Pediatric capacity crisis: A framework and strategies to prepare for a pediatric surge.

A pediatric capacity crisis developed across the country in the Fall and Winter of 2022 due to a combination of factors, including a surge in respiratory viruses, staffing shortages, and historical closures of inpatient pediatric units. The COVID-19 pandemic and associated surge in critically ill adult patients demonstrated that health care systems and health care workers can quickly implement creative and collaborative system-wide solutions to deliver the best care possible during a capacity crisis. Similar solutions are needed to respond to future surges in pediatric volume and to maintain a high standard of care during such a surge. This paper aims to build upon insights from the COVID-19 and H1N1 pandemic responses and the 2022 pediatric capacity crisis. We provide specific recommendations addressing governmental/policy, hospital/health care system, and individual clinician strategies that can be implemented to manage future surges in pediatric patient volume.

Impact of a hypothetical COVID-19 vaccine mandate on parental likelihood to vaccinate children: Exploring school-related concerns and vaccination decision-making.

OBJECTIVE: We assessed the impact of a hypothetical school-entry COVID-19 vaccine mandate on parental likelihood to vaccinate their child. METHODS: We collected demographics, COVID-19-related school concerns, and parental likelihood to vaccinate their child from parents of patients aged 3-16 years seen across nine pediatric Emergency Departments from 06/07/2021 to 08/13/2021. Wilcoxon signed-rank test compared pre- and post-mandate vaccination likelihood. Multivariate linear and logistic regression analyses explored associations between parental concerns with baseline and change in vaccination likelihood, respectively. RESULTS: Vaccination likelihood increased from 43% to 50% with a hypothetical vaccine mandate (Z = -6.69, p < 0.001), although most parents (63%) had no change, while 26% increased and 11% decreased their vaccination likelihood. Parent concerns about their child contracting COVID-19 was associated with greater baseline vaccination likelihood. No single school-related concern explained the increased vaccination likelihood with a mandate. CONCLUSION: Parental school-related concerns did not drive changes in likelihood to vaccinate with a mandate.

The Effect of COVID-19 on United States Pediatric Emergency Departments and Its Impact on Trainees.

INTRODUCTION: The purpose of this study was to quantify the effects of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency departments (PED) across the United States (US), specifically its impact on trainee clinical education as well as patient volume, admission rates, and staffing models. METHODS: We conducted a cross-sectional study of US PEDs, targeting PED clinical leaders via a web-based questionnaire. The survey was sent via three national pediatric emergency medicine distribution lists, with several follow-up reminders. RESULTS: There were 46 questionnaires included, completed by PED directors from 25 states. Forty-two sites provided PED volume and admission data for the early pandemic (March-July 2020) and a pre-pandemic comparison period (March-July 2019). Mean PED volume decreased >32% for each studied month, with a maximum mean reduction of 63.6% (April 2020). Mean percentage of pediatric admissions over baseline also peaked in April 2020 at 38.5% and remained 16.4% above baseline by July 2020. During the study period, 33 (71.1%) sites had decreased clinician staffing at some point. Only three sites (6.7%) reported decreased faculty protected time. All PEDs reported staffing changes, including decreased mid-level use, increased on-call staff, movement of staff between the PED and other units, and added tele-visit shifts. Twenty-six sites (56.5%) raised their patient age cutoff; median was 25 years (interquartile ratio 25-28). Of 44 sites hosting medical trainees, 37 (84.1%) reported a decrease in number of trainees or elimination altogether. Thirty (68.2%) sites had restrictions on patient care provision by trainees: 28 (63.6%) affected medical students, 12 (27.3%) affected residents, and two (4.5%) impacted fellows. Fifteen sites (34.1%) had restrictions on procedures performed by medical students (29.5%), residents (20.5%), or fellows (4.5%). CONCLUSION: This study highlights the marked impact of the COVID-19 pandemic on US PEDs, noting decreased patient volumes, increased admission rates, and alterations in staffing models. During the early pandemic, educational restrictions for trainees in the PED setting disproportionately affected medical students over residents, with fellows' experience largely preserved. Our findings quantify the magnitude of these impacts on trainee pediatric clinical exposure during this period.

