Decreasing Blood Culture Collection in Hospitalized Patients with CAP, SSTI, and UTI.

Background: Blood culture collection in pediatric patients with community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) remains high despite evidence of its limited utility. We aimed to decrease the number of cultures collected in children hospitalized for CAP, SSTI, and UTI by 25% over 11 months. Methods: Quality improvement initiative at a children's hospital among well-appearing patients aged 2 months or more to 18 years diagnosed with CAP, SSTI, or UTI. Our primary and secondary outcomes were blood culture collection rate and positivity rate, respectively. Interventions focused on three key drivers: academic detailing, physician awareness of personal performance, and data transparency. Results: Over the 2-year study period, there were 105 blood cultures collected in 223 hospitalized patients. Blood culture collection rates demonstrated special cause variation, decreasing from 63.5% to 24.5%. For patients with UTI, 86% (18/21) of blood cultures were negative, whereas 100% were negative for CAP and SSTI. All three patients with bacteremic UTI had a concurrent urine culture growing the same pathogen. Balancing measures remained unchanged, including escalation to a higher level of care and return to the emergency department or hospital within 14 days for the same infection. Conclusions: A multifaceted quality improvement approach can reduce blood culture collection for hospitalized patients with CAP, SSTI, and UTI without significant changes to balancing measures. Despite the reduction achieved, the near-universal negative culture results suggest continued overutilization and highlight the need for more targeted approaches to blood culture collection.

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol.

INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

Mental Health Revisits at US Pediatric Emergency Departments.

Importance: Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. Objective: To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. Design, Setting, and Participants: In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Exposures: Characteristics of patients, encounters, hospitals, and communities. Main Outcomes and Measures: The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. Results: There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Conclusions and Relevance: Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

Parental attitudes in the pediatric emergency department about the COVID-19 vaccine.

BACKGROUND: COVID-19 vaccinations are now recommended in the United States (U.S.) for children ≥ 6 months old. However, pediatric vaccination rates remain low, particularly in the Hispanic/Latinx population. OBJECTIVE: Using the 4C vaccine hesitancy framework (calculation, complacency, confidence, convenience), we examined parental attitudes in the emergency department (ED) towards COVID-19 vaccination, identified dimensions of parental vaccine hesitancy, and assessed parental willingness to have their child receive the COVID-19 vaccine. METHODS: As part of a larger multi-methods study examining influenza vaccine hesitancy, we conducted interviews that included questions about COVID-19 vaccine authorization for children. We used directed content analysis to extract qualitative themes from 3 groups of parents in the ED: Hispanic/Latinx Spanish speaking (HS), Hispanic/Latinx English speaking (HE), non-Hispanic/non-Latinx White English speaking (WE). Themes were triangulated with the Parent Attitudes about Childhood Vaccines (PACV) survey, where higher scores indicate increased vaccine hesitancy. RESULTS: Factors influencing vaccine hesitancy were mapped to the 4C framework from 58 sets of interviews and PACVs. HE and HS parents, compared to WE parents, had less knowledge about COVID-19 and its vaccine, and more beliefs in COVID-19 vaccine myths. However, both HS and HE parent groups were more inclined to endorse COVID-19 vaccine effectiveness as a reason to have their children vaccinated. HS parents felt that COVID-19 increased their fear of illnesses in general and were worried about confusing COVID-19 with other infections. Median PACV scores of HS (Mdn = 20) and HE (Mdn = 20) parent groups were higher than of WE parents (Mdn = 10), but parental willingness to have their child receive COVID-19 vaccination was similar across groups. CONCLUSIONS: Higher COVID-19 vaccine hesitancy among HS and HE parents compared to WE parents may be attributed to insufficient knowledge about COVID-19, its vaccine, along with COVID-19 vaccine myths. Efforts to provide targeted vaccine education to different populations is warranted.

Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency.

OBJECTIVE: A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization. METHODS: A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization. RESULTS: In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration. CONCLUSIONS: Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.

