Outcomes for Children With a Nonvisualized Appendix on Ultrasound.

OBJECTIVES: Oftentimes while pursing the diagnosis of appendicitis, an ultrasound cannot visualize the appendix, and physicians must utilize other resources for evaluation. The primary objective of this study was to determine if there was a lower rate of appendicitis when the appendix was not visualized on ultrasound. Furthermore, we assessed the importance of specific clinical predictors in this population. METHODS: We conducted a retrospective chart review of all children who presented to our pediatric emergency department from 2011 to 2013 and had an abdominal ultrasound. We identified total numbers of ultrasounds with a nonvisualized appendix and then assessed follow-up for a randomly selected group of patients. We performed logistic regression to assess the predictive value of different clinical factors. RESULTS: A total of 3245 ultrasounds were analyzed, and in 54% of these, the appendix was nonvisualized. In total, 28% of the total patients and 11.9% of patients who received a nonvisualized ultrasound had appendicitis (95% confidence interval [CI], 8.3%-16.2%). Among those patients who had follow-up studies performed during the same visit, 21.2% had appendicitis (95% CI, 14.9%-28.8%), and of those discharged without a diagnosis, 1.5% had appendicitis (95% CI, 0.2%-5.4%). Male sex, leukocytosis, and an elevated absolute neutrophil count were each significantly associated with appendicitis after a nonvisualized appendix on ultrasound. CONCLUSIONS: A significant proportion of patients with suspected appendicitis who had an initial nonvisualized appendix on ultrasound were ultimately diagnosed with appendicitis. Clinicians must be vigilant about pursuing a definitive diagnosis if an initial ultrasound is nondiagnostic.

Development and Considerations for Virtual Reality Simulations for Resuscitation Training and Stress Inoculation.

INTRODUCTION: Resuscitation simulations immerse learners into the complexity of emergency patient management. Head-Mounted Display Virtual Reality (VR) has been used for stress inoculation therapy for phobias and posttraumatic stress disorder. However, VR for stress inoculation in resuscitation leadership training has not been studied. We sought to develop VR simulation for stress inoculation, as exposure therapy training, for resuscitations. METHODS: We explain the conceptual design, development, production, and initial evaluation process for 2 VR simulations in infant status epilepticus and pediatric anaphylactic shock. We further describe deliberate game mechanic choices to maximize psychological fidelity. In-virtual reality performance data for time-to-critical actions and stress physiology markers (heart rate, salivary cortisol) were collected from expert pediatric emergency physicians and novice pediatric residents. Data were analyzed to examine differences between the 2 groups for both outcome types to determine the extent of stress response or performance deficit the VR induced. RESULTS: Multiple difficulties and distractions were designed for the 2 scenarios; we evaluated the highest difficulty and environmental distraction versions. Between 19 expert physicians and 15 novice physicians, no performance differences were found in typical airway, breathing, and circulation actions. Residents preferred more lorazepam first-line antiepileptics than attendings (P = 0.003) and performed a cricothyrotomy later than attendings (P = 0.02). Residents, however, manifested higher salivary cortisol levels than attendings (+0.07 µg/dL, 95% confidence interval = 0.03-0.12, P = 0.001). CONCLUSIONS: A VR resuscitation simulation manifested expected stress physiology changes in physicians. Further evaluation is needed to determine the effect of VR simulation as longitudinal stress inoculation for healthcare providers.

Barriers to Effective Teamwork Relating to Pediatric Resuscitations: Perceptions of Pediatric Emergency Medicine Staff.

BACKGROUND: In the pediatric emergency department (PED), resuscitations require medical teams form ad hoc, rarely communicating beforehand. Literature has shown that the medical community has deficiencies in communication and teamwork. However, we as medical providers do not know or understand the perceived barriers of our colleagues. Physicians may perceive a barrier that is different from nurses, respiratory therapists, pharmacists, or technicians. Perhaps we do not know in which area of teamwork and communication we are deficient. Only when we understand the perceptions of our fellow coworkers can we take steps toward improvement in quality resuscitations and therefore patient safety. OBJECTIVE: The primary objectives of this study were to describe and understand the perceived barriers to effective communication and teamwork among different disciplines forming spontaneous resuscitation teams at a tertiary urban PED and to determine if providers of different disciplines perceived these barriers differently. METHODS: This was a mixed-methods study conducted in a single, tertiary care freestanding children's hospital emergency department. Survey questions were iteratively developed to measure the construct of barriers and best practices within resuscitation teamwork, which was administered to staff among 5 selected roles: physicians, nurses, respiratory technicians, PED technicians, and PED pharmacists. It contained open-ended questions to provide statements on specific barriers or goals in effective teamwork, as well as a priority ranking on 25 different statements on teamwork extracted from the literature. From the participant data, 9 core themes related to resuscitation teamwork were coalesced using affinity diagramming by the authors. All statements from the survey were coded to the 9 core themes by 2 authors, with high reliability (κ = 0.93). Descriptive statistics were used to summarize the prevalence of themes mentioned by survey participants. A χ test was used to determine differences in prevalence of core themes by role. Rank data for the 25 statements were converted to a point system (5 points for most important, 4 points for second most important, etc), and a mixed within-between analysis of variance was used to determine the association of role and relative rank. RESULTS: There were 125 respondents (62% response rate) who provided 893 coded statements. The core theme of communication-in particular, closed-loop communication-was the most prevalent theme, although no differences in the proportion of themes represented were seen by PED staff of different roles (P = 0.18). There was a significant effect from the core theme (P = 0.002, partial η = 0.13), with highest priority on team leader performance (mean points out of 5 = 2.5 ± 1.9), but neither effect nor interaction with role (P = 0.6, P = 0.7). CONCLUSIONS: When answering open-ended questions regarding barriers to effective resuscitations, all disciplines perceived communication, particularly closed-loop communication, as the primary theme lacking during resuscitations. However, when choosing from a list of themes, all groups except physicians perceived deficiencies in team leader qualities to be the greatest barrier. We as physicians must work on improving our communication and leadership attributes if we want to improve the quality of our resuscitations.