Reducing Pediatric Emergency Department Prescription Errors.

BACKGROUND: Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines. METHODS: From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing. RESULTS: Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased. CONCLUSION: QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.

Factors Associated With Parental Acceptance of COVID-19 Vaccination: A Multicenter Pediatric Emergency Department Cross-Sectional Analysis.

STUDY OBJECTIVE: During the delta surge of the COVID-19 pandemic in 2021, we sought to identify characteristics and beliefs associated with COVID-19 vaccination acceptance in parents of pediatric emergency department (ED) patients. METHODS: We conducted a cross-sectional survey-based study of the parents of children aged 3 to 16 years presenting to 1 of 9 pediatric EDs from June to August 2021 to assess the parental acceptance of COVID-19 vaccines. Using multiple variable regression, we ascertained which factors were associated with parental and pediatric COVID-19 vaccination acceptance. RESULTS: Of 1,491 parents approached, 1,298 (87%) participated, of whom 50% of the parents and 27% of their children aged 12 years or older and older were vaccinated. Characteristics associated with parental COVID-19 vaccination were trust in scientists (adjusted odds ratio [aOR] 5.11, 95% confidence interval [CI] 3.65 to 7.15), recent influenza vaccination (aOR 2.66, 95% CI 1.98 to 3.58), college degree (aOR 1.97, 95% CI 1.36 to 2.85), increasing parental age (aOR 1.80, 95% CI 1.45 to 2.22), a friend or family member hospitalized because of COVID-19 (aOR 1.34, 95% CI 1.05 to 1.72), and higher income (aOR 1.60, 95% CI 1.27 to 2.00). Characteristics associated with pediatric COVID-19 vaccination (children aged ≥12 years) or intended COVID-19 pediatric vaccination, once approved for use, (children aged <12 years) were parental trust in scientists (aOR 5.37, 95% CI 3.65 to 7.88), recent influenza vaccination (aOR 1.89, 95% CI 1.29 to 2.77), trust in the media (aOR 1.68, 95% CI 1.19 to 2.37), parental college degree (aOR 1.49, 95% CI 1.01 to 2.20), and increasing parental age (aOR 1.26, 95% CI 1.01 to 1.57). CONCLUSION: Overall COVID-19 vaccination acceptance was low. Trust in scientists had the strongest association with parental COVID-19 vaccine acceptance for both themselves and their children.

University Marching Band Members' Noise Dosages and Hearing Health-Related Knowledge.

OBJECTIVES: (1) To measure sound exposures of marching band and non-marching band students during a football game, (2) to compare these to sound level dose limits set by NIOSH, and (3) to assess the perceptions of marching band students about their hearing health risk from loud sound exposure and their use of hearing protection devices (HPDs). METHODS: Personal noise dosimetry was completed on six marching band members and the band director during rehearsals and performances. Dosimetry measurements for two audience members were collected during the performances. Noise dose values were calculated using NIOSH criteria. One hundred twenty-three marching band members responded to a questionnaire analyzing perceptions of loud music exposure, the associated hearing health risks, and preventive behavior. RESULTS: Noise dose values exceeded the NIOSH recommended limits among all six marching band members during rehearsals and performances. Higher sound levels were recorded during performances compared to rehearsals. The audience members were not exposed to hazardous levels. Most marching band members reported low concern for health effects from high sound exposure and minimal use of HPDs. CONCLUSION: High sound exposure and low concern regarding hearing health among marching band members reflect the need for comprehensive hearing conservation programs for this population.

Does Timing Matter?: Timing and Outcomes Among Early Unplanned PICU Transfers.

