A Novel Risk Score to Guide the Evaluation of Acute Hematogenous Osteomyelitis in Children.

OBJECTIVES: To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children. METHODS: We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis. RESULTS: We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00). CONCLUSIONS: We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making.

Coronary artery dilation in non-hospitalised children with asymptomatic or mild COVID-19.

INTRODUCTION: Infection with Sars-CoV-2 is known to cause cardiac injury and coronary artery changes in moderate to severe acute COVID-19 and post-acute multisystem inflammatory syndrome in children (MIS-C). However, little is known about the potential for cardiac involvement, in particular coronary artery dilation, in asymptomatic or mild cases of COVID-19. METHODS: A retrospective review of children ≤ 18 years of age with a history of asymptomatic or mild COVID-19 disease who underwent echocardiography after Sars-CoV-2 infection is conducted. Patients were excluded if they had been hospitalised for COVID-19/MIS-C or had a history of cardiac disease that could affect coronary artery dimension. Coronary artery dilation was defined as the Boston Z-score greater than 2.0. RESULTS: One hundred and fifty-seven patients met inclusion criteria with a mean age of 9.4 years (+/- 5.4 years). Eighty-four (54%) patients were identified as having COVID-19 through positive antibody testing. All patients underwent electrocardiogram and echocardiogram as part of their cardiology evaluation. One hundred and thirty-five (86%) patients had a normal evaluation or only a minor variant on electrocardiogram, while 22 patients had abnormalities on echocardiogram, 4 of which demonstrated coronary artery dilation based on the Boston Z-score. CONCLUSIONS: Much of the literature for post-infectious screening and follow-up focuses on patients with a history of moderate to severe COVID-19 disease, emphasising the need for surveillance for the potential development of myocarditis. In this study, 4 out of 157 (2.5%) children with a history of asymptomatic or mild COVID-19 disease without MIS-C were found to have some degree of coronary artery dilation. The significance of this finding currently remains unknown.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City.

OBJECTIVES: To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions. METHODS: We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index. RESULTS: Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index. CONCLUSIONS: The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region.

OBJECTIVES: Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock. METHODS: We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors. RESULTS: Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]). CONCLUSIONS: Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

Risk factors for physician burnout: a perspective from Tanzania.

Introduction: while physician burnout has been studied in high-income countries, more research is necessary on burnout in lesser-income regions such as Tanzania. This study aimed to determine levels of burnout in Tanzanian physicians and to understand the contributing risk factors for burnout in this region. Methods: the Maslach Burnout Inventory (MBI-HSS) was adapted to assess burnout in Tanzanian physicians. Utilizing a cross-sectional design, we studied two distinct cohorts: 1) Emergency Medicine (EM) trained physicians in Tanzania and; 2) specialists at Bugando Medical Centre. We surveyed demographic, personal, and workplace data to identify risk factors for burnout. Results: seventy-seven percent (30/39) of Tanzanian EM providers and 39% (37/94) of Bugando specialists completed the survey. We identified burnout in 67% of Tanzanian EM providers and in 70% of specialists at Bugando. Burnout risk factors in EM physicians included dissatisfaction with career choice, considering switching institutions, working in an urban setting, inadequate coverage for emergencies/leave, and financial housing responsibilities. In Bugando specialists, risk factors were unnecessary administrative paperwork, working overnight shifts, pressure to achieve patient satisfaction or decrease length of stay, meaningful mentorship, and not having a close friend/family member die. Conclusion: this study reports a high prevalence of burnout in Tanzanian physicians. Risk factors for burnout were multifactorial but mainly related to institutional and workplace constituents. Targeting these risk factors provides opportunities to boost physician wellness and guides important areas for future research in this African region.

Rapid Absolute Neutrophil Count Testing Guides Targeted Antimicrobial Therapy in Febrile Pediatric Oncology Patients.

OBJECTIVES: It is well established that early antibiotic administration leads to improved outcomes in febrile neutropenic patients. To achieve this, many institutions administer empiric antibiotics to all febrile oncology patients in the emergency setting, before knowing their neutropenic status. This study evaluates the role of rapid absolute neutrophil count (ANC) testing in the targeted antimicrobial management of nonneutropenic febrile oncology patients. METHODS: We conducted a retrospective review of patients 19 years or younger presenting to the pediatric emergency service with an oncologic process and fever or history of fever. We examined the administration of antibiotics and outcomes in nonneutropenic patients. RESULTS: We included 101 patient encounters, representing 62 distinct patients. The rapid ANC test influenced antibiotic management in 94% (95/101) of patient encounters and resulted in no antibiotics or targeted antibiotic therapy in 88% (60/68) of nonneutropenic patients. Use of the rapid ANC test to guide treatment would have spared antibiotic administration in 68% (46/68) of well-appearing nonneutropenic patients with no alternate indication. No well-appearing, nonneutropenic patient had a positive blood culture, and only 1 required hospital admission on a repeat visit. CONCLUSIONS: The rapid ANC is a useful tool to balance the goal of early antibiotic administration in febrile neutropenic oncology patients while promoting antibiotic stewardship in this vulnerable population.

