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.

Omphalitis and Concurrent Serious Bacterial Infection.

OBJECTIVE: Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with omphalitis. METHODS: Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants ≤90 days of age with omphalitis seen in the emergency department from January 1, 2008, to December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS: Among 566 infants (median age 16 days), 537 (95%) were well-appearing, 64 (11%) had fever at home or in the emergency department, and 143 (25%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 472 (83%), 326 (58%), and 222 (39%) infants, respectively. Pathogens grew in 1.1% (95% confidence interval [CI], 0.3%-2.5%) of blood, 0.9% (95% CI, 0.2%-2.7%) of urine, and 0.9% (95% CI, 0.1%-3.2%) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 320 (57%) infants, with 85% (95% CI, 80%-88%) growing a pathogen, most commonly methicillin-sensitive Staphylococcus aureus (62%), followed by methicillin-resistant Staphylococcus aureus (11%) and Escherichia coli (10%). Four hundred ninety-eight (88%) were hospitalized, 81 (16%) to an ICU. Twelve (2.1% [95% CI, 1.1%-3.7%]) had sepsis or shock, and 2 (0.4% [95% CI, 0.0%-1.3%]) had severe cellulitis or necrotizing soft tissue infection. There was 1 death. Serious complications occurred only in infants aged <28 days. CONCLUSIONS: In this multicenter cohort, mild, localized disease was typical of omphalitis. SBI and adverse outcomes were uncommon. Depending on age, routine testing for SBI is likely unnecessary in most afebrile, well-appearing infants with omphalitis.

Neonatal Mastitis and Concurrent Serious Bacterial Infection.

OBJECTIVES: Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis. METHODS: Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS: Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths. CONCLUSIONS: In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.

Correlation of Level of Trauma Activation With Emergency Department Intervention.

BACKGROUND: In-hospital trauma team activation criteria are formulated to identify severely injured patients requiring specialized multidisciplinary care. Efficacy of trauma activation (TA) criteria is commonly measured by emergency department (ED) disposition, injury severity score, and mortality. Necessity of critical ED interventions is another measure that has been proposed to evaluate the appropriateness of TA criteria. METHODS: Two-year retrospective cohort study of 1715 patients from our trauma registry at a Level 1 pediatric trauma center. We abstracted data on acute interventions, level and criterion of TA, ED disposition, and mortality. We report odds ratio (OR) with 95% confidence intervals (CIs), positive predictive value, and frequency of acute interventions. RESULTS: Trauma activation was initiated for 947 (55%) of the 1715 patients. There were 426 ED interventions performed on 235 patients (14%); 67.8% were in level 1 activations; 17.6% in level 2, and 14.6% in level 3. Highest-level activations were highly associated with need for ED interventions (OR, 16.1; 95% CI, 11.5-22.4). The ORs for requiring an ED intervention were low for lower level activations (OR, 0.4; 95% CI, 0.3-0.5), trauma service consults (OR, 0.3; 95% CI, 0.2-0.4), and certain mechanism-based criteria. The ORs for ED intervention for isolated motor vehicle collision (0.2; 95% CI, 0.1-0.7), isolated all-terrain vehicle rollover (0.4; 95% CI, 0.1-1.7), and suspected spinal cord injury (0.5; 95% CI, 0.1-3.7) were significantly lower than 1. CONCLUSIONS: Highest-level activation criteria correlate with high utilization of ED resources and interventions. Lower level activation criteria and trauma service consult criteria are not highly correlated with need for ED interventions. Downgrading isolated motor vehicle collision and all-terrain vehicle rollovers and suspected spinal cord injury to lower level activations could decrease the overtriage rate, and adding age-specific bradycardia as a physiologic criterion could improve our undertriage rate.

The greater good: how supervising physicians make entrustment decisions in the pediatric emergency department.

