Proadrenomedullin Predicts Severe Disease in Children With Suspected Community-acquired Pneumonia.

BACKGROUND: Proadrenomedullin (proADM), a vasodilatory peptide with antimicrobial and anti-inflammatory properties, predicts severe outcomes in adults with community-acquired pneumonia (CAP) to a greater degree than C-reactive protein and procalcitonin. We evaluated the ability of proADM to predict disease severity across a range of clinical outcomes in children with suspected CAP. METHODS: We performed a prospective cohort study of children 3 months to 18 years with CAP in the emergency department. Disease severity was defined as mild (discharged home), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with supplemental oxygen, broadening of antibiotics, complicated pneumonia), and severe (eg, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined using proportional odds logistic regression within the cohort with suspected CAP and in a subset with radiographic CAP. RESULTS: Among 369 children, median proADM increased with disease severity (mild: median [IQR], 0.53 [0.43-0.73]; mild-moderate: 0.56 [0.45-0.71]; moderate-severe: 0.61 [0.47-0.77]; severe: 0.70 [0.55-1.04] nmol/L) (P = .002). ProADM was significantly associated with increased odds of developing severe outcomes (suspected CAP: OR, 1.68; 95% CI, 1.2-2.36; radiographic CAP: OR, 2.11; 95% CI, 1.36-3.38) adjusted for age, fever duration, antibiotic use, and pathogen. ProADM had an AUC of 0.64 (95% CI, .56-.72) in those with suspected CAP and an AUC of 0.77 (95% CI, .68-.87) in radiographic CAP. CONCLUSIONS: ProADM was associated with severe disease and discriminated moderately well children who developed severe disease from those who did not, particularly in radiographic CAP.

Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department.

PURPOSE: Adolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings. METHODS: This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED. RESULTS: Both EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9-4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7-1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: -1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: -12.2 to -2.2; p = .01). CONCLUSIONS: A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.

Development and Internal Validation of a Prediction Model to Risk Stratify Children With Suspected Community-Acquired Pneumonia.

BACKGROUND: Although community-acquired pneumonia (CAP) is one of the most common infections in children, no tools exist to risk stratify children with suspected CAP. We developed and validated a prediction model to risk stratify and inform hospitalization decisions in children with suspected CAP. METHODS: We performed a prospective cohort study of children aged 3 months to 18 years with suspected CAP in a pediatric emergency department. Primary outcome was disease severity, defined as mild (discharge home or hospitalization for <24 hours with no oxygen or intravenous [IV] fluids), moderate (hospitalization <24 hours with oxygen or IV fluids, or hospitalization >24 hours), or severe (intensive care unit stay for >24 hours, septic shock, vasoactive agents, positive-pressure ventilation, chest drainage, extracorporeal membrane oxygenation, or death). Ordinal logistic regression and bootstrapped backwards selection were used to derive and internally validate our model. RESULTS: Of 1128 children, 371 (32.9%) developed moderate disease and 48 (4.3%) severe disease. Severity models demonstrated excellent discrimination (optimism-corrected c-indices of 0.81) and outstanding calibration. Severity predictors in the final model included respiratory rate, systolic blood pressure, oxygenation, retractions, capillary refill, atelectasis or pneumonia on chest radiograph, and pleural effusion. CONCLUSIONS: We derived and internally validated a score that accurately predicts disease severity in children with suspected CAP. Once externally validated, this score has potential to facilitate management decisions by providing individualized risk estimates that can be used in conjunction with clinical judgment to improve the care of children with suspected CAP.

Development of Resident-Sensitive Quality Measures for Inpatient General Internal Medicine.

BACKGROUND: Graduate medical education (GME) training has long-lasting effects on patient care quality. Despite this, few GME programs use clinical care measures as part of resident assessment. Furthermore, there is no gold standard to identify clinical care measures that are reflective of resident care. Resident-sensitive quality measures (RSQMs), defined as "measures that are meaningful in patient care and are most likely attributable to resident care," have been developed using consensus methodology and piloted in pediatric emergency medicine. However, this approach has not been tested in internal medicine (IM). OBJECTIVE: To develop RSQMs for a general internal medicine (GIM) inpatient residency rotation using previously described consensus methods. DESIGN: The authors used two consensus methods, nominal group technique (NGT) and a subsequent Delphi method, to generate RSQMs for a GIM inpatient rotation. RSQMs were generated for specific clinical conditions found on a GIM inpatient rotation, as well as for general care on a GIM ward. PARTICIPANTS: NGT participants included nine IM and medicine-pediatrics (MP) residents and six IM and MP faculty members. The Delphi group included seven IM and MP residents and seven IM and MP faculty members. MAIN MEASURES: The number and description of RSQMs generated during this process. KEY RESULTS: Consensus methods resulted in 89 RSQMs with the following breakdown by condition: GIM general care-21, diabetes mellitus-16, hyperkalemia-14, COPD-13, hypertension-11, pneumonia-10, and hypokalemia-4. All RSQMs were process measures, with 48% relating to documentation and 51% relating to orders. Fifty-eight percent of RSQMs were related to the primary admitting diagnosis, while 42% could also be related to chronic comorbidities that require management during an admission. CONCLUSIONS: Consensus methods resulted in 89 RSQMs for a GIM inpatient service. While all RSQMs were process measures, they may still hold value in learner assessment, formative feedback, and program evaluation.

