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Introduction: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network. Methods: We describe the challenges encountered when EMERGE proposed the development of a global emergency department (ED) visit registry. The proposed registry was to be a six-month, retrospective, deidentified, minimal dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition. Results: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable taxonomies, need for language translation, varying site processes for curation and transfer of deidentified data, navigating institution- and country-specific data protection regulations, and substantial variation in each participating institution’s research infrastructure including training in research-related activities. We have overcome many of these challenges by creating detailed data-sharing agreements with bilateral regulatory oversight agreements between EMERGE and participating EDs, developing relationships with and training health informaticians at each site to ensure secure transfer of deidentified data, and formalizing an electronic transfer process ensuring data privacy. Conclusion: We believe that networks like EMERGE are integral to providing the necessary platforms for education, training, and research collaborations for emergency care. We identified substantial challenges in data sharing and variation in local sites’ research infrastructure and propose potential approaches to address these challenges.

BackgroundEarly differentiation of febrile young infants with from those without serious infections (SIs) remains a diagnostic challenge. We sought to (1) compare vital signs and heart rate variability (HRV) parameters between febrile infants with versus without SIs, (2) assess the performance of HRV and vital signs with reference to current triage tools and (3) compare HRV and vital signs to HRV, vital signs and blood biomarkers, when predicting for the presence of SIs.MethodsUsing a prospective observational design, we recruited patients ResultsAmong 203 infants with a mean age of 38.4 days (SD 27.6), 67 infants (33.0%) had an SI. There were significant differences in the time, frequency and non-linear domains of HRV parameters between infants with versus without SIs. In predicting SIs, gender, temperature and the HRV non-linear parameter Poincaré plot SD2 (AUC 0.78, 95% CI 0.71 to 0.84) performed better than SIS alone (AUC 0.61, 95% CI 0.53 to 0.68). Model performance improved with the addition of absolute neutrophil count and C reactive protein (AUC 0.82, 95% CI 0.76 to 0.89).ConclusionAn exploratory prediction model incorporating HRV and biomarkers improved prediction of SIs. Further research is needed to assess if HRV can identify which young febrile infants have an SI at ED triage.Trial registration numberNCT04103151.

Study objective This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice. Methods This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit. Results In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ. Conclusion Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

Background Febrile infants commonly present to emergency departments for evaluation. Objective We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network. Methods We enrolled a convenience sample of non-critically ill–appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0–28 days of age) and older (29–60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance. Results Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0–28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29–60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%. Conclusions The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29–60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

This is a revision of the previous joint Policy Statement titled “Guidelines for Care of Children in the Emergency Department.” Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report “The Future of Emergency Care in the US Health System.” Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

BACKGROUND: Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data. METHODS: We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to RESULTS: In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8). CONCLUSIONS: Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.

Growth plate (physeal) fractures are defined as a disruption in the cartilaginous physis of bone with or without the involvement of epiphysis or metaphysis. These represent around 15-18% of all pediatric fractures. It is important to diagnose physeal injury as early as possible, as misdiagnosis or delay in diagnosis may result in long term complications. Physeal injuries may not be initially obvious in children who present with periarticular trauma, and a high index of suspicion is important for diagnosis. Differential diagnosis for a Salter-Harris fracture includes a ligamentous sprain, acute osteomyelitis, or an extraphyseal fracture such as a Torus fracture. Salter-Harris I & Salter-Harris II growth plate fractures commonly are commonly managed by closed manipulation, reduction & immobilization. These are relatively stable injuries and can be retained by adequate plaster. Salter-Harris III & Salter-Harris IV fractures require anatomical reduction with the maintenance of congruity of joint. Physeal fractures can have many complications such as malunion, bar formation, acceleration of growth of physis, posttraumatic arthritis, ligament laxity and shortening of the bone. The key to well-healing fractures is successful anatomic reduction and patients must have regular follow-up for these injuries.

