Trends in the Use of Procalcitonin at US Children's Hospital Emergency Departments.

OBJECTIVES: Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing. METHODS: We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count). RESULTS: The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%). CONCLUSIONS: PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses.

Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments.

OBJECTIVES: National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs. METHODS: Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care. RESULTS: More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis. CONCLUSIONS: Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.

A method to identify pediatric high-risk diagnoses missed in the emergency department.

BACKGROUND: Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review. METHODS: Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance. RESULTS: Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis. CONCLUSIONS: We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.

Fluid Balance Is Associated with Clinical Outcomes and Extravascular Lung Water in Children with Acute Asthma Exacerbation.

RATIONALE: The effects of fluid administration during acute asthma exacerbation are likely unique in this patient population: highly negative inspiratory intrapleural pressure resulting from increased airway resistance may interact with excess fluid administration to favor the accumulation of extravascular lung water, leading to worse clinical outcomes. OBJECTIVES: Investigate how fluid balance influences clinical outcomes in children hospitalized for asthma exacerbation. METHODS: We analyzed the association between fluid overload and clinical outcomes in a retrospective cohort of children admitted to an urban children's hospital with acute asthma exacerbation. These findings were validated in two cohorts: a matched retrospective and a prospective observational cohort. Finally, ultrasound imaging was used to identify extravascular lung water and investigate the physiological basis for the inferential findings. MEASUREMENTS AND MAIN RESULTS: In the retrospective cohort, peak fluid overload [(fluid input - output)/weight] is associated with longer hospital length of stay, longer treatment duration, and increased risk of supplemental oxygen use (P values < 0.001). Similar results were obtained in the validation cohorts. There was a strong interaction between fluid balance and intrapleural pressure: the combination of positive fluid balance and highly negative inspiratory intrapleural pressures is associated with signs of increased extravascular lung water (P < 0.001), longer length of stay (P = 0.01), longer treatment duration (P = 0.03), and increased risk of supplemental oxygen use (P = 0.02). CONCLUSIONS: Excess volume administration leading to fluid overload in children with acute asthma exacerbation is associated with increased extravascular lung water and worse clinical outcomes.

Impact of Chest Radiography on Antibiotic Treatment for Children With Suspected Pneumonia.

OBJECTIVE: National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia. METHODS: Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5-10%, 11-20%, 21-50%, 51-75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results. RESULTS: Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%). CONCLUSIONS: Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

Abdominal Lymphatic Malformation Presenting as Acute Abdominal Pain: A Common Pediatric Complaint, but an Unusual Diagnosis.

We present the clinical and radiological findings involving a mesenteric lymphatic malformation causing volvulus in a toddler presenting with acute abdominal pain, as well as its treatment options.

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children.

OBJECTIVES: To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children. METHODS: We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP. RESULTS: One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06). CONCLUSIONS: Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

Asthma update.

Asthma continues to be one of the most common reasons for emergency department visits and a leading cause of hospitalization. Acute management involves severity-based treatment of bronchoconstriction and underlying airway inflammation. Optimal treatment has been defined and standardized through randomized controlled trials, systematic reviews, and consensus guidelines. Implementation of clinical practice guidelines may improve clinical, quality, and safety outcomes. Asthma morbidity is disproportionately high in poor, urban, and minority children. Children treated in emergency departments commonly have persistent chronic severity, significant morbidity, and infrequent follow-up and primary asthma care, and prescription of inhaled corticosteroids is appropriate.

Emergency department epidemiology of pneumococcal bacteremia in children since the institution of widespread PCV7 vaccination.

