Scalp Nodules and Facial Droop in an Infant.

A previously healthy, term, 5-week-old girl initially presented to her primary care physician with a solitary, enlarging scalp nodule. The infant was otherwise well without additional signs or symptoms of illness. Over the next several weeks, the nodule continued to grow, and additional lesions appeared on her scalp. An ultrasound of the primary nodule revealed a hypoechoic structure favored to represent a serosanguinous fluid collection. After evaluation by general surgery and dermatology, she underwent a scalp biopsy of the largest lesion. While biopsy specimen results were pending, her parents noted that she was developing increased irritability, difficulty closing her right eye, and facial weakness. She was referred to the emergency department where a right-sided facial droop involving the brow and forehead was noted. The skin biopsy specimen results, along with subsequent laboratory studies and imaging, led to the final diagnosis.

Eliminating Lumbar Puncture for Low-Risk Febrile Infants: A Quality Improvement Initiative.

BACKGROUND: Bacterial meningitis in low-risk febrile young infants (FYIs) aged >28 days has become increasingly rare. Routine performance of lumbar puncture (LP) in these infants is associated with adverse consequences and may be unnecessary. We modified our clinical practice guideline (CPG) to reduce the number of FYIs 29 to 56 days old who receive LP. METHODS: This quality improvement project sought to modify a preexisting CPG to diagnose and manage FYIs 0 to 56 days old that eliminated routine performance of LP in children 29 to 56 days old who were considered low-risk for serious bacterial infection. The change was implemented by making adjustments to the online CPG. A statistical process control chart was used to assess the affect of the initiative on our primary outcome of LP rate in this population of FYIs. RESULTS: Postimplementation of the CPG initiative, 71% of FYIs 29 to 56 days old did not receive LP, compared with 42% preimplementation. This practice change was also associated with fewer hospitalizations, lower median emergency department (ED) length of stay, and fewer 72-hour ED revisits. Over 3 years of sustained practice, 1/713 (0.1%; 95% confidence interval, 0%-0.8%) low-risk FYI returned within 72 hours and was subsequently treated for probable bacterial meningitis, although cerebrospinal fluid culture was negative for bacterial growth. CONCLUSIONS: A change in CPG reduced the number of LPs performed in febrile infants 29 to 56 days old. This change resulted in fewer LPs, hospitalizations, ED revisits, and a lower ED length of stay for FYIs 29 to 56 days old.

Understanding Graduating Pediatric Emergency Medicine Fellow Priorities for Career Pathways and Faculty Recruitment for Academic or Community Emergency Departments.

OBJECTIVES: Factors influencing the employment of pediatric emergency medicine (PEM) fellows in a career in academic medicine versus community emergency department (ED) settings have not previously been explored. The purpose of this study was to explore PEM fellows' priorities in selecting jobs and to identify factors that influence their decisions regarding career choices through a multicenter, qualitative approach. We also explored program directors' beliefs about graduates' job selection priorities. METHODS: This was a cross-sectional study among a convenience sample of PEM fellows and PEM fellowship program directors and/or associate program directors in the United States. The data were collected in 2017, using a qualitative methodology known as free listing. The fellows and program directors were solicited through the American Academy of Pediatrics Section on Emergency Medicine. Using content analysis, all free-listing responses from participant samples were categorized into 14 distinct groupings. Thematic saturation was achieved, and member checking was performed to ensure trustworthiness. RESULTS: A sample of 63 fellows from six geographically diverse programs and 41 program and/or associate program directors were surveyed. Location, schedule/work-life balance and compensation were the most frequently cited factors taken into consideration for employment; these are not specific to PEM as a career choice. Other factors included patient population and ED resources. When deciding between academic and community employment, similar areas for the PEM physician emerged on both sides of the dichotomy: work-life balance, clinical hours, burnout, and acuity/patient complexity. CONCLUSIONS: There are universal factors that PEM physicians consider when choosing employment. The information elicited from this exploratory technique can inform content for national survey or other qualitative work to achieve richer descriptions of reported items and dichotomies to guide fellow recruitment and retention strategies.

Cognitive Errors in Pediatric Emergency Medicine.

