Transfers From a Pediatric Urgent Care to an Academic Pediatric Emergency Department.

OBJECTIVES: Patient transfers from outpatient urgent care centers are common occurrences in a pediatric emergency department (ED). A previous study done at our institution evaluated the clinical appropriateness of transfers from general urgent care centers into our pediatric ED, showing that a significant proportion (27%) of such transfers were discharged home with minimal ED resource utilization. This study investigated the hypothesis that transfers to a pediatric ED from a pediatric urgent care have higher rates of ED resource utilization when compared with patients transferred from general urgent care centers. METHODS: A retrospective chart review was completed during an 11-month period on all patients transferred from a pediatric urgent care center to the pediatric ED. Demographic, diagnoses, reason for transfer, ED resource utilization, ED disposition, and 72-hour ED return data were collected from the electronic medical record. Each encounter was classified as acute or nonacute based on previously established resource utilization criteria. This data were then compared with findings from a prior study of transfers from all urgent care centers to our institution's pediatric ED. RESULTS: A total of 240 patients met the inclusion criteria. Of these, 160 (66.7%) were discharged from the ED. Twenty-six (10.8%) of the transferred patients met the nonacute transfer criteria. The odds of nonacute transfer from pediatric urgent care were 0.66 times lower than from general urgent care (odds ratio, 0.34; 95% confidence interval, 0.18-0.93). CONCLUSIONS: A significantly lower proportion of transfers from the pediatric urgent care center were classified as nonacute, as compared with transfers from general urgent care centers. This suggests that the pediatric urgent care model may help to reduce the number of nonacute ED visits, thus producing cost savings and better patient care.

Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.

BACKGROUND: The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. OBJECTIVE: The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. METHODS: This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. RESULTS: A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). CONCLUSIONS: Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

Urgent Care Transfers to an Academic Pediatric Emergency Department.

OBJECTIVES: The aim of this study was to investigate the hypothesis that a significant percentage of urgent care center to pediatric ED transfers can be discharged home without emergency department (ED) resource utilization. METHODS: A retrospective chart review was completed for a 6-month period on all patients transferred from urgent care centers. A data collection tool focusing on demographics, diagnoses, reason for transfer, ED resource utilization, ED disposition, and 72-hour ED return was used. Each encounter was classified as "urgent" or "nonurgent" based on resource utilization criteria. Descriptive statistics were reported for demographics, encounter data, and 72-hour ED return stratified by nonurgent versus urgent classification. Two-sample t, χ, and Fisher exact tests were used to assess differences in characteristics between the nonurgent and urgent groups. RESULTS: One hundred nine patients met inclusion criteria. Of these, 93 (85%) were discharged from the ED. Twenty nine (27%) of the transferred patients were discharged without ED resource utilization. Seventy-two-hour return was noted for only 1 patient who was again discharged at the subsequent encounter. CONCLUSIONS: A large proportion of patients transferred from urgent care centers were directly discharged from the ED without any ED resource utilization. Eliminating or reducing such transfers has the potential to limit the amount of nonurgent ED visits, thus producing cost savings and better patient care.

Emergency Department Diagnosis of Dietl Crisis in a 7-Year-Old Girl With Abdominal Pain.

Children with Dietl crisis often experience a delay in diagnosis, with the clinical entity being underdiagnosed. Pain is caused by compression of an aberrant artery crossing dilated kidney. Pain is often worsened after the consumption of liquids and resolves after fluid reabsorption. There are no clear criteria for evaluating ureter obstruction in childhood abdominal pain in the emergency department setting; however, it has been suggested that ultrasound may aid in the diagnosis. As renal parenchyma is typically preserved, and there is a paucity of associated urological complaints, once properly diagnosed, most patients are well served by a pyeloplasty.

Internal Applicants to Pediatric Emergency Medicine Fellowships and Current Use of the National Resident Matching Program Match: A Survey of Fellowship Directors.

