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ObjectiveAppendiceal diameter is a primary sonographic determinant of paediatric appendicitis. We sought to determine if the diagnostic performance of outer appendiceal diameter differs based on age or with the addition of secondary sonographic findings.MethodsWe retrospectively reviewed patients aged less than 19 years who presented to the Boston Children’s Hospital ED and had an ultrasound (US) for the evaluation of appendicitis between November 2015 and October 2018. Our primary outcome was the presence of appendicitis. We analysed the cases to evaluate the optimal outer appendiceal diameter as a predictor for appendicitis stratified by age (ResultsOverall, 945 patients met criteria for inclusion, of which 43.9% had appendicitis. Overall, appendiceal diameter as a continuous measure demonstrated excellent test performance across all age groups (area under the curve (AUC) >0.95) but was most predictive of appendicitis in the youngest age group (AUC=0.99 (0.98–1.00)). Although there was no significant difference in optimal diameter threshold between age groups, both 7- and 8-mm thresholds were more predictive than 6 mm across all groups (pConclusionsAppendiceal diameter as a continuous measure was more predictive of appendicitis in the youngest group. Across all age groups, the optimal diameter threshold was 7 mm for the diagnosis of paediatric appendicitis. The addition of individual or combination secondary sonographic findings increases diagnostic performance.

BACKGROUND The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia. METHODS We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia. RESULTS Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73). CONCLUSIONS In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia.

Background BV is a score for differentiating between bacterial and viral etiologies. Recently FDA cleared, it is based on computational integration of the blood levels of three host-proteins (TRAIL, IP-10, CRP). Here we report a multi-cohort analysis validating its diagnostic performance in comparison to a microbiology confirmed reference standard for children recruited in the Netherlands, Germany, Italy, Israel and the United States. Methods Febrile pediatric patients (age < 18) were recruited in Emergency Departments and Urgent Care Centers in the Apollo (NCT04690569), Autopilot (NCT03052088) and Opportunity (NCT01931254) studies. Eligibility criteria included suspicion of acute bacterial or viral infection symptoms for < 7 days in patient deemed to be immunocompetent. BV is indicative of bacterial or viral infection (MeMed BV®) based on pre-defined thresholds: 0 ≤ score < 35 indicates viral (or other non-bacterial) infection, 35 ≤ score ≤ 65 indicates equivocal and 65 < score ≤ 100 indicates bacterial infection (or co-infection). BV performance was assessed against the reference standard. Three experts independently reviewed comprehensive patient data including follow-up data but were blinded to BV. A bacterial or viral microbiology confirmed reference standard required all 3 experts to assign the same etiology in addition to a positive microbiology result supporting the experts’ decision (Figure legend). Results Among the 1,747 children recruited in the 3 studies, 861 were assigned a microbiology confirmed reference standard, with 811 viral and 50 bacterial cases (bacterial prevalence 6%). The median age was 1.8 years (interquartile range: 0.9-3.5 years), 42.3% were female, and 72.7% were diagnosed with respiratory tract infection or unspecified viral infection. BV yielded sensitivity and specificity of 95.6% (95% confidence interval: 84.9%-99.5%) and 95.4% (95%CI: 93.6%-96.8%), and negative predictive value of 99.7% (95%CI: 98.9%-99.9%), with 9.6% of cases yielding equivocal scores. Conclusion BV accurately distinguishes bacterial from viral etiology in microbiology confirmed cases and has the potential to support clinical diagnosis in children presenting to acute care settings. Disclosures Sheldon L. Kaplan, MD, MeMed: Advisor/Consultant|MeMed: Grant/Research Support|Pfizer: Grant/Research Support|Pfizer: Honoraria Cesar A. Arias, MD, PhD, Entasis Phramceuticals: Grant/Research Support|MeMed Diagnostics: Grant/Research Support|Merck: Grant/Research Support Richard G. Bachur, M.D., Appendicitis Biomarker: U.S. Patent|MeMed: Advisor/Consultant|MeMed: Grant/Research Support|UpToDate.com: Honoraria|Wolters-Kluwer: Honoraria Louis J Bont, M.D., MeMed: Principal Investigator (Payment made to institution for conduct of the Opportunity study) Adi Klein, M.D., MeMed: Principal Investigator (Payment made to institution for conduct of the Apollo study) Cihan Papan, M.D., MeMed: Grant/Research Support.

BACKGROUND Illness complications are condition-specific adverse outcomes. Detecting complications of pediatric illness in administrative data would facilitate widespread quality measurement, however the accuracy of such detection is unclear. METHODS We conducted a cross-sectional study of patients visiting a large pediatric emergency department. We analyzed those RESULTS We analyzed 1534 encounters. PPVs and NPVs for complications were >80% for 8 of 14 conditions: appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. Lower PPVs for complications were observed for DKA (57%), empyema (53%), encephalitis (78%), ovarian torsion (21%), and septic arthritis (64%). A lower NPV was observed in stroke (68%). The κ between reviewers was 0.88. CONCLUSIONS An automated method to measure complications by using administrative data can detect complications in appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. For DKA, empyema, encephalitis, ovarian torsion, septic arthritis, and stroke, the tool may be used to screen for complicated cases that may subsequently undergo manual review.