Geospatial data in pediatric asthma in the United States: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify and describe the literature on the use of geospatial data in pediatric asthma research. INTRODUCTION: Asthma is one of the most common pediatric chronic diseases in the United States, disproportionately affecting low-income patients. Asthma exacerbations may be triggered by local environmental factors, such as air pollution or exposure to indoor allergens. Geographic information systems are increasingly recognized as tools that use geospatial data to enhance understanding of the link between environmental exposure, social determinants of health, and clinical outcomes. Geospatial data in pediatric asthma may help inform risk factors for asthma severity, and guide targeted clinical and social interventions. INCLUSION CRITERIA: This review will consider studies that utilize geospatial data in the evaluation of pediatric patients with asthma, ages 2 to 18 years, in the United States. Mixed samples of adults and children will also be considered. Geospatial data will include any external non-clinical geographic-based data source that uses a patient's environment or context. METHODS: The following databases will be searched: PubMed, Embase, Cochrane CENTRAL, CINAHL, ERIC, Web of Science, and IEEE. Gray literature will be searched in DBLP, the US Environmental Protection Agency, Google Scholar, Google search, and a hand search of recent abstracts from relevant conferences. Articles published in English, Spanish, and French from 2010 to the present will be included. Study screening and selection will be performed independently by 2 reviewers. Data extraction will be performed by a trained research team member following pilot testing.

Social Emergency Medicine: Capitalizing on the Pediatric Emergency Department Visit to Screen and Connect Patients and Families to Community Resources.

OBJECTIVE: To describe the social needs of families screened by the Community Health Advocates Team (CHAT) Desk, situated within a pediatric emergency department (PED); and to evaluate the effectiveness of this help desk in connecting families to community resources. METHODS: Trained undergraduates, onsite in the PED 30 hours/week during daytime and evening hours, weekdays and weekends, screened a convenience sample of families of patients in the PED for social needs, and provided information on available community resources. Families were offered a follow-up phone call several weeks after their PED visit to assess program satisfaction and success, and identify remaining social needs. RESULTS: Between January 2019 and March 2020, CHAT Desk screened and assisted 682 families. CHAT routinely provided resources about free outdoor recreational activities for families, but after that, the most commonly provided informational resources pertained to: health care (n = 200), housing (n = 143), and food (n = 137). Of families who completed the follow-up phone call (n = 294), almost half (n = 134, 46%) reported being able to contact at least one of the resources; 100 reported that the resource was able to assist them, and 99 families planned to continue using the resource. When asked about satisfaction, 93% (n = 274) reported being very satisfied or somewhat satisfied with CHAT; 94% (n = 276) said they would recommend it to others. CONCLUSIONS: The PED of a busy tertiary care children's hospital is an opportune location to screen families for social needs, and provide them with information on requested community resources.

Leaving Without Being Seen From a Pediatric Emergency Department: Identifying Caregivers' Perspectives Using Q-methodology.

OBJECTIVE: National rates of left (or leaving) without being seen (LWBS) in pediatric emergency departments (PED) are higher than general emergency departments. We investigated coexisting perspectives on LWBS. METHODS: Q-methodology was implemented through a mixed-methods design. Semistructured interviews elicited a concourse of caregivers' thoughts on waiting in the PED and their consideration of LWBS. Themes from the concourse were identified and framed as statements. Caregivers sorted these statements, which ranged from choosing to stay versus leave the PED before their child is seen by a physician. Sorted data were analyzed through centroid factor analysis. RESULTS: Seventy-seven caregivers contributed interview data, from which 31 themes were identified and framed as statements. Thirty-one different caregivers contributed Q-sort data, from which 2 factors were revealed, each representing a unique perspective on LWBS. Most caregivers (26 of 31) shared the following perspective: "I would leave the PED before my child is seen by a doctor if there are no reassessments for my child while we are in the queue, no updates on our queue position, or no explanations for wait time." The remaining caregivers (5 of 31) perceived feelings of uncertainty and helplessness, lack of updates, and competing obligations as primary influences on LWBS. CONCLUSIONS: Elements that factor into caregivers' decision to LWBS from a PED include lack of reassessments, lack of updates on queue position, and lack of information about the triage process. Quality improvement interventions for decreasing LWBS rates should account for diverse coexisting perspectives such as these.

Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department.

OBJECTIVE: To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use. STUDY DESIGN: QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions. RESULTS: The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P < .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit. CONCLUSION: After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.

A Multifaceted Quality Improvement Intervention to Improve Watchful Waiting in Acute Otitis Media Management.

INTRODUCTION: Despite the American Academy of Pediatrics (AAP) guidelines for acute otitis media (AOM) describing a watchful waiting (WW) approach in qualifying patients, immediate antibiotics are consistently overutilized. The study team developed a multifaceted quality improvement intervention that educated providers and families about WW and included a behavioral component to modify physician prescribing patterns. METHODS: We used data from a prior study of 250 patients 18 years old and younger with AOM in a tertiary care children's hospital emergency department (ED) to characterize baseline AOM management before interventions. In this study, interventions took place from September to December 2016. Following the interventions, 65 patients were randomly selected, which would allow for the detection of a 20% increase in adherence to AAP guidelines for management of AOM. RESULTS: In the preintervention cohort of 250 patients, 247 had documented AOM. Two hundred thirty-one (93.5%) received immediate antibiotics, 7 (2.8%) underwent WW, and 9 (3.6%) were sent home without antibiotics. Overall management agreed with AAP guidelines at a rate of 44.1%. In the postintervention cohort of 65 patients, 63 met age and diagnostic criteria for AOM; 56 (88.9%) patients received immediate antibiotics; and 7 (11.1%) underwent WW. Postintervention, which the ED management of AOM agreed with AAP guidelines 60.3% of the time, was significantly increased from preintervention adherence (P = 0.02). CONCLUSIONS: A multipronged quality improvement intervention for AOM management in a single pediatric ED significantly improved adherence to AAP guidelines by increasing WW and reducing immediate antibiotic prescriptions.

The cost of callbacks: return visits for diagnostic imaging discrepancies in a pediatric emergency department.

PURPOSE: Diagnostic imaging has mirrored the steady growth of healthcare utilization in the USA. This has created greater opportunity for diagnostic errors, which can be costly in terms of morbidity and mortality as well as dollars and cents. The purposes of this study were to describe all return visits to a tertiary care urban pediatric emergency department (PED) resulting from diagnostic imaging discrepancies and to calculate the costs of these return visits. METHODS: From July 2014 to February 2015, all children who underwent a diagnostic imaging study during an ED visit were assembled. Analysis was performed on all children who were called back and returned to the ED following a discrepant read. Direct and indirect costs to the patient, family, hospital, and society for these return visits were calculated. RESULTS: During the study period, 8310 diagnostic imaging studies were performed, with 207 (2.5%) discrepant reads. Among the discrepant reads, 37 (0.4% of total, 17.9% of discrepant) patients had a return visit to the ED for further management. Including ED charges, time and travel costs to the family, and costs of radiation exposure, return visits for radiologic discrepancies over this 8-month period cost a total of $84,686.47, averaging $2288.82 per patient. CONCLUSIONS: Though the overall diagnostic imaging discrepancy rate among our study population was low, the clinically significant discrepancies requiring return ED visits were potentially high risk, and costly for the patient, family, and healthcare system.

Community Resource Needs Assessment Among Families Presenting to a Pediatric Emergency Department.