Comparisons of Stress Physiology of Providers in Real-Life Resuscitations and Virtual Reality-Simulated Resuscitations.

BACKGROUND: Virtual reality (VR) is a promising simulation medium for high-stakes, low-frequency events such as pediatric resuscitation. The psychological fidelity of VR compared with a real resuscitation in an emergency department (ED) is relatively unknown. The objective was to determine whether stress physiology changes were equivalent between ED and VR resuscitations. METHODS: This was a single-site pilot equivalence study evaluating head-mounted VR resuscitation scenarios using board-certified/eligible pediatric ED physicians. Subjects had heart rates (HRs) and salivary cortisol levels recorded throughout 8-hour evening ED shifts and during one 1-hour VR session. Additional samples and subjective workload perception (NASA Task Load Index) were collected for critical resuscitations. A delta HR and delta cortisol level described the difference in mean HR and mean cortisol level between shifts with and shifts without resuscitations. Another delta calculation was performed from pre-VR to post-VR. Nonparametric univariate statistics was examined for significant differences in delta HR or cortisol levels between the ED setting and VR. RESULTS: Sixteen subjects had 69 shifts monitored with 31 resuscitations. In the ED, delta HR was +13.9 bpm (P < 0.001) and delta cortisol was +0.10 µg/dL (P = 0.006). In VR, delta HR was +6.5 bpm (P < 0.001) but minimal delta cortisol (-0.02 µg/dL, P = 0.05). Emergency department resuscitations both HR and cortisol levels were more than VR resuscitations (P < 0.03). NASA Task Load Index scores were higher in VR resuscitations with +26 score difference (P = 0.01). CONCLUSIONS: Virtual reality resuscitations increase HR but show less stress physiology changes than ED resuscitations within an actual 8-hour shift. Further inquiry into stress physiology and optimal VR simulation is warranted.

Let Us Use LET: A Quality Improvement Initiative.

BACKGROUND: Well-managed pain is associated with faster recovery, fewer complications, and decreased use of resources. In children, pain relief is also associated with higher patient and parent satisfaction. Studies have shown that there are deficiencies in pediatric pain management. LET gel (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.5%) is a topical anesthetic that is routinely used before laceration repair. OBJECTIVE: The aim of this study was to determine if educational initiatives as part of a quality improvement initiative lead to increased rates of early topical anesthetic usage in a large urban pediatric emergency department. METHODS: The initiative consisted of an educational session and a triage booth poster. We then reviewed the charts of patients with facial and scalp lacerations for the month before the initiative, the month after the initiative, and 1 year after the initiative. We assessed if LET gel usage and time to administration improved and were sustainable. RESULTS: We reviewed 138 charts. Before the initiative, only 57.4% received LET gel before facial laceration repair with a mean time to application of 58.3 minutes. One month after the initiative, there was an increase in LET gel application by 20.1% with a reduction in time to application by 35.9 minutes (P < 0.05). In addition, these improvements were significantly sustainable. One year after the interventions, 82.4% received LET before facial laceration repair, and the time to LET application was 27.8 minutes. CONCLUSIONS: Simple educational initiatives can improve the use of topical anesthetics. By using educational tools as part of a quality improvement initiative, we were able to significantly improve the rates of LET gel application for facial lacerations in children and decrease the time to administration.

Current challenges in the diagnosis and management of fever.

PURPOSE OF REVIEW: We review recommendations from recent publications on the management of fever with antipyretics, the classification and diagnosis of fevers of unknown origin (FUO), and the evaluation of fever in infants under 90 days of age. RECENT FINDINGS: Anxiety about fever persists in the population, while the toxicity of antipyretics is an increasing concern. The numerous opportunities for overdosing with antipyretics have been emphasized by the American Academy of Pediatrics (AAP). The practice of alternating acetaminophen and ibuprofen has limited value. Nonclassic FUO and pseudo-FUO are as important to consider as true FUO, and clinicians should become familiar with the variety of periodic fever syndromes. The clinical utility of low-risk criteria to identify febrile infants at low risk for serious bacterial infection (SBI) was demonstrated in a systematic review of studies. SUMMARY: Pediatricians should spend more time educating parents about fever and antipyretic use. Not all persistent fever is FUO, and testing should be targeted to the child's clinical condition. Existing low-risk criteria should be used to identify febrile infants who can be managed without extensive work-up and antibiotics. Adherence to evidence-based recommendations will lessen the morbidity and mortality associated with febrile illnesses in children.