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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 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 (

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.

Objective Diabetic ketoacidosis (DKA) is a common emergency department presentation of both new-onset and established diabetes mellitus (DM). β-Hydroxybutyrate (BOHB) provides a direct measure of the pathophysiologic derangement in DKA as compared with the nonspecific measurements of blood pH and bicarbonate. Our objective was to characterize the relationship between BOHB and DKA. Methods This is a cross-sectional retrospective study of pediatric patients with DM presenting to an urban pediatric emergency department between January 1, 2016, and September 30, 2018. Analyses were performed on each patient's initial, simultaneous BOHB and pH. Diagnostic test characteristics of BOHB were calculated, and logistic regression was performed to investigate the effects of age and other key clinical factors. Results Among 594 patients with DM, with median age of 12.3 years (interquartile range, 8.7-15.9 years), 176 (29.6%) presented with DKA. The inclusion of age, transfer status, and new-onset in the statistical model did not improve the prediction of DKA beyond BOHB alone. β-Hydroxybutyrate demonstrated strong discrimination for DKA, with an area under the curve of 0.95 (95% confidence interval, 0.93-0.97). A BOHB value of 5.3 mmol/L predicted DKA with optimal accuracy (90.6% of patients were correctly classified). The sensitivity, specificity, and positive and negative predictive values of this cut point were 76.7% (95% confidence interval, 69.8%-82.7%), 96.4% (94.2%-98.0%), 90.0% (84.0%-94.3%), and 90.8% (87.7%-93.3%), respectively. Conclusions β-Hydroxybutyrate accurately predicts DKA in children and adolescents. More importantly, because plasma BOHB is the ideal biochemical marker of DKA, BOHB may provide a more optimal definition of DKA for management decisions and treatment targets.

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.

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.

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.

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 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.

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

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 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.

Objectives Differences in emergency care for children exist between general and pediatric emergency departments (EDs). Some pediatric quality measures are available but are not routinely employed nationwide. We sought to create a short list of applied measures that would provide a starting point for EDs to measure pediatric emergency care quality and to compare care between general and pediatric EDs for these measures. Methods Previously reported lists comprising 465 pediatric emergency care quality measures were reconciled. Preset criteria were used to create a diverse list of quality measures measurable using a national database. We used the National Hospital Ambulatory Medical Care Survey from 2010 to 2015 to measure performance. Measures were excluded for total observation counts under a prespecified power threshold, being unmeasurable in the data set, or for missing clear definitions. Using survey-weighted statistics, we reported summary performance (mean, proportion, or count) with 95% confidence intervals for each analyzed quality measure and compared general and pediatric ED performance. Results Among 465 quality measures, 28 (6%) were included in the analysis, including seven condition-specific measures and 21 general measures. We analyzed a sample of 36,430 visits corresponding to 179.0 million survey-weighted ED visits, of which 150.8 million (84.3%) were in general EDs. Performance was better in pediatric EDs for three of seven condition-specific measures, including antibiotics for viral infections (-6.2%), chest X-rays for asthma (-18.7%), and topical anesthesia for wound closures (+25.7%). Performance was similar for four of seven condition-specific measures: computed tomography for head trauma, steroids for asthma, steroids for croup, and oral rehydration for dehydration. Compared with pediatric EDs, general EDs discharged and transferred higher proportions of children, had shorter lengths of stay, and sent patients home with fewer prescriptions. General EDs obtained fewer pain scores for injured children. Pediatric EDs had a lower proportion of pediatric visits in which patients left against medical advice. General and pediatric EDs had similar rates of mortality, left without being seen, incomplete vital signs, labs in nonacute patients, and similar numbers of medications given per patient. Conclusions Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement.