BACKGROUND: The heptavalent pneumococcal conjugate vaccine (PCV7) has produced a shift in the epidemiology of invasive infections from Streptoccoccus pneumoniae. OBJECTIVE: Our aim was to determine the temporal changes in pneumococcal bacteremia (Streptococcus pneumoniae bacteremia [SPB]) in the emergency department (ED) since the introduction of PCV7. METHODS: This was a retrospective cohort study of children 0-18 years with SPB evaluated from 1998-2009 in a tertiary-care pediatric ED. The primary outcome was annual proportion of children with SPB from PCV7 serotypes (ie, 4, 6B, 9V, 14, 18C, 19F, and 23F) and nonvaccine serotypes (NVT). Rates of SPB (per 10,000 ED visits) were calculated. SPB was analyzed by time period: before October 2000 was considered "pre-PCV7," November 2000 to October 2003 was considered "peri-PCV7," and after November 2003 was "post-PCV7." Febrile young children (FYC) were defined as children age <36 months and fever without source. RESULTS: A total of 201 episodes of SPB occurred during the study, with a median age of 20.3 months (interquartile range 10.7-49.5 months; range 1.6-215.4 months); 56.7% were male and 69.7% were African American. SPB from PCV7 serotypes decreased more than fourfold, from 82.2% pre-PCV7 to 19.5% peri- and post-PCV7. Most SPB was from NVT serotype 19A (31.3%) peri- and post-PCV7. Annual rates of SPB were 4.01/10,000 ED visits pre-PCV7, decreasing to 2.10 peri-PCV7, and 1.75 post-PCV7. Among the 56 (27.8%) FYC with SPB, NVT were responsible for 11.5% of SPB pre-PCV7, and increased to 80.0% peri- and post-PCV7 (p < 0.001). CONCLUSIONS: Rates of SPB have decreased since the introduction of PCV7, yet SPB still occurs among children in the ED. NVT are increasing in prevalence, and SPB from PCV7-serotypes have decreased.

Factors associated with attaining coaching goals during an intervention to improve child asthma care.

PURPOSE: To examine parent and child characteristics associated with engagement in a coaching intervention to improve pediatric asthma care and factors associated with readiness to adopt and maintain targeted asthma management behaviors. METHODS: Using methods based on the Transtheoretical Model, trained lay coaches worked with 120 parents of children with asthma promoting adoption and maintenance of asthma management strategies (behaviors). Coaches assigned stage-of-change (on continuum: pre-contemplation, contemplation, preparation, action, maintenance) for each behavior every time it was discussed. Improvement in stage-of-change was analyzed for association with characteristics of the participants (parents and children) and coaching processes. RESULTS: Having more coach contacts was associated with earlier first contact (p<0.001), fewer attempts per successful contact (p<0.001), prior asthma hospitalization (p=0.021), more intruding events (p<0.001), and less social support (p=0.048). In univariable models, three factors were associated with forward movement at least one stage for all three behaviors: more coach contacts overall, fewer attempts per successful contact, and more discussion/staging episodes for the particular behavior. In multivariable models adjusting for characteristics of participants and coaching process, the strongest predictor of any forward stage movement for each behavior was having more contacts (p<0.05). CONCLUSIONS: Improvement in readiness to adopt and maintain asthma management behaviors was mostly associated with factors reflecting more engagement of participants in the program. Similar coaching interventions should focus on early and frequent contacts to achieve intervention goals, recognizing that parents of children with less severe disease and who have more social support may be more difficult to engage.

Nuclear reactor pulse calibration using a CdZnTe electro-optic radiation detector.

A CdZnTe electro-optic radiation detector was used to calibrate nuclear reactor pulses. The standard configuration of the Pockels cell has collimated light passing through an optically transparent CdZnTe crystal located between crossed polarizers. The transmitted light was focused onto an IR sensitive photodiode. Calibrations of reactor pulses were performed using the CdZnTe Pockels cell by measuring the change in the photodiode current, repeated 10 times for each set of reactor pulses, set between 1.00 and 2.50 dollars in 0.50 increments of reactivity.

Neisseria sicca endocarditis requiring mitral valve replacement in a previously healthy adolescent.

Infective endocarditis due to Neisseria sicca, a normal inhabitant of the upper respiratory tract, is rarely reported but associated with embolic phenomena and large vegetations often requiring surgical intervention. We report a previously healthy 12-year-old girl who presented with prolonged fever and altered mental status. The patient developed rapidly progressive respiratory insufficiency and cardiovascular instability, and echocardiography demonstrated a large vegetation on the mitral valve. She developed worsening mitral regurgitation with resultant pulmonary hemorrhage and underwent mitral valve replacement. Her blood culture was positive for N. sicca. This infection should be considered in patients with prolonged high fever and multiorgan dysfunction. Despite a typically severe course, reported mortality is low.