Background Secondary sonographic findings of appendicitis can aid image analysis and support diagnosis with and without visualization of an appendix. Objective We sought to determine if age affected the test performance of secondary findings for pediatric appendicitis. Materials and methods We performed a medical record review of emergency department patients younger than 19 years of age who had a sonogram for suspected appendicitis. Our primary patient outcome was appendicitis, as determined by pathology or by image-confirmed perforation/abscess. Our primary analysis was test performance of secondary sonographic findings as recorded by sonographers on the final diagnosis of appendicitis stratified by age (

OBJECTIVES/GOALS: Children with traumatic intracranial hemorrhage are monitored closely for deterioration and need for intervention. Data on risk factors for deterioration in nonsevere head injury are limited. Our objective was to identify children with hemorrhage from non-severe head injury who are at risk for deterioration. METHODS/STUDY POPULATION: We conducted a 10-site cross-sectional study of children 8. Our primary outcome was clinically important hemorrhage after injury and within 96 hours of ED arrival, defined as ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (new or worsening signs/symptoms with an acute change in management). After testing model assumptions, we used logistic regression to identify clinical and neuroradiographic factors associated with clinically important hemorrhage. RESULTS/ANTICIPATED RESULTS: We studied 763 children with intracranial hemorrhage, with a median (IQR) age of 3.0 (0.4, 10.5) years. Initial GCS was mild (14-15) in 89.4% (n=682) and moderate (9-13) in 10.6% (n=81). Clinically important hemorrhage was observed in 19.5% (n=149), and 7.8% (n=59) developed clinically important deterioration. Median (IQR) time to deterioration was 17.6 (4.6, 37.9) hours. In our sample, 16.3% (n=124) underwent critical interventions, 54.9% (n=419) were admitted to an ICU, and 50.1% (n=382) underwent repeat neuroimaging. We found older age (OR 1.6; 95% CI 1.3, 1.9), lower GCS (OR 5.0; 95% CI 2.9, 8.5), and epidural hemorrhage (OR 3.3; 95% CI 2.0, 5.5) was associated with clinically important hemorrhage. DISCUSSION/SIGNIFICANCE: Clinically important hemorrhage occurred in one in five children with non-severe head injury. Clinical and neuroradiographic factors associated with ED interventions and deterioration were identified. Risk stratification algorithms using these data will be developed to assist clinicians caring for children with head injury.

BACKGROUND AND OBJECTIVES Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking. METHODS We queried the Pediatric Health Information System database to identify children RESULTS We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05–1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period. CONCLUSIONS NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.

Objective To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS. Data sources The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey. Data collection/extraction methods Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown. Study design We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series. Principal findings There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95). Conclusions For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research.

Objective We sought to assess interrater reliability (IRR) of lung point-of-care ultrasound (POCUS) findings among pediatric patients with suspected pneumonia. Methods A convenience sample of patients between the ages of 6 months and 18 years with a clinical suspicion of pneumonia had a lung ultrasound performed by a POCUS-credentialed emergency medicine physician with subsequent expert review. Each lung zone was assessed as either normal or abnormal, and specific ultrasound findings were recorded. IRR was assessed by intraclass correlation coefficient (ICC) and kappa statistics. Results Seventy-one patients, with a total of 852 lung zones imaged, were included. The sonographer assessment of normal versus abnormal, across each of the zones, demonstrated moderate agreement with ICC 0.46 (95% CI: 0.41, 0.52) and kappa 0.56. Right-sided zones demonstrated moderate agreement [0.43 (CI 0.35, 0.51)] while left-sided zones, specifically left-sided anterior zones, showed only fair agreement [0.36 (0.28, 0.44)]. IRR varied between specific findings: ICC for B-lines 0.52 (95% CI: 0.46, 0.57), pleural effusion 0.40 (0.34, 0.45), consolidation 0.39 (0.33, 0.44), subpleural consolidation 0.31 (0.25, 0.37), and pleural line irregularity 0.16 (0.10, 0.23). A composite indicator of typical pneumonia findings (consolidation, B-lines, and pleural effusion) demonstrated moderate [ICC 0.52 (0.46, 0.57)] reliability. Conclusions We found moderate interrater reliability of lung POCUS findings for the assessment of pediatric patients with suspected pneumonia. B-lines had the highest reliability. Further assessment of lung POCUS is necessary to guide proper training and optimal scanning techniques to ensure adequate reliability of ultrasound findings in the assessment of pediatric pneumonia.

