Short-term outcomes in children following emergency department visits for minor injuries sustained at home.

BACKGROUND: Minor injuries are very common in the pediatric population and often occur in the home environment. Despite its prevalence, little is known about outcomes in children following minor injury at home. Understanding the impact of these injuries on children and their families is important for treatment, prevention, and policy. The objectives of our study were (1) To describe the distribution of short-term outcomes following pediatric minor injuries sustained at home and (2) To explore the relationship of injury type and patient and household demographics with these outcomes. METHODS: Children (n = 102) aged 0-7 years with a minor injury sustained at home were recruited in an urban pediatric emergency department as part of the Child Housing Assessment for a Safer Environment (CHASE) observational study. Each patient had a home visit following the emergency department visit, where five parent-reported outcomes were assessed. Relationships were explored with logistic regression. RESULTS: The most common type of injury was soft tissue (57.8 %). 13.2 % of children experienced ≥ 7 days of pain, 21.6 % experienced ≥ 7 days of abnormal activity, 8.9 % missed ≥ 5 days of school, 17.8 % of families experienced ≥ 7 days of disruption, and 9.1 % of parents missed ≥ 5 days of work. Families reported a total of 120 missed school days and 120 missed work days. Children who sustained a burn had higher odds of experiencing pain (OR 6.97), abnormal activity (OR 8.01), and missing school (OR 8.71). The parents of children who sustained a burn had higher odds of missing work (OR 14.97). CONCLUSIONS: Families of children suffering a minor injury at home reported prolonged pain and changes in activity as well as significant school and work loss. In this cohort, burns were more likely than other minor injuries to have these negative short-term outcomes reported and represent an important target for interventions. The impact of these injuries on missed school and disruption of parental work warrants further consideration.

Results of an RCT in Two Pediatric Emergency Departments to Evaluate the Efficacy of an m-Health Educational App on Car Seat Use.

INTRODUCTION: The growing interest in incorporating prevention into emergency health care make it timely to examine the use of computer technology to efficiently deliver effective education in this setting. STUDY DESIGN: This RCT compared results from an intervention group (n=367) that received child passenger safety information, to an attention-matched control (n=375). A baseline survey and two follow-up surveys at 3 and 6 months were conducted. SETTING/PARTICIPANTS: Data were collected from June 2014 to September 2016 from a sample of parents with children aged 4-7 years recruited from a pediatric emergency department in an East Coast urban area and one in a Midwest semi-rural area. INTERVENTION: A theory-based, stage-tailored educational program, Safety in Seconds v2.0TM, delivered on a mobile app. MAIN OUTCOME MEASURES: Four car seat behaviors: (1) having the correct restraint for the child's age and weight; (2) having the child ride in the backseat all the time; (3) buckling up the child all the time; and (4) having the child's restraint inspected by a child passenger safety technician. RESULTS: At 3 months, adjusting for baseline behaviors and attrition, the odds of reporting the correct behavior by the intervention group relative to the control group was 2.07 (p<0.01) for using the correct car seat; 2.37 (p<0.05) times for having the child ride in the back seat; 1.04 (nonsignificant) for riding buckled up all the time; and 1.99 (p<0.01) times for having the car seat inspected. At 6 months, there were statistically significant effects for reporting use of the correct car seat (OR=1.84, p<0.01) and having the car seat inspected (OR=1.73, p<0.01). CONCLUSIONS: Mobile apps hold promise for reaching large populations with individually tailored child passenger safety education. TRIAL REGISTRATION: Clinical Trial Registration # NCT02345941.

Health-related quality of life for pediatric emergency department febrile illnesses: an evaluation of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales.

OBJECTIVE: We sought to assess the validity and short-term responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) for febrile illnesses evaluated in the pediatric emergency department (ED). DESIGN: Prospective cohort study of children 2-18 years discharged after ED evaluation for fever (>or= 38 degrees C). Self-administered, parent-report of health-related quality of life (HRQOL) was assessed using the PedsQL Acute Version, a validated HRQOL instrument. HRQOL was measured on ED presentation and at 7-10 day follow-up. At follow-up, duration of fever, child functional impairment, missed daycare/school, and disrupted family unit functioning, were assessed. RESULTS: Of 160 subjects enrolled, 97 (61%) completed the study; mean follow-up was 8.7 days. Mean total HRQOL score on ED presentation was 76.4; mean follow-up score was 86.3. Compared to subjects that returned to baseline, statistically significant differences in HRQOL were noted for those with prolonged fever, child functional impairment, and relapse. Significant correlation was observed between HRQOL at follow-up and days of daycare/school missed (r = -0.35, p = .003) and days of family disruption (r = -0.43, p < .001). Mean change in HRQOL within subjects, from ED visit to follow-up, was +9.8 (95% CI: 5.6-14.6). Effect size was 0.53, indicating moderate responsiveness. CONCLUSION: The PedsQL appears to be a valid and responsive indicator of HRQOL for short-term febrile illnesses evaluated in the ED.