A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children.

OBJECTIVES: To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits. DESIGN: Randomized controlled trial. SETTING: Urban tertiary care children's hospital. PARTICIPANTS: Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care. INTERVENTION: Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group). MAIN OUTCOME MEASURES: The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment. RESULTS: We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27). CONCLUSION: This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00149500.

Exhaled nitric oxide levels during treatment of pediatric acute asthma exacerbations and association with the need for hospitalization.

OBJECTIVES: To examine how exhaled nitric oxide (eNO) levels measured before and after treatment of asthma exacerbations relate to emergency department (ED) disposition. METHODS: We enrolled children 6 to 17 years old treated for asthma exacerbations in a pediatric ED. Using an offline single-breath eNO sampling technique, we collected replicate initial samples before treatment and replicate final samples when disposition was decided. We determined correlations and coefficients of variability of eNO values (parts per billion, ppb) of samples and compared by disposition (hospitalization or discharge) mean initial and final eNO levels and initial-to-final change. RESULTS: Eighty-one subjects had initial and final eNO values; 24 subjects with more severe presentations had final values only. Replicate eNO samples were correlated (initial r = 0.98, final r = 0.99) and had low coefficients of variability (initial, 0.059 ± 0.057; final, 0.061 ± 0.070). For subjects with initial and final values, initial eNO levels were similar by disposition (mean difference, -8.0 ppb; 95% confidence interval [CI], -24.8 to 8.9 ppb), as were final levels (mean difference, -2.8 ppb; 95% CI, -23.8 to 18.2 ppb). Overall, final eNO was higher than initial (36.3 ± 29.7 vs 31.5 ± 23.9 ppb), but only 63% of subjects had any increase. Change in eNO was similar by disposition (mean difference, 4.6 ppb; 95% CI, -3.4 to 12.6). For more severe subjects with final eNO only, eNO was similar by disposition (P = 0.47). CONCLUSIONS: For children aged 6 to 17 years with asthma exacerbations, eNO levels can be reliably measured. However, eNO levels measured before treatment or when disposition was determined did not distinguish children needing hospitalization.

Emergency physicians' knowledge and provision of child passenger safety information.

OBJECTIVES: While physicians provide discharge instructions to patients and families following emergency department (ED) visits, injury prevention information may not be routinely included in these instructions. This study assessed emergency physicians' knowledge and provision of child passenger safety (CPS) information to patients following motor vehicle crashes (MVCs). METHODS: This study was both a survey of emergency physician knowledge and provision of CPS information and an examination of frequency of CPS information in discharge instructions at a single institution. Members of the American Academy of Pediatrics (AAP) Section on Emergency Medicine were invited to participate in the survey. Respondents were asked about their provision of CPS information to patients and knowledge of national AAP CPS recommendations. The institutional ED medical record chart review assessed the frequency of written CPS information for patients of MVC-related visits who were discharged home. RESULTS: There were 317 survey respondents from 1,024 eligible physicians, of whom 43 began but did not complete the survey. The data analyzed are from the 274 who completed the survey. While 85% (95% confidence interval [CI] = 81% to 89%) of physicians believed that CPS information should be included in discharge instructions, only 36% (95% CI = 31% to 42%) correctly answered all knowledge questions. Of the 51 self-identified division/department chiefs, 15 (29.4%; 95% CI = 16.9% to 41.9%) reported that their EDs routinely provide CPS information in discharge instructions for pediatric passengers in MVCs. For the medical record review, of the 152 randomly selected MVC visits, 13 (8.6%; 95% CI = 4.1% to 13.0%) had documented CPS information in the discharge instructions. Patients with documented CPS information were younger, but there were no significant differences in race, sex, or maximum abbreviated injury scale score between patients with versus without CPS information. CONCLUSIONS: While emergency physicians value the use of CPS information in discharge instructions following MVCs, they do not have adequate knowledge of, nor do they regularly disseminate, this information.