OBJECTIVE We aimed to characterize recent trends in bronchiolitis at US children’s hospitals and to compare severity of illness in bronchiolitis in the most recent year to the previous seasonal epidemics. METHODS This is a cross-sectional study of visits for bronchiolitis in infants RESULTS The study included 389 411 emergency visits for bronchiolitis. Median age of infants with bronchiolitis was higher in October 2020 to September 2021 compared to previous epidemics (8 and 6 months, respectively, P < .001) The odds of hospitalization, ICU admission, invasive mechanical ventilation, and noninvasive ventilation did not differ in October 2020 to September 2021 compared to previous epidemics from October 2016 to September 2020 (all P > .05 for unadjusted models and models adjusted for age). Seasonality varied significantly among these 2 periods (P < .001). CONCLUSIONS Although the seasonality of bronchiolitis differed in October 2020 to September 2021, severity of illness in infants with bronchiolitis was consistent with previous epidemics.

ObjectiveTo derive and validate a tool that retrospectively identifies delayed diagnosis of appendicitis in administrative data with high accuracy.DesignCross-sectional study.SettingFive paediatric emergency departments (EDs).Participants669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis.OutcomeDelayed diagnosis was defined as appendicitis being present but not diagnosed at the first ED encounter based on standardised record review. The cohort was split into derivation (2/3) and validation (1/3) groups. We derived a prediction rule using logistic regression, with covariates including variables obtainable only from administrative data. The resulting trigger tool was applied to the validation group to determine area under the curve (AUC). Test characteristics were determined at two predicted probability thresholds.ResultsDelayed diagnosis occurred in 471 (70.4%) patients. The tool had an AUC of 0.892 (95% CI 0.858 to 0.925) in the derivation group and 0.859 (95% CI 0.806 to 0.912) in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% (95% CI 78.2% to 89.8%) and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% (95% CI 87.4% to 98.6%) and identified 46.8% of delayed cases.ConclusionsThis tool accurately identified delayed diagnosis of appendicitis. It may be used to screen for potential missed diagnoses or to specifically identify a cohort of children with delayed diagnosis.

OBJECTIVES We examined trends in resource use for infants undergoing emergency department evaluation for serious bacterial infection, including lumbar puncture (LP), antibiotic administration, hospitalization, and procalcitonin testing, as well as the association between procalcitonin testing and LP, administration of parenteral antibiotics, and hospitalization. METHODS We performed a cross-sectional study of infants aged 0 to 60 days who underwent emergency department evaluation for serious bacterial infection with blood and urine cultures from 2010 to 2019 in 27 hospitals in the Pediatric Health Information System. We examined temporal trends in LP, antibiotic administration, hospitalization, and procalcitonin testing from 2010 to 2019. We also estimated multivariable logistic regression models for 2017–2019, adjusted for demographic factors and stratified by age ( RESULTS We studied 106 547 index visits. From 2010 to 2019, rates of LP, antibiotic administration, and hospitalization decreased more for infants aged 29 to 60 days compared with infants aged 0 to 28 days (annual decrease in odds of LP, antibiotics administration, and hospitalization: 0 to 28 days: 5%, 5%, and 3%, respectively; 29–60 days: 15%, 12%, and 7%, respectively). Procalcitonin testing increased significantly each calendar year (odds ratio per calendar year 2.19; 95% confidence interval 1.82–2.62), with the majority (91.1%) performed during 2017–2019. From 2017 to 2019, there was no association between hospital-level procalcitonin testing and any outcome studied (all P values > .05). CONCLUSIONS Rates of LP, antibiotic administration, and hospitalization decreased significantly for infants 29 to 60 days during 2010–2019. Although procalcitonin testing increased during 2017–2019, we found no association with hospital-level procalcitonin testing and patterns of resource use.

Significant variation exists in the management of febrile infants, particularly those between 1 and 2 months of age. An established algorithm for well-appearing febrile infants 1-2 months of age guided clinical care for three decades in our emergency department. With mounting evidence for procalcitonin (PCT) to detect invasive bacterial infection (IBI), we revised our algorithm intending to decrease lumbar punctures (LPs) and antibiotic administration without increasing hospitalizations, revisits, or missed IBI.The algorithm's risk stratification was revised based on the expert review of evidence regarding test performance of PCT for IBI in febrile infants. With the revision, routine LP and empiric antibiotics were not recommended for low-risk infants. We used quality improvement strategies to disseminate the revised algorithm and reinforce uptake. The primary outcomes were the proportion of infants undergoing lumbar punctures or receiving antibiotics. Admission rates, 72-hour revisits requiring admission, and missed IBI were monitored as balancing measures.We studied 616 infants including 326 (52.9%), after the implementation of the revised algorithm. LP was performed in 66.2% prerevision and 31.9% postrevision (34.3% absolute reduction,A revised pathway with the addition of PCT resulted in a safe, sustained reduction in LPs and reduced antibiotic administration in febrile infants 1-2 months of age.

To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound.We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural consolidations, stratified by the presence of larger (1 cm) sonographic consolidations. The children were followed prospectively for 2 weeks to identify a delayed diagnosis of pneumonia.A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these patients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger (1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated subcentimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations (59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consolidations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up period.Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; however, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolidations should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these cases.

