Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection: A Multi-Center Study of Clinical Decision Support for Children with Head Trauma.

BACKGROUND: Overuse of cranial computed tomography scans in children with blunt head trauma unnecessarily exposes them to radiation. The Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma prediction rules identify children who do not require a computed tomography scan. Electronic health record (EHR) based clinical decision support (CDS) may effectively implement these rules but must only be provided for appropriate patients in order to minimize excessive alerts. OBJECTIVES: To develop, implement and evaluate site-specific groupings of chief complaints (CC) that accurately identify children with head trauma, in order to activate data collection in an EHR. METHODS: As part of a 13 site clinical trial comparing cranial computed tomography use before and after implementation of CDS, four PECARN sites centrally developed and locally implemented CC groupings to trigger a clinical trial alert (CTA) to facilitate the completion of an emergency department head trauma data collection template. We tested and chose CC groupings to attain high sensitivity while maintaining at least moderate specificity. RESULTS: Due to variability in CCs available, identical groupings across sites were not possible. We noted substantial variability in the sensitivity and specificity of seemingly similar CC groupings between sites. The implemented CC groupings had sensitivities greater than 90% with specificities between 75-89%. During the trial, formal testing and provider feedback led to tailoring of the CC groupings at some sites. CONCLUSIONS: CC groupings can be successfully developed and implemented across multiple sites to accurately identify patients who should have a CTA triggered to facilitate EHR data collection. However, CC groupings will necessarily vary in order to attain high sensitivity and moderate-to-high specificity. In future trials, the balance between sensitivity and specificity should be considered based on the nature of the clinical condition, including prevalence and morbidity, in addition to the goals of the intervention being considered.

Test characteristics of the urine Gram stain in infants

OBJECTIVE: The utility of the Gram stain for the preliminary diagnosis of urinary tract infections (UTI) in infants or= 38.0 degrees C presenting to a pediatric emergency department during 2 consecutive winter seasons. Single pathogen growth of >or= 10(4) cfu/mL from a catheterized specimen and >or= 10(3) cfu/mL from a suprapubic specimen was considered positive. A positive Gram stain was defined as the identification of any organisms. Urinalysis was tested for the presence of nitrites and for leukocyte esterase (LE). Urine microscopy was analyzed for white blood cells per high power field (WBC/hpf). RESULTS: Fourteen of 246 patients were excluded; 11 because no Gram stain was completed. Of the remaining 232 patients, Gram stain had a sensitivity of 85.2% (95% CI 71.9-98.6%), a specificity of 99.0% (95% CI 97.7-100%), a likelihood ratio for a positive test of 87.3 (95% CI 21.8-349.9), and a likelihood ratio for a negative test of 0.15 (95% CI 0.06-0.37). There were 193 specimens for which a Gram stain and a complete UA and microscopy were completed and compared. Urine microscopy had a lower sensitivity and specificity than Gram stain for both >or= 5 WBC/hpf and >or= 10 WBC/hpf. In addition to the Gram stain, a dipstick negative for nitrites and LE had a low negative likelihood ratio (0.16), useful for decreasing the likelihood of a UTI. CONCLUSIONS: The Gram stain has excellent test characteristics for the preliminary diagnosis of a UTI in febrile infants. Patient disposition and therapy will likely change if clinical protocols and guidelines use the Gram stain rather than urine microscopy for preliminary diagnosis of UTI in infants.

Medical causes of pneumomediastinum in children.

The purpose of this study was to determine the possible causes, clinical findings, and associated complications of pneumomediastinum in children. Medical records from January 1985 to December 1994 were retrospectively reviewed at Children's Hospital Medical Center of Akron using International Classification of Diseases, ninth revision, codes to identify cases of pneumomediastinum. The medical causes, nontraumatic and noniatrogenic, of pneumomediastinum were studied; intubated or trauma patients and patients having undergone procedures were excluded. Neonates were also excluded. Twenty-nine cases of pneumomediastinum were identified. Two patients (7%) had recurrent pneumomediastinum. Only the first episode of pneumomediastinum was included in the data analysis. Twenty males (69%) and nine females (31%) were affected. The most common medical causes of pneumomediastinum were asthma exacerbations (17/59%) and infections (8/28%). Over the 10-year period, the prevalence of pneumomediastinum in children with asthma exacerbations was 0.2% (21/10,472); 1% (1/126) in children with airway foreign bodies and 0.2% (1/351) in children with esophageal foreign bodies. The most common signs and symptoms were subcutaneous emphysema (22/76%), sore throat or neck pain (11/38%), and Hamman's crunch (3/10%). The most common complication was pneumothorax with small pneumothoraces in 2 patients (7%) and a tension pneumothorax in 1 asthmatic with recurrent pneumomediastinum. Patients without sore throat or neck pain and patients admitted to the intensive care unit had greater hospital lengths of stay. Pneumomediastinum appears to be uncommon in children. The most common medical causes were asthma and infections. The most common signs and symptoms were subcutaneous emphysema, sore throat or neck pain, and Hamman's crunch. The most common complication was pneumothorax. The clinical significance of pneumomediastinum is its cause and association with significant complications.

