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Gender inequity is pervasive in medicine, including emergency medicine (EM), and is well documented in workforce representation, leadership, financial compensation, and resource allocation. The reasons for gender inequities in medicine, including academic EM, are multifactorial and include disadvantageous institutional parental, family, and promotion policies; workplace environment and culture; implicit biases; and a paucity of women physician leader role models, mentors, and sponsors. To address some of the challenges of gender inequities and career advancement for women in academic EM, we established an innovative, peer-driven, multi-institutional consortium of women EM faculty employed at four distinct hospitals affiliated with one medical school. The consortium combined financial and faculty resources to execute gender-specific programs not feasible at an individual institution due to limited funding and faculty availability. The programs included leadership skill-building and negotiation seminars for consortium members. The consortium created a collaborative community designed specifically to enrich career development for women in academic EM, with a formal organizational structure to connect faculty from four hospitals under one academic institution. The objective of this report is to describe the creation of this cross-institutional consortium focused on career development, academic productivity, and networking and sharing best practices for work-life integration for academic EM women faculty. This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges., (© 2021 by the Society for Academic Emergency Medicine.)

Objective: Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits., Methods: This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted., Results: There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results., Conclusions: These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED., (© 2021 Society for Academic Emergency Medicine.)

Objective: The objective was to validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum)., Methods: We conducted a prospective cohort study of males 3 months to 18 years old presenting with an acute scrotum. History and physical examination findings, including components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter-rater reliability and calculated the test characteristics and receiver operator characteristics curves for the TWIST score (range = 0-7)., Results: During the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean (±SD) age was 9.8 (±0.3) years. The high-risk TWIST score of 7 had 100% specificity (95% confidence interval [CI] = 98%-100%) with 100% positive predictive value (95% CI = 40%-100%) for testicular torsion. The area under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39., Conclusions: In this prospective validation of the TWIST score among pediatric emergency providers, the high-risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care., (© 2017 by the Society for Academic Emergency Medicine.)

Objective: Firearm injuries among children are a major clinical and public health concern and one of the leading causes of pediatric fatalities. Our objective was to investigate differences in predictors and clinical outcomes between self-inflicted, violent, and unintentional pediatric firearm injuries for patients who present to pediatric emergency departments (EDs)., Methods: We conducted a retrospective study of patients 0 to 21 years old treated in 37 pediatric academic EDs from 2004 to 2014. Patients were classified into the injury intent categories of self-inflicted, violent, and unintentional firearm injury using the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnoses and external causes of injury codes. Multivariable multinomial regression models compared groups., Results: We identified 9,628 firearm injuries from 2004 to 2014: 109 (1%) self-inflicted, 2,394 (25%) violent, and 7,125 (74%) unintentional. Male sex, increasing age, nonwhite race, public insurance, residing in an urban zip code, and lower zip code-level median household income were all independently associated with violent firearm injuries, relative to self-inflicted and unintentional injuries. Self-inflicted injuries were at the highest risk for hospital admission, death, intensive care unit services, surgical services, and increased length of stay, followed by violent injuries with intermediate risk and unintentional injuries at the lowest risk, Conclusions: Self-inflicted, violent, and unintentional firearm injuries in children had distinct demographic risk factors and clinical and utilization outcomes. Targeted prevention and intervention efforts should be developed to reduce the incidence and severity of these injuries., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma., Methods: This was a planned subanalysis of a prospective, multicenter observational study of children (<18 years old) with blunt torso trauma conducted in 20 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Clinicians documented their suspicion for the presence of intra-abdominal injuries needing acute intervention as <1, 1 to 5, 6 to 10, 11 to 50, or >50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention., Results: Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled in the parent study. Intra-abdominal injuries undergoing acute intervention were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI = 32% to 34%) patients with clinician suspicion < 1%. Sensitivity of the prediction rule for intra-abdominal injuries undergoing acute intervention (197 of 203; 97.0%, 95% CI = 93.7% to 98.9%) was higher than that of clinician suspicion ≥1% (168 of 203; 82.8%, 95% CI = 76.9% to 87.7%; difference = 14.2%, 95% CI = 8.6% to 20.0%). Specificity of the prediction rule (4,979 of the 11,716; 42.5%, 95% CI = 41.6% to 43.4%), however, was lower than that of clinician suspicion (9,217 of the 11,716, 78.7%, 95% CI = 77.9% to 79.4%; difference = -36.2%, 95% CI = -37.3% to -35.0%). Thirty-five (0.4%, 95% CI = 0.3% to 0.5%) patients with clinician suspicion < 1% had intra-abdominal injuries that underwent acute intervention., Conclusions: The derived clinical prediction rule had a significantly higher sensitivity, but lower specificity, than clinician suspicion for identifying children with intra-abdominal injuries undergoing acute intervention. The higher specificity of clinician suspicion, however, did not translate into clinical practice, as clinicians frequently obtained abdominal CT scans in patients they considered very low risk. If validated, this prediction rule can assist in clinical decision-making around abdominal CT use in children with blunt torso trauma., (© 2015 by the Society for Academic Emergency Medicine.)

Objectives: Plain chest x-ray (CXR) is often the initial screening test to identify pneumothoraces in trauma patients. Computed tomography (CT) scans can identify pneumothoraces not seen on CXR ("occult pneumothoraces"), but the clinical importance of these radiographically occult pneumothoraces in children is not well understood. The objectives of this study were to determine the proportion of occult pneumothoraces in injured children and the rate of treatment with tube thoracostomy among these children., Methods: This was a planned substudy from a large prospective multicenter observational cohort study of children younger than 18 years old evaluated in emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network (PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs as part of their trauma evaluations were included for analysis. The faculty radiologist interpretations of the CXRs and any subsequent imaging studies, including CT scans, were reviewed for the absence or presence of pneumothoraces. An "occult pneumothorax" was defined as a pneumothorax that was not identified on CXR, but was subsequently demonstrated on cervical, chest, or abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies and rate differences with 95% confidence intervals (CIs) were calculated., Results: Of 12,044 enrolled in the parent study, 8,020 (67%) children (median age=11.3 years, interquartile range [IQR]=5.3 to 15.2 years) underwent CXRs in the ED, and these children make up the study population. Among these children, 4,276 had abdominal CT scans performed within 24 hours. A total of 372 of 8,020 children (4.6%; 95% CI=4.2% to 5.1%) had pneumothoraces identified by CXR and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI=1.6% to 2.2%), including one false-positive pneumothorax, which was identified on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in 224 of 372 (60.2%; 95% CI=55.0% to 65.2%) children with pneumothoraces. Tube thoracostomies were performed in 85 of 148 (57.4%; 95% CI=49.0% to 65.5%) children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI=11.1% to 21.1%) children with occult pneumothoraces (rate difference=-41.8%; 95% CI=-50.8 to -32.3%)., Conclusions: In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and most are not identified on the ED CXR. Nearly half of pneumothoraces, and most occult pneumothoraces, are managed without tube thoracostomy. Observation, including in children requiring endotracheal intubation, should be strongly considered during the initial management of children with occult pneumothoraces., (© 2014 by the Society for Academic Emergency Medicine.)

Objectives: The objectives were to identify patient and hospital characteristics associated with the use of computed tomography (CT) imaging of the cervical spine (c-spine) in the evaluation of injured children and, in particular, to examine the influence of hospital setting., Methods: This was a retrospective cohort of children younger than 19 years of age from the Massachusetts Hospital Emergency Department (ED) database who were discharged from the ED with an injury diagnosis from 2005 through 2009. Multivariable logistic regression was used to analyze characteristics associated with CT imaging of the c-spine., Results: Of the 929,626 pediatric patients diagnosed with an injury in Massachusetts EDs and then discharged home, 1.3% underwent CT imaging of the c-spine. Rates of CT imaging nearly doubled over the 5 years. In the multivariable model, patient age (adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI] = 2.0 to 2.7 for children age 12 to 18 years vs. under 1 year of age) and evaluation outside of a pediatric Level I trauma center (AOR = 2.2, 95% CI = 1.1 to 4.3 for children evaluated at non Level I trauma centers vs. pediatric Level I trauma centers; AOR = 2.1, 95% CI = 0.93 to 4.7 for children evaluated at adult Level I trauma centers vs. pediatric Level I trauma centers) were associated with higher rates of CT imaging of the c-spine., Conclusions: Cervical spine CT imaging for children discharged from the ED with trauma diagnoses increased from 2005 through 2009. Older age and evaluation outside a Level I pediatric trauma center were associated with a higher c-spine CT rate. Educational interventions focused outside pediatric trauma centers may be an effective approach to decreasing CT imaging of the c-spine of pediatric trauma patients., (© 2011 by the Society for Academic Emergency Medicine.)