OBJECTIVES: We sought to develop and validate a clinical calculator that can be used to quantify risk for appendicitis on a continuous scale for patients with acute abdominal pain. METHODS: The pediatric appendicitis risk calculator (pARC) was developed and validated through secondary analyses of 3 distinct cohorts. The derivation sample included visits to 9 pediatric emergency departments between March 2009 and April 2010. The validation sample included visits to a single pediatric emergency department from 2003 to 2004 and 2013 to 2015. Variables evaluated were as follows: age, sex, temperature, nausea and/or vomiting, pain duration, pain location, pain with walking, pain migration, guarding, white blood cell count, and absolute neutrophil count. We used stepwise regression to develop and select the best model. Test performance of the pARC was compared with the Pediatric Appendicitis Score (PAS). RESULTS: The derivation sample included 2423 children, 40% of whom had appendicitis. The validation sample included 1426 children, 35% of whom had appendicitis. The final pARC model included the following variables: sex, age, duration of pain, guarding, pain migration, maximal tenderness in the right-lower quadrant, and absolute neutrophil count. In the validation sample, the pARC exhibited near perfect calibration and a high degree of discrimination (area under the curve: 0.85; 95% confidence interval: 0.83 to 0.87) and outperformed the PAS (area under the curve: 0.77; 95% confidence interval: 0.75 to 0.80). By using the pARC, almost half of patients in the validation cohort could be accurately classified as at 8. CONCLUSIONS: In our validation cohort of patients with acute abdominal pain, the pARC accurately quantified risk for appendicitis.

BACKGROUND: Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED. METHODS: We studied ED discharges for children RESULTS: Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%–34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19–0.36). CONCLUSIONS: Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.

Objective The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions. Methods We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model. Results The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years. Conclusions The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

The promises of data-independent acquisition (DIA) strategies are a comprehensive and reproducible digital qualitative and quantitative record of the proteins present in a sample. We developed a fast and robust DIA method for comprehensive mapping of the urinary proteome that enables large scale urine proteomics studies. Compared to a data-dependent acquisition (DDA) experiments, our DIA assay doubled the number of identified peptides and proteins per sample at half the coefficients of variation observed for DDA data (DIA = ~8%; DDA = ~16%). We also tested different spectral libraries and their effects on overall protein and peptide identifications and their reproducibilities, which provided clear evidence that sample type-specific spectral libraries are preferred for reliable data analysis. To show applicability for biomarker discovery experiments, we analyzed a sample set of 87 urine samples from children seen in the emergency department with abdominal pain. The whole set was analyzed with high proteome coverage (~1300 proteins/sample) in less than 4 days. The data set revealed excellent biomarker candidates for ovarian cyst and urinary tract infection. The improved throughput and quantitative performance of our optimized DIA workflow allow for the efficient simultaneous discovery and verification of biomarker candidates without the requirement for an early bias toward selected proteins.

The objective of this study was to examine the use of WBC count and polymorphonuclear leukocyte differential (PMN%) for improving the predictive value of ultrasound (US) in children with suspected appendicitis.We conducted a retrospective cohort study of children undergoing US for suspected appendicitis between January 1, 2010 and December 31, 2012 at a single children's hospital (n=845). Negative (NPV) and positive predictive values (PPV) for appendicitis were calculated for common constellations of US findings and compared with and without the use of laboratory thresholds (WBC9×10(3)/μL and PMN%65% for PPV; WBC≤9×10(3)/μL and PMN%≤65% for NPV).Fifty-one percent of US were considered "equivocal" (ie, appendix incompletely visualized, no primary or secondary signs, or presence of fluid only) and NPV increased significantly for this cohort using laboratory thresholds (41.9% vs 95.8%; p0.001). Primary signs of appendicitis, without secondary signs, were documented in 18% of examinations, and the PPV associated with this cohort increased from 79.1% to 91.3% (p0.001) using laboratory thresholds. Secondary signs with or without primary signs were documented in 24% of examinations, and laboratory thresholds improved the PPV in this cohort from 89.1% to 96.8% (p0.001). Guidelines recommending against the use of CT for very high-risk and low-risk categories (NPV95% and PPV95%) on the basis of combined US and laboratory data could have reduced the number of CTs by 27.1% (101 of 373) during the study period.The incorporation of WBC count and PMN% can substantially improve the predictive value of US in the diagnosis of suspected appendicitis in children.

