High-Risk Markers and Infection Rates in Febrile Infants Aged 29 to 60 Days Presenting to an Emergency Department During the COVID-19 Pandemic.

OBJECTIVES: There was an overall decline in pediatric emergency department visits during the COVID-19 pandemic. Caregivers are educated to bring febrile neonates promptly to the emergency department; however, for infants aged 29 to 60 days, there may not be the same urgency especially during a pandemic. There may have been a resultant change in the clinical and laboratory high-risk markers and infection rates in this patient population during the pandemic. METHODS: This was a single-center retrospective cohort study of infants aged 29 to 60 days presenting to the emergency department of an urban tertiary care children's hospital because of fever (>38°C) between March 11 and December 31, 2020, compared with those presenting in the same period during the 3 prior years (2017 through 2019). Patients were categorized as having high-risk criteria on a predetermined definition of ill appearance, white blood cell count, and urinalysis based on our hospital's evidence-based pathway. Information on infection type was also collected. RESULTS: A total of 251 patients were included in the final analysis. Comparison of the prepandemic and pandemic cohorts showed a significant increase in the proportion of patients with urinary tract infections ( P = 0.017) and bacteremia ( P = 0.02) and those presenting with high-risk white blood cell count ( P = 0.028) and urinalysis ( P = 0.034). There was no significant difference in patient demographics or in high-risk ill appearance ( P = 0.208). CONCLUSIONS: This study demonstrates a significant increase in the rates of urinary tract infection and bacteremia in addition to the objective markers used to risk-stratify febrile infants aged 29 to 60 days. This supports the need for attentiveness in evaluating these febrile infants in the emergency department.

Reducing Antibiotic Prescription Errors in the Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Discharge prescription errors from the pediatric emergency department (ED) are common. Despite the implementation of clinical pathways for common infections recommending specific antibiotic therapy and aids built into the electronic health record, errors in antibiotic prescriptions for patients discharged home from the ED persist. METHODS: We developed and implemented ED antibiotic discharge order panels for urinary tract infection (UTI) and skin and soft tissue infections (SSTI) that modeled antibiotic therapy from our institutional clinical pathways. We aimed to reduce antibiotic prescription errors by 50% within 6 months of implementation. RESULTS: With the implementation of the ED discharge order panels, the overall error rate for prescriptions for UTI and SSTI improved from a baseline rate of 29.3% to 12.6% (P < 0.001). Individually, the baseline number of prescriptions with errors for UTI and SSTI improved from 26.1% and 32.8%, respectively, to 13.8% and 12.5% within 6 months. Sustained improvement continued for 17 months after the implementation of the order panels. CONCLUSIONS: Development and implementation of ED antibiotic discharge order panels decrease antibiotic prescription errors for UTI and SSTI by improving compliance with institutional clinical pathways. Additional order panels should be developed and implemented for other conditions to help reduce discharge prescription errors.

A Quality Improvement Initiative to Improve the Administration of Systemic Corticosteroids in the Pediatric Emergency Department.

INTRODUCTION: Timely administration of corticosteroids improves asthma care in the pediatric emergency department (ED). Using the Model for Improvement, we aimed to decrease time to delivery of corticosteroids in patients presenting to the ED with an acute asthma exacerbation. METHODS: This is a single-center, prospective, multidisciplinary quality improvement (QI) project targeting ED patients 1-18 years of age with an acute asthma exacerbation. We collected 5 months of baseline data from the arrival time of an ED patient with an asthma exacerbation with a Modified Pulmonary Index Score ≥5 to the time of administration of corticosteroids. A quality improvement project was launched in October 2017 involving multiple Plan-Do-Study-Act ramps. Improvement interventions continued for 9 months through June 2018, including reeducation of residents and nurses in the ED asthma order set and nursing treatment protocols, respectively, and changes to the electronic health record. Data were tacked for 15 additional months until September 2019. To promote the use of the nursing treatment protocol, we utilized real-time improvement feedback and continuing nursing education. RESULTS: The mean percentage of patients receiving steroids within 60 minutes of arrival improved from 59.3% to 84.3% over the first 5 months. The mean time to the administration of steroids within 60 minutes of arrival improved from 71.4 to 48.1 minutes. There was no increase in ED return rates. CONCLUSIONS: Our project improved the percentage of patients with acute asthma exacerbations receiving steroids within 60 minutes of ED arrival and mean time to administration of steroids. We sustained improvement for 18 months after the implementation of our QI interventions.

Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway.

BACKGROUND AND OBJECTIVES: Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI). METHODS: The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures. RESULTS: Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders. CONCLUSIONS: Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.

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.

Death Investigation of Diabetes Mellitus: Scene Investigation and Interrogation of Technology.

Diabetes mellitus (DM) affects millions of Americans and is a common cause of death. The medical examiner/coroner (ME/C) may be called to investigate the death of a person with DM due to the possibility of a suicide, accident, or even homicide that relates to the treatment or lack of treatment of the disease. The ME/C can ellicit abundant circumstantial information from a death scene investigation and interrogation of devices such as glucometers, insulin pumps, continuous glucose monitors, and insulin injector pens used for the management of diabetes. These devices contain stored information that can very powerfully assist the ME/C in determining the cause and manner of death. This article provides a review of DM treatment and common medical devices used in the treatment and management of DM, offers the ME/C some instruction for interrogating the devices on their own, and highlights the benefits of beholding the information contained within the devices. At the conclusion of this review, the reader should have an understanding of how these devices work, how the information they contain can be accessed, and how useful that information can be in death investigation.

A content analysis of parents' written communication of needs and expectations for emergency care of their children.