Burnout in Pediatric Emergency Medicine Physicians: A Predictive Model.

OBJECTIVES: This study aims to determine the prevalence of and identify predictors associated with burnout in pediatric emergency medicine (PEM) physicians and to construct a predictive model for burnout in this population to stratify risk. METHODS: We conducted a cross-sectional electronic survey study among a random sample of board-certified or board-eligible PEM physicians throughout the United States and Canada. Our primary outcome was burnout assessed using the Maslach Burnout Inventory on 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. We defined burnout as scoring in the high-degree range on any 1 of the 3 subscales. The Maslach Burnout Inventory was followed by questions on personal demographics and work environment. We compared PEM physicians with and without burnout using multivariable logistic regression. RESULTS: We studied a total of 416 PEM board-certified/eligible physicians (61.3% women; mean age, 45.3 ± 8.8 years). Surveys were initiated by 445 of 749 survey recipients (59.4% response rate). Burnout prevalence measured 49.5% (206/416) in the study cohort, with 34.9% (145/416) of participants scoring in the high-degree range for emotional exhaustion, 33.9% (141/416) for depersonalization, and 20% (83/416) for personal accomplishment. A multivariable model identified 6 independent predictors associated with burnout: 1) lack of appreciation from patients, 2) lack of appreciation from supervisors, 3) perception of an unfair clinical work schedule, 4) dissatisfaction with promotion opportunities, 5) feeling that the electronic medical record detracts from patient care, and 6) working in a nonacademic setting (area under the receiver operating characteristic curve, 0.77). A predictive model demonstrated that physicians with 5 or 6 predictors had an 81% probability of having burnout, whereas those with zero predictors had a 28% probability of burnout. CONCLUSIONS: Burnout is prevalent in PEM physicians. We identified 6 independent predictors for burnout and constructed a scoring system that stratifies probability of burnout. This predictive model may be used to guide organizational strategies that mitigate burnout and improve physician well-being.

Recognition and Management of Pediatric Sepsis in a Resource-Limited Emergency Department in Mwanza, Tanzania: A Qualitative Study.

OBJECTIVE: The World Health Organization aims to reduce worldwide under-five mortality rates (U5MR), with a focus on resource-limited settings (RLS). Tanzania reports a mean U5MR of 54 per 1000 live births, largely due to treatable infectious diseases that may lead to sepsis, accounting for 40% of the under-five deaths. Bugando Medical Centre in Mwanza, Tanzania represents a resource-limited setting in Sub-Saharan Africa and estimates a 14% pediatric mortality rate. We sought to better understand provider experience in recognizing and managing pediatric sepsis in the emergency department (ED) at Bugando Medical Centre in Mwanza, Tanzania. METHODS: We conducted a qualitative study with a purposive sampling of 14 Bugando Medical Centre ED providers from January to February 2019, via minimally structured interviews, to identify factors influencing the recognition and management of children presenting to the ED with concern for sepsis. Interviews were conducted in English, audio recorded, and transcribed. Data saturation determined the sample size. Three primary coders independently coded all transcripts and developed an initial coding list. Consensus among all authors generated a final coding scheme. A grounded theory approach guided data analysis. RESULTS: We achieved thematic saturation after 13 interviews. Responses identified patient-, provider-, and health care system-related factors influencing sepsis recognition and management in children presenting to the ED. Patient-related factors include the use of traditional healers, limited parent health literacy, and geographic factors impacting access to medical care. Provider-related factors include limited knowledge of pediatric sepsis, lack of a standard communication process among providers, and insufficient experience with procedural skills on children. Health care system-related factors include limited personnel and resources, delayed transfers from referral hospitals, and lack of standard antibiotic-use guidelines. CONCLUSIONS: This qualitative study identified patient, provider, and health care system-related factors that influence the emergency care of children with suspected sepsis in a quaternary hospital in Mwanza, Tanzania. These factors may serve as a framework for educational opportunities to improve the early recognition and management of pediatric sepsis in a resource-limited setting.

Telemedicine Medical Screening Evaluation Expedites the Initiation of Emergency Care for Children.