BACKGROUND AND OBJECTIVESThere are no effective interventions to prevent hospital admissions in infants with bronchiolitis. The American Academy of Pediatrics recommends against routine bronchodilator use for bronchiolitis. The objective of this study was to characterize trends in and outcomes associated with the use of bronchodilators for bronchiolitis.METHODSThis is a multicenter retrospective study of infants RESULTSA total of 446 696 ED visits of infants with bronchiolitis were included. Bronchodilator use, hospital admissions, and ED return visits decreased between 2010 and 2018 (all P < .001). ICU admissions and invasive and noninvasive ventilation increased over the study period (all P < .001). Hospital-level early bronchodilator use (hospitals with high versus low use) was not associated with differences in patient-level hospital admissions, ICU admissions, ED return visits, noninvasive ventilation, or invasive ventilation (all P > .05).CONCLUSIONSIn a large study of infants at children’s hospitals, bronchodilator therapy decreased significantly from 2010 to 2018. Hospital-level early bronchodilator use was not associated with a reduction in any outcomes. This study supports the current American Academy of Pediatrics recommendation to limit routine use of bronchodilators in infants with bronchiolitis.

OBJECTIVES Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest. DESIGN Multicenter retrospective cross-sectional study. SETTING Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database. PATIENTS Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018. MEASUREMENTS AND MAIN RESULTS Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0). CONCLUSIONS In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.

Pediatric visits to the Emergency Department (ED) for concussion are common and increasing. ED clinicians evaluating children with concussion should first ensure the absence of more serious injuries requiring immediate intervention, such as intracranial hemorrhage or cervical spine injury. In the ED setting, signs and symptoms of concussion are sometime subtle and often overlooked. A thorough physical exam is warranted but may be normal. Imaging and laboratory studies have no role in concussion diagnosis and should be reserved for cases where an injury requiring immediate intervention is suspected. Symptom management may include avoiding symptom-triggers (such as bright lights triggering headaches) and/or specific treatments such as nonsteroidal anti-inflammatories or antiemetics. Discharge instructions should include a recommendation for a brief period of rest, followed by outpatient management for return-to-activity decisions in conjunction with a primary care provider.

As both fever and pneumonia can be associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia.In this retrospective cross-sectional analysis of 91,429 children5 years of age presenting to an urban pediatric emergency department, the relationship between triage RR and temperature was analyzed using regression analysis. We assessed the predictive value of temperature-adjusted RR for the diagnosis of pneumonia; diagnostic performance was evaluated for continuous RR as well as World Health Organization (WHO) age-based RR thresholds.The mean RR increased 2.6 breaths/minute for each 1°C increase in temperature. Interpatient variability was comparatively large; at any temperature, the interquartile range (75th percentile minus 25th percentile) varied from 4 to 16 breaths/minute. For predicting pneumonia, temperature- and age-adjusted RR was superior to age-adjusted RR: area under the curve (AUC) = 0.76 (95% confidence interval [CI], 0.75-0.78) versus AUC = 0.73 (95% CI, 0.72-0.75), respectively. Using WHO RR criteria, temperature-adjusted RR improved diagnostic discrimination, as the AUC increased from 0.58 (95% CI, 0.57-0.59) to 0.72 (95% CI, 0.70-0.73).The effects of temperature on respiratory rate are modest, with a mean increase of 2.6 breaths/minute for each 1°C rise in temperature. Despite considerable interpatient variability in respiratory rates by temperature, temperature adjustment improves the diagnostic value of respiratory rate for pneumonia.

Objectives The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers. Methods We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training. Results The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest. Conclusions Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Starting in 2022, the American Board of Pediatrics will launch the Maintenance of Certification Assessment for Pediatrics: Pediatric Emergency Medicine (MOCA-Peds: PEM) longitudinal assessment, which will provide an at-home alternative to the point-in-time examination. This longitudinal assessment will help engage PEM physicians participating in continuing certification in a more flexible and continuous lifelong, self-directed learning process while still providing a summative assessment of their knowledge. This commentary provides background information on MOCA-Peds and an introduction to MOCA-Peds: PEM and how it gives the PEM physician another option to participate in continuing certification.

