Access to Optimal Emergency Care for Children.

Every year, millions of pediatric patients seek emergency care. Significant barriers limit access to optimal emergency services for large numbers of children. The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have a strong commitment to identifying these barriers, working to overcome them, and encouraging, through education and system changes, improved access to emergency care for all children.

Patient- and family-centered care of children in the emergency department.

Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This revised technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care.

Pediatric observation units.

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

Dispensing medications at the hospital upon discharge from an emergency department.

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED's outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.

Pediatric infectious diseases: 2009 update for the Rogers' Textbook of Pediatric Intensive Care.

OBJECTIVE: To review important articles in the field of infectious diseases that pertain to the care of children in pediatric critical care units, published subsequent to the fourth edition of the Rogers' Textbook of Pediatric Intensive Care. DATA SOURCES: The U.S. National Library of Medicine was searched for the terms: critical care, nosocomial, antimicrobial resistance, opportunistic infection, sepsis, central nervous system infections, encephalitis, meningitis-bacterial, meningitis-tuberculous, brain abscess, measles, dengue, hemorrhagic fever, human immunodeficiency virus infection (HIV), opportunistic infections, fungal infections, tetanus, diphtheria, botulism, toxic shock syndrome, and pediatrics. STUDY SELECTION AND DATA EXTRACTION: Promising articles were reviewed and the decision to include them or not in this review was made by the authors, based on clinical relevance. DATA SYNTHESIS: Articles were included based on their relevance to specific chapters included in this section of the textbook. CONCLUSIONS: Significant advances continue to be made in our understanding of specific diseases as well as the approach to treatment. There are significant variations in outcome from specific infectious diseases in developing countries compared with the developed world. The looming problem of antimicrobial resistance and relative lack of new anti-infective agents in development is an issue that will be faced by pediatric intensive care units throughout the world in the near future. Updated evidence-based guidelines have appeared for early treatment of septic shock in children, and on prevention and treatment of opportunistic infections in adults and adolescents with human immunodeficiency virus. In patients with measles, use of oral co-trimoxazole or amoxicillin reduces the risk of secondary bacterial infections of respiratory tract; however, the same may not be true for other systemic viral infections, such as influenza. In patients with acute bacterial meningitis, maintenance fluids-instead of restricted fluids-and use of glycerol may improve the outcomes; however, the role of dexamethasone in prevention of adverse outcome needs reevaluation. Intravenous use of botulism immune globulin decreases the length of hospital stay and mechanical ventilation. Pediatric patients with aspergillosis have radiologic findings distinct from those of adults and present more often with nodules, and only rarely with cavitation; early focal surgical resection may improve the survival of these patients.

Implications of thrombocytopenia and platelet course on pediatric intensive care unit outcomes.

INTRODUCTION: Thrombocytopenia has been shown to be an independent predictor of mortality and prolonged hospital length of stay in critically ill adults. Studies are lacking in the pediatric intensive care unit population. We evaluated the relationship between platelet counts at admission, platelet course, and outcomes. HYPOTHESES: 1) Thrombocytopenia at the time of admission to the pediatric intensive care unit is a risk factor for increased mortality and prolonged length of stay. 2) Thrombocytopenia at any point during pediatric intensive care unit stay is associated with increased mortality and length of stay. 3) Falling platelet counts during a pediatric intensive care unit course are associated with greater mortality and longer length of stay. METHOD: Prospective observational study. STUDY POPULATION: All patients admitted to a multidisciplinary tertiary care pediatric intensive care unit in a University Hospital over the course of a year. ANALYSIS OF DATA: Data were analyzed using logistic and linear regression. RESULTS: Thrombocytopenia (platelet count <150 x 10/L) was present in 17.3% of pediatric intensive care unit patients on admission. Mortality was higher in thrombocytopenic patients (17.6% vs. 2.47%, p < 0.001). The median length of stay in the thrombocytopenia and nonthrombocytopenia groups was 4 days vs. 1.6 days, respectively (p < 0.001). The pediatric intensive care unit patients (25.3%) were thrombocytopenic at some point in their stay. They had higher mortality (17.1% vs. 0.9%, odds ratio [OR] 23.8, 95% confidence interval [CI] 5.2-108.6, p < 0.0005) and longer length of stay (median 6.6 days vs. 1.5 days, p < 0.0005) compared with those who were never thrombocytopenic. For every 10% fall in platelet count from the time of admission, the OR for mortality was 1.4 (95% CI 1.1-1.8) and the length of stay was longer (p < 0.0005). Patients with normal platelet counts at admission who later developed thrombocytopenia had increased mortality (OR 18.6, 95% CI 3.2-107.3) and longer length of stay (p < 0.0005) compared with those who did not develop thrombocytopenia. CONCLUSION: Thrombocytopenia and falling platelet counts are associated with increased risk of mortality and length of stay in the pediatric intensive care unit.