Association of outcomes in point-of-care lung ultrasound for bronchiolitis in the pediatric emergency department.

BACKGROUND: Acute bronchiolitis (AB) is the most common lower respiratory tract infection in infants. Objective scoring tools and plain film radiography have limited application, thus diagnosis is clinical. The role of point-of-care lung ultrasound (LUS) is not well established. OBJECTIVE: We sought to characterize LUS findings in infants presenting to the pediatric ED diagnosed with AB, and to identify associations between LUS and respiratory support (RS) at 12 and 24 h, maximum RS during hospitalization, disposition, and hospital length of stay (LOS). METHODS: Infants ≤12 months presenting to the ED and diagnosed with AB were enrolled. LUS was performed at the bedside by a physician. Lungs were divided into 12 segments and scanned, then scored and summated (min. 0, max. 36) in real time accordingly: 0 - A lines with <3 B lines per lung segment. 1 - ≥3 B lines per lung segment, but not consolidated. 2 - consolidated B lines, but no subpleural consolidation. 3 - subpleural consolidation with any findings scoring 1 or 2. Chart review was performed for all patients after discharge. RS was categorized accordingly: RS (room air), low RS (wall O2 or heated high flow nasal cannula <1 L/kg), and high RS (heated high flow nasal cannula ≥1 L/kg or positive pressure). RESULTS: 82 subjects were enrolled. Regarding disposition, the mean (SD) LUS scores were: discharged 1.18 (1.33); admitted to the floor 4.34 (3.62); and admitted to the ICU was 10.84 (6.54). For RS, the mean (SD) LUS scores at 12 h were: no RS 1.56 (1.93), low RS 4.34 (3.51), and high RS 11.94 (6.17). At 24 h: no RS 2.11 (2.35), low RS 4.91 (3.86), and high RS 12.64 (6.48). Maximum RS: no RS 1.22 (1.31), low RS 4.11 (3.61), and high RS 10.45 (6.16). Mean differences for all dispositions and RS time points were statistically significant (p < 0.05, CI >95%). The mean (SD) hospital LOS was 84.5 h (SD 62.9). The Pearson correlation coefficient (r) comparing LOS and LUS was 0.489 (p < 0.0001). CONCLUSION: Higher LUS scores for AB were associated with increased respiratory support, longer LOS, and more acute disposition. The use of bedside LUS in the ED may assist the clinician in the management and disposition of patient's diagnosed with AB.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities.

OBJECTIVES: In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language. METHODS: A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test. RESULTS: Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers. CONCLUSIONS: Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

Pediatric Cervical Spine Clearance and Immobilization Practice Among Prehospital Emergency Medical Providers: A Statewide Survey.

OBJECTIVES: Pediatric cervical spine injuries are rare but potentially life threatening. Although published guidelines for assessment of such injuries exist, there is less uniformity in its implementation in out-of-hospital settings. Our purpose was to assess the knowledge and practice patterns for pediatric cervical spine immobilization among prehospital emergency medical services (EMS) providers in Arizona. METHODS: A cross-sectional web-based survey was conducted (October-December 2018), using an electronic mailing list of certified EMS providers (ground and air) in Arizona. A 20-question structured web-based survey was developed and deployed. RESULTS: One hundred eight EMS stations were contacted with the survey. Sixty-eight providers responded; majority were emergency medical paramedics (73.1%). Most of the stations surveyed did not have a pediatric trauma center (66.2%). When treating children younger than 3 years, half of the respondents stated they did not know of a specific cervical spine clearance criterion; 59.3% felt that cervical spine immobilization was required "sometimes," and 40.0% were unaware of the state's EMS pediatric cervical spine clearance algorithm; 93.9% of EMS providers felt that an age-based algorithm for cervical spine clearance in children would be useful. CONCLUSIONS: In this statewide survey involving prehospital EMS providers, we found that pediatric cervical spine clearance and immobilization practices, even within a specific geographic location, remain inconsistent.

Implementing Routine HIV Screening in an Urban Adolescent Population at a General Pediatric Clinic.

PURPOSE: To increase the rate of routine HIV screening during preventative visits for adolescent patients aged 15 to 21 in a pediatric and adolescent clinic in accordance with national recommendations, which are poorly implemented nationwide. METHODS: This was a quality improvement initiative. Four plan-do-study-act (PDSA) cycles were conducted from May 2016 to February 2020. Interventions included education of and reminders for the multidisciplinary team on guidelines and testing, creation of a standardized workflow, introduction of a rapid point-of-care HIV antibody test (POCT), and implementation of an opt-out, medical assistant/nursing-driven protocol for HIV rapid point-of-care testing. The primary outcome measure was the monthly percentage of adolescents screened for HIV during preventative visits. Data is presented in a p-control chart and means were adjusted for special cause variation according to the Institute for Healthcare Improvement guidelines. RESULTS: Rates of routine HIV screening at preventative visits for youth ages 15 to 21 increased from the pre-intervention rate of 5.16% to a final rate of 41.5% over four PDSA cycles. Mean screening rates were adjusted after introducing the HIV POCT (+18.5%) and after implementing the medical assistant/nursing-driven protocol (+17.9%). CONCLUSIONS: We successfully increased routine HIV screening rates at preventative visits for adolescents at an urban pediatric and adolescent clinic. This was in large part due to testing with a rapid HIV POCT and a clinic protocol allowing medical assistants and nurses to order the test under a physician's name as part of the intake process. Ours can be a model for other clinics.