Comparing nasal suction devices in children with bronchiolitis: A pilot randomized control trial.

BACKGROUND/OBJECTIVES: Bronchiolitis is the most common cause of lower respiratory tract infections that lead to hospitalizations in infants and young children. METHODS: In this randomized controlled pilot study, we compared two separate nasal suction devices, namely the over counter device by the brand name of NoseFrida and the standard hospital device NeoSucker, in hospitalized children with bronchiolitis to assess equivalence of length of stay within a ± 5-h equivalence margin and to compare readmission rates and associated complications. Additionally, parental satisfaction for the NoseFrida device was measured with a six question (5-point Likert scale) survey. RESULTS: There were 20 patients randomized to the NeoSucker group and 24 randomized to the NoseFrida group. The mean length of stay for the NoseFrida group was 33.5 ± 25.4 h compared to 31.0 ± 15.6 h in the NeoSucker group, which did not establish equivalence within the ±5-h equivalence margin (p = 0.352). Parents were generally satisfied with the NoseFrida. Patients treated with the two devices had similar frequencies of deep suctioning and readmission within 48 h. CONCLUSIONS: Although the mean length of stay was comparable for bronchiolitis patients treated with the NoseFrida and NeoSucker, the relatively small sample size and large amount of variability precluded demonstrating equivalence. Since this was a pilot, further studies are needed to evaluate the recommendation for the use of such devices in both the hospital setting and in the outpatient management of bronchiolitis.

When "the runs" also burns: Case reports of severe diaper dermatitis in children with acute gastroenteritis mimicking scald burns.

Burns to the buttocks of a child are highly concerning for child abuse unless there is a clear history to support an alternative diagnosis. We report two cases of severe erosive diaper dermatitis presenting as buttocks and perineal burns caused by prolonged exposure to diarrheal stool. These cases underscore the importance of making the right diagnosis to avoid the undue psychosocial stress to families that comes with a mistaken diagnosis of inflicted injury, and further add to our understanding of diarrheal contact burns in the absence of laxative use.

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department.

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit.

BACKGROUND: Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics. OBJECTIVES: The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI. METHODS: A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted. RESULTS: One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study. CONCLUSIONS: The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Utility of Emergency Department Observation Units for Neurologically Intact Children With Head CT Abnormalities Secondary to Acute Closed Head Injury.

OBJECTIVE: The aim of the study was to evaluate the utility of the emergency department observation unit (EDOU) for neurologically intact children with closed head injuries (CHIs) and computed tomography (CT) abnormalities. METHODS: A retrospective cohort study of children aged 0 to 18 years with acute CHI, abnormal head CT, and a Glasgow Coma Scales score of 14 or higher admitted to the EDOU of a tertiary care children's hospital from 2007 to 2010. Children with multisystem trauma, nonaccidental trauma, and previous neurosurgical or coagulopathic conditions were excluded. Medical records were abstracted for demographic, clinical, and radiographic findings. Poor outcome was defined as death, intensive care unit admission, or medically/surgically treated increased intracranial pressure. RESULTS: Two hundred two children were included. Median (range) age was 14 (4 days-16 years) months; 51% were male. The most common CT findings were nondisplaced (136, 67%) or displaced (46, 23%) as well as skull fractures and subdural hematomas (38, 19%); 54 (27%) had less than 1 CT finding. The most common interventions included repeat CT (42, 21%), antiemetics (26, 13%), and pain medication (29, 14%). Eighty-nine percent were discharged in less than 24 hours. Inpatient admission from the EDOU occurred in 6 (3%); all were discharged in less than 3 days. One patient required additional intervention (corticosteroid therapy). She had a subdural hematoma, persistent vomiting, intractable headache, and a nonevolving CT. CONCLUSIONS: Neurologically intact patients on initial ED evaluation had a very low likelihood of requiring further interventions, irrespective of CT findings. Although prospective evidence is necessary, this supports reliance on clinical findings when evaluating a well-appearing child with an acute CHI.

The utility of the emergency department observation unit for children with abdominal pain.

OBJECTIVE: This study aimed to determine the outcome of children with unclear etiology for acute abdominal pain admitted to the emergency department observation unit (EDOU). METHODS: This is a retrospective cohort study of children 18 years or younger who presented with acute abdominal pain to a tertiary pediatric ED and were observed in the EDOU. Children with alternative explanations for abdominal pain were excluded. Patients were classified based on disposition, and data were analyzed using χ tests. RESULTS: There were 237 patients included in the study (median age, 9 years; 46% male). Mean length of stay in EDOU was 14.4 hours. Fifty-four percent were evaluated by surgery. Two hundred (84%) were discharged; 37 (16%) were admitted, of whom 22 (9%) underwent surgical intervention (13 appendectomies, 6 ovarian cystectomies, 2 small-bowel obstructions, 1 cholecystectomy). Eight had acute appendicitis on pathology reports. The duration of symptoms, the presence of fever, nausea/vomiting, right-lower-quadrant pain, rebound tenderness, or leukocytosis greater than 10,000 cells/µL did not predict admission. Patients with diarrhea were more likely to be discharged home (P = 0.02). Intravenous hydration (86%) and pain control (63%) were the most common interventions in the EDOU. Abdominal pain not otherwise specified and acute gastroenteritis were the 2 most common discharge diagnoses. Eight (4%) of the 200 discharged patients returned to the ED within 48 hours, and all were discharged home from the ED. CONCLUSIONS: The majority of children admitted to the EDOU with abdominal pain have nonsurgical causes of abdominal pain. The EDOU provides a reasonable alternative for monitoring these patients pending disposition.