Objectives: The objective was to identify patient, provider, and hospital characteristics associated with the use of neuroimaging in the evaluation of head trauma in children., Methods: This was a cross-sectional study of children (< or =19 years of age) with head injuries from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected by the National Center for Health Statistics. NHAMCS collects data on approximately 25,000 visits annually to 600 randomly selected hospital emergency and outpatient departments. This study examined visits to U.S. emergency departments (EDs) between 2002 and 2006. Multivariable logistic regression was used to analyze characteristics associated with neuroimaging in children with head injuries., Results: There were 50,835 pediatric visits in the 5-year sample, of which 1,256 (2.5%, 95% confidence interval [CI] = 2.2% to 2.7%) were for head injury. Among these, 39% (95% CI = 34% to 43%) underwent evaluation with neuroimaging. In multivariable analyses, factors associated with neuroimaging included white race (odds ratio [OR] = 1.5, 95% CI = 1.02 to 2.1), older age (OR = 1.3, 95% CI = 1.1 to 1.5), presentation to a general hospital (vs. a pediatric hospital, OR = 2.4, 95% CI = 1.1 to 5.3), more emergent triage status (OR = 1.4, 95% CI = 1.1 to 1.8), admission or transfer (OR = 2.7, 95% CI = 1.4 to 5.3), and treatment by an attending physician (OR = 2.0, 95% CI = 1.1 to 3.7). The effect of race was mitigated at the pediatric hospitals compared to at the general hospitals (p < 0.001)., Conclusions: In this study, patient race, age, and hospital-specific characteristics were associated with the frequency of neuroimaging in the evaluation of children with closed head injuries. Based on these results, focusing quality improvement initiatives on physicians at general hospitals may be an effective approach to decreasing rates of neuroimaging after pediatric head trauma., (2010 by the Society for Academic Emergency Medicine)

Objectives: To describe the epidemiology and outcomes of serious pediatric submersion injuries and to identify factors associated with an increased risk of death or chronic disability., Methods: A retrospective database review of 1994-2000 Massachusetts death and hospital discharge data characterized demographic factors; International Classification of Diseases, Ninth Revision (ICD-9), Clinical Modification (ICD-9-CM), or ICD-10 injury codes; and outcomes for state residents 0-19 years of age identified with unintentional submersion injuries. The authors performed logistic regression analysis to correlate outcomes with risk and demographic factors., Results: The database included 267 cases of serious submersion injury, defined as those requiring hospitalization or leading to death. Of these 267 patients, 125 (47%) drowned, 118 (44%) were discharged home, 13 (5%) were discharged home with intravenous therapy or with availability of a home health aide, and 11 (4%) were discharged to an intermediate care/chronic care facility. The authors observed a trend of improved outcome in successively younger age groups (p < 0.0001). The multivariable logistic regression analysis showed an increased likelihood of poor outcome for males compared with females (odds ratio [OR]: 2.52; 95% confidence interval [95% CI] = 1.31 to 4.84) and for African Americans compared with whites (OR: 3.47; 95% CI = 1.24 to 9.75), and a decreased likelihood of poor outcome for Hispanics compared with whites (OR: 0.056; 95% CI = 0.013 to 0.24)., Conclusions: After serious pediatric submersion injuries, the overall outcome appears largely bimodal, with children primarily discharged home or dying. The observations that better outcomes occurred among younger age groups, females, and Hispanic children, with worse outcomes in African American children, suggest that injury prevention for submersion injuries should consider differences in age, gender, and race/ethnicity.