ABSTRACT: Fundamental to the practice of pediatric emergency medicine is making timely and accurate diagnoses. However, studies have shown errors in this process are common. A number of factors in the emergency department environment as well as identifiable errant patterns of thinking can contribute to such challenges. Cognitive psychologists have described 2 types of thinking: system 1 (fast) relies primarily on intuition and pattern recognition, whereas system 2 (slow) is more deliberative and analytical. Reviewing how these 2 styles of thinking are applied in clinical practice provides a framework for understanding specific cognitive errors. This article uses illustrative examples to introduce many of these common errors, providing context for how and why they occur. In addition, a practical approach to reducing the risk of such errors is offered.

Clinical Experience in a Community Setting During Pediatric Emergency Medicine Fellowship Training.

OBJECTIVES: The aim of this study is to explore current community emergency department (ED) experiences available to pediatric emergency medicine (PEM) trainees and estimate the proportion of graduates taking positions that involve working in a community ED setting. METHODS: We conducted an e-mail-based survey among PEM fellowship directors and assistant directors. RESULTS: There were 55 program director respondents (74% response rate). Thirty-one percent of the surveyed PEM fellowship programs provide training exposure to a community ED setting. Twenty-nine percent of the surveyed programs reported that 25% to 49% of graduating trainees accepted positions that involve working in a community hospital ED setting, 13% responded 50% to 74%, and 4% report 75% to 100% from 2012 to 2016. CONCLUSIONS: There is an overall paucity of a dedicated community rotation for PEM trainees, yet many graduates are seeking employment in community-based EDs. Because the need for community-based PEM physicians continues to rise and to adequately prepare the PEM workforce, PEM fellowship training should consider a curriculum that includes community-based ED clinical experiences.

Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler.

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

Supraventricular Tachycardia Associated With Severe Anemia.

We present the unusual case of a 7-year-old girl with severe iron-deficiency anemia who concurrently was determined to be in a supraventricular tachycardia (SVT) rhythm. To our knowledge, the association of anemia with SVT has not been reported previously. We review the presentation of SVT, management strategies for treating both severe anemia and SVT, risks and benefits of using the classic treatments for SVT in a severely anemic patient and discuss iron-deficiency anemia-related cardiac disease.

A Teenager With Sickle Cell Disease and Scalp Swelling.

An intracranial bleed with a midline shift is a potentially life-threatening clinical condition. We present the unusual case of a 13-year-old boy with sickle cell disease who had numerous emergency department visits for a scalp hematoma and was subsequently determined to have subdural and epidural hematomas with midline shift, associated with a skull bone infarction. We review the pathophysiology of this unusual condition and emphasize the importance of including it in the differential diagnosis of any child with sickle cell anemia presenting with a nontraumatic scalp hematoma.

Identification of Optic Nerve Swelling Using Point-of-Care Ocular Ultrasound in Children.

OBJECTIVE: The aim of this study was to determine the feasibility and accuracy of point-of-care (POC) ocular ultrasound (US) when performed by a pediatric emergency medicine (PEM) physician to detect optic nerve abnormalities concerning for swelling, as compared with the fundus examination performed by an ophthalmologist. METHODS: This was a single-center, prospective cohort pilot study of children aged 12 months to 18 years who required optic disc evaluation by an ophthalmologist. Eligible subjects were enrolled from the emergency department, inpatient wards, and neuro-ophthalmology outpatient clinic of an urban, tertiary care children's hospital. Point-of-care ocular US, specifically assessing optic nerve sheath diameter and optic disc elevation, was performed. Findings on US were compared with findings identified by an ophthalmologist on dilated fundus examination. RESULTS: Seventy-six subjects were enrolled; 20 (26%) of 76 had findings concerning for optic nerve swelling diagnosed by an ophthalmologist on fundus examination. Using a sonographic definition for optic nerve swelling of optic nerve sheath diameter greater than 4.5 mm or the presence of optic disc elevation, the sensitivity and specificity were 90% and 55%, respectively. The success rate of POC ocular US was 100%, and the mean time to completion was 8 minutes. For emergency department subjects in whom direct fundus examination was attempted, the PEM physician could visualize the optic disc and assess for swelling in only 40% (14/35) of examinations. CONCLUSIONS: The results of our study suggest that POC ocular US performed by PEM physicians was feasible and determined to be sensitive but nonspecific in the detection of optic nerve swelling. Additional larger studies may determine generalizability to other nonophthalmologist physicians performing POC ocular US.