OBJECTIVE: Prior studies show that staffing a physician at triage expedites care in the emergency department. Our objective was to describe the novel application and effect of a telemedicine medical screening evaluation (Tele-MSE) at triage on quality metrics in the pediatric emergency department (PED). METHODS: We conducted a retrospective quasi-experimental pre-post intervention study of patients presenting to an urban PED from December 2017 to November 2019 who received a Tele-MSE at triage. We analyzed 4 diagnostic cohorts: gastroenteritis, psychiatry evaluation, burn injury, and extremity fracture. We matched cases with controls who received standard triage, from December 2015 to November 2017, by age, diagnosis, weekday versus weekend, and season of presentation. Outcome measures included door-to-provider time, time-to-intervention order, and PED length of stay (LOS). RESULTS: We included 557 patients who received Tele-MSE during the study period. Compared with controls, patients who received a Tele-MSE at triage had a shorter median door-to-provider time (median difference [MD], 8.4 minutes; 95% confidence interval [CI], 6.0-11.0), time-to-medication order (MD, 27.3 minutes; 95% CI, 22.9-35.2), time-to-consult order (MD, 10.0 minutes; 95% CI, 5.3-12.7), and PED LOS (MD, 0.4 hours; 95% CI, 0.3-0.6). CONCLUSIONS: A Tele-MSE is an innovative modality to expedite the initiation of emergency care and reduce PED LOS for children. This novel intervention offers potential opportunities to optimize provider and patient satisfaction and safety during the COVID-19 pandemic.

Telemedicine Surge for Pediatric Patients in Response to the COVID-19 Pandemic in New York City.

Background: Our objective is to describe our pediatric virtual urgent care (VUC) experience at a large urban academic medical center, in response to the COVID-19 pandemic in New York City (NYC). Materials and Methods: We conducted a retrospective cohort study of our pediatric VUC program of patients less than age 18 years, from March 1 to May 31, 2020. We include data on expansion of staffing, patient demographics, virtual care, and outcomes. Results: We rapidly onboarded, educated, and trained pediatric telemedicine providers. We evaluated 406 pediatric patients with median age 4.4 years and 53.9% male. Median call time was 5:12 pm, median time to provider was 5.7 min, and median duration of call was 11.1 min. The most common reasons for a visit were COVID-19-related symptoms (36%), dermatologic (15%), and trauma (10%). Virtual care for patients consisted of conservative management (72%), medication prescription (18%), and referral to an urgent care or pediatric emergency department (PED) (10%). Of 16 patients referred and presented to our emergency department, 2 required intensive care for multisystem inflammatory syndrome in children. Oral antibiotics were prescribed for 7.1% of all patients. Only 0.005% of patients had an unplanned 72-h PED visit resulting in hospitalization after a VUC visit. Conclusion: Pediatric emergency VUC allowed for high-quality efficient medical care for patients during the peak of the COVID-19 pandemic in NYC. Although most patients were managed conservatively in their home, telemedicine also enabled rapid identification of patients who required in-person emergency care.

A Blueprint for Pediatric Emergency Resource Reallocation During the COVID-19 Pandemic: An NYC Hospital Experience.

OBJECTIVE: We present a blueprint for the reallocation of pediatric emergency resources in response to the COVID-19 pandemic. METHODS: New York-Presbyterian Hospital - Weill Cornell Medical Center is an urban, quaternary, academic medical center, a level 1 trauma center, and a regional burn center located in New York City. The novel coronavirus (COVID-19) pandemic created a unique challenge for pediatric emergency medicine. As the crisis heightened for adult patients, pediatric emergency services experienced a significant decline in volume and acuity. RESULTS: We offer guidelines to modify physical space, clinical services, staffing models, and the importance of steady leadership. Pediatric emergency space was converted to adult COVID-19 beds, necessitating the repurposing of nonclinical areas for pediatric patients. Efficient clinical pathways were created in collaboration with medical and surgical subspecialists for expedited emergency care of children. We transitioned staffing models to meet the changing clinical demands of the emergency department by both reallocation of pediatric emergency medicine providers to telemedicine and by expanding their clinical care to adult patients. Concentrated communication and receptiveness by hospital and department leadership were fundamental to address the dynamic state of the pandemic and ensure provider wellness. CONCLUSIONS: Modification of physical space, clinical services, staffing models, and the importance of steady leadership enabled us to maintain outstanding clinical care for pediatric patients while maximizing capacity and service for adult COVID-19 patients in the emergency department.

Implementation of a Pediatric Emergency Telemedicine Program.

