning and doffing of PPE with regular reminders during prolonged pandemics. Transparency with the workforce regarding supplies, testing, and safety protocols help alleviate fear and anxiety. Medical caregivers can limit their exposure by utilizing cardiac monitors visible from outside patient rooms and providing updates via telephone in patient rooms. For a full list of challenges and recommendations, see Table 1. Conclusion: By sharing COVID-19 experiences and offering solutions to commonly encountered problems nationwide, pediatric emergency centers and their institutions may better prepare both themselves and one another for future pandemics.

Attitudes Towards COVID-19 Testing in Pediatric Emergency Department Settings in Pakistan

Background: The COVID-19 global pandemic has shed light on the importance of testing to stop the spread of disease. For a developing country with a large population of over 200 million inhabitants such as Pakistan, widespread testing can be difficult. To date, 957,371 cases have been confirmed and over 14 million tests have been performed in Pakistan, with only 1% of the population vaccinated. In a country already burdened by health disparities with little to no resources, the challenges became ever apparent as case numbers grew. According to the WHO, complacency among the population in cooperating with public protective measures is a rising challenge. Several violent incidents have occurred in hospital wards in Pakistan, prompting medical staff to fear for their lives and demand extra security not only from the virus, but from volatile patients and families. The incidents are thought to be rooted in a mix of anger at a lack of resources, and mistrust of the medical system. The objective of this study was to survey Pediatric emergency medicine (PEM) physicians in Pakistan on their ability to test for COVID-19 and their limitations experienced. Methods: An anonymous prospective survey was performed from February to March 2021 in association with the ChildLife Foundation, a nonprofit organization that operates and manages Pediatric EDs in 10 government teaching hospitals in the province of Sindh. 170 PEM providers were surveyed on their experiences with COVID-19 testing, reasoning for why testing was not performed when infection was suspected and reasoning for patient refusals. Results: 68% of respondents had COVID-19 on their differential for patients under their care in the week prior to survey. However, 49% of respondents did not order any COVID-19 testing. 37% of those providers had at least one patient in whom COVID-19 was on the differential. 81% of providers claimed to collect COVID-19 testing every time when suspected. When surveying reasoning for not acquiring COVID-19 testing, providers listed patient refusal as the top reason, followed by limited availability and cost, mild presentation of disease, patient leaving AMA, fear of violence against healthcare professionals, social stigma/fear from patients of being labelled as COVID-19 positive and denial of the diagnosis. Conclusion: According to this survey, PEM providers in Pakistan were not always able to send COVID-19 testing, when indicated, due to a variety of factors. Testing limitations despite suspicion for disease can be a major hurdle in identifying cases and limiting spread in unvaccinated populations.

PEM Physicians' Perceptions of Colleagues' Clinical Competencies over Four Age Categories