Objective To determine the predictive value of ultrasonography (US) for appendicitis in children when combined with clinical assessment based on the Pediatric Appendicitis Score (PAS). Study design Observational study of children aged 3-18 years who had an US examination for possible appendicitis. A PAS was calculated on the basis of historical elements, examination, and laboratory studies and was used to classify patients into 3 risk groups (low, medium, high). The predictive value of the PAS for appendicitis was calculated and stratified by the result of the US (positive, negative, or equivocal). Results A total of 728 children with a median age 11.7 (IQR 7.8-14.9) years were studied; 29% had appendicitis. The negative predictive value of US decreased with increasing PAS-based risk assignment: low risk 1.00 (95% CI, 0.97-1.00), medium risk 0.94 (0.91-0.97), and high risk 0.81 (0.73-0.89). With increasing PAS, the positive predictive value increased: low risk 0.73 (0.47-0.99), medium risk 0.90 (0.82-0.98), and high risk 0.97 (0.95-1.0). Among children with equivocal ultrasound results, the proportion with appendicitis ranged from 0.09 (0.0-0.19) for low-risk patients to 0.47 (0.33-0.61) among for high-risk patients. Conclusion Ultrasound findings in children with possible appendicitis should be integrated with clinical assessment, such as a clinical score, to determine next steps in management. Rates of false-negative US increase with increasing PAS, and false-positive US results occur more often with lower PAS. When discordance exists between US results and the clinical assessment, serial examinations or further imaging are warranted.

BACKGROUND AND OBJECTIVES: Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits. METHODS: Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009–2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit. RESULTS: The study identified 32 124 children with migraine; 27 317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists. CONCLUSIONS: The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.

BACKGROUND AND OBJECTIVES: Pediatric out-of-hospital cardiac arrest (OHCA) has a low rate of survival to hospital discharge. Understanding whether pediatric emergency departments (EDs) have higher survival than general EDs may help identify ways to improve care for all patients with OHCA. We sought to determine if OHCA survival differs between pediatric and general EDs. METHODS: We used the 2009–2014 Nationwide Emergency Department Sample to study children under 18 with cardiac arrest. We compared pediatric EDs (those with >75% pediatric visits) to general EDs on the outcome of survival to hospital discharge or transfer. We determined unadjusted and adjusted survival, accounting for age, region, and injury severity. Analyses were stratified by nontraumatic versus traumatic cause. RESULTS: The incidences of nontraumatic and traumatic OHCA were 7.91 (95% confidence interval [CI]: 7.52–8.30) and 2.67 (95% CI: 2.49–2.85) per 100 000 person years. In nontraumatic OHCA, unadjusted survival was higher in pediatric EDs than general EDs (33.8% vs 18.9%, P < .001). The adjusted odds ratio of survival in pediatric versus general EDs was 2.2 (95% CI: 1.7–2.8). Children with traumatic OHCA had similar survival in pediatric and general EDs (31.7% vs 26.1%, P = .14; adjusted odds ratio = 1.3 [95% CI: 0.8–2.1]). CONCLUSIONS: In a nationally representative sample, survival from nontraumatic OHCA was higher in pediatric EDs than general EDs. Survival did not differ in traumatic OHCA. Identifying the features of pediatric ED OHCA care leading to higher survival could be translated into improved survival for children nationally.