OBJECTIVES: Our goal was to describe the experiences after the launch of a pediatric emergency telemedicine program at a large, urban, academic medical center. METHODS: We launched 3 unique pediatric emergency telemedicine programs at an urban, academic medical center: direct-to-consumer pediatric virtual urgent care, pediatric emergency department (PED) telemedicine follow-up, and telemedicine medical screening examination in the PED. RESULTS: We evaluated 84 patients via direct-to-consumer pediatric virtual urgent care with the most common chief complaint related to fever, dermatologic, or respiratory systems; we referred 12% to the PED, and 20% of those required hospital admission. We evaluated 38 patients via PED telemedicine follow-up; we referred 19% back to the PED, and 43% of those required hospital admission. Median duration for a telemedicine encounter was 10 minutes. We screened 3809 patients in the PED using telemedicine medical screening examination. CONCLUSIONS: We offer a description of an innovative and comprehensive new pediatric emergency telemedicine program implemented at a large, urban, academic medical center. Our initial findings demonstrate short visit times, antibiotic stewardship, and low rates of PED referral and subsequent admission for patients who use a telemedicine service. We plan to further examine the impact of pediatric emergency telemedicine on the care of children as our program expands.

The Use of Ultrasound-Measured Optic Nerve Sheath Diameter to Predict Ventriculoperitoneal Shunt Failure in Children.

OBJECTIVE: The goal of this study was to assess the accuracy of ultrasound-measured optic nerve sheath diameter (ONSD) as a screen for ventriculoperitoneal shunt failure. METHODS: We prospectively enrolled a convenience sample of children presenting to the ED with suspected shunt failure. The ONSD was measured by ultrasound and compared with computed tomography/magnetic resonance imaging (CT/MRI) and neurosurgical impression. We defined shunt failure on ultrasound as an ONSD greater than 4.0 mm in infants 12 months and younger or greater than 4.5 mm in children older than 12 months. A single emergency radiologist at our institution read all CTs and MRIs for categorical determination of shunt failure. We defined shunt failure based on neurosurgical impression as a decision to admit and perform shunt revision. We report test characteristics and 95% confidence intervals of ONSD as a predictor for shunt failure. RESULTS: We enrolled 32 subjects. The sensitivities of ONSD compared with CT/MRI and neurosurgical impression, 60.0% and 75.0%, respectively, were low. However, the negative predictive values of ONSD compared with CT/MRI and neurosurgical impression were 90.0% and 95.0%, respectively. CONCLUSIONS: Optic nerve sonography may be a useful tool to identify children presenting with suspected ventriculoperitoneal shunt failure who do not require further imaging. This would reduce the use of CT scan and exposure to ionizing radiation in children with suspected shunt malfunction who do not require neurosurgical intervention. Consideration of additional risk factors and a larger sample size may yield stronger results.

Adolescents' and young adults' perspectives on their emergency care.

OBJECTIVES: The aim of this study was to assess the perspectives of adolescents and young adults seen in the emergency department (ED) on the optimal age for transition from a pediatric ED (PED) to an adult ED (AED) as well as the appropriateness of their assigned ED site. Secondary aims were to determine ED physicians' understanding and assessment of their psychosocial needs, to determine whether subjects had a primary care provider (PCP), as well as to identify resources they felt would improve their ED experience. METHODS: This study used in-person structured interviews on a convenience sample of ED patients aged 15 to 25 years. Data were analyzed with the SPSS for Windows (v15.0) using t tests and uncertainty coefficients. RESULTS: We interviewed 200 subjects; the mean age was 20.5 (SD, 3) years, 65% were female, and 54% were seen in the PED. The subjects reported a mean age of 18.5 years as optimal for transition to an AED (mode, 18; second peak, 21); only 5% chose an age older than 21 years. The AED subjects more likely felt that their site of care was appropriate (Likert scale, 1-3; 2.5 vs 2.2, P < 0.05). HEADSS (Home, Education/Employment, Activity, Drugs, Sexuality, Suicide) topics were rarely addressed in both ED sites. The PED subjects more often identified a PCP (87% vs 68%); there was no difference in notifying their PCP (27% vs 19%). The PED subjects more often desired magazines (83% vs 70%) and entertainment videos (61% vs 34%). CONCLUSIONS: Adolescents and young adults identify the age of 18 years as optimal for transition from a PED to an AED setting. Instituting a standardized HEADSS assessment protocol and offering age-appropriate resources may enhance the emergency experience for this population.

Apparent life-threatening events in children: practical evaluation and management.

Apparent life-threatening events account for 0.6% to 0.8% of all emergency department visits for children aged < 1 year. Risk factors for serious underlying pathology in a well-appearing infant have been identified as prematurity, underlying medical conditions, age < 60 days (considered controversial), suspicion of child abuse, possible seizure activity, and recurrent apparent life-threatening events. A detailed history and physical examination is crucial for the management of these patients. Targeted testing is warranted, as there is little evidence to support routine testing. A period of inpatient observation is often appropriate, as well. This review seeks to: (1) present actors that may place a patient at higher risk for serious underlying disease and/or a future adverse event requiring intervention; (2) provide guidance on taking a thorough history; and (3) describe guidelines for diagnostic testing and admission to the hospital for infants with an apparent life-threatening event.