Biomarkers and Disease Severity in Children With Community-Acquired Pneumonia.

BACKGROUND: Host biomarkers predict disease severity in adults with community-acquired pneumonia (CAP). We evaluated the association of the white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP), and procalcitonin with the development of severe outcomes in children with CAP. METHODS: We performed a prospective cohort study of children 3 months to 18 years of age with CAP in the emergency department. The primary outcome was disease severity: mild (discharged from the hospital), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with receipt of intravenous fluids, supplemental oxygen, complicated pneumonia), and severe (eg, intensive care, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined within the cohort with suspected CAP and in a subset with radiographic CAP. RESULTS: Of 477 children, there were no statistical differences in the median WBC count, ANC, CRP, or procalcitonin across severity categories. No biomarker had adequate discriminatory ability between severe and nonsevere disease (area under the curve [AUC]: 0.53-0.6 for suspected CAP and 0.59-0.64 for radiographic CAP). In analyses adjusted for age, antibiotic use, fever duration, and viral pathogen detection, CRP was associated with moderate-severe disease (odds ratio 1.12; 95% confidence interval, 1.0-1.25). CRP and procalcitonin revealed good discrimination of children with empyema requiring chest drainage (AUC: 0.83) and sepsis with vasoactive infusions (CRP AUC: 0.74; procalcitonin AUC: 0.78), although prevalence of these outcomes was low. CONCLUSIONS: WBC count, ANC, CRP, and procalcitonin are generally not useful to discriminate nonsevere from severe disease in children with CAP, although CRP and procalcitonin may have some utility in predicting the most severe outcomes.

Information Technology-Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department.

PURPOSE: The aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data. METHODS: The study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14-21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS. RESULTS: Outcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%. CONCLUSIONS: Implementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.

Sharing personal health record data elements in protective custody: youth and stakeholder perspectives.

OBJECTIVE: The study sought to develop the necessary elements for a personalized health record (PHR) for youth emancipating from child protective custody (eg, foster care) by collecting thoughts and ideas from current and former foster youth and community stakeholders who have a significant amount of experience working with emancipating young people. MATERIALS AND METHODS: We employed a mixed methods, participatory research design using concept mapping to identify key features for PHR across stakeholders. RESULTS: In the clusters, common themes for necessary elements for a PHR included health education, health tips, medication instructions, diagnoses including severity, and website resources that could be trusted to provide reliable information, and addressed data privacy issues such as the primary user being able to choose what diagnoses to share with their trusted adult and the ability to assign a trusted adult to view a part of the record. DISCUSSION: By directly involving youth in the design of the PHR, we are able to ensure we included the necessary health and life skills elements that they require. As a PHR is created for foster youth, it is important to consider the multiple uses that the data may have for emancipated youth. CONCLUSION: A PHR for foster youth needs to include an appropriate combination of information and education for a vulnerable population. In addition to providing some of their basic health and custody information, a PHR provides an opportunity to give them information that can be trusted to explain common diagnoses, medications, and family health history risks.

The Reliability of Computerized Physician Order Entry Data for Research Studies.

OBJECTIVES: In the United States, adolescents account for nearly half of the newly diagnosed sexually transmitted infections annually, and many of these infections are asymptomatic. Adolescents often seek care in pediatric emergency departments; thus, the emergency department is an important setting to implement adolescent sexually transmitted infection screening. Before implementation, baseline data reflecting current screening rates of symptomatic and asymptomatic patients were needed. This study aimed to evaluate the accuracy of provider-reported rates of symptomatic and asymptomatic chlamydia (CT) and gonorrhea (GC) testing in adolescents overall and pre-electronic health record (EHR) and post-EHR order modification in preparation for a research intervention. METHODS: This was a 1-year prospective, observational study. Provider reason for CT/GC testing was added to the existing EHR order. Chart reviews were performed to ensure the accuracy of clinician CT/GC testing choices (symptomatic vs asymptomatic). Frequencies of testing choices were obtained. Order modifications were made to further clarify the definitions. A Student t test was used to compare data preorder and postorder modification. RESULTS: When relying on providers to report reasons for CT/GC testing (symptomatic vs asymptomatic), many patients were misclassified based on a priori defined testing reasons. After order modification, rates of provider-reported symptomatic testing remained unchanged (P = 0.16). Provider-reported asymptomatic testing significantly declined (P = 0.004); however, 23.2% of those tested continued to be misclassified. CONCLUSIONS: Provider-entered EHR data are increasingly being used in research studies; thus, it is important to ensure its accuracy and reliability before study implementation.

A Time-and-Motion Study of Clinical Trial Eligibility Screening in a Pediatric Emergency Department.

