Diastolic Hypotension, Troponin Elevation, and Electrocardiographic Changes Associated With the Management of Moderate to Severe Asthma in Children.

OBJECTIVE: The objective was to determine the occurrence of, and the factors associated with, diastolic hypotension and troponin elevation or electrocardiogram (ECG) ST-segment changes in a convenience sample of children with moderate to severe asthma receiving continuous albuterol nebulization. METHODS: This was a prospective, descriptive study in a pediatric emergency department and an intensive care unit of a tertiary academic center. Fifty children with moderate to severe asthma (clinical asthma score > 8) who received 10 to 15 mg/hour continuous albuterol for >2 hours between June 5, 2007, and February 4, 2008, were approached. Hourly diastolic blood pressures were recorded. Cardiac troponin I (cTnI) and ECG tracings were obtained following the first 2 hours of albuterol and then subsequently every 12 hours while receiving continuous albuterol. Main outcome measures were: 1) incidence of diastolic hypotension, 2) incidence of troponin elevation, and 3) incidence of ECG ST-depression. RESULTS: Fifty patients were enrolled. Thirty-three (66%) patients developed diastolic hypotension during the first 6 hours of continuous albuterol. Diastolic blood pressure declined from baseline at 1-6 hours (p < 0.01 vs. baseline). Twelve patients (24%) had elevated cTnI, 15 patients (30%) had ST-segment change, four patients (8%) had both, and 23 patients (46%, 95% confidence interval [CI] = 32 to 60) had either a cTnI elevation or an ECG ST-segment change. Troponin elevation and diastolic hypotension were not associated (RR = 1.2, 95% CI = 0.6 to 2.3). CONCLUSIONS: In a subset of children with moderate to severe asthma, diastolic hypotension, troponin elevation, and ECG ST-segment change occur during administration of continuous albuterol. Future studies are necessary to determine the clinical significance of these findings.

Pediatric disaster preparedness and response and the nation's children's hospitals.

OBJECTIVE: Children account for 30 percent of the US population; as a result, many victims of disaster events are children. The most critically injured pediatric victims would be best cared for in a tertiary care pediatric hospital. The Children's Hospital Association (CHA) undertook a survey of its members to determine their level of readiness to respond to a mass casualty disaster. DESIGN: The Disaster Response Task Force constructed survey questions in October 2011. SETTING AND PARTICIPANTS: The survey was distributed via e-mail to the person listed as an "emergency manager/disaster contact" at each association member hospital and was designed to take less than 15 minutes to complete. MAIN OUTCOME MEASURES: The survey sought to determine how children's hospitals address disaster preparedness, how prepared they feel for disaster events, and how CHA could support their efforts in preparedness. RESULTS: One hundred seventy-nine surveys were distributed with a 36 percent return rate. Seventy percent of respondent hospitals have a structure in place to plan for disaster response. There was a stronger level of confidence for hospitals in responding to local casualty events than for those responding to large-scale regional, national, and international events. Few hospitals appear to interact with nonmedical facilities with a high concentration of children such as schools or daycares. CONCLUSIONS: Little commonality exists among children's hospitals in approaches to disaster preparedness and response. Universally, respondents can identify a disaster response plan and routinely participate in drills, but the scale and scope of these plans and drills vary substantially.

Hospital Readmissions Among Children With H1N1 Influenza Infection.