OBJECTIVE: To identify community resource needs among families presenting to a pediatric emergency department (PED). METHODS: A convenience sample of English- and Spanish-speaking caregivers residing in Los Angeles County who presented to the PED of a large urban children's hospital were surveyed. The needs assessment survey assessed demographics, food insecurity, and previous and anticipated need for 12 common community resources. RESULTS: Of 768 caregivers who completed the survey, 75% identified as Hispanic/Latinx. Across all survey participants, 83% used at least 1 resource in the past, and 67% anticipated needing at least 1 resource in the next 12 months. Low-cost/free health clinics were the most common resources used in the past and needed for the future. Caregivers with younger children tended to need baby formula/breastfeeding and women's health resources, whereas caregivers with older children tended to need safe housing, subsidized utilities, and counseling/therapy. Many families who needed resources in the past and for the future resided south of the children's hospital where median household income was relatively lower than in other areas of the county. A pattern of heightened use emerged among caregivers who primarily spoke Spanish. On average, caregivers reported feeling comfortable approaching hospital staff about community resources. CONCLUSIONS: We found significant needs for community resources among families who presented to an urban PED. Needs were particularly salient among Spanish-speaking families and families living in close proximity to the children's hospital. Findings from this study help to inform future work connecting families to community resources.

Parent activation in the pediatric emergency department: Theory vs. reality.

OBJECTIVE: To measure parent activation and test for its associations with sociodemographics, clinical factors, and short-term outcomes. METHODS: By convenience sampling, 246 parents of children treated in an emergency department (ED) of a children's hospital completed the Parent-Patient Activation Measure (P-PAM) and answered sociodemographic questions. Clinical information was abstracted from medical records. Phone calls to parents and primary care physician offices were conducted within one-month post-ED visit for information about short-term outcomes. RESULTS: We discovered higher than expected activation among our sample (mean = 73), higher activation scores by Spanish language and child chronic illness status, and associations between activation scores and ED visit and discharge instruction comprehension and filling prescriptions (short-term outcomes). However, the theory of parent activation did not adequately fit the data. CONCLUSION: Before the P-PAM in pediatric clinical care becomes widespread, further research is necessary to better understand parent activation and its associations with pediatric outcomes. PRACTICE IMPLICATIONS: Although the PAM has shown promise in accurately measuring patient activation across various populations and disease processes, the same is not yet true of the P-PAM. To date, pediatric studies using the P-PAM have called its psychometric properties into question. Further research is needed to understand and measure parent activation.

Radiologic discrepancies in children with special healthcare needs in a pediatric emergency department.

BACKGROUND: After-hours radiologic interpretation by nonradiology attendings or resident radiologists introduces the risk of discrepancies. Clinical outcomes following radiologic discrepancies among pediatric emergency department (ED) patients are poorly described. In particular, children with special healthcare needs (CSHCN), have more opportunities for discrepancies and potential consequences than non- CSHCN. Our objective was to determine the rates and types of radiologic discrepancies, and to compare CSHCN to non-CSHCN. METHODS: From July 2014 to February 2015, all children who underwent a diagnostic imaging study at a free-standing children's ED were included. Data collected included radiologic studies - type and location - and clinical details - chief complaint and CSHCN type. Differences between preliminary reads and final pediatric radiology attending reads were defined as discrepancies, and categorized by clinical significance. Descriptive statistics, z-tests, and chi-square were used. RESULTS: Over 8months, 8310 visits (7462 unique patients) had radiologic studies (2620 CSHCN, 5690 non-CSHCN). A total of 198 (2.4%) radiologic discrepancies [56 (28.3%) CSHCN, 142 (71.7%) non-CSHCN] were found. Chief complaints for CSCHN were more often within the cardiac, pulmonary and neurologic systems (p<0.001 for each), whereas non-CSHCN presented with more trauma (p<0.001). The rates of discrepancies (CSHCN 2.1%, non- CSHCN 2.5%, p=0.3) and severity of clinical consequences (p=0.6) were not significantly different between CSHCN and non-CSHCN. CONCLUSION: Though the frequency and type of radiologic studies performed between CSHCN and non-CSHCN were different, we found no significant difference in the rate of radiologic discrepancies or the rate of clinically significant radiologic discrepancies.

Cost-Effectiveness of Watchful Waiting in Acute Otitis Media.