OBJECTIVE: Challenges with efficient patient recruitment including sociotechnical barriers for clinical trials are major barriers to the timely and efficacious conduct of translational studies. We conducted a time-and-motion study to investigate the workflow of clinical trial enrollment in a pediatric emergency department. METHODS: We observed clinical research coordinators during 3 clinically staffed shifts. One clinical research coordinator was shadowed at a time. Tasks were marked in 30-second intervals and annotated to include patient screening, patient contact, performing procedures, and physician contact. Statistical analysis was conducted on the patient enrollment activities. RESULTS: We conducted fifteen 120-minute observations from December 12, 2013, to January 3, 2014 and shadowed 8 clinical research coordinators. Patient screening took 31.62% of their time, patient contact took 18.67%, performing procedures took 17.6%, physician contact was 1%, and other activities took 31.0%. CONCLUSIONS: Screening patients for eligibility constituted the most time. Automated screening methods could help reduce this time. The findings suggest improvement areas in recruitment planning to increase the efficiency of clinical trial enrollment.

Reliability of Examination Findings in Suspected Community-Acquired Pneumonia.

BACKGROUND: The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP. METHODS: This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables. RESULTS: No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate. CONCLUSIONS: In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.

A comprehensive view of parental satisfaction with pediatric emergency department visits.

STUDY OBJECTIVE: We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data. METHODS: This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview-style question. RESULTS: Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview-style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their child's diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care. CONCLUSION: Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.

Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal.

OBJECTIVE: The AAP recommends that a follow-up skeletal survey be obtained for all children < 24 months of age who are strongly suspected to be victims of abuse. The objective of the current study was to evaluate the utility of a follow-up skeletal survey in suspected child physical abuse evaluations when the initial skeletal survey is normal. METHODS: A retrospective review of radiology records from September 1, 1998 - January 31, 2007 was conducted. Suspected victims of child abuse who were < 24 months of age and received initial and follow-up skeletal surveys within 56 days were enrolled in the study. Children with a negative initial skeletal survey were included for further analysis. RESULTS: Forty-seven children had a negative initial skeletal survey and were included for analysis. The mean age was 6.9 months (SD 5.7); the mean number of days between skeletal surveys was 18.7 (SD 10.1)Four children (8.5%) had signs of healing bone trauma on a follow-up skeletal survey. Three of these children (75%) had healing rib fractures and one child had a healing proximal humerus fracture. The findings on the follow-up skeletal survey yielded forensically important information in all 4 cases and strengthened the diagnosis of non-accidental trauma. CONCLUSION: 8.5 percent of children with negative initial skeletal surveys had forensically important findings on follow-up skeletal survey that increased the certainty of the diagnosis of non-accidental trauma. A follow-up skeletal survey can be useful even when the initial skeletal survey is negative.

Biomarkers to distinguish surgical etiologies in females with lower quadrant abdominal pain.

OBJECTIVES: Lower abdominal pain is a common complaint in girls and young women presenting to a pediatric emergency department (PED). An extensive evaluation may be required to exclude surgical emergencies such as appendicitis and ovarian torsion. However, clinicians and families prefer to limit invasive procedures and radiation exposure. The literature suggests that serum biomarkers such as the cytokine interleukin-6 (IL-6) can predict ovarian torsion in adults, while the membrane glycoprotein cluster of differentiation-64 (CD64) has been linked with bacterial infections and sepsis. Therefore, the study objective was to assess whether plasma IL-6 or neutrophil CD64 surface levels would assist clinicians in distinguishing surgical diagnoses (ovarian torsion and appendicitis) from nonsurgical diagnoses in young females with lower abdominal pain. METHODS: This study was a prospective, cross-sectional, pilot study of young females presenting with lower abdominal pain. Demographics, clinical and laboratory data, and final diagnoses were recorded. Plasma IL-6 and neutrophil CD64 were quantified. Nonparametric Kruskal-Wallis test was used to detect significant differences in IL-6 and CD64 values between surgical and nonsurgical patients. Further analysis was done to detect differences among the surgical patients (appendicitis vs. ovarian torsion). A bivariate analysis using the Wilcoxon rank sum was used to test for significant differences in IL-6 and CD64 by selected clinical factors. RESULTS: There were 112 female subjects ages 6 to 21 years enrolled. Final diagnoses were grouped as appendicitis (n = 38, 34%), ovarian torsion (n = 15, 13%), and nonsurgical (n = 59, 53%). Surgical cases had significantly higher levels of IL-6 compared to nonsurgical cases (p < 0.0001), and appendicitis patients had significantly higher CD64 indexes compared to ovarian torsion patients (p = 0.007). The clinical characteristics of fever of ≥38°C (p = 0.0002) and constant pain (p = 0.02) were significantly associated with elevated IL-6. Fever of ≥38°C (p = 0.02) was significantly associated with a higher CD64 index. CONCLUSIONS: Interleukin-6 was significantly elevated in surgical patients compared to nonsurgical patients in this sample of young females, and CD64 was significantly elevated in appendicitis patients compared to ovarian torsion patients. These data suggest that with larger sample sizes and future confirmatory studies, these biomarkers may be useful in the evaluation of young women with lower quadrant abdominal pain.