Risk factors for admission in children with bronchiolitis from pediatric emergency department observation unit.

BACKGROUND: Patients with bronchiolitis are increasingly being admitted to emergency department observation units (EDOUs) but often require subsequent hospitalization. To better identify ED patients who should be directly admitted to the hospital rather than the EDOU, the predictors of admission must be identified. OBJECTIVES: The objective of this study was to determine the predictors of subsequent hospital admission from the EDOU in infants and young children with bronchiolitis. METHOD: This was a retrospective cohort study of patients younger than 2 years admitted to an EDOU with bronchiolitis between April 1, 2003, and March 31, 2007. Univariate analysis was followed by logistic regression to identify the significant predictors of hospital admission from the EDOU. RESULTS: There were 325 patients in the study: 67% were younger than 6 months, and 60% were male. Eighty-five (26%) were admitted to the hospital from the EDOU. Predictors for admission from the EDOU included parental report of poor feeding or increased work of breathing, oxygen saturation less than 93%, or ED treatment with racemic epinephrine (Vaponephrine) and intravenous fluids (IVFs). CONCLUSION: Patients with a history of increased work of breathing or oxygen saturation less than 93% and ED treatment with IVFs are at high risk for admission from the EDOU to the hospital. Direct admission to the hospital from the ED should be considered for these patients, particularly patients treated with IVFs and having an oxygen saturation less than 93% in the ED.

State of the art: emergency department observation units.

Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.

Intussusception: postreduction fasting is not necessary to prevent complications and recurrences in the emergency department observation unit.

OBJECTIVES: This study aimed to compare the incidence of complications and intussusception recurrences in patients in the pediatric emergency department observation unit (EDOU) who are fed early (< 2 hours) versus late (≥ 2 hours) after radiologic intussusception reduction. METHODS: This is a retrospective cohort study of children observed in the Texas Children's Hospital EDOU after radiologic intussusception reduction between April 1, 2003, and August 31, 2009. Complications were defined as the postreduction occurrence of intestinal perforation, shock, or sepsis. RESULTS: There were 149 patients included in the study (median age, 16 months; range, 3-95 months). Oral refeeding was started early in 61 patients (41%) and late in 88 patients (59%). The median length of EDOU stay was 15.6 hours in early refeeders and 16.1 hours in late refeeders (P = 0.58). None of the patients developed any complications. There was no difference in the frequency of postreduction fever, abdominal pain, or vomiting (13% early vs 16% late, P = 0.65); imaging to assess for intussusception recurrence (20% early vs 22% late, P = 0.79); and subsequent hospitalization (3% early vs 8% late, P = 0.31) between the groups. The frequency of intussusception recurrence was higher, but not significantly so (P = 0.31), in the late refeeders (15%) compared with the early refeeders (8%). CONCLUSIONS: There is no evidence for a difference in complication frequency, intussusception recurrence, or EDOU length of stay between patients who are fed early (< 2 hours) or late (≥ 2 hours) after radiologic intussusception reduction. This indicates that there is no need to withhold feeds from patients after intussusception reduction.

Managing well-appearing neonates with hyperbilirubinemia in the emergency department observation unit.

BACKGROUND: In September 2005, Texas Children's Hospital initiated a protocol for all neonates presenting to the emergency department (ED) with hyperbilirubinemia based on the American Academy of Pediatrics guidelines. As part of the protocol, low-risk neonates with hyperbilirubinemia requiring phototherapy are treated in the ED observation unit (EDOU). OBJECTIVE: The aim of the study was to compare time to phototherapy and duration of hospital stay in low-risk neonates with hyperbilirubinemia presenting to the Texas Children's Hospital ED before and after the initiation of a triage-based protocol. DESIGN/METHODS: We performed a retrospective historical control study comparing neonates with hyperbilirubinemia treated in the EDOU between January 1 and December 31, 2006 (EDOU group), with neonates with hyperbilirubinemia admitted to the inpatient unit between January 1 and December 31, 2004 (inpatient group). RESULTS: There were 167 neonates included in the study: 62 neonates were treated in the EDOU and 105 in the inpatient unit. Median time to phototherapy (inpatient: 6.7 hours, EDOU: 1.6 hours) and duration of hospital stay (inpatient: 41.8 hours, EDOU: 17.8 hours) were shorter for neonates treated in the EDOU compared with neonates treated in the inpatient unit. Of the neonates treated in the EDOU initially, 11 were admitted to the inpatient unit after 24 hours because their bilirubin level did not decline adequately. CONCLUSIONS: Low-risk neonates with hyperbilirubinemia can be managed more efficiently in an EDOU than in an inpatient unit. Phototherapy is initiated more rapidly, and patients are discharged sooner in the EDOU than in the inpatient setting.