Background: Febrile infants aged

Objective To compare the clinical presentation of intussusception among children younger and older than 24 months of age. Design/methods We performed a retrospective cross-sectional cohort study of children treated in the emergency department, aged 1 month to 6 years, who had an abdominal ultrasound to evaluate for intussusception over a 5-year period. After stratifying by an age cut-point of 24 months, univariate and multivariate analyses were performed. Results One thousand two hundred fifty-eight cases of suspected intussusception were studied; median age was 1.7 years (interquartile range, 0.8, 2.9 years), and 37% were female. Intussusception was identified in 176 children (14%); 153 (87%) were ileocolic, and 23 were ileoileal. Abdominal pain (odds ratio, 4.0; 95% confidence interval [CI], 1.5-10.5), emesis (OR, 3.5; 95% CI, 1.8-6.7), bilious emesis (OR, 2.9; 95% CI, 1.5-5.7), lethargy (OR, 2.3; 95% CI, 1.3-5.7), rectal bleeding (OR, 2.8; 95% CI, 1.4-5.7), and irritability (OR, 0.4; 95% CI, 0.2-0.8) were found to be predictors in those younger than 24 months. In children older than 24 months, male sex was the only predictor identified (OR, 2.0; 95% CI, 1.1-3.7). In cases where abdominal radiographs were obtained (n = 1212), any abnormality on abdominal radiograph was found to be predictive in both age groups (OR, 7.8; 95% CI, 3.8-25.7; and OR, 3.1; 95% CI, 1.8-5.2, respectively). Conclusions Intussusception presents differently in children younger than 24 months compared with older children. "Traditional" clinical predictors of intussusception should be interpreted with caution when assessing children older than 2 years.

Objectives Using case review to determine whether a patient experienced a delayed diagnosis is challenging. Measurement would be more accurate if case reviewers had access to multi-expert consensus on grading the likelihood of delayed diagnosis. Our objective was to use expert consensus to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. Methods Case vignettes were constructed for each condition. In each vignette, a patient has the condition and had a previous emergency department (ED) visit within 7 days. Condition-specific multi-specialty expert Delphi panels reviewed the case vignettes and graded the likelihood of a delayed diagnosis on a five-point scale. Delayed diagnosis was defined as the condition being present during the previous ED visit. Consensus was defined as ≥75% agreement. In each Delphi round, panelists were given the scores from the previous round and asked to rescore. A case scoring guide was created from the consensus scores. Results Eighteen expert panelists participated. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes. We reached consensus on 23/30 (77%) DKA vignettes. A case review guide was created from the consensus scores. Conclusions Multi-specialty expert reviewers can agree on the likelihood of a delayed diagnosis for cases of appendicitis and sepsis, and for most cases of DKA. We created a guide that can be used by researchers and quality improvement specialists to allow for objective case review to determine when delayed diagnoses have occurred for appendicitis, DKA, and sepsis.

Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization.Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate.Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost.

Objectives The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs). Methods We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED). Results From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%). Conclusion Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.

OBJECTIVE: While emergency medicine (EM) physicians treat the majority of pediatric EM (PEM) patients in the United States, little is known about their PEM experience during training. The primary objective was to characterize the pediatric case exposure and compare to established EM residency training curricula among EM residents across five U.S. residency programs. METHODS: We performed a multicenter medical record review of all pediatric patients (aged

Background There is a growing body of evidence to support the utility of lung point-of-care ultrasound (POCUS) in pediatric patients with multiple pulmonary pathologies, particularly pneumonia. As we increase our use of lung POCUS for pediatric patients with respiratory complaints, we must be mindful of the normal anatomy and sonographic findings within the pediatric chest and aware of how to distinguish normal findings (e.g., thymus) from pathologic findings (e.g., consolidation). Case Reports We report four cases of pediatric patients who presented to the Emergency Department with respiratory complaints for which POCUS was able to distinguish lung consolidation and normal thymus in the anterior chest. Why Should an Emergency Physician Be Aware of This? The use of lung ultrasound to detect pneumonia is extensively documented in the pediatric literature. Emergency physicians may not be aware of how to discriminate the normal sonographic appearance of the thymus from lung consolidation on POCUS. The ability to identify normal and pathologic findings within the pediatric chest by POCUS will be increasingly important to appropriately reduce the use of plain radiography for pediatric patients with respiratory complaints.

OBJECTIVE To estimate rates of critical medical and neurosurgical interventions and resource utilization for children with traumatic intracranial hemorrhage (ICH). METHODS This was a retrospective study of children younger than 18 years hospitalized in 1 of 35 hospitals in the Pediatric Health Information System from 2009 to 2019 for ICH. We defined critical intervention as a critical medical (hyperosmotic agents and intubation) or neurosurgical intervention. We determined rates of critical interventions, intensive care unit (ICU) admission, and repeat neuroimaging. We used hierarchical logistic regression to identify high-level factors associated with undergoing critical interventions, controlling for hospital-level effects. RESULTS There were 12,714 children with ICH included in the study. Median (interquartile range) age was 4.3 (0.7-11.0) years. Twelve percent (n = 1470) of children underwent a critical clinical intervention. Critical medical interventions occurred in 10% (n = 1219), and neurosurgical interventions occurred in 3% (n = 419). Intensive care unit admission occurred in 44% (n = 5565), whereas repeat neuroimaging occurred in 40% (n = 5072). Among ICU patients, 79% (n = 4366) did not undergo a critical intervention. Of the 11,244 children with no critical interventions, 39% (n = 4366) underwent ICU admission, and 37% (n = 4099) repeat neuroimaging. After controlling for hospital, children with isolated subdural (P = 0.013) and isolated subarachnoid (P < 0.001) hemorrhage were less likely to receive critical interventions. CONCLUSIONS Critical medical interventions occurred in 10% of children with ICH, and neurosurgical interventions occurred in 3%. Intensive care unit admission and repeat neuroimaging are common, even among those who did not undergo critical interventions. Selective utilization of ICU admission and repeat neuroimaging in children who are at low risk of requiring critical interventions could improve overall quality of care and decrease unnecessary resource utilization.