BACKGROUND: Graduate medical education is transitioning to the use of entrustable professional activities to contextualize educational competencies. Factors influencing entrustment decisions have been reported in adult medicine. Knowing how such decisions are made in pediatrics is critical to this transition. PURPOSE: To understand how supervisors determine the level of procedural supervision to provide a resident, taking into consideration simulation performance; to understand factors that affect supervisors' transparency to parents about residents' procedural experience. METHODS: We conducted 18 one-on-one interviews with supervisors in a tertiary care pediatric emergency department, iteratively revising interview questions as patterns in the data were elucidated. Two researchers independently coded transcripts and then met with the investigative team to refine codes and create themes. RESULTS: Five factors influenced supervisors' entrustment decisions: 1) resident characteristics that include self-reported confidence, seniority, and prior interactions with the resident; 2) supervisor style; 3) nature of the procedure/characteristics of the patient; 4) environmental factors; and 5) parental preferences. Supervisors thought that task-based simulators provided practice opportunities but that simulated performance did not provide evidence for entrustment. Supervisors reported selectively omitting details about a resident's experience level to families to optimize experiential learning for residents they entrusted to perform a procedure. CONCLUSIONS: In pediatrics, supervisors consider various factors when making decisions regarding resident procedural readiness, including parental preferences. An educational system using entrustable professional activities may facilitate holistic assessment and foster expertise-informed decisions about residents' progression toward entrustment; such a system may also lessen supervisors' need to omit information to parents about residents' procedural readiness.

Prevalence and predictors of return visits to pediatric emergency departments.

OBJECTIVE: To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return. DESIGN AND SETTING: Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System. PARTICIPANTS: Patients <18 years old discharged following an ED visit. MEASURES: The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization. RESULTS: 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7-2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively. CONCLUSIONS: Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization.

Qualitative evaluation of just-in-time simulation-based learning: the learners' perspective.

INTRODUCTION: Just-in-time training (JITT) is an educational strategy where training occurs in close temporal proximity to a clinical encounter. A multicenter study evaluated the impact of simulation-based JITT on interns' infant lumbar puncture (LP) success rates. Concurrent with this multicenter study, we conducted a qualitative evaluation to describe learner perceptions of this modality of skills training. METHODS: Eleven interns from a single institution participated in a face-to-face semistructured interview exploring their JITT experience. Interviews were audio-recorded and transcribed. Two investigators reviewed the transcripts, assigned codes to the data, and categorized the codes. Categories were modified by 4 emergency physicians. As a means of data triangulation, we performed focus groups at a second institution. RESULTS: Benefits of JITT included review of anatomic landmarks, procedural rehearsal, and an opportunity to ask questions. These perceived benefits improved confidence with infant LP. Deficits of the training included lack of mannequin fidelity and unrealistic context when compared with an actual LP. An unexpected category, which emerged from our analysis, was that of barriers to JITT performance. Barriers included lack of time in a busy clinical setting and various instructor factors. The focus group findings confirmed and elaborated the benefits and deficits of JITT and the barriers to JITT performance. CONCLUSIONS: Just-in-time training improved procedural confidence with infant LP, but work place busyness and instructor lack of support or unawareness were barriers to JITT performance. Optimal LP JITT would occur with improved contextual fidelity. More research is needed to determine optimal training strategies that are effective for the learner and maximize clinical outcomes for the patient.

An educational video improves technique in performance of pediatric lumbar punctures.

BACKGROUND: Unsuccessful or traumatic lumbar punctures (LPs) occur commonly and contribute to patient discomfort and to challenges in medical decision making in the pediatric emergency department (ED). OBJECTIVE: We produced an instructional video demonstrating the best practices in pediatric LP technique. We hypothesized that the performance of LPs would change and the rate of successful LPs would increase after watching the video. METHODS: This was a prospective study of LPs performed in an urban, academic pediatric ED before and after an educational intervention. Lumbar punctures performed during year 1 constituted the control arm. During year 2, all medical practitioners working in the ED watched the instructional video, and this constituted the interventional arm. The practitioner performing the LP completed a standardized data collection form after each LP procedure, and medical records were reviewed. RESULTS: Data forms were collected on 668 LPs during the study period, 391 during year 1 and 277 during year 2. There was neither a significant change in overall LP success rate between the 2 years (56.8% year 1 vs 53.4% year 2) nor a significant difference in median number of LP attempts required per patient (P = 0.78). Seventy-eight percent of participants who viewed the LP video during year 2 stated that the video helped increase their comfort level with performing LPs. The odds of using the techniques endorsed in the educational video were significantly higher during year 2 compared to year 1 for use of local anesthetic, early stylet removal, and vertical patient position. CONCLUSIONS: The video increased practitioners' comfort level with the performance of pediatric LPs and adherence to evidence-based best practices. It was not associated with an increased rate of successful LPs.