Short-term outcomes of pediatric emergency department febrile illnesses.

OBJECTIVE: To describe short-term outcomes relevant to children and their caregivers after evaluation in the emergency department (ED) for febrile illnesses. METHODS: This was a prospective cohort study of children aged 28 days to 18 years presenting with fever (> or =38 degrees C), or chief complaint of fever, who were evaluated and discharged to home from tertiary care pediatric ED. Enrollment occurred on randomly selected study days over 1 year. Caregivers were then contacted via telephone after 7 to 10 days to assess outcomes, including days of fever, child and family activity impairments, as well as return to health care. RESULTS: Follow-up was complete for 322 (72%) of 451 enrolled subjects. Mean age of subjects was 31.5 months. The most common discharge diagnosis was undifferentiated febrile illness (20.5%). Mean total duration of fever was 4.41 days (95% confidence interval [CI], 4.14-4.81); 38.9% remained febrile for 5 days or longer. For children, impairments in each outcome (activity, oral intake, sleep, behavior) persisted longer than 2.5 days; over 14% of them remained impaired at follow-up in each outcome. Children missed a mean of 2.63 days of day care or school (95% CI, 2.21-3.06); 37.4% missed 3 days or longer. Primary caregivers missed 1.47 days of work or school (95% CI, 1.19-1.75); 10.5% missed 5 days or longer. After ED evaluation, 23.7% made a nonscheduled revisit to the primary medical doctor or ED. CONCLUSIONS: Children, and their caregivers, experience prolonged fever and impairments in activities, and frequently relapse to health care as a result of febrile illnesses. Often considered minor in nature, febrile illnesses have considerable effects on the child, caregivers, and families after ED evaluation.

Validity and responsiveness of a brief, asthma-specific quality-of-life instrument in children with acute asthma.

OBJECTIVE: To test the validity and short-term responsiveness to change of a pediatric, asthma-specific, health-related quality-of-life (HRQL) instrument. METHODS: Children 2 years and older treated in the emergency department (ED) for acute asthma were eligible for this prospective cohort study. A 10-item instrument, the Integrated Therapeutics Group Child Asthma Short Form (ITG-CASF), was administered at the time of the ED visit and again 14 days later (via telephone). At the follow-up call, parents were also asked about the child's current overall asthma status, missed school or limited activities, and persistence of asthma symptoms. RESULTS: A total of 121 children were enrolled (mean age, 7.9 years), and follow-up was complete for 96 (79%). Mean +/- SD ITG-CASF scores at follow-up were significantly higher among children reported to have improved overall (61.8 +/- 19.6) than those not improved (41.9 +/- 21.2), and there was a significant correlation between ITG-CASF score at follow-up and the number of days of school missed or limited activities (r = -0.45; 95% confidence interval [CI], -0.24 to -0.66). There was also a significant difference in improvement in ITG-CASF score from ED visit to follow-up among those improved (13.7-point improvement) compared with those not improved (3.3-point improvement; difference = 10.4; 95% CI, 1.2 to 19.5). The effect size was 0.68, indicating a large responsiveness to change. CONCLUSIONS: The ITG-CASF is a valid and responsive measure of HRQL in children with acute asthma and may be a useful outcome measure in evaluating ED treatment.

Performance of a novel clinical score, the Pediatric Asthma Severity Score (PASS), in the evaluation of acute asthma.

OBJECTIVES: To evaluate the reliability, validity, and responsiveness of a new clinical asthma score, the Pediatric Asthma Severity Score (PASS), in children aged 1 through 18 years in an acute clinical setting. METHODS: This was a prospective cohort study of children treated for acute asthma at two urban pediatric emergency departments (EDs). A total of 852 patients were enrolled at one site and 369 at the second site. Clinical findings were assessed at the start of the ED visit, after one hour of treatment, and at the time of disposition. Peak expiratory flow rate (PEFR) (for patients aged 6 years and older) and pulse oximetry were also measured. RESULTS: Composite scores including three, four, or five clinical findings were evaluated, and the three-item score (wheezing, prolonged expiration, and work of breathing) was selected as the PASS. Interobserver reliability for the PASS was good to excellent (kappa = 0.72 to 0.83). There was a significant correlation between PASS and PEFR (r = 0.27 to 0.37) and pulse oximetry (r = 0.29 to 0.41) at various time points. The PASS was able to discriminate between those patients who did and did not require hospitalization, with area under the receiver operating characteristic curve of 0.82. Finally, the PASS was shown to be responsive, with a 48% relative increase in score from start to end of treatment and an overall effect size of 0.62, indicating a moderate to large effect. CONCLUSIONS: This clinical score, the PASS, based on three clinical findings, is a reliable and valid measure of asthma severity in children and shows both discriminative and responsive properties. The PASS may be a useful tool to assess acute asthma severity for clinical and research purposes.