BACKGROUND: Many institutions track early ICU transfers (transfer from an inpatient floor to an ICU within 24 hours of admission) as a marker of quality of emergency department (ED) care. There are limited data evaluating whether patient characteristics or clinical outcomes differ on the basis of timing of ICU transfer within this 24-hour window. METHODS: We conducted a retrospective cohort study examining all patients ≤21 years old admitted to an inpatient pediatric floor from the ED and subsequently transferred to an ICU within 24 hours of hospitalization. Patient characteristics and clinical outcomes were compared on the basis of timing (0-6 hours, 6-12 hours, 12-24 hours) of ICU transfer. Outcomes assessed included receipt of critical intervention, timing of intervention with respect to transfer, type of intervention received, hospital and ICU length of stay, and mortality at 72 hours and during hospitalization. RESULTS: A total of 841 patients were transferred to an ICU within 24 hours from admission to a pediatric ward from the ED; 266 patients (32%) transferred within 6 hours of admission, 269 patients (32%) transferred between 6 and 12 hours, and 306 patients (36%) transferred between 12 and 24 hours. Patient characteristics did not materially differ on the basis of timing of ICU transfer, nor did clinical outcomes. CONCLUSIONS: Among children transferred to an ICU within 24 hours of hospitalization, patient characteristics and clinical outcomes did not materially differ based on the timing of transfer relative to admission from the ED.

Improving the prediction of streptococcal pharyngitis; time to move past exudate alone.

BACKGROUND: Palatal petechiae are predictive of Group A streptococcal (GAS) pharyngitis. We sought to (a) quantify the value of considering petechiae in addition to exudate, and (b) assess provider incorporation of petechiae's predictive nature for GAS into clinical decision making. METHODS: We conducted a cross-sectional study of patients 3-21 years with sore throat and GAS testing performed in a pediatric emergency department (ED) in 2016. Patients were excluded if immunosuppressed, nonverbal, medically complex, had chronic tonsillitis, or received antibiotics in the preceding week. As a proxy of provider incorporation of petechiae into clinical decision making we assessed how often petechiae were documented, compared with exudate. We performed univariate analysis using χ2 analysis for categorical data and Mann-Whitney U test for continuous data. RESULTS: 1574 patients met inclusion criteria. Median age 8 years [IQR 5, 13]; 54% female. 372 patients (24%) were GAS positive. Both palatal petechiae and tonsillar exudates were predictive of GAS [OR 8.5 (95% CI 5.2-13.9), and 1.9 (95% CI 1.4-2.6) respectively]. Examining petechiae or exudate vs. exudate alone increases OR from 1.9 to 2.9 (95% CI 2.2-3.8). Sensitivity improves (23% to 34%) with minimal change to specificity (87% to 85%). Among those with a normal or erythematous throat exam, petechiae were mentioned as a pertinent negative in 28%; absence of tonsillar exudate was mentioned in 78% (p = .02). CONCLUSIONS: Palatal petechiae are highly associated with GAS, yet rarely addressed in documentation. Incorporating palatal petechiae into common scoring systems could improve prediction and disseminate this knowledge into practice.

Impact of viral symptoms on the performance of the modified centor score to predict pediatric group A streptococcal pharyngitis.

BACKGROUND: Clinicians use the Modified Centor Score (MCS) to estimate the risk of group A streptococcal (GAS) pharyngitis in children with sore throat. The Infectious Diseases Society of America (IDSA) recommends neither testing nor treating patients with specific viral symptoms. The goal of this study is to measure the impact of those symptoms on the yield of GAS testing predicted by the MCS. METHODS: Retrospective cohort study of all patients aged 3-21 years presenting with sore throat and tested for GAS in a pediatric emergency department (ED) in 2016. After identifying all patients tested for GAS, we used natural language processing (NLP) to identify the subgroup complaining of sore throat. We abstracted all MCS variables as well as symptoms suggestive of a viral etiology per the IDSA guideline (conjunctivitis, coryza, cough, diarrhea, hoarseness, ulcerative oral lesions, viral exanthema). We calculated the proportion of patients who tested positive for GAS by MCS with and without viral symptoms. RESULTS: Of the 1574 patients included, 372 patients (24%) tested GAS positive. Patients with at least one viral symptom had a reduced GAS risk compared to those without any of the viral symptoms 91/547 (17% GAS positive) vs. 281/1027 (27%), odds ratio 0.53 (95% CI 0.41-0.69). CONCLUSIONS: The presence of viral symptoms specified by the IDSA alters the predicted yield of testing by traditional MCS. Clinicians may consider adjusting interpretation of a patient's MCS based on the presence of viral symptoms, but viral symptoms may not always fully obviate the need for GAS testing.