Objective Few prospective studies have assessed the occurrence of radiographic pneumonia in young febrile infants. We analyzed factors associated with radiographic pneumonias in febrile infants 60 days or younger evaluated in pediatric emergency departments. Study design We conducted a planned secondary analysis of a prospective cohort study within 26 emergency departments in a pediatric research network from 2008 to 2013. Febrile (≥38°C) infants 60 days or younger who received chest radiographs were included. Chest radiograph reports were categorized as "no," "possible," or "definite" pneumonia. We compared demographics, Yale Observation Scale scores (>10 implying ill appearance), laboratory markers, blood cultures, and viral testing among groups. Results Of 4778 infants, 1724 (36.1%) had chest radiographs performed; 2.7% (n = 46) had definite pneumonias, and 3.9% (n = 67) had possible pneumonias. Patients with definite (13/46 [28.3%]) or possible (15/67 [22.7%]) pneumonias more frequently had Yale Observation Scale score >10 compared with those without pneumonias (210/1611 [13.2%], P = 0.002) in univariable and multivariable analyses. Median white blood cell count (WBC), absolute neutrophil count (ANC), and procalcitonin (PCT) were higher in the definite (WBC, 11.5 [interquartile range, 9.8-15.5]; ANC, 5.0 [3.2-7.6]; PCT, 0.4 [0.2-2.1]) versus no pneumonia (WBC, 10.0 [7.6-13.3]; ANC, 3.4 [2.1-5.4]; PCT, 0.2 [0.2-0.3]; WBC, P = 0.006; ANC, P = 0.002; PCT, P = 0.046) groups, but of unclear clinical significance. There were no cases of bacteremia in the definite pneumonia group. Viral infections were more frequent in groups with definite (25/38 [65.8%]) and possible (28/55 [50.9%]) pneumonias than no pneumonias (534/1185 [45.1%], P = 0.02). Conclusions Radiographic pneumonias were uncommon, often had viruses detected, and were associated with ill appearance, but few other predictors, in febrile infants 60 days or younger.

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.

Key Points Question What factors are associated with a potentially missed diagnosis of appendicitis in the emergency department among adults and children? Findings In this cohort study of 123 711 patients diagnosed with appendicitis, insurance claims data indicated that appendicitis was potentially missed in 6.0% of adults and 4.4% of children during the initial emergency department visit. Factors associated with potentially missed appendicitis included female sex, the coexistence of abdominal pain and constipation, and the presence of comorbidities. Meaning Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may alert clinicians and mitigate the risk of missed diagnosis., Importance Appendicitis may be missed during initial emergency department (ED) presentation. Objective To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. Design, Setting, and Participants In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged, This cohort study uses insurance claims data to compare patients with a potentially missed diagnosis of appendicitis with those diagnosed with appendicitis during the initial emergency department visit to identify factors associated with potentially missed appendicitis among adults and children.

* Abbreviations: ED — : emergency department miniMAGIC — : Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics NTCVAD — : nontunneled central vascular access device PED — : pediatric emergency department PICC — : peripherally inserted central catheter PIVC — : peripheral intravenous catheter VAD — : vascular access device Vascular access devices (VADs) are commonly inserted, often in a time sensitive manner, in critically ill children to provide life-sustaining therapy, including but not limited to fluid resuscitation, antibiotics, vasopressors, or parenteral nutrition, and for hemodynamic monitoring. Among children admitted to the pediatric emergency department (PED), VAD selection is limited to peripheral intravenous catheter (PIVC), intraosseous device, and nontunneled central vascular access device (NTCVAD). VAD selection is more varied in the PICU and includes peripherally inserted central catheter (PICC), midline catheter, tunneled cuffed central VAD, and totally implanted venous device in addition to those that are available in the PED. Regardless of setting of care, currently there is no evidence-based guidance for VAD selection. In general, PIVCs are the mainstay for critically ill children in the PED, and PIVC and NTCVAD are the mainstays for those in the PICU. However, given the concerns of central line–associated bloodstream … Address correspondence to Sarah B. Kandil, MD, Department of Pediatrics, Yale School of Medicine, Yale University, 333 Cedar St, New Haven, CT 06520. E-mail: sarah.kandil{at}yale.edu

Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care.We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics.The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008.Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels.Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.

The Accreditation Council for Graduate Medical Education requires training in quality improvement (QI) but does not provide specifics of content or methods. We aimed to describe the current state of pediatric emergency medicine (PEM) fellowship training in QI and the integration of such QI training with related institutional efforts. We surveyed PEM fellowship program directors (PDs) between January 2017 and March 2017. A group of PEM-boarded physicians with expertise in QI created survey questions to assure face validity. Questions were focused on the current QI curricula, the integration of QI training within institutional efforts, and future fellowship needs in QI training. Of the 81 eligible PDs surveyed, 70 (86.4%) completed surveys. A formal QI curriculum was present in 68.9% of programs. A median of 12 hours was dedicated to the curriculum over the entire course of fellowship. Thirty (42.8%) PDs felt that their fellows were integrated into the broader departmental QI efforts. Only 3 (4.3%) PDs reported that they had evaluated the efficacy of the QI curriculum in their fellowship. QI training is common among PEM fellowship programs. However, integration, as well as formal evaluation of efficacy, is uncommon.

Study objective We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures. Methods We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm3) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm3 for infants aged 28 days or younger and greater than or equal to 10 cells/mm3 for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis. Results Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days. Conclusion Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.

Objectives The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network. Methods This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based. Results Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization. Conclusions We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

OBJECTIVES: In