OBJECTIVES: To describe readmissions among children hospitalized with H1N1 (influenza subtype, hemagglutinin1, neuraminidase 1) pandemic influenza and secondarily to determine the association of oseltamivir during index hospitalization with readmission. METHODS: We reviewed data from 42 freestanding children's hospitals contributing to the Pediatric Health Information System from May through December 2009 when H1N1 was the predominant influenza strain. Children were divided into 2 groups by whether they experienced complications of influenza during index hospitalization. Primary outcome was readmission at 3, 7, and 30 days among both patient groups. Secondary outcome was the association of oseltamivir treatment with readmission. RESULTS: The study included 8899 children; 6162 patients had uncomplicated index hospitalization, of whom 3808 (61.8%) received oseltamivir during hospitalization, and 2737 children had complicated influenza, of whom 1055 (38.5%) received oseltamivir. Median 3-, 7-, and 30-day readmission rates were 1.6%, 2.5%, and 4.7% for patients with uncomplicated index hospitalizations and 4.3%, 5.8%, and 10.3% among patients with complicated influenza. The 30-day readmission rates did not differ by treatment group among patients with uncomplicated influenza; however, patients with complicated index hospitalizations who received oseltamivir had lower all-cause 30-day readmissions than untreated patients. The most common causes of readmission were pneumonia and asthma exacerbations. CONCLUSIONS: Oseltamivir use for hospitalized children did not decrease 30-day readmission rates in children after uncomplicated index hospitalization but was associated with a lower 30-day readmission rate among children with complicated infections during the 2009 H1N1 pandemic. Readmission rates for children who had complicated influenza infection during index hospitalizations are high.

Making disaster care count: consensus formulation of measures of effectiveness for natural disaster acute phase medical response.

INTRODUCTION: No standard exists for provision of care following catastrophic natural disasters. Host nations, funders, and overseeing agencies need a method to identify the most effective interventions when allocating finite resources. Measures of effectiveness are real-time indicators that can be used to link early action with downstream impact. HYPOTHESIS: Group consensus methods can be used to develop measures of effectiveness detailing the major functions of post natural disaster acute phase medical response. METHODS: A review of peer-reviewed disaster response publications (2001-2011) identified potential measures describing domestic and international medical response. A steering committee comprised of six persons with publications pertaining to disaster response, and those serving in leadership capacity for a disaster response organization, was assembled. The committee determined which measures identified in the literature review had the best potential to gauge effectiveness during post-disaster acute-phase medical response. Using a modified Delphi technique, a second, larger group (Expert Panel) evaluated these measures and novel measures suggested (or "free-texted") by participants for importance, validity, usability, and feasibility. After three iterations, the highest rated measures were selected. RESULTS: The literature review identified 397 measures. The steering committee approved 116 (29.2%) of these measures for advancement to the Delphi process. In Round 1, 25 (22%) measures attained >75% approval and, accompanied by 77 free-text measures, graduated to Round 2. There, 56 (50%) measures achieved >75% approval. In Round 3, 37 (66%) measures achieved median scores of 4 or higher (on a 5-point ordinal scale). These selected measures describe major aspects of disaster response, including: Evaluation, Treatment, Disposition, Public Health, and Team Logistics. Of participants from the Expert Panel, 24/39 (63%) completed all rounds. Thirty-three percent of these experts represented international agencies; 42% represented US government agencies. CONCLUSION: Experts identified response measures that reflect major functions of an acute medical response. Measures of effectiveness facilitate real-time assessment of performance and can signal where practices should be improved to better aid community preparedness and response. These measures can promote unification of medical assistance, allow for comparison of responses, and bring accountability to post-disaster acute-phase medical care. This is the first consensus-developed reporting tool constructed using objective measures to describe the functions of acute phase disaster medical response. It should be evaluated by agencies providing medical response during the next major natural disaster.

Engagement and education: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: Engagement and education of ICU clinicians in disaster preparedness is fragmented by time constraints and institutional barriers and frequently occurs during a disaster. We reviewed the existing literature from 2007 to April 2013 and expert opinions about clinician engagement and education for critical care during a pandemic or disaster and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this article are important for all of those involved in a pandemic or large-scale disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: A systematic literature review was performed and suggestions formulated according to the American College of Chest Physicians (CHEST) Consensus Statement development methodology. We assessed articles, documents, reports, and gray literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: (1) situational awareness, (2) clinician roles and responsibilities, (3) education, and (4) community engagement. Together, these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care. CONCLUSIONS: The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals. An effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians.

Creation and Delphi-method refinement of pediatric disaster triage simulations.

OBJECTIVE: There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. METHODS: We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. RESULTS: After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. CONCLUSIONS: The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Going viral: adapting to pediatric surge during the H1N1 pandemic.

OBJECTIVES: The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. METHODS: Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant's hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. RESULTS: The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. CONCLUSIONS: Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.

Feasibility of web-based self-triage by parents of children with influenza-like illness: a cautionary tale.

IMPORTANCE: Self-triage using web-based decision support could be a useful way to encourage appropriate care-seeking behavior and reduce health system surge in epidemics. However, the feasibility and safety of this strategy have not previously been evaluated. OBJECTIVE: To assess the usability and safety of Strategy for Off-site Rapid Triage (SORT) for Kids, a web-based decision support tool designed to translate clinical guidance developed by the Centers for Disease Control and Prevention to help parents and adult caregivers determine if a child with influenza-like illness requires immediate care in an emergency department (ED). DESIGN: Prospective pilot validation study conducted between February 8 and April 30, 2012. Staff who abstracted medical records and made follow-up calls were blinded to the SORT algorithm's assessment of the child's level of risk. SETTING: Two pediatric emergency departments in the National Capital Region. PARTICIPANTS: Convenience sample of 294 parents and adult caregivers who were at least 18 years of age; able to read and speak English; and the parent or legal guardian of a child 18 years or younger presenting to 1 of 2 EDs with signs and symptoms meeting Centers for Disease Control and Prevention criteria for influenza-like illness. INTERVENTION: Completion of the SORT for Kids survey. MAIN OUTCOME MEASURES: Caregiver ratings of the website's usability and the sensitivity of the underlying algorithm for identifying children who required immediate ED management of influenza-like illness, defined as receipt of 1 or more of 5 essential clinical services. RESULTS: Ninety percent of participants reported that the website was "very easy" to understand and use. Ratings did not differ by respondent race, ethnicity, or educational attainment. Of the 15 patients whose initial ED visit met explicit criteria for clinical necessity, the Centers for Disease Control and Prevention algorithm classified 14 as high risk, resulting in an overall sensitivity of 93.3% (exact 95% CI, 68.1%-99.8%). Specificity of the algorithm was poor. CONCLUSIONS AND RELEVANCE: This pilot study suggests that web-based decision support to help parents and adult caregivers self-triage children with influenza-like illness is feasible. However, prospective refinement of the clinical algorithm is needed to improve its specificity without compromising patient safety.

Comparison of pandemic and seasonal influenza A infections in pediatric patients: were they different?

This retrospective cohort study revealed that the presence of pandemic H1N1 influenza resulted in a 77.7% increase of patient visits in the emergency department for influenza like illnesses and a 67.2% increase of hospital days in our hospital by comparing to a regular influenza season (2008-2009 season). However, median length of hospital stay was no different in either period (pandemic: 3 days versus seasonal: 4 days, P = 0.06). Except for the patients hospitalized for pandemic H1N1 influenza (n = 111) were older (median age: 4.7 years versus 1.6 years, P = 0.04) and tended to have pre-existing asthma (21.6% versus 9.0%, P = 0.07) than those hospitalized for seasonal influenza A infections (n = 44), this study found no significant difference between the two comparison groups with regards of other clinical and epidemiological features.

Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States.

Quantifying how close hospitals came to exhausting capacity during the outbreak of pandemic influenza A (H1N1) 2009 can help the health care system plan for more virulent pandemics. This ecologic analysis used emergency department (ED) and inpatient data from 34 US children's hospitals. For the 11-week pandemic (H1N1) 2009 period during fall 2009, inpatient occupancy reached 95%, which was lower than the 101% occupancy during the 2008-09 seasonal influenza period. Fewer than 1 additional admission per 10 inpatient beds would have caused hospitals to reach 100% occupancy. Using parameters based on historical precedent, we built 5 models projecting inpatient occupancy, varying the ED visit numbers and admission rate for influenza-related ED visits. The 5 scenarios projected median occupancy as high as 132% of capacity. The pandemic did not exhaust inpatient bed capacity, but a more virulent pandemic has the potential to push children's hospitals past their maximum inpatient capacity.

