Impact of point-of-care gonorrhea and chlamydia testing in the emergency department on reducing overtreatment rates.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections continue to increase in the United States. Advancement in technology with point-of-care (POC) testing can improve the overall treatment of sexually transmitted infections (STI) in the emergency department (ED) by shortening the time to test result and administration of accurate treatment. The purpose of this study was to assess if the POC test reduced the rate of overtreatment for CT and/or NG compared to the standard-of-care (SOC) test. METHODS: This retrospective cohort study included adult patients tested for CT and NG at two urban EDs between August 2020 and October 2022. This cohort excluded hospital admissions, elopement, pregnancy, rectal and oral samples, victims of sexual assault, and diagnoses for which antimicrobial treatment overlapped that of CT/NG. The primary outcome assessed overtreatment, defined as receiving treatment in the ED or a prescription prior to discharge for patients who tested negative for CT and/or NG. Secondary outcomes included undertreatment rates, overtreatment rates in select populations, test turnaround time, and ED length of stay (LOS). RESULTS: Of 327 patients screened, 97 patients were included in the SOC group and 100 in POC. Overtreatment for CT was provided in zero POC patients and 29 (29.9%) SOC patients (p < 0.001). NG was overtreated in 1 (1%) POC and 23 (23.7%) SOC (p < 0.001). POC was associated with undertreatment of CT and/or NG in two patients, compared to four patients tested with SOC. Overall, treatment was deemed inappropriate for 5 (5%) of those tested with POC, compared to 35 (36%) tested with SOC (p < 0.001). There was no difference in ED LOS (2.7 vs 3.01 h, p = 0.41). CONCLUSIONS: POC testing facilitated the return of results prior to patients being discharged from the ED. Compared to standard testing, POC improved appropriateness of CT and NG treatment by reducing the rates of overtreatment.

Scheduling doesn't matter! A noninferiority study of block versus longitudinal scheduling for emergency medicine resident pediatric procedural training experience.

Background: Emergency medicine (EM) residencies offer a wide variety of scheduling models for pediatric patient experience, including blocked weeks in pediatric emergency departments and longitudinal models with pediatric emergency pod/department shifts integrated within other clinical experiences. Concerns with autonomy, attending entrustment, and resident comfort imply that these different scheduling models may impact EM residents' pediatric procedure volumes. The purpose of this study is to quantitatively compare EM residents' pediatric procedure experience and volumes between block versus longitudinal scheduling models. We hypothesize noninferiority between the scheduling models. Methods: A retrospective review characterized the numbers and types of procedures performed by The Ohio State Emergency Medicine residents at the tertiary care pediatric hospital where residents' receive their pediatric emergency medicine clinical experience. Procedure numbers and variety were compared across six academic years: four with a block model, one reorganization year, and one integrated longitudinal year. Results: 2552 procedures were performed by 266 resident academic years over the 6-year period. Overall, no statistically significant differences in the number of procedures performed per year or the variety of types of procedures performed per year were found when comparing the block and longitudinal models. Differences were seen in experience of PGY1 versus PGY3 residents between scheduling models and the overall experience and volumes of the PGY2 residents during the reorganization year. Conclusions: Our study quantitatively concluded that the longitudinal scheduling model is noninferior to the more traditional block scheduling model for emergency medicine residents' pediatric emergency medicine clinical experience when reviewing volumes and types of procedures performed in a pediatric emergency department. This suggests that procedural opportunities do not need to dictate scheduling models.

Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department.

INTRODUCTION: Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. METHODS: The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. RESULTS: Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. DISCUSSION: The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.

Primary Measles Encephalitis.

Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of primary measles encephalitis. Introduction: Measles is a highly infectious ribonucleic acid (RNA) virus whose prevalence in the United States has continued to increase despite being declared eliminated in 2000,1 and larger outbreaks have been noted among those who elect not to vaccinate.2 The recommended live-attenuated measles, mumps, and rubella (MMR) vaccine schedule for pediatrics includes one routine dose at 12-15 months of age and a second dose between 4-6 years of age with at least 28 days in between dose administration.1-2 Measles-associated complications include otitis media, pneumonia, laryngotracheobronchitis, diarrhea, and corneal ulceration.2 Patients may also develop central nervous system complications, including primary measles encephalitis, acute post-infectious measles encephalomyelitis, measles inclusion body encephalitis, and subacute sclerosing panencephalitis. Primary measles encephalitis and measles inclusion body encephalitis involve an active ongoing measles infection.3 We will focus on primary measles encephalitis for this case scenario. One out of every 1000 measles patients will develop primary measles encephalitis,1 with onset typically occurring within seven days of the measles prodrome. Treatment is largely supportive. Mortality from primary measles encephalitis is 10%-15%, with an additional 25% developing permanent neurodevelopmental sequalae.3 It is critical to maintain a high index of suspicion for this diagnosis, to place the patient in airborne precautions to protect other immunocompromised individuals, and to transfer to a pediatric intensive care unit (PICU). Educational Objectives: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history, including immunization status, associated symptoms, sick contacts, and travel history. 2) Develop a differential for fever, rash, and altered mental status in a pediatric patient. 3) Discuss management of primary measles encephalitis, including empiric broad spectrum antibiotics and antiviral treatment. 4) Discuss appropriate disposition of the patient from pediatric emergency departments, community hospitals, and freestanding emergency departments, including appropriate time to call for transfer and the appropriate time to transfer this patient during emergency department (ED) workup. 5) Review types of isolation and indications for each. Educational Methods: This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of primary measles encephalitis. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Research Methods: Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. Results: Feedback from the residents was overwhelmingly positive with an average score of 7 (consistently effective/very good or extremely effective/outstanding) across all categories. The subsequent debriefings allowed for multiple areas of discussion, including differential diagnoses of fever and rash, the clinical presentation of measles, empiric treatment of meningitis/encephalitis, types and indications of isolation, when to call for transfer to a pediatric center, and when a child is deemed stable enough for transfer. Discussion: This is a cost-effective method for reviewing primary measles encephalitis. There are multiple measles complications that may be reviewed via simulation, including pneumonia and dehydration from diarrhea. We encourage readers to utilize clinical photos of measles rashes, because this was difficult to capture via standard moulage techniques. Topics: Medical simulation, measles, primary measles encephalitis, encephalitis, infectious disease, emergency medicine, pediatric emergency medicine.

A Modified Delphi Study for Development of a Pediatric Curriculum for Emergency Medicine Residents.

OBJECTIVES: Emergency medicine (EM) trainees are expected to learn to provide acute care for patients of all ages. The American Council for Graduate Medical Education provides some guidance on topics related to caring for pediatric patients; however, education about pediatric topics varies across residency programs. The goal of this project was to develop a consensus curriculum for teaching pediatric emergency care. METHODS: We recruited 13 physicians from six academic health centers to participate in a three-round electronic modified Delphi project. Participants were selected on the basis of expertise with both EM resident education and pediatric emergency care. The first modified Delphi survey asked participants to generate the core knowledge, skills, and experiences needed to prepare EM residents to effectively treat children in an acute care setting. The qualitative data from the first round was reformulated into a second-round questionnaire. During the second round, participants used rating scales to prioritize the curriculum content proposed during the first round. In round 3, participants were asked to make a determination about each curriculum topic using a three-point scale labeled required, optional, or not needed. RESULTS: The first modified Delphi round yielded 400 knowledge topics, 206 clinical skills, and 44 specific types of experience residents need to prepare for acute pediatric patient care. These were narrowed to 153 topics, 84 skills, and 28 experiences through elimination of redundancy and two rounds of prioritization. The final lists contain topics classified by highly recommended, partially recommended, and not recommended. The partially recommended category is intended to help programs tailor their curriculum to the unique needs of their learners as well as account for variability between 3- and 4-year programs and the amount of time programs allocate to pediatric education. CONCLUSION: The modified Delphi process yielded the broad outline of a consensus core pediatric emergency care curriculum.

Yield of skeletal survey by age in children referred to abuse specialists.

OBJECTIVE: To determine rates of skeletal survey completion and injury identification as a function of age among children who underwent subspecialty evaluation for concerns of physical abuse. STUDY DESIGN: This was a retrospective secondary analysis of an observational study of 2609 children <60 months of age who underwent evaluation for possible physical abuse. We measured rates of skeletal survey completion and fracture identification for children separated by age into 6-month cohorts. RESULTS: Among 2609 subjects, 2036 (78%) had skeletal survey and 458 (18%) had at least one new fracture identified. For all age groups up to 36 months, skeletal survey was obtained in >50% of subjects, but rates decreased to less than 35% for subjects >36 months. New fracture identification rates for skeletal survey were similar between children 24-36 months of age (10.3%, 95% CI 7.2-14.2) and children 12-24 months of age (12.0%, 95% CI 9.2-15.3) CONCLUSIONS: Skeletal surveys identify new fractures in an important fraction of children referred for subspecialty consultation with concerns of physical abuse. These data support guidelines that consider skeletal survey mandatory for all such children <24 months of age and support a low threshold to obtain skeletal survey in children as old as 36 months.