Pediatric ICU Transfers Within 24 Hours of Admission From the Emergency Department: Rate of Transfer, Outcomes, and Clinical Characteristics.

BACKGROUND: There is a paucity of data describing pediatric patients transferred to an ICU within 24 hours of hospital admission from the emergency department (ED). METHODS: We conducted a retrospective cohort study of patients ≤21 years old transferred from an inpatient floor to an ICU within 24 hours of ED disposition from 2007 to 2016 in a tertiary children's hospital. Patients transferred to an ICU after planned operative procedures were excluded. Rate of transfer, clinical course, and baseline demographic and/or clinical characteristics of these patients are described. RESULTS: The study cohort consisted of 841 children, representing 1% of 82 397 non-ICU ED admissions over the 10-year period. Median age was 5.1 years, 43% had ≥1 complex chronic condition, and 47% were hospitalized within the previous year (27% in the ICU). The majority of transfers were for respiratory conditions (65%) and cardiovascular compromise (18%). Median time from hospitalization to ICU transfer was 9.1 hours (interquartile range 5.1-14.9 hours). Thirty-eight percent of transfers received 1 or more critical interventions within 72 hours of hospitalization, most commonly positive pressure ventilation (29%) and vasoactive infusion (9%). Median time to intervention from hospitalization was 13.6 hours (interquartile range 7.5-21.6 hours), 0.8% of children died within 72 hours of hospitalization, and 2.4% died overall. CONCLUSIONS: In this single pediatric academic center, 1% of hospitalized children were transferred to an ICU within 24 hours of ED disposition. One-third of patients received a critical intervention, and 2.4% died. Although most ED dispositions are appropriate, future efforts to identify patients at the highest risk of deterioration are warranted.

The effects of obesity on pulmonary function in children.

The prevalence of obesity has risen rapidly in the United States in the past 20 years. Up to 25% of US children are obese, and obesity can be directly correlated with immediate and long-term health consequences. Pediatric obesity can harm multiple body systems and is a public health issue. This article focuses on how obesity affects a child's respiratory system, including pulmonary function, exercise intolerance, gas exchange, and airway musculature.

Pediatric Disaster Triage System Utilization Across the United States.

OBJECTIVES: The study goal was to determine which pediatric disaster triage (PDT) systems are used in US states/territories and whether there is standardization to their use. Secondary goals were to understand user satisfaction with each system, user preferences, and the nature and magnitude of incidents for which the systems are activated. METHODS: A survey was developed regarding PDT systems used in each state/territory, satisfaction with those used, preference for specific systems, and type and magnitude of incidents prompting system activation. The survey was distributed to emergency medical services for children leads in each state/territory. RESULTS: Eighty-six percent of states/territories responded. Eighty-eight percent of respondents used some formal PDT system, 50% of whom reported utilization of multiple systems. JumpSTART was most commonly used, most often in conjunction with other systems. Of formal systems, JumpSTART has been in use the longest. JumpSTART was also preferred by 71% of those stating a preference; it tied with Smart for median satisfaction level. Although types of incidents prompting system activation was similar across responding states/territories, number of patients prompting activation varied from 1 to 3 to greater than 20, median range of 4 to 7. CONCLUSIONS: Most states/territories use some formal PDT system; few have 1 standardized approach. JumpSTART is predominantly used and is preferred by most respondents. With all systems, there is marked variation in number of patients prompting activation although the reported nature of incidents prompting activation is similar.