Resource burden at children's hospitals experiencing surge volumes during the spring 2009 H1N1 influenza pandemic.

OBJECTIVES: The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. METHODS: The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). RESULTS: Overall, 390,983 visits, and 88,885 visits for IRI, were included for Calendar Weeks 16 through 29, when 2009 H1N1 influenza was circulating. The subset of 106,330 visits and 31,703 IRI visits made to the 14 hospitals experiencing the authors' definition of ED surge during Weeks 16 to 29 was also studied. During surge weeks, the 14 EDs experienced 29% more total visits and 51% more IRI visits than expected (p < 0.01 for both comparisons). Of ED IRI visits during surge weeks, only 4.8% were admitted to non-intensive care beds (70% of expected, p < 0.01), 0.19% were admitted to intensive care units (44% of expected, p < 0.01), and 0.01% received mechanical ventilation (5.0% of expected, p < 0.01). Factors associated with more-than-expected visits included ages 2-17 years, payer type, and asthma. No factors were associated with more-than-expected hospitalizations from the ED. CONCLUSIONS: During the spring 2009 H1N1 influenza pandemic, pediatric EDs nationwide experienced a marked increase in visits, with far fewer than expected requiring nonintensive or intensive care hospitalization. The data in this study can be used for future pandemic planning.

A rapid medical screening process improves emergency department patient flow during surge associated with novel H1N1 influenza virus.

STUDY OBJECTIVE: We compare emergency department (ED) patient flow during the fall 2009 novel H1N1-associated surge in patient volumes at an urban, tertiary care, pediatric medical center to that in the previous winter virus season. METHODS: A rapid medical screening process was instituted to manage the surge in patient census. The process included the use of a new, separate clinical area converted from office space adjacent to the ED, the introduction of a new preprinted checklist for rapid documentation of medical history and physical examination of patients with influenza-like illness, the use of classroom-style parent discharge education, and the use of preprinted discharge prescription and instructions. We compared patient flow parameters, including waiting time, length of stay, and elopement rates, and returns within 48 hours and 7 days for a comparable period in winter 2008 to 2009. RESULTS: During the first 30 days of the novel H1N1-associated surge in patient volumes (October 12 to November 10, 2009), overall ED daily volumes increased by a mean of 113 (51.8%) compared with baseline (daily increase range 49 to 118 patients). Of the 10,013 patients treated during this period, 4,287 (42.8%) had complaints consistent with influenza-like illness and 1,767 (17.6%) were treated with the rapid screening process. The mean wait time decreased from 92.9 to 81.2 minutes (difference 11.7 minutes; 95% confidence interval [CI] 10.2 to 13.2 minutes). Overall mean ED length of stay decreased from 241 to 212.3 minutes (difference 28.7 minutes; 95% CI 25.8 to 31.6 minutes). Rates of elopement were unchanged, and elopement rates as a function of daily patient volumes showed improved responsiveness to high volumes. Rates of return were unchanged within 48 hours (3.0% in 2009 versus 2.9% in 2008; odds ratio 1.03 [0.91 to 1.18]) and within 7 days (6.2% in 2009 versus 5.7% in 2008; odds ratio 1.09 [0.99 to 1.20]). The use of the rapid screening process required a mean of 23.5 (95% CI 16.4 to 30.6) additional hours per day of physician staffing and a mean of 26.3 (95% CI 18.5 to 34.1) additional hours of nursing staffing. CONCLUSION: The implementation of a rapid screening process during the fall 2009 H1N1-associated surge in patient volumes was associated with improved patient flow without affecting rates of return to the ED within 48 hours or 7 days. This was accomplished with only a modest increase in staffing.