OBJECTIVE: We investigated the potential value of information shared by parents on a written form designed to capture needs and expectations for care to an emergency department (ED) system that values patient-centeredness. METHODS: We conducted a retrospective content analysis of parent-completed written forms collected during an improvement project focused on parent-provider communication in a pediatric ED. The primary outcome was potential value of the completed forms to a patient-centered ED system, defined as a form that was legible, included observations that mapped to medical problems, and included reasonable parental requests. We analyzed variation in potential value and other form attributes across a priori-defined visit type and acuity. Visit type was validated by a separate, blinded medical record review. RESULTS: A random stratified sample of 1008 forms was established from 6937 parent-completed forms collected during the 6-month improvement project; 995 of 1008 forms had matching medical records; 922 (92.7%) of 995 forms demonstrated potential value; 990 (99.5%) of 995 forms were legible; 948 (95.3%) of 995 forms included observations that mapped to a medical problem, and 599 (93.3%) of 642 forms contained reasonable parental requests. There was good agreement between the form and medical record for visit type (κ = 0.62). The potential value of forms did not vary significantly across visit type (88.2%-92.8%) or acuity (88.9%-93.4%). CONCLUSIONS: Information shared by parents on written forms designed to capture needs and expectations provides potential value to a patient-centered ED system. The high level of informational value is consistent across patient type and acuity level.

Improving parent-provider communication in the pediatric emergency department: results from the clear and concise communication campaign.

OBJECTIVE: We implemented and evaluated a quality improvement initiative targeting parents' communication with clinicians in a pediatric emergency department (ED). METHODS: A quality improvement initiative ("Clear and Concise Communication" or "3C") targeting parent-provider communication was implemented in an urban tertiary care pediatric ED. A 1-page form that solicited parent worries, questions, and expectations for care was developed. Parent-provider communication was measured using an 8-item subset of questions from an ongoing satisfaction survey adopted for pediatric emergency care. The primary outcome was the communication score for a given ED visit scaled from 0 to 100 and was calculated as the simple average of answers where the best possible response was given a value of 1 and all others were scored as 0. A multivariate model adjusting for time-related factors, ED volume, and system-level events was developed to examine the influence of the communication initiative. RESULTS: A total of 29,005 patients received care during implementation of 3C; a total of 100,810 patients received care during the 2-year period of interest. Data from 1233 satisfaction surveys were used to create the communication scores. Communication scores ranged from 0 to 100, with a mean of 88 and SD of 17.7. In a linear model adjusting for day, weekend, volume, system-level introduction of electronic charting for nurses, and electronic-order entry for physicians, the 3C initiative demonstrated a positive and statistically significant effect-increasing the communication score by 2.8 points/100 d (95% confidence interval, 0.1-5.5). CONCLUSIONS: The 3C initiative succeeded in improving parents' communication experience with emergency providers during the intervention period.

Focal motor seizure in a wrestler with a sport-related concussion.

UNLABELLED: Although sport-related concussion is a common injury, it is infrequently associated with seizure. While concussive convulsions, consisting of brief, generalized myoclonic activity while an athlete is unconscious have been described, the authors are aware of no published cases of concussion complicated by focal motor seizures. The authors describe the case of a 16-year-old male wrestler who sustained a sport-related concussion complicated by a focal motor seizure. The acute assessment and management of his injury, as well as follow-up until resolution of his symptoms, is presented. A brief review of the association between convulsive activity and mild traumatic brain injury follows. KEYWORDS: concussion; mild traumatic brain injury; seizure.

Lyme disease update.

PURPOSE OF REVIEW: Lyme disease is endemic to areas in both Europe and the United States and the incidence is increasing. Despite published guidelines, controversy persists about its diagnosis and management in patients who do not meet strict diagnostic criteria. This review summarizes important recently published studies and recommendations for the diagnosis and management of Lyme disease. RECENT FINDINGS: Recent comprehensive guidelines have been published for the diagnosis and management of pediatric Lyme disease. In addition, recent studies may help physicians differentiate between Lyme and aseptic meningitis, as well as show the poor sensitivity of cerebrospinal fluid polymerase chain reaction. Controversy continues about the diagnosis and management of "chronic Lyme disease", despite the current medical literature. Recently published studies in the US have also better described southern tick-associated rash illness, an entity that may present a similar clinical picture to Lyme disease. Guidelines have also been published on the management and diagnosis of other tick-borne illnesses often seen as co-infections with Lyme disease. Finally, case reports have been published describing new cardiac manifestations associated with Lyme disease. SUMMARY: Controversies persist about the diagnosis and management of Lyme disease. Recently published guidelines and primary research can aid clinicians in diagnosing Lyme properly.

Bathing suit mesh entrapment: an unusual case of penile injury.

Penile injury is a rare chief complaint in the pediatric emergency department. The most common penile injuries are iatrogenic or postsurgical complications, blunt trauma, tourniquet injuries, fractures, and zipper injuries. We report a series of 3 cases of penile foreskin entrapment within the mesh lining of bathing suits as a new, recognized form of penile injury.

Dilated cardiomyopathy in a 7-year-old girl.

Pediatric patients with dilated cardiomyopathy can initially be present for medical attention with non-specific and misleading signs and symptoms. We present the case of a 7-year-old girl with vague complaints of fever, vomiting, and abdominal pain and cardiac murmur on physical exam who progressed to congestive heart failure before her dilated cardiomyopathy was diagnosed. Clinicians should maintain a high index of suspicion for dilated cardiomyopathy in any patient with cardiac murmur and systematic symptoms.