OBJECTIVE The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of

Background Currant jelly stool is a late manifestation of intussusception and is rarely seen in clinical practice. Other forms of GI bleeding have not been thoroughly studied and little is known about their respective diagnostic values. Objective To assess the predictive value of GI bleeding (positive guaiac test, bloody stool and rectal bleeding in evaluation of intussusception. Methods We performed a retrospective cross-sectional study cohort of all children, ages 1 month-6 years of age, who had an abdominal ultrasound obtained evaluating for intussusception over 5 year period. We identified intussusception if diagnosed by ultrasound, air-contrast enema or surgery. Univariate and a multivariate logistic regression analysis were performed. Results During the study period 1258 cases met the study criteria; median age was 1.7 years (IQR 0.8, 2.9) and 37% were females. Overall 176 children had intussusception; 153 (87%) were ileo-colic and 23 were ileo-ileal. Univariate risk ratio and adjusted Odds ratio were 1.3 (95% CI, 0.8, 2.0) and 1.3 (0.7, 2.4) for positive guaiac test, 1.1 (0.6, 2.1) and 0.9 (0.3, 3.0) for bloody stool, and 1.7 (1.02, 2.8) and 1.3 (0.5, 3.1) for rectal bleeding . Conclusion Blood in stool, whether visible or tested by guaiac test has poor diagnostic performance in the evaluation of intussusception and is not independently predictive of intussusception. If the sole purpose of a rectal exam in these patients is for guaiac testing it should be reconsidered.

Background Disparities exist in the care children receive in the emergency department (ED) based on their insurance type. It is unknown if these differences exist among children transferred from outside EDs to pediatric tertiary care EDs. Objective To compare reasons for transfer and services received at pediatric tertiary care EDs between children with private and public insurance. Methods We performed a secondary analysis of a multicenter survey of ED providers transferring patients to pediatric tertiary care EDs in three major U.S. cities. Risk differences (RD) and 95% confidence intervals (CI) were calculated to compare reasons for transfer and care received at pediatric tertiary care EDs based on insurance type. Results There were 561 surveys completed by transferring providers describing reasons for transfer to pediatric tertiary care EDs with 52.2% of patients with private insurance and 47.8% with public insurance. We found no significant differences between privately and publicly insured children in reason for transfer for subspecialty consultation or need for admission. We found no significant differences in frequency of admission, radiologic studies, or ED procedures at the receiving facilities. However, a greater proportion of privately insured children had a subspecialty consultation at receiving facilities compared to publicly insured children (RD 9.7, 95% CI 2.0 to 17.4). Conclusions Transferred pediatric patients with private insurance were more likely to have subspecialty consultations than children with public insurance. Further studies are needed to better characterize the interplay between patients' insurance type and both the request for, and the provision of, ED subspecialty consultations.

BACKGROUND AND OBJECTIVES: Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization. METHODS: Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients RESULTS: 99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy. CONCLUSIONS: A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy.

Objectives The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility. Methods We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer. Results Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission. Conclusions Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

Children with recurrent urinary tract infections (rUTI) often show no identifiable cause of their infections. Neutrophil gelatinase-associated lipocalin (NGAL) is known to be upregulated within the uroepithelium and kidney of patients with UTI and exhibits a localized bacteriostatic effect through iron chelation. We hypothesize that some patients with rUTI without an identifiable cause of their recurrent infections have locally deficient NGAL production. We therefore explored whether a lack of NGAL production may be a factor in the pathogenesis of rUTI.Patients seen in the urology clinic for rUTI who were21 years of age were enrolled. Patients were excluded if they had UTI at the time of enrollment, evidence of renal disease, decreased renal function, known anatomic abnormality of the genitourinary tract, or other reasons that predispose to UTI, such as neurogenic bladder, the need for intermittent catheterization, or unrepaired posterior urethral valves. Control patients were healthy children enrolled from the emergency department with no history of UTI or renal dysfunction, normal urinalysis at the time of enrollment, and presenting no diagnosis associated with increased NGAL levels, such as acute kidney injury or infection. NGAL was measured by immunoblot.Fifteen cases and controls were enrolled. Median urinary NGAL levels were significantly decreased in rUTI patients compared with controls [15 (14-29) ng/ml vs 30 (27-61) ng/ml; p = 0.002)] Although comparatively diminished, measurable NGAL levels were present in all patients with rUTI.Urinary NGAL is significantly decreased in patients with compared with patients without rUTI. These data suggest that some patients with rUTI may be predisposed to UTI because of a relative local deficiency in urinary NGAL production.

To identify independent predictors of and use recursive partitioning to develop a multivariate regression tree predicting symptom duration greater than 28 days after a sport-related concussion.We conducted a prospective cohort study of patients in a sports concussion clinic. Participants completed questionnaires that included the Post-Concussion Symptom Scale (PCSS). Participants were asked to record the date on which they last experienced symptoms. Potential predictor variables included age, sex, score on symptom inventories, history of prior concussions, performance on computerized neurocognitive assessments, loss of consciousness and amnesia at the time of injury, history of prior medical treatment for headaches, history of migraines, and family history of concussion. We used recursive partitioning analysis to develop a multivariate prediction model for identifying athletes at risk for a prolonged recovery from concussion.A total of 531 patients ranged in age from 7 to 26 years (mean 14.6 ± 2.9 years). The mean PCSS score at the initial visit was 26 ± 26; mean time to presentation was 12 ± 5 days. Only total score on symptom inventory was independently associated with symptoms lasting longer than 28 days (adjusted odds ratio 1.044; 95% confidence interval [CI] 1.034, 1.054 for PCSS). No other potential predictor variables were independently associated with symptom duration or useful in developing the optimal regression decision tree. Most participants (86%; 95% CI 80%, 90%) with an initial PCSS score of13 had resolution of their symptoms within 28 days of injury.The only independent predictor of prolonged symptoms after sport-related concussion is overall symptom burden.

BACKGROUND: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care. METHODS: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability. RESULTS: The national median HCI was 0.06 (interquartile range: 0.01–0.17) in 2008 and 0.02 (interquartile range: 0.00–0.09) in 2016 (P CONCLUSIONS: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children.

BackgroundDelayed diagnoses of serious emergency conditions can lead to morbidity in children, but are challenging to identify and measure. We developed and piloted an automated tool for identifying delayed diagnosis of two serious conditions commonly seen in the ED using administrative data.MethodsWe identified cases with a final diagnosis of appendicitis or sepsis in a freestanding children’s hospital from 2008 to 2018, with any hospital ED encounter within the preceding 7 days. Two investigators reviewed a subset of these cases using the electronic health records (EHR) to determine if there was a delayed diagnosis and interrater reliability was assessed using the intraclass correlation coefficient (ICC). An automated tool was applied to the same cases to assess its positive predictive value (PPV) to identify those with a delayed diagnosis, using the manual chart review as the gold standard. The tool used number of days since visit, presence of a related diagnosis on the initial visit, and whether or not the patient was discharged.ResultsPrevious ED encounters preceded 91/3703 (2.5%) appendicitis cases and 159/1754 (9.1%) sepsis cases; 78 cases of each were sampled for review. In manual review, 73.4% and 22.8% were thought to have delayed diagnoses; reviewer agreement was excellent (appendicitis ICC 0.77, 95% CI 0.62 to 0.86 and sepsis ICC 0.77, 95% CI 0.43 to 0.89). The PPVs of the automated tool for determination of delayed diagnosis for appendicitis within 1, 3 or 7 days were 96.2%, 95.1% and 93.6%, respectively. For sepsis, the PPVs were 71.4%, 63.6% and 41.2% within 1, 3 or 7 days, respectively.ConclusionsThis automated tool performed well compared with expert EHR review. Performance was stronger for appendicitis. Further tool refinement could improve performance.

Objectives Children with gastroenteritis often develop dehydration with metabolic acidosis. Serum ketones are frequently elevated in this population. The goal was to determine the relationship between initial serum ketone concentration and both the degree of dehydration and the magnitude of acidosis. Methods This was a secondary analysis of a prospective trial of crystalloid administration for rapid rehydration. Children 6 months to 6 years of age with gastroenteritis and dehydration were enrolled. A point-of-care serum ketone (beta-hydroxybutyrate) concentration was obtained at the time of study enrollment. The relationship between initial serum ketone concentration and a prospectively assigned and previously validated clinical dehydration score, and serum bicarbonate concentration, was analyzed. Results A total of 188 patients were enrolled. The median serum ketone concentration was elevated at 3.1 mmol/L (interquartile range [IQR] = 1.2 to 4.6 mmol/L), and the median dehydration score was consistent with moderate dehydration. A significant positive relationship was found between serum ketone concentration and the clinical dehydration score (Spearman's rho = 0.22, p = 0.003). Patients with moderate dehydration had a higher median serum ketone concentration than those with mild dehydration (3.6 mmol/L vs. 1.4 mmol/L, p = 0.007). Additionally, the serum ketone concentration was inversely correlated with serum bicarbonate concentration (ρ = –0.26, p

Return visits to the Emergency Department (ED) requiring admission are frequently reviewed for the purpose of quality improvement. Treating physicians typically perform this review, but it is unclear if they accurately identify the reasons for the returns.To assess the characteristics of pediatric return visits to the ED, and the ability of treating physicians to identify the root causes for these return visits.This retrospective cohort study reviewed all returns within 96 h of an initial visit over a 2-year period at a tertiary care pediatric ED. Baseline characteristics were determined from review of patients' charts. The treating physicians, the primary author, and independent reviewers identified the root cause for the returns.There were 97,374 patients that presented to the ED during the study, and 1091 (1.1%) of these children returned to the ED and were admitted. Returns were most common among children aged5 years, arriving between 3:00 p.m. and 11:00 p .m. via private transportation, with infectious diseases. The physician involved in the care of the patient attributed 3.1% of returns to potential deficiencies in medical management, whereas the independent reviewers attributed 13% to potential deficiencies.Both returns and the subset of returns due to potential deficiencies in management are more common than previously estimated, rendering review of returns a valuable quality improvement tool. However, EDs should not rely exclusively on the treating physicians to identify the reason for returns, as they seem to underestimate the frequency of returns due to potential deficiencies in medical management.

Objective To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis. Methods Patients with suspected appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8–18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with 0.4 were entered into a multivariable model. Resultant β-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios. Results The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval [CI], 20%–29%), specificity of 98% (95% CI, 96%–99%), and positive predictive value of 93% (95% CI, 86%–97%) for ruling in appendicitis. Conclusions We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging.

OBJECTIVE White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted. METHODS This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology. Absence of definitive diagnostic markers limits the accuracy of clinical evaluations of suspected KD with significant increases in morbidity. In turn, incomplete understanding of its molecular pathogenesis hinders the identification of rational targets needed to improve therapy. We used high-accuracy mass spectrometry proteomics to analyse over 2000 unique proteins in clinical urine specimens of patients with KD. We discovered that urine proteomes of patients with KD, but not those with mimicking conditions, were enriched for markers of cellular injury such as filamin and talin, immune regulators such as complement regulator CSMD3, immune pattern recognition receptor muclin, and immune cytokine protease meprin A. Significant elevations of filamin C and meprin A were detected in both the serum and urine in two independent cohorts of patients with KD, comprised of a total of 236 patients. Meprin A and filamin C exhibited superior diagnostic performance as compared to currently used markers of disease in a blinded case-control study of 107 patients with suspected KD, with receiver operating characteristic areas under the curve of 0.98 (95% confidence intervals [CI] of 0.97‐1 and 0.95‐1, respectively). Notably, meprin A was enriched in the coronary artery lesions of a mouse model of KD. In all, urine proteome profiles revealed novel candidate molecular markers of KD, including filamin C and meprin A that exhibit excellent diagnostic performance. These disease markers may improve the diagnostic accuracy of clinical evaluations of children with suspected KD, lead to the identification of novel therapeutic targets, and allow the development of a biological classification of Kawasaki disease.