Lumbar Puncture for All Febrile Infants 29-56 Days Old: A Retrospective Cohort Reassessment Study.

OBJECTIVES: To determine the incidence of bacterial meningitis (BM) among all febrile infants 29-56 days old undergoing a lumbar puncture (LP) in the emergency department of a tertiary care children's hospital and the number of low-risk febrile infants with BM to reassess the need for routine LP in these infants. STUDY DESIGN: Retrospective cohort study using a quality improvement registry from July 2007-April 2014. Infants included were 29-56 days old with fever and who had an LP in the emergency department. Low-risk criteria were adapted from the Philadelphia criteria. BM was defined as having a bacterial pathogen isolated from the cerebrospinal fluid. A medical record review of one-third of randomly selected patients in the cohort determined the proportion who met low-risk criteria. RESULTS: One of 1188 febrile infants (0.08%) had BM; this patient did not meet low-risk criteria. An additional 40 (3.4%) had positive cerebrospinal fluid cultures; all were contaminants. Subanalysis of one-third of the study population revealed that 45.6% met low-risk criteria; the most common reasons for failing low-risk classification included abnormal white blood cell count or urinalysis. CONCLUSIONS: In a cohort of febrile infants, BM is uncommon and no cases of BM would have been missed had LPs not been performed in those meeting low-risk criteria.

Identification of optic disc elevation and the crescent sign using point-of-care ocular ultrasound in children.

Point-of-care ocular ultrasound has been used to detect papilledema. In previous studies, investigators have evaluated only optic nerve sheath diameter as a screen for increased intracranial pressure. In this series of 4 children, we demonstrate 2 additional optic nerve abnormalities using point-of-care ocular ultrasound: optic disc elevation and the crescent sign. Assessing the optic nerve for each of these 3 findings may assist the examiner in detecting papilledema.

Pediatric integrated delivery system's experience with pandemic influenza A (H1N1).

OBJECTIVE: To describe 1 pediatric integrated delivery system's experience with the influenza A (H1N1) pandemic in 2009 to illustrate the benefits of coordination, scale, scope, and flexibility in handling large volumes of patients in many locations. METHODS: Through multidisciplinary planning across a large, multisite pediatric delivery system, an effective 3-tier plan was developed to handle anticipated increased volumes associated with the fall 2009 influenza pandemic in the Philadelphia region. RESULTS: Patient demand for services increased to record-setting levels, particularly for emergency department visits and phone calls. The 3-tier plan of response allowed for graded and appropriate response to volumes that more than doubled in many locations. Measured by wait times and leftwithout- being-seen rates, the system appeared to match capacity to demand effectively. Lessons learned in terms of successes and challenges are useful for future planning. CONCLUSIONS: The experience of 1 pediatric delivery system in handling increased volume due to pandemic influenza may hold lessons for other organizations and for policy makers seeking to improve the preparedness, quality, and value of healthcare. These experiences do not imply the need for vertical integration with ownership, but do support tight coordination, communication, integration, and alignment in any management structure.

Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial.

OBJECTIVES: The goal was to determine if adding inhaled budesonide to standard asthma therapy improves outcomes of pediatric patients presenting to the emergency department (ED) with acute asthma. METHODS: The authors conducted a randomized, double-blind, placebo-controlled trial in a tertiary care, urban pediatric ED. Patients 2 to 18 years of age with moderate to severe acute asthma were randomized to receive either a single 2-mg dose of budesonide inhalation suspension (BUD) or normal sterile saline (NSS) placebo, added to albuterol, ipratropium bromide (IB), and systemic corticosteroids (SCS). The primary outcome was the difference in median asthma scores between treatment groups at 2 hours. Secondary outcomes included differences in vital signs and hospitalization rates. RESULTS: A total of 180 patients were enrolled. Treatment groups had similar baseline demographics, asthma scores, and vital signs. A total of 169 patients (88 BUD, 81 NSS) were assessed for the primary outcome. No significant difference was found between groups in the change in median asthma score at 2 hours (BUD -3, NSS -3, p = 0.64). Vital signs at 2 hours were also similar between groups. Fifty-six children (62%) were admitted to the hospital in the BUD group and 55 (62%) in the NSS group (difference 0%, 95% confidence interval [CI] = -14% to 14%). Neither multivariate adjustment nor planned subgroup analysis by inhaled corticosteroids (ICS) use prior to the ED significantly altered the results. CONCLUSIONS: For children 2 to 18 years of age treated in the ED for acute asthma, a single 2-mg dose of budesonide added to standard therapy did not improve asthma severity scores or other short-term ED-based outcomes.

Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity.

UNLABELLED: In the spring of 2009, the first patients infected with 2009 H1N1 virus were arriving for care in hospitals in the United States. Anticipating a second wave of infection, our hospital leaders initiated multidisciplinary planning activities to prepare to increase capacity by expansion of emergency department (ED) and inpatient functional space and redeployment of medical personnel. EXPERIENCE: During the fall pandemic surge, this urban, tertiary-care children's hospital experienced a 48% increase in ED visits and a 12% increase in daily peak inpatient census. However, several strategies were effective in mitigating the pandemic's impact including using a portion of the hospital's lobby for ED waiting, using a subspecialty clinic and a 24-hour short stay unit to care for ED patients, and using physicians not board certified in pediatric emergency medicine and inpatient-unit medical nurses to care for ED patients. The average time patients waited to be seen by an ED physician and the proportion of children leaving the ED without being seen by a physician was less than for the period when seasonal influenza peaked in the winter of 2008-2009. Furthermore, the ED did not go on divert status, no elective medical or surgical admissions required cancellation, and there were no increases in serious patient safety events. SUMMARY: Our health center successfully met the challenges posed by the 2009 H1N1 outbreak. The intent in sharing the details of our planning and experience is to allow others to determine which elements of this planning might be adapted for managing a surge of patients in their setting.

A case of spontaneous chylothorax in an adolescent.

We discuss an male adolescent who presented to the emergency department with fever and respiratory distress. He was subsequently diagnosed with spontaneous chylothorax. We review his clinical presentation and diagnostic and therapeutic interventions and provide a discussion of the subject.

A febrile young infant with splenomegaly and ecchymoses.

We discuss a young infant who presented to the emergency department with fever, ecchymoses, and splenomegaly with subsequent diagnosis of infant acute lymphoblastic leukemia. We review the infant's presentation, diagnostic, and therapeutic interventions, as well as the rare diagnosis of infant acute lymphoblastic leukemia and its poor prognosis. We pay particular attention to the hyperleukocytosis seen in this patient, a true oncologic emergency, and its treatment in the emergency department setting.

Emergency physicians' prescribing of asthma controller medications.

OBJECTIVES: To determine the frequency with which emergency department (ED) physicians prescribe long-term controller medications (LTCMs) for children with asthma, to assess ED physicians' awareness of and level of agreement with national guidelines for LTCM use, and to identify criteria ED physicians use to prescribe LTCMs and barriers to the use of LTCMs. METHODS: A survey of all physician members of the American Academy of Pediatrics Section on Emergency Medicine who provide care for children in an ED was performed. RESULTS: Surveys were returned by 391 (50%) of 782 physicians. The majority (80%) indicated that fewer than one half of children with persistent asthma were using LTCMs on ED arrival. Although 99% believe that children with persistent asthma should be treated with LTCMs, <20% provide LTCMs for the majority of such children at ED discharge. For 49%, the main reason for not prescribing these medications was the belief that this was the role of the primary care provider or asthma specialist. Practice setting, prior training, and annual patient volume were not associated significantly with prescribing LTCM. Patient's age and likelihood of compliance and physician's belief in efficacy and concerns about adverse effects were not important criteria in the decision to begin LTCM. CONCLUSIONS: ED physicians often encounter children with persistent asthma who are not receiving LTCMs, they believe in the efficacy and safety of LTCMs, and they think that children with persistent disease should be treated with LTCMs, but they prescribe LTCMs infrequently.