BACKGROUND: American Academy of Pediatrics guidelines for acute otitis media (AOM) allow for children meeting certain criteria to undergo watchful waiting (WW). The cost-effectiveness of this policy has not been evaluated in the United States. METHODS: A retrospective review of a random selection of 250 patients ≤18 years old with AOM in the emergency department of a tertiary care children's hospital was used to characterize current practice of AOM management. These data were incorporated into a decision-analytic cost-utility model comparing the cost-effectiveness of implementing WW to current practice. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed in 2015 USD per disability-adjusted life year (DALY) averted from a societal perspective. Multiple sensitivity analyses were conducted. RESULTS: From this cohort, chart review confirmed 247 actually had AOM on physical examination. Of these, 231 (93.5%) were prescribed antibiotics, 7 (2.8%) underwent WW, and 9 (3.6%) were sent home without an antibiotic prescription. When American Academy of Pediatrics criteria for WW were applied to this population, 104 patients (42.1%) met conditions for immediate antibiotic prescription, and 143 patients (57.9%) qualified for WW. In our modeled scenario, for every 1000 patients with AOM, implementing WW yielded 514 fewer immediate antibiotic prescriptions and 205 fewer antibiotic prescriptions used, averting 14.3 DALYs, and saving $5573. The preferability of WW over current practice proved highly robust to sensitivity analysis. CONCLUSIONS: WW for AOM management is cost-effective. Implementing WW may improve outcomes and reduce health care expenditures.

Pediatric advance directives: parents' knowledge, experience, and preferences.

OBJECTIVES: To explore parents' and caregivers' experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. METHODS: We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child's past and current health status, and family demographics. RESULTS: Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. CONCLUSIONS: The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.

Low rates of follow-up with primary care providers after pediatric emergency department visits for respiratory tract illnesses.

OBJECTIVES: We sought to determine diagnosis-specific rates of follow-up with primary care providers (PCPs) after emergency department (ED) visits for respiratory tract illnesses. We hypothesized that follow-up rates would be higher among patients with acute infectious illnesses than among those with asthma. METHODS: This was a retrospective cohort study of a random sample of patients aged 0 to 12 years discharged over a 12-month period from an urban, tertiary care pediatric ED with 4 different respiratory tract illnesses (asthma, bronchiolitis, croup, and pneumonia). Primary care provider follow-up was examined for associations with sociodemographic and clinical factors and with subsequent ED visits. RESULTS: Rates of follow-up in the overall cohort were low: 23.6% (95% confidence interval, 19.7-27.4) by 7 days and 40.5% (95% confidence interval, 36.0-44.9) by 30 days. Compared with patients with asthma, the relative risks (RRs) of follow-up within 7 and 30 days were significantly higher among patients with bronchiolitis and pneumonia, but not with croup. For the cohort as a whole, the RR of follow-up within 7 and 30 days significantly decreased for each 1-year increase in age, and the RR of follow-up within 7 days significantly increased with the provision of explicit ED discharge instructions recommending follow-up. Among patients with asthma, follow-up with PCPs within 30 days was not associated with decreased ED visits for asthma over the following year. CONCLUSIONS: Rates of PCP follow-up were globally low but significantly higher for patients with acute infectious illnesses, for younger patients, and for those receiving explicit ED discharge instructions.

Management of anaphylaxis in children.

Anaphylaxis is a severe, life-threatening immunoglobulin E (IgE)-mediated hypersensitivity reaction. The key to successful management of anaphylaxis involves rapid diagnosis, assessment, and early initiation of therapy. Epinephrine is the undisputed initial therapy for anaphylaxis, and its administration should never be delayed. In most cases, additional interventions such as oxygen therapy, fluid resuscitation, beta-agonists, antihistamines, and corticosteroids should be strongly considered. Although hospital course must be individualized to meet each patient's needs, a minimum of 4 to 6 hours of observation period after complete symptom resolution may be reasonable to monitor for recurrence of symptoms and biphasic reaction. Before discharge, every patient should receive patient education about anaphylaxis, a prescription for self-injectable epinephrine, and instructions for follow-up care.