CA FIRST (California Febrile Infant Risk Stratification Tool) Algorithm Development in a Learning Health System.

Introduction There is considerable variation in the approach to infants presenting to the emergency department (ED) with fever. The authors' primary aim was to develop a robust set of algorithms using community ED data to inform modifications of broader clinical guidance. Methods The authors report the development of California Febrile Infant Risk Stratification Tool (CA FIRST) using key components of the Roseville Protocol (ROS) and American Academy of Pediatrics (AAP) Clinical Practice Guideline (CPG). Expanded guidance was derived using a retrospective analysis of a cohort of 3527 febrile infants aged 7-90 days presenting to any Kaiser Permanente Northern California ED between 2010 and 2019 who underwent a core febrile infant evaluation. Results Melding ROS and AAP CPG algorithms in infants 7-60 days old, CA FIRST Algorithms had comparable performance characteristics to ROS and AAP CPG. CA FIRST enhancements included guidance on febrile infants 61-90 days old, high-risk infants, infants with bronchiolitis, and infants who received immunizations within the prior 48 hours. This retrospective analysis revealed that of 235 febrile infants 22-90 days old with respiratory syncytial virus and 221 who had fever in the 48 hours following vaccination, there were no cases of invasive bacterial infection. Discussion CA FIRST is a set of 13 algorithms providing a thoughtful and flexible approach to the febrile infant while minimizing unnecessary interventions. Conclusions CA FIRST Algorithms empower clinicians to manage most febrile infants. Algorithms are being modified as new data become available, imparting useful and ever-current educational information within a learning health care system.

Clinical management and outcomes for febrile infants 29-60 days evaluated in community emergency departments.

Objective: Describe emergency department (ED) management and patient outcomes for febrile infants 29-60 days of age who received a lumbar puncture (LP), with focus on timing of antibiotics and type of physician performing LP. Methods: Retrospective observational study of 35 California EDs from January 1, 2010 through December 31, 2019. Primary analysis was among patients with successful LP and primary outcome was hospital length of stay (LOS). Logistic regression analysis included variables associated with LOS of at least 2 days. Secondary outcomes were bacterial meningitis, hospital admission, length of antibiotics, and readmission. Results: Among 2569 febrile infants (median age 39 days), 667 underwent successful LP and 633 received intravenous antibiotics. Most infants (n = 559, 88.3%) had their LP before intravenous antibiotic administration. Pediatricians performed 54% of LPs and emergency physicians 34%. Sixteen infants (0.6% of 2569) were diagnosed with bacterial meningitis, and none died. Five hundred and fifty-eight (88%) infants receiving an LP were hospitalized. Among patients receiving an LP and antibiotics (n = 633), 6.5% were readmitted within 30 days. Patients receiving antibiotics before LP had a longer length of antibiotics (+ 7.9 hours, 95% confidence interval [CI] 3.8-13.4). Primary analysis found no association between timing of antibiotics and LOS (odds ratio [OR] 0.67, 95% CI 0.34-1.30), but shorter LOS when emergency physicians performed the LP (OR 0.66, 95% CI 0.45-0.97). Conclusions: Febrile infants in the ED had no deaths and few cases of bacterial meningitis. In community EDs, where a pediatrician is often not available, successful LP by emergency physician was associated with reduced inpatient LOS.

High-Flow Nasal Cannula Use in Children with Bronchiolitis in a Community Hospital Setting: Evaluation of Safety, Flow Limits, and Intensive Care Unit Transfers.

INTRODUCTION: High-flow nasal cannula (HFNC) oxygen therapy is being used in pediatric wards at increasing rates, including community hospitals that do not have a pediatric intensive care unit (PICU). This study describes the use of HFNC in a pediatric ward at a community hospital, evaluating safety, flow limits, and outcomes for children transferred to a PICU. METHODS: A descriptive, single center retrospective cohort study of consecutive subjects from birth to 24 months of age treated with HFNC for bronchiolitis in our pediatric ward from January 2016 to May 2019. We report demographic and clinical characteristics of the patients. The outcomes of interest include episodes of aspiration, pneumothorax, intubation, cardiorespiratory arrest, and transfers to the PICU. RESULTS: There were 157 hospitalizations. One hundred twenty-three children (78.3%) were weaned off HFNC and discharged to home. Flow rates of up to 3 L/kg/min (average, 1.22 L/kg/min; range 0.28-3.08 L/kg/min) were tolerated. Of the 34 children transferred to the PICU, 29 were continued on HFNC, 1 required continuous positive airway pressure, and 4 were intubated. The median time from initiation of HFNC to transfer was 13 hours (interquartile range 6.0-23.0). There were no documented episodes of aspiration, pneumothorax, cardiorespiratory arrest, or death. CONCLUSION: HFNC could be safely administered in a community hospital pediatric ward without PICU expertise and capability. Most patients who deteriorate on HFNC do so within the first 24 hours when close monitoring is needed. For children transferred to a PICU, the vast majority did not require more invasive forms of respiratory support.

Opioid prescribing patterns in emergency departments and future opioid use in adolescent patients.

