Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study.

BACKGROUND: The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research. METHODS: Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility. RESULTS: Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception. CONCLUSIONS: This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

The P2Network-Advancing Pediatric Emergency Care With Point-of-Care Ultrasound.

ABSTRACT: Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.

CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis.

Protocols for the sanitation and maintenance of point-of-care ultrasound (US) equipment are lacking. This study introduces the CLEAR protocol (clean, locate, energize, augment supplies, and remove patient identifiers) as a tool to improve the readiness of US equipment, termed US equipment homeostasis. The state of US equipment homeostasis in the emergency department of a single academic center was investigated before and after implementing this protocol, with an improvement in outcomes. These findings demonstrate that the CLEAR protocol can improve US homeostasis. CLEAR can function as a teaching tool to promote homeostasis as well as a checklist to assess compliance.

Distraction Injury of the Thoracic Spine With Spinal Cord Transection and Vascular Injury in a 5-Week-Old Infant Boy: A Case of Child Physical Abuse.

Distraction injury of the spine with spinal cord transection and adjacent vascular injury is rarely described in the setting of child physical abuse. We report a 5-week-old infant boy who sustained these injuries after an abusive event. The clinical presentation, imaging findings, and recommended evaluation modalities are discussed. An overview of pediatric spinal column and vascular injuries secondary to physical abuse is given.

Pediatric Emergency Medicine Physicians' Use of Point-of-care Ultrasound and Barriers to Implementation: A Regional Pilot Study.

OBJECTIVES: Point-of-care ultrasound (POCUS) has been identified as a critical skill for pediatric emergency medicine (PEM) physicians. The purpose of this study was to profile the current status of PEM POCUS in pediatric emergency departments (EDs). METHODS: An electronic survey was distributed to PEM fellows and attending physicians at four major pediatric academic health centers. The 24-item questionnaire covered professional demographics, POCUS experience and proficiency, and barriers to the use of POCUS in pediatric EDs. We used descriptive and inferential statistics to profile respondent's PEM POCUS experience and proficiency and Rasch analysis to evaluate barriers to implementation. RESULTS: Our return rate was 92.8% (128/138). Respondents were attending physicians (68%) and fellows (28%). Most completed pediatric residencies prior to PEM fellowship (83.6%). Almost all had some form of ultrasound education (113/128, 88.3%). Approximately half (46.9%) completed a formal ultrasound curriculum. More than half (53.2%) said their ultrasound education was pediatric-specific. Most participants (67%) rated their POCUS proficiency low (Levels 1-2), while rating proficiency in other professional competencies (procedures 52%, emergency stabilization 70%) high (Levels 4-5). There were statistically significant differences in POCUS proficiency between those with formal versus informal ultrasound education (p < 0.001) and those from pediatric versus emergency medicine residencies (p < 0.05). Participants identified both personal barriers discomfort with POCUS skills (76.7%), insufficient educational time to learn POCUS (65%), and negative impact of POCUS on efficiency (58.5%)-and institutional barriers to the use of ultrasound-consultants will not use ultrasound findings from the ED (60%); insufficient mentoring (64.7%), and POCUS not being a departmental priority (57%). CONCLUSIONS: While POCUS utilization continues to grow in PEM, significant barriers to full implementation still persist. One significant barrier relates to the need for dedicated time to learn and practice POCUS to achieve sufficient levels of proficiency for use in practice.

Evaluating the Pediatric Early Warning Score (PEWS) system for admitted patients in the pediatric emergency department.

OBJECTIVES: The Pediatric Early Warning Score (PEWS) systems were developed to provide a reproducible assessment of a child's clinical status while hospitalized. Most studies investigating the PEWS evaluate its usefulness in the inpatient setting. Limited studies evaluate the effectiveness and integration of PEWS in the pediatric emergency department (ED). The goal of this study was to explore the test characteristics of an ED-assigned PEWS score for intensive care unit (ICU) admission or clinical deterioration in admitted patients. METHODS: This was a prospective 12-month observational study of patients, aged 0 to 21 years, admitted from the ED of an urban, tertiary care children's hospital. ED nurses were instructed in PEWS assignment and electronic medical record (EMR) documentation. Interrater reliability between nurses was evaluated. PEWS scores were measured at initial assessment (P0) and time of admission (P1). Patients were stratified into outcome groups: those admitted to the ICU either from the ED or as transfers from the floor and those admitted to the floor only. Clinical deterioration was defined as transfer to the ICU within 6 hours or within 6 to 24 hours of admission. PEWS scores and receiver operating characteristic (ROC) curves were compared for patients admitted to the floor, ICU, and with clinical deterioration. RESULTS: The authors evaluated 12,306 consecutively admitted patients, with 99% having a PEWS documented in the EMR. Interrater reliability was excellent (intraclass coefficient = 0.91). A total of 1,300 (10.6%) patients were admitted to the ICU and 11,066 (89.4%) were admitted to the floor. PEWS scores were higher for patients in the ICU group (P0 = 2.8, SD ± 2.4; P1 = 3.2, SD ± 2.4; p < 0.0001) versus floor patients (P0 = 0.7, SD ± 1.2; P1 = 0.5, SD ± 0.9; p < 0.0001). To predict the need for ICU admission, the optimal cutoff points on the ROC are P0 = 1 and P1 = 2, with areas under the ROC curve (AUCs) of 0.79 and 0.86, respectively. The likelihood ratios (LRs) for these optimal cutoff points were as follows: P0 +LR = 2.5 (95% confidence interval [CI] = 2.4 to 2.6, p < 0.05), -LR = 0.32 (95% CI = 0.28 to 0.36, p < 0.05); and P1 +LR = 6.2 (95% CI = 5.8 to 6.6, p < 0.05), -LR = 0.32 (95% CI = 0.29 to 0.35, p < 0.05). For every unit increase in P0 and P1 , the odds of admission to the ICU were 1.9 times greater (95% CI = 1.8 to 1.9, p < 0.0001) and 2.9 times greater (95% CI = 2.7 to 3.1, p < 0.0001) than to the floor. There were 89 patients in the clinical deterioration group, with 36 (0.3%) patients transferred to the ICU within 6 hours of admission and 53 (0.4%) patients transferred within 6 to 24 hours. In this group, an elevated P0 and P1 were statistically associated with an increased risk of transfer with optimal cutoff points similar to above; however, there were poorer AUCs and test characteristics. CONCLUSIONS: A PEWS system was implemented in this pediatric ED with excellent data capture and nurse interrater reliability. The study found that an elevated PEWS is associated with need for ICU admission directly from the ED and as a transfer, but lacks the necessary test characteristics to be used independently in the ED environment.