The association of weight percentile and motor vehicle crash injury among 3 to 8 year old children.

The use of age-appropriate child restraint systems significantly reduces injury and death associated with motor vehicle crashes (MVCs). Pediatric obesity has become a global epidemic. Although recent evidence suggests a possible association between pediatric obesity and MVC-related injury, there are potential misclassifications of body mass index from under-estimated height in younger children. Given this limitation, age- and sex-specific weight percentiles can be used as a proxy of weight status. The specific aim of this study was to determine the association between weight percentile and the risk of significant injury for children 3-8 years in MVCs. This was a cross-sectional study of children aged 3-8 years in MVCs in 16 US states, with data collected via insurance claims records and a telephone survey from 12/1/98-11/30/07. Parent-reported injuries with an abbreviated Injury Scale (AIS) score of 2+ indicated a clinically significant injury. Age- and sex-specific weight percentiles were calculated using pediatric norms. The study sample included 9,327 children aged 3-8 years (weighted to represent 157,878 children), of which 0.96% sustained clinically significant injuries. There was no association between weight percentiles and overall injury when adjusting for restraint type (p=0.71). However, increasing weight percentiles were associated with lower extremity injuries at a level that approached significance (p=0.053). Further research is necessary to describe mechanisms for weight-related differences in injury risk. Parents should continue to properly restrain their children in accordance with published guidelines.

Management of acute asthma.

Current management of acute asthma has been defined in clinical practice guidelines developed from systematic reviews and expert opinion. Initial treatment with inhaled high-dose beta-agonists and anticholinergics is recommended for severe exacerbations. Most patients treated in emergency departments should receive systemic corticosteroids. Adjunctive therapy for those not improving is less well-defined, but options include intravenous magnesium sulfate and heliox-driven nebulized beta-agonists. Poor adherence to preventive therapies and infrequent primary care follow-up are well documented among children and adolescents treated in emergency departments. These factors may contribute to disparities in outcomes for minority populations and are important considerations during acute care visits.

Risk factors for extremely long length-of-stay among pediatric emergency patients.

OBJECTIVE: Over time, we observed more visits in our pediatric emergency department with length-of-stay (LOS) of more than 10 hours, whereas our mean LOS was approximately 3 hours. We sought to characterize factors associated with this extremely long LOS. METHODS: Eighty-one visits with LOS more than 10 hours were identified from January 1, 2001, to June 30, 2003. In this retrospective study, we compared these cases with 405 randomly selected age-matched controls with LOS less than 10 hours (5 controls per case). RESULTS: The groups were similar for sex, visit month, arrival mode, and level of training of the supervising physician. Cases more frequently arrived during night shifts (30% vs 13%) and had laboratory tests (93% vs 32%), radiological studies (83% vs 34%), procedures (28% vs 15%), sedations (24% vs 4%), subspecialty consultations (84% vs 20%), chief complaints of abdominal pain (42% vs 6%) and diagnoses of appendicitis (10% vs 1%), and had a greater hospitalization rate (67 vs 19%). Although more cases involved white patients (57% vs 31%), race was not associated with LOS more than 10 hours in adjusted analysis. In multivariable analysis, longer waiting time (odds ratio [OR], 1.013; 95% confidence interval [CI], 1.007-1.019), night shift arrival (OR, 5.0; 95% CI, 1.9-12.8), higher triage acuity (lowest acuity: OR, 0.003; 95% CI, 0.0-0.286), radiology study other than radiographs (OR, 18.0; 95% CI, 7.5-43.1), and subspecialty consultation (OR, 7.6; 95% CI, 3.2-18.3) were associated with LOS more than 10 hours. CONCLUSIONS: In our pediatric emergency department, risk factors for LOS more than 10 hours included longer waiting time, night shift arrivals, high triage acuity, radiology studies, and subspecialty consultations. These factors may also be important considerations for quality improvement initiatives at other institutions.