Difficulty in obtaining peak expiratory flow measurements in children with acute asthma.

OBJECTIVE: To determine the frequency with which children >or=6 years with acute asthma can perform peak expiratory flow rate measurements (PEFR) in an emergency department (ED). DESIGN/METHODS: Data were obtained from a prospective cohort study of children with acute asthma. All children (age 2-18 years old) treated in an urban pediatric ED for an acute exacerbation during randomly selected days over a 12-month period were prospectively evaluated. According to treatment protocols, PEFR was to be measured in all children age 6 years and older before therapy and after each treatment with inhaled bronchodilators. Registered respiratory therapists obtained PEFR and evaluated whether patients were able to perform the maneuver adequately. RESULTS: Four hundred and fifty-six children, 6 to 18 years old (median 10 years), were enrolled; 291 (64%) had PEFR measured at least once. Of those in whom PEFR was attempted at least once, only 190 (65%) were able to perform adequately. At the start of therapy, 54% (142/262) were able to perform PEFR. Of the 120 who were unable to perform initially, 76 had another attempt at the end of the ED treatment, and 55 (72%) were still unable to perform. A total of 149 patients had attempts at PEFR both at the start and end of treatment, of these, only 71 (48%) provided valid information on both attempts. Patients unable to perform PEFR were younger (mean +/- SD = 8.7 +/- 2.8 years) than those who were able to perform successfully (11.2 +/- 3.2 years) and those with no attempts (10.0 +/- 3.4 years). Children admitted to the hospital were more likely to be unable to perform PEFR (58/126 = 46%) than those discharged from the ED (43/330 = 13%, P < 0.0001). CONCLUSION: Adequate PEFR measurements are difficult to obtain in children with acute asthma. Treatment and research protocols cannot rely exclusively on PEFR for evaluation of severity.

Construct validity and responsiveness of the Child Health Questionnaire in children with acute asthma.

OBJECTIVE: To examine the validity and responsiveness of the Child Health Questionnaire (CHQ-PF28) in the context of acute exacerbation of asthma in children. DESIGN AND METHODS: This was a prospective cohort study of children age 5 years and older treated for acute asthma at two urban pediatric emergency departments (EDs). At 14 days after the visit, all patients were contacted by telephone and the CHQ-PF28 (modified to have a 2-week recall period) was administered. Poor 14-day outcome was defined as one or more of the following: child or parent missed at least 5 days of school/day care/work; child still having asthma symptoms above baseline at 14 days; or unscheduled care within 7 days after the ED visit. RESULTS: A total of 732 subjects (median age, 9 years) were enrolled; 622 (85%) had successful follow-up at day 14. At the 14-day follow-up, 254 (43%) were classified as having a poor outcome. The mean physical subscale score of the CHQ-PF28 was 48.2 among those with a good outcome, vs 35.9 among the poor outcome group (difference = 12.3; 95% confidence interval, 10.2 to 14.3). For the psychosocial subscale the average difference between groups was 6.9 (95% confidence interval, 5.1 to 8.7). Among the 146 patients at one site who also had a CHQ score obtained at the initial visit, there was a significant improvement in mean physical subscale score among those with good, but not poor, outcome. However, the relative responsiveness was moderate, with an effect size of only 0.37. CONCLUSIONS: Both the physical and psychosocial subscales of the CHQ-PF28 administered 14 days after an ED visit for acute exacerbation of asthma are correlated with poor short-term functional outcome, but scores are only moderately responsive to acute changes in functional status.

Comparability of acute asthma severity assessments by parents and respiratory therapists.

OBJECTIVE: To compare the assessments of parents and respiratory therapists (RTs) of acute asthma severity in children discharged after emergency department (ED) treatment. DESIGN: Prospective cohort study. SETTING: Home care visit within 24 hours of discharge from an urban children's hospital ED. PARTICIPANTS: Children aged 2 to 17 years discharged to home after treatment in the ED (at least 1 inhaled bronchodilator treatment administered) were randomly selected to have a home care visit. MAIN OUTCOME MEASURES: Registered RTs went to the child's home and asked the parent questions about his or her perception of the child's symptoms. The RT performed a clinical assessment including pulse oximetry. RESULTS: Ninety children were selected for home care, and 51 patients (57%) successfully completed the home care visit; 48 (53%) underwent a complete assessment by both raters. There were no differences in demographic features or ED clinical variables between those successfully contacted and those not reached. Of those evaluated, 43 parents (84%) reported their child's asthma was improved, and the rest reported no change. Parents underestimated the degree of wheezing or work of breathing relative to the RT in 3 of 48 patients (6%), but only 1 of these was considered substantial (>1 point discrepancy). Findings were overestimated in 14 (29%) of 48 cases, but only 5 (10%) were substantial. CONCLUSIONS: Parents and RTs provide comparable assessments of acute asthma severity in children within 24 hours of discharge from the ED. Clinically important discrepancies are uncommon, and underestimation of severity by parents is rare.