Importance Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear. Objective To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes. Design, setting, and participants This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis. Exposures Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC). Main outcomes and measures Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures. Results A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4). Conclusions and relevance In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.

Proficient physician performance is crucial to high-quality health care. Physicians must acquire and apply new knowledge and skills throughout their careers. Successful physician performance improvement requires leadership with vision and a strategic plan, engagement of front line providers, resources and support to improve, and feedback and communication that facilitates a culture of learning and improvement. A fluid and balanced performance dashboard, aligned with local improvement efforts, can inform individuals and groups of physicians, ensure the trust of other stakeholders, and improve the quality of patient care. We propose a framework for the development of a performance program for pediatric emergency physicians and share the experience of development and use of the program at a single tertiary care site.

The approach to febrile young infants remains challenging. This review serves as an update on the care of febrile infants less than 90 days of age with a focus on the changing epidemiology of serious bacterial infection (SBI), refinement of management strategies based on biomarkers, and the development of novel diagnostics.There is high variability in the emergency department management of febrile young infants without significant differences in outcomes. C-reactive protein (CRP) and procalcitonin have emerged as valuable risk-stratification tests to identify high-risk infants. When interpreting automated urinalyses for suspected urinary tract infection (UTI), urine concentration influences the diagnostic value of pyuria. Novel diagnostics including RNA biosignatures and protein signatures show promise in better identifying young febrile infants at risk of serious infection.The majority of febrile infants with an SBI will have a UTI but the diagnosis of invasive bacterial infection in infants continues to be challenging. The use of procalcitonin and CRP as biomarkers in prediction algorithms facilitates identification of low-risk infants.

Opportunities to learn advanced airway management skills on pediatric patients in the emergency department are limited. Current strategies have focused largely on traditional didactics coupled with procedural skills training using simulation. However, these approaches are limited in their exposure to anatomic variation and realism. Here, we describe the development and assessment of an advanced airway curriculum that integrates videolaryngoscopic recordings obtained during actual patient intubations into a series of interactive educational sessions. Trainees and attending physicians were surveyed anonymously to assess the impact of participation in the curriculum. A mixed methods approach to statistical analysis was used. Rating questions were used to evaluate the relative impact of this approach over other traditional strategies and recurrent themes within open-ended questions were identified. Participants reported this to be a highly effective means of learning about pediatric laryngoscopy and endotracheal intubation and regarded it more highly than other traditional educational approaches. Identified benefits included repetitive exposure, approaches to laryngoscopy, the realism of teaching using real and varied anatomy, and the opportunities to identify and troubleshoot difficulty in a learning environment. An advanced pediatric airway curriculum that integrates intubation videos obtained during videolaryngoscopy was highly regarded by pediatric emergency medicine providers. Content emphasis can be shifted to meet the needs of pediatric emergency medicine providers with all levels of skill and experience.

Concerns about radiation exposure have led to a decrease in the use of computed tomography in suspected appendicitis, with increased reliance on ultrasound. Children with suspected appendicitis should be risk stratified using a combination of clinical signs and symptoms, white blood cell count, and ultrasound in order to guide further evaluation and management. Magnetic resonance imaging is a promising imaging modality but remains costly. Ongoing research is evaluating the role of nonoperative management in children with confirmed appendicitis.

Pediatric emergency care research suffers from a generalizability problem. Such research in the United States largely relies on data collected from within academic medical centers or large health systems with the infrastructure to conduct and publish clinical research. Such research also includes studies ranging from trials of fluid infusion rates for diabetic ketoacidosis1 from the Pediatric Emergency Care Applied Research Network to retrospective cohort studies defining the incidence of herpes simplex virus by week of life.2 This research is extremely valuable because it informs how to distribute limited health care resources and where to focus efforts to improve care. However, academic and large health systems are a narrow lens through which to view care because 90% of children do not visit academic pediatric emergency departments (EDs) but rather visit community general EDs.3 Children who visit academic EDs differ from the larger population of children demographically, especially related to their access to, need for, and receipt of acute care. Because of these differences, epidemiological insights cannot always be generalized beyond the populations that academic centers serve. Large, population-based, administrative databases offer 1 solution to this problem. Administrative data are collected in the course of routine clinical operations and include claims, which are billing records. These databases do not typically contain clinical information and instead contain demographics, diagnoses, procedures, and billing information, such as charges. They therefore represent a blurrier but wider field of view than the narrow lens of academia-based investigation, thereby allowing more complete insight into diseases and outcomes. Furthermore, these databases eliminate the selection bias introduced by studying only children who present to academic hospitals, which often outweighs the advantages of prospective data collection. The main advantages of administrative data …

Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described.The objective was to characterize the critically ill pediatric EM case exposure among EM residents.This is a secondary analysis of a multicenter retrospective review of pediatric patients (aged 18 years) seen by the 2015 graduating resident physicians at four U.S. EM training programs. The per-resident exposure to Emergency Severity Index (ESI) Level 1 pediatric patients was measured. Resident-level counts of pediatric patients were measured; specific counts were classified by age and Pediatric Emergency Care Applied Network diagnostic categories.There were 31,552 children seen by 51 residents across all programs; 434 children (1.3%) had an ESI of 1. The median patient age was 8 years (interquartile range [IQR] 3-12 years). The median overall pediatric critical case exposure per resident was 6 (IQR 3-12 cases). The median trauma and medical exposure was 2 (IQR 0-3) and 3 (IQR 2-10), respectively. For 13 out of 20 diagnostic categories, at least 50% of residents did not see any critical care case in that category. Sixty-eight percent of residents saw 10 or fewer critically ill cases by the end of training.Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area.

To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications.Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges.We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke).Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

OBJECTIVES:Unlike community-acquired pneumonia (CAP), there is a paucity of data characterizing the patient demographics and hospitalization characteristics of children with aspiration pneumonia. We used a large national database of US children’s hospitals to assess the patient and hospitalization characteristics associated with aspiration pneumonia and compared these characteristics to patients with CAP.METHODS:We identified children hospitalized with a diagnosis of aspiration pneumonia or CAP at 47 hospitals included in the Pediatric Health Information System between 2009 and 2014. We evaluated whether differences exist in patient characteristics (median age and proportion of patients with a complex chronic condition), and hospital characteristics (length of stay, ICU admission, cost, and 30-day readmission rate) between children with aspiration pneumonia and CAP. Lastly, we assessed whether seasonal variability exists within these 2 conditions.RESULTS:Over the 6-year study period, there were 12 097 children hospitalized with aspiration pneumonia, and 121 489 with CAP. Compared with children with CAP, children with aspiration pneumonia were slightly younger and more likely to have an associated complex chronic condition. Those with aspiration pneumonia had longer hospitalizations, higher rates of ICU admission, and higher 30-day readmission rates. Additionally, the median cost for hospitalization was 2.4 times higher for children with aspiration pneumonia than for children with CAP. More seasonal variation was observed for CAP compared with aspiration pneumonia hospitalizations.CONCLUSIONS:Aspiration pneumonia preferentially affects children with medical complexity and, as such, accounts for longer and more costly hospitalizations and higher rates of ICU admission and readmission rates.

Objectives The presence of critically ill patients may impact care for other ED patients. We sought to evaluate whether the presence of a critically ill child was associated with the time to (1) receipt of the first medication among other patients, and (2) administration of diagnosis-specific medications. Methods We performed a retrospective cohort study of all paediatric ED visits over 3 years. Patients were exposed if they arrived during the first hour of a critically ill patient's care. The primary outcome was the time from arrival to first medication administration. Secondary outcomes were time to corticosteroids in asthma and time to antibiotics for fever/neutropenia. We modelled times to medication using median regression, adjusting for demographics, arrival time and weekday, and census (number of patients in the ED). Results We analysed 170 112 visits. Median times to first medication for those exposed to 0, 1 and >1 simultaneous critically ill patients were 90 min (IQR 54–146), 96 min (IQR 58–157) and 113 min (IQR 72–166), respectively (p

The optimal staffing model for emergency departments (EDs) is not known. Improving staffing could lead to more timely, efficient, and effective care. We created a model of staffing to identify times of staffing limitation by provider type.We analyzed data from an academic pediatric ED with 60,000 visits per year. Each 10-minute interval from January 1, 2011, through December 31, 2012, was categorized as nonlimited (no staffing limitation), space limited (≥2 patients in the waiting room with wait times30 minutes and ≥ 80% ED bed occupancy), nurse limited (≥2 patients in the waiting room with wait times30 min and80% ED bed occupancy), or physician limited (≥2 patients in examination rooms who have waited30 minutes for a physician) using computer modeling. We calculated the percentage of time each type of limitation was in effect and the median lengths of stay for patients presenting during times of each category of limitation.The ED was space limited 5.0% of the time, nurse limited 16.1% of the time, and physician limited 0.1% of the time. In nonlimited times, length of stay was 201 minutes (interquartile range, 128-301), whereas patients presenting during space-limited, nurse-limited, and physician-limited times had statistically significantly higher LOS of 265 (187-360), 244 (169-337), and 247 (174-334) minutes, respectively.Times identified as space and staffing limited were associated with longer LOS. This computer model could be used to rapidly identify targeted staffing needs and then measure the effect of modifying staffing.