OBJECTIVE: Evidence suggests that exposure to opioids in adolescence increases risk of future opioid use. We evaluate if exposure to high versus low intensity opioid prescribers in the Emergency Department (ED) influences the risk of future opioid use in adolescents. METHODS: Retrospective study of opioid-naïve patients 10 to 17 years seen in one of 14 EDs between January 2013 and December 2014. We categorized ED providers into quartiles according to the proportion of encounters resulting in opioid prescriptions. Primary outcome was use of opioids in the subsequent 12 months. Analysis adjusted for patient characteristics and compared future use of opioids for patients seen by the lowest versus the highest prescribing quartiles. RESULTS: We included 9,688 patient encounters evaluated by the lowest opioid prescribing physician quartile versus 9,467 in the highest. The highest quartile gave opioid prescriptions to 14.9% of their patients compared to 2.8% for the lowest quartile. No association with future opioid use was found for patients evaluated by low versus high prescriber quartiles (OR 0.99, 95% CI 0.90-1.08). Patients with increasing age (OR 2.15, 95% CI 1.92-2.42) and white versus Hispanic ethnicity (OR 1.55, 95% CI 1.33-1.80) were associated with recurrent opioid use. CONCLUSION: We found no association between high intensity opioid prescribers and recurrent 12 month use of opioids in opioid-naïve adolescents seen in the ED. This likely reflects various factors that put adolescents at risk for recurrent opioid use and may indicate the importance of the second prescription from primary care after initial exposure to opioids.

Association of age and opioid use for adolescents and young adults in community emergency departments.

OBJECTIVES: Adolescents and young adults are at high risk for opioid misuse and abuse. The emergency department (ED) plays a key role in treatment of acute and chronic pain and is a primary place that this patient population is exposed to prescription opioids. We evaluate the effect of patient age on use of opioids for adolescents and young adults in community EDs. METHODS: Retrospective cohort study of adolescent and young adult encounters in 14 community EDs from 2013 to 2014. We evaluate the percent of ED encounters with parenteral and/or oral opioids administered, morphine milligram equivalents per ED patient encounter, and percent of patient encounters discharged with an opioid prescription. Age was the main exposure. The association between outcomes and age was examined using bivariate and multivariate logistic regression adjusting for measurable confounders. RESULTS: There were 259,632 adolescent and young adult encounters in our sample, average age 17.6 years, with 15.8% given opioids. Increasing patient age was associated with a significant increase in the percent of encounters with opioids given (AOR, 1.11; 95% CI 1.10-1.11), morphine milligram equivalents administered (ß 0.38; 95% CI 0.33-0.43 for parenteral and ß 0.26; 95% CI 0.23-0.28 for oral), and percent of patients receiving outpatient prescriptions (AOR, 1.14; 95% CI 1.13-1.14). Significant variability also existed between medical centers (AOR, 2.02; 95% CI 1.86-2.20). CONCLUSION: For adolescent and young adult patients in the ED, there is a significant association between opioid prescribing and increasing age. This describes an opportunity to reduce opioid use in older adolescents and young adults.

Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines.

OBJECTIVE: Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture. METHODS: We conducted a pre-post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre- and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing. RESULTS: There were 508,337 pre- and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR] = 0.89, 95% CI = 0.87-0.91) and a decrease in the monthly trend compared to the preintervention period (OR = 0.99, 95% CI = 0.99-0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR = 0.81, 95% CI = 0.72-0.91), whereas the fracture cohort showed no change (OR = 1.10, 95% CI = 0.97-1.25). CONCLUSION: The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.

Blunt head trauma in children in a community health care setting: outcomes and variables associated with the use of computed tomography.

OBJECTIVE: To evaluate the incidence of clinically important traumatic brain injury (ciTBI) in children presenting to a community hospital setting and identified factors associated with computed tomography (CT) use. STUDY DESIGN: Retrospective cohort study of consecutive children presenting with blunt head trauma to a community emergency department or clinic over 12 months. Logistic regression models were used to compare differences in characteristics between patients who received and did not receive CT scans. RESULTS: Of 1007 patients, 62% male, age 14 days-18 years (270 <2 years, 737 ≥2 years), 189 (18%) had CT scans, 2 (0.2%) showed evidence of ciTBI on CT, 13 (1.3%) hospitalized, and none required neurosurgical intervention or died. Factors associated with CT use in patients ≥2 years: history of vomiting (OR 4.08, 95% CI 2.08-7.99, P < .001), change in behavior (OR 2.83, 95% CI 1.63-4.91, P < .001), headache (OR 3.4, 95% CI 1.87-6.16, P < .001), loss of consciousness (OR 2.83, 95% CI 1.38-5.8, P = .004), and abnormal neurologic examination (OR 26.18, 95% CI 2.26-303.05, P = .009). Patients were more likely to receive CT scans in community emergency departments than clinics (OR 7.04, 95% CI 2.40-20.65, P = .002). CONCLUSION: Patients in our community hospital setting are at low risk of ciTBI. The clinical indicators used to determine the need for CT in patients with more significant mechanisms of injury to pediatric or academic centers may not apply to this group. Future studies are required to determine which clinical indications are significant in this setting.