Background: The US physician workforce is aging, prompting concerns regarding clinical performance of senior physicians. Pediatric Emergency Medicine (PEM) is a high acuity, multitasking, diagnostically complex and procedurally demanding pediatric specialty. The impact of aging on clinical competence in PEM has not been previously examined;our aim was to assess peer ratings of the clinical competency of four age groups of PEM physician colleagues using an electronic survey instrument Methods: We invited all 478 PEM physicians who were members of the AAP Section on Emergency Medicine survey study list-serve in June 2020 to participate anonymously. The survey was designed by the investigators with iterative input from institutional colleagues. Respondents were asked to rate, using a 5-point Likert scale, the average competency of four age categories of PEM physicians in performing 9 clinical tasks. Additional items included concerns about de-identified colleague's clinical competence, preferences for age of physician managing a hypothetical critically ill child family member of the respondent, self-ratings of clinical competencies, late career transition plans and impact of COVID-19 on personal practice pattern. This analysis focuses on respondents' rating of colleagues' clinical competencies and age preference for physician managing a child relative. Our study was exempted from IRB review. Results: We received 256 survey responses;24 failed to answer at least one question central to our hypotheses and were excluded, leaving 232 for analysis (adjusted response rate of 48.9%). Most respondents were 36-49 years old (yo) (34.9%) or 50-64 yo (47.0%), with 45.8% female and 40.9% male. The majority of respondents (53%) reported some concern about a colleague's competence. A lower percentage of the senior PEM physician age group (≥ 65 yo) was rated as very good or excellent for critical care-related competencies when compared to midcareer physicians (36-49 yo or 50-64 yo) (Table). The performance ratings for effective communication to hostile or anxious families and delivery of bad news found the senior group rated better than the youngest group (≤ 35 yo). Among the 129 of 224 (57.6%) respondents who ranked an age category for a colleague managing a critically ill child relative, almost all indicated preference for a 36-49 yo (69%), followed by a 50-64 yo (27.9%) colleague (Figure). Conclusion: In this exploratory study, PEM physicians' perceptions of their peers' clinical competencies demonstrated significant differences by peer age group. For competence domains posing procedural and multitasking challenges, PEM physicians ≥ 65 yo were generally perceived as less competent than those aged 36-64 yo. However, for those practice domains that required considerable “clinical wisdom” such as demanding communication skills, senior PEM physicians were perceived as performing as well if not better than younger peers. Further study of age-related PEM competencies with more objective measures may be warranted.

Increasing Underrepresented Minority Undergraduate Student Exposure to Pediatrics via a Longitudinal Mentorship Program

Background: The United States is increasingly diverse, but representation of minorities (specifically Black/African-American) in medicine has not followed this trend. Lack of mentorship is identified as a barrier at multiple levels. We developed and piloted a mentorship program between pediatric emergency medicine (PEM) physicians and underrepresented minority (URM) undergraduate students in the Porter Scholars program (the largest African American student organization at the University of Louisville), known as the Porter Scholars in Medicine Program (PSMP). By providing robust mentorship and educational activities, our goal is to encourage students in this program to matriculate to medical school. Methods: The pilot program included clinical experiences (simulation and ultrasound), direct mentorship, connections with medical school admissions agents, and personal development programming including a book club. Students selected for the PSMP completed a survey upon entry into the program including demographic questions, as well as 5-point Likert scale questions regarding familiarity with the medical school application process, comfort with being a physician, and barriers to becoming a physician. Additionally, they received a survey after specific experiences and at the end of the year. A final survey will be sent following graduation. Data were analyzed using descriptive statistics, and Wilcoxon-Signed Rank tests were used to compare entry to end of year results. Results: Twenty-three PEM faculty, fellows and clinicians volunteered as mentors or led clinical programs in the PSMP program. Twenty-five undergraduate students were accepted into the program in fall of 2020;22(88%) completed the initial survey. Mean age was 18.6 (+/- 0.8) years, 19 (86.4%) were female. On initial surveys, the median Likert scores were: awareness of available resources to assist with medical school application 2, understanding of the medical school application process 2.5, confidence in acceptance to medical school 3, and mentor support 4. Eight (36.3%) students completed the end of year survey. For these 8 students, significant increases in median Likert scores were noted for the following categories: awareness of available resources to assist with medical school application median 3.5 (p = 0.03) and understanding of the medical school application process median 4 (p = 0.03). While not statistically significant, increases were also noted in confidence in acceptance to medical school median 4 (p = 0.10), and mentor support median 5 (p = 0.06). Student comments were generally positive though experiences were limited by the COVID 19 pandemic, see table 2. Conclusion: This pilot program demonstrates feasibility of a longitudinal mentorship program for URM premedical students which was generally well-received by students and physicians. The pandemic was a limitation, with few opportunities for in-person activities, but we look forward to more robust programing this year.

Effects of COVID-19 Pandemic on Pediatric Emergency Medicine Fellowship Training

Background: The COVID-19 pandemic brought shelter-in-place orders by public health organizations and eliminated large gatherings. Training programs abruptly stopped in-person learning to ensure the safety of medical trainees and redesigned curricula to use virtual platforms for didactic learning with variable success. Trainees had decreased patient contact time as pediatric emergency department (ED) patient volumes dropped, operative cases were canceled, clinic visits rescheduled, and use of telehealth visits became more prominent. Resident well-being became even more vital with social isolation and fears of infecting loved ones increased. Our study evaluated the impacts of COVID-19 on pediatric emergency medicine (PEM) fellowship programs, including effects on fellows' clinical, didactic, and research experiences, and effects on fellows' health and wellbeing. Methods: Two surveys were developed using an iterative process by the PEM Collaborative Scholarship Committee, 1 for program leadership (29 questions) and 1 for trainees (27 questions). Surveys were approved and distributed by the PEMPD Survey Committee to program directors (PD) a total of 3 times in 2-week intervals. PDs were asked to forward the trainee survey to their fellows. Survey responses were anonymous. Survey questions met our study objectives and consisted of multiple choice, 5-point Likert scale, and free text responses. Surveys were completed online using Qualtrics software between March 17, 2021 and April 19, 2021. Results: PDs had a 56.8% (50/88) response rate, fellows 34.6% (144/416). The majority of PD responses represented the Northeast US (n = 18) followed by the Midwest (n = 10). For trainees, responses mostly represented the Midwest (n = 39) followed by the Northeast (n = 38). Fifty-seven respondents self-identified as 1st year, 41 as 2nd years, 45 as 3rd years and 1 as 4th year fellows. All PDs reported a decrease in patient volumes during the height of the pandemic, estimating volumes decreased by 25-50% (n = 17, 36%), 51-75% (n = 20, 43%), or >75% (n = 10, 21%). Most common responses included change in rotations and block schedules, didactics moving to a virtual platform, increased frequency of speakers from outside the institution, fellows being able to participate in COVID related research, and additional mental health services for providers (see Table 1). Reasons for changes to the rotation schedules included rotation cancelations, extra time in the pediatric ED, modifications to rotations, and pregnancy (see Figure 1). PDs and trainees report being required to provide service to COVID patients outside of a pediatric ED. Commonly cited locations included the adult ED and medical intensive care units (MICU). Conclusion: COVID-19 had a clear impact on PEM fellowship training including decreases in pediatric patient volumes, canceled electives, increased care of adults, and altered didactics/conferences in accordance to CDC guidelines. The impact of these changes remains unclear. Future research might assess pandemic-related differences on intraining exam scores or how prepared fellows feel for unsupervised practice.

Five years of outpatient parenteral antibiotic therapy with ceftriaxone in the paediatric emergency department: what clinical features are associated with need for admission?

BACKGROUND: More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission. METHODS: We conducted a service evaluation over a 5-year period (12 September 2015-12 September 2020) at a single UK tertiary centre paediatric ED formally known as the Royal Hospital for Sick Children Edinburgh. All children referred from the ED for OPAT with ceftriaxone were included. OPAT failure was defined as a decision by a senior clinician of need for admission. Univariate statistical testing and multivariate logistic regression modelling were performed. RESULTS: 754 children received OPAT in the ED over a 5-year period. 95 children (13%) required admission for inpatient management. Need for admission was independently associated with having a positive blood culture (adjusted OR (aOR) 8.9; 95% CI 1.49 to 47; p=0.01) or an ultrasound performed (aOR 6.8; 95% CI 3.74 to 12.7; p<0.001). We observed no significant association between age and systemic features (fever, white cell count or C reactive protein) with need for admission in our multivariate analysis. CONCLUSION: In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.

Croup during the Coronavirus Disease 2019 Omicron Variant Surge.

We conducted a retrospective review of medical records of patients with croup seen during the coronavirus disease 2019 pandemic. Approximately 50% underwent testing for severe acute respiratory syndrome coronavirus 2. During the Delta wave, 2.8% of those tested were positive for severe acute respiratory syndrome coronavirus 2; this increased to 48.2% during the Omicron wave, demonstrating a strong correlation between the Omicron variant and croup.

Patterns in emergency department unscheduled return visits during the COVID-19 pandemic.

INTRODUCTION: Fear surrounding nosocomial infections, expanded telehealth, and decreases in ED (emergency department) utilization altered the way patients sought emergency care during the COVID pandemic. This study aims to evaluate COVID-19's impact on the frequency and characteristics of unscheduled return visits (URVs) to the adult and pediatric ED. METHODS: In this retrospective cohort study, the electronic medical record was used to identify ≤9-day URVs at a tertiary adult and pediatric ED from 4/16/19-2/29/20 (control) and 4/16/20-2/28/21 (COVID). The primary outcome, proportion of total ED visits made up by URVs, and secondary outcomes, patient characteristics (age), illness acuity (emergency severity index (ESI)), disposition, and mortality were compared between the cohorts. Pediatric and adult data were analyzed separately. A sub-analysis was performed to exclude patients with suspected respiratory infections. RESULTS: For adults, n = 4265, there was no significant difference between the proportion of ED census made up by URVs (4.56% (control) vs 4.76% (COVID), p = 0.17), mean patient age (46.33 (control) vs 46.18 (COVID), p = 0.80), ESI acuity (2.95 (control) vs 2.95 (COVID), p = 0.83), disposition (admission 0.32% (control) vs 0.39% (COVID), p = 0.69), and mortality (0.23% (control) and 0.49% (COVID), p = 0.15). When excluding possible respiratory infections comparisons remained insignificant. For pediatrics, n = 1214, there was a significant difference in the proportion of ED census made up by URVs (4.83% (control) to 3.55% (COVID), p < 0.01), age (5.52 (control) vs 6.43 (COVID), p = 0.01), and ESI acuity (3.31 (control) vs 3.17 (COVID), p < 0.01). There was no difference in disposition (admission 0.12% (control) vs 0% (COVID), p = 1). When excluding possible respiratory infections acuity (p = 0.03) remained significant. CONCLUSION: In the adult population, COVID did not significantly alter any of our outcomes. For pediatric patients, a decrease in the proportion of URVs and increase in acuity during COVID suggests that patients may have had other means of accessing care, avoided the ED, received more adequate care at initial presentation, or represented when more acutely ill.

Pediatric appendicitis in the time of the COVID-19 pandemic: A retrospective chart review.

Aim: Conduct a time trend analysis that describes 2 groups of patients admitted to a large tertiary children's hospital that presented with appendicitis and determine if there was an increase in complicated appendicitis when compared between 2 time periods before and during the early coronavirus disease 2019 (COVID-19) pandemic of 2020. Methods: We conducted a retrospective analysis of all children presenting to a single-center site with appendicitis between March 23 and August 31, 2020, in the Central Texas region. We compared 507 patients presenting with appendicitis from the non-COVID-19 era in 2019 with n = 249 to patients presenting during the COVID time period with n = 258. All patients with appendicitis within those time periods were reviewed with analysis of various characteristics in regard to presentation, diagnosis of uncomplicated versus complicated appendicitis, and management outcomes. Results: There were no significant demographic differences or change in the number of appendicitis cases noted between the 2 time periods of comparison. There was no significant difference in rates of complicated appendicitis or presentation time following symptom onset between the 2 eras. There was no significant difference in intraoperative or postoperative complications. There was a statistically significant increase in the use of computed tomography (CT) scans (P-value = 0.004) with patients 1.81 times more likely to have a CT scan in the pandemic era after adjusting for patient-level factors. The effect of severe acute respiratory syndrome coronavirus 2 status on outcomes was not part of the data analysis. Conclusion: Our study is the largest to date examining appendicitis complications in the era of COVID. In the time of the COVID-19 pandemic, we found no delay in presentation in children presenting to the emergency department and no increase in complicated appendicitis. We did identify an increase in the use of CT scans for definitive diagnosis of appendicitis noted in the pandemic era. Although COVID-19 status was not studied, the finding of increased CT use for a definitive diagnosis of appendicitis was a distinctive finding of this study showing a change in practice in pediatric emergency medicine.