OBJECTIVES: Applicants to fellowship programs are divided into the following 2 distinct groups: the external versus internal candidate. Internal fellowship candidates did residency at the same institution they are applying to, whereas the external candidate is from another institution. Internal candidates have likely done rotation(s) within the fellowship's division and are known to faculty, whereas the external candidates are evaluated by their applications and interviews alone. Acceptance of internal fellowship candidates may be complicated by competing interests of the associated residency program and overlapping faculty who have academic roles in both training programs. The current percentage of pediatric emergency medicine (PEM) fellowships exclusively using the National Resident Matching Program (NRMP) Specialties Matching Service (SMS) for filling fellowship slots is not known. METHODS: We surveyed all the current US PEM fellowship directors in April/May 2013 using a 15-question anonymous institutional review board-approved survey. This survey was hosted through http://www.surveymonkey.com and was available between April 08, 2013 and May 08, 2013. The unique link sent to each fellowship director recorded completion of the survey but no individual responses. All questions had to be answered for the results to be recorded. RESULTS: Fifty-four of 70 fellowship directors responded. Each question was individually evaluated. Fellowship directors had different feelings toward internal candidates. The NRMP-SMS exclusive use was high. Possible confounders using the NRMP match seemed uncommon. CONCLUSIONS: Twenty-nine percent of current PEM fellows are in training at the same institution where they completed their residency. Both internal and external candidates are valued by PEM fellowship directors. The exclusive use of the NRMP SMS is high and not confounded by internal factors.

Parental knowledge of radiation exposure in medical imaging used in the pediatric emergency department.

OBJECTIVES: We sought to quantify the knowledge base among parents and legal guardians presenting to our pediatric emergency department regarding radiation exposure during medical imaging and potential risks to children resulting from ionizing radiation. We sought to examine if a child's previous exposure to medical imaging changed caregiver knowledge base and discern caregivers' preference for future education on this topic. METHODS: A prospective convenience sample survey was performed of caregivers who presented with their child to our tertiary pediatric emergency department. Parents or legal guardians (18-89 years) who accompanied a child (0-17 years) were eligible for inclusion and approached for enrollment. A structured questionnaire was administered by trained interviewers, and a chart review was conducted to ascertain if their child had a history of previous imaging. RESULTS: Sixty percent of caregivers interviewed (n = 205 of 340) did not associate any long-term negative effects with medical imaging. Among participants who did express a perceived risk from medical imaging radiation exposure, only 50% could indicate a known negative effect from exposure. We found no significant association between a child having had documented imaging studies and awareness of long-term negative effects (P = 0.22). Participants preferred to learn more about this topic from an Internet-based resource (50%), informational pamphlet (38%), or via treating physician (33%). CONCLUSIONS: Parents and legal guardians are largely unaware that exposure to radiation during medical imaging carries an inherent risk for their child. Health care providers wishing to educate caregivers should utilize reliable Internet sources, educational pamphlets, and direct communication.

Most frequently missed fractures in the emergency department.

This study quantified the types of extremity fractures most commonly missed on plain radiographs by pediatric emergency medicine specialists after an initial emergency department (ED) encounter. From February 2006 to June 2009, extremity radiographs obtained in a pediatric ED in which a radiologist categorized the ED attendings' read of normal as incorrect were tabulated. The authors also counted the total number of each type of radiograph completed when radiologists were unavailable. The percentage of each type of fracture missed was calculated based on the total number of missed fractures. It was found that a total of 220 fractures were missed during ED encounters in the study period. The most frequently missed fractures were of the hand phalanges (26.4%) followed by metatarsus (9.5%), distal radius (7.7%), tibia (7.3%), and phalanges of the foot (5.5%). Emergency physicians should be aware that the most commonly missed fractures were phalanges of the hand and metatarsal fractures.

Apparent desaturation on pulse oximetry because of hemoglobinopathy.

Hemoglobinopathies are an uncommon cause of cyanosis and low oxygen saturation on pulse oximetry. However, when they do occur, they can present a complex clinical scenario for the emergency physician. We report the index case of a previously undescribed hemoglobinopathy that presented to the pediatric emergency department. The evaluation and management of the cyanotic/hypoxic child and review of hemoglobinopathies are presented here.