Parental attitudes toward BB and pellet guns.

As well as describing our pediatric BB and pellet gun injuries and the circumstances surrounding these injuries, we also evaluated parental perceptions of the dangers of BB and pellet guns. A convenience sample of three groups of parents and their children presenting to a Midwest, urban, children's hospital emergency department was prospectively enrolled. The three groups of parents included the injured group, which consisted of the parents whose children had been injured by BB or pellet guns; the gun group, which consisted of the parents who allowed their children to possess BB or pellet guns but had not sustained injury from these guns; and the no gun group, which consisted of the parents who did not allow their children to have these guns. All parents completed a survey concerning their attitudes toward BB and pellet guns. Twenty-eight parents completed questionnaires in each of the three groups. Most BB and pellet gun injuries occurred in adolescent males at home without adult supervision and were inflicted by a friend or by themselves. The injured group and the no gun group viewed BB and pellet guns as significantly more dangerous than the gun group. Parents who allow their children to have BB or pellet guns appear to misperceive their potential for injury by allowing their children to use these guns in an unsafe manner. Clinicians must educate parents about the significant potential for injury of nonpowdered guns.

A comparison of the initial to the later stream urine in children catheterized to evaluate for a urinary tract infection.

BACKGROUND: To avoid potential contamination, it is recommended that the first few drops of urine be discarded when obtaining a catheterized urine sample from a child being evaluated for a urinary tract infection (UTI). The existing evidence to make such a recommendation is scant. Our goal, therefore, was to determine whether the urinalysis, Gram stain, and culture results were significantly different from the initial and later urine samples collected from catheterized children. METHODS: A prospective diagnostic discrimination between early and later urine samples was conducted on a convenience sample of pediatric patients being evaluated for a UTI in an urban emergency department. Results of the urinalysis, Gram stain, and quantitative culture were compared between the early and later stream urine samples. RESULTS: Data from 86 children were analyzed. Four of 80 patients had a false identification of low colony count bacteruria from the early but not from the later stream. For patients with negative cultures, the early stream was also more likely to falsely identify > or =5 wbc/hpf (P<0.01) or bacteruria (P<0.05) on urinalysis than the later stream. CONCLUSIONS: There is a small but potentially meaningful contamination of the early stream urine compared with the later stream in young children catheterized to evaluate for a urinary tract infection.

Streptococcus pneumoniae bacteremia in children infected with HIV: presentation, course, and outcome.

OBJECTIVE: To examine the presentation, course, and outcome of pneumococcal bacteremia in children infected with human immunodeficiency virus (HIV). METHODS: A retrospective series of HIV-infected children less than 18 years of age with Streptococcus pneumoniae bacteremia from four urban, tertiary care hospitals was evaluated. The main outcome measures included persistent bacteremia, the development of a focal infection, and death. RESULTS: Seventy-two episodes of pneumococcal bacteremia were identified in 59 patients. Fifty-four first episodes were included; 26/54 were occult. Mean temperature was 39.8 degrees C. In patients with bacteremia, white blood cells (WBCs) > or = 15,000 and > or = 10,000 had sensitivities of 40% and 75%, respectively. At the time of bacteremia, age >3 years old was associated with a lower mean WBC count compared with episodes occurring in patients <3 years old (11.2 vs 16.1, P < 0.05). Patients with occult bacteremia who were discharged with antibiotics (12 i.m., 7 p.o.) were less likely than patients without antibiotic treatment to have persistent bacteremia at a return visit within 72 hours (0/19 vs 2/5, P < 0.05). No patient with occult bacteremia died, progressed to clinical meningitis, or had other sequelae. Two of fifty-four patients died as a result of their first episode of invasive pneumococcal disease. Both patients who died had meningitis and appeared ill on initial presentation. CONCLUSIONS: Neither a WBC count > or = 15,000 nor > or = 10,000 is a sensitive indicator of pneumococcal bacteremia in HIV-infected children. Empiric antibiotics are useful to decrease the risk of persistent bacteremia. Children infected with HIV who have occult pneumococcal bacteremia appear to do well with appropriate antibiotics. Patients who are afebrile and well appearing on reevaluation may be safely treated as outpatients.

Fatal accidental dibucaine poisoning in children.

Dibucaine is a potent amide anesthetic available in over-the-counter preparations. Compared with lidocaine, substantially lower doses of dibucaine may result in seizures, dysrhythmias, and death. We present three fatal cases of accidental dibucaine ingestion in children and discuss the toxicity, treatment, and prevention of such ingestions.

Idiopathic, bilateral pneumothorax: case report in a young child.

Unilateral, idiopathic pneumothorax (IP) is relatively common and occurs predominantly in males in their teens and twenties, with 85% presenting before age forty. In contrast, bilateral IP occurs rarely, with only three cases reported from 1977-87. To our knowledge, only one case of bilateral IP has been reported in the pediatric population, an adolescent male with likely recurrent disease. We present a case of a 7-year-old child with bilateral IP and discuss the diagnosis, pathophysiology, and treatment of this entity.