Objectives: Biomarkers that can measure illness severity and predict the risk of delayed recovery may be useful in guiding pediatric septic shock. Amino-terminal pro-B-type natriuretic peptide has not been assessed in pediatric septic patients at the time of presentation to the emergency department prior to any interventions. The primary aim was to assess if emergency department amino-terminal pro-B-type natriuretic peptide is associated with worse outcomes and severity of illness. Design: Prospective observational pilot study. Settings: Tertiary free-standing children’s hospital. Patients: Children 0–17 years old with a diagnosis of septic shock were enrolled. Patients with preexisting cardiac and renal dysfunction were excluded. Interventions: None. Measurements and Main Results: Amino-terminal pro-B-type natriuretic peptide analysis was performed on samples obtained in the emergency department prior to any intervention. The association between biomarkers and clinical outcomes and illness severity using Pediatric RISk of Mortality 3 were assessed. Eighty-two patients with septic shock underwent analysis. The median (interquartile range) amino-terminal pro-B-type natriuretic peptide levels was 394 pg/mL (102–1,392 pg/mL). Each decile change increase in amino-terminal pro-B-type natriuretic peptide was associated with a change in ICU length of stay by 8.7%, (95% CI, 2.4–15.5), hospital length of stay by 5.7% (95% CI, 0.4–11.2), organ dysfunction by 5.1% (95% CI, 1.8–8.5), a higher inotropic score at 12, 24, and 36 hours, and longer time requiring vasoactive agents. There was a significant correlation between baseline amino-terminal pro-B-type natriuretic peptide and the Pediatric RISk of Mortality 3 score (Spearman rho = 0.247; p = 0.029). Conclusions: This pilot study shows an association between emergency department amino-terminal pro-B-type natriuretic peptide on presentation and worse septic shock outcomes and amino-terminal pro-B-type natriuretic peptide levels correlates with an ICU severity score.

Vascular endothelial growth factor (VEGF) and its receptor, soluble fms-like tyrosine kinase (sFLT), are biomarkers of endothelial activation. Vascular endothelial growth factor and sFLT have been associated with sepsis severity among adults, but pediatric data are lacking. The goal of this study was to assess VEGF and sFLT as predictors of outcome for children with sepsis. METHODS Biomarkers measured for each patient at time of presentation to the emergency department were compared in children with septic shock versus children with sepsis without shock. For children with septic shock, the associations between biomarker levels and clinical outcome measures, including intensive care unit and hospital length of stay, vasoactive inotrope score, and measures of organ dysfunction, were assessed. RESULTS Soluble fms-like tyrosine kinase and VEGF were elevated in children with septic shock (n = 73) compared with those with sepsis (n = 93). Elevated sFLT but not VEGF was associated with longer intensive care unit length of stay (P = 0.003), longer time requiring vasoactive agents (P < 0.001), higher maximum vasoactive inotrope score (P < 0.001), and higher maximum pediatric logistic organ dysfunction score (P < 0.001). CONCLUSIONS Vascular endothelial growth factor and sFLT measured in the emergency department are elevated in children with septic shock, and elevated sFLT but not VEGF is associated with worse clinical outcomes.

BACKGROUND: Although oral antibiotics are recommended for the management of most urinary tract infections (UTIs), the administration of parenteral antibiotics before emergency department (ED) discharge is common. We investigated the relationship between the administration of a single dose of parenteral antibiotics before ED discharge and revisits requiring admission among children with UTIs. METHODS: A retrospective analysis of administrative data from 36 pediatric hospitals was performed. Patients aged 29 days to 2 years who were evaluated in the ED with a UTI between 2010 and 2016 were studied. Primary outcome was adjusted 3-day ED revisit rates resulting in admission. All revisits, regardless of disposition, served as a secondary outcome. Average treatment effects were estimated by using inverse probability weighted regression, with adjustment for demographic factors, diagnostic testing, ED medications, and hospital-level factors. RESULTS: We studied 29 919 children with a median age of 8.6 (interquartile range: 5.1–13.8) months. Of those studied, 36% of the children received parenteral antibiotics before discharge. Patients who received parenteral antibiotics had similar adjusted rates of revisits leading to admission as those who did not receive parenteral antibiotics (1.3% vs 1.0%, respectively; risk difference: 0.3% [95% confidence interval: −0.01% to 0.6%]), although overall revisit rates were higher among patients who received parenteral antibiotics (4.8% vs 3.3%; risk difference 1.5% [95% confidence interval: 0.9% to 2.1%]). CONCLUSIONS: Among discharged patients, a parenteral dose of antibiotics did not reduce revisits leading to admission, supporting the goal of discharging patients with oral antibiotics alone for most children with UTIs.

BACKGROUND AND OBJECTIVES: The ability of the chest radiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia. METHODS: Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit. RESULTS: There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4–5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%–99.6%). CONCLUSIONS: A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy.

BACKGROUND: Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated. METHODS: We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type. RESULTS: Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303–209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789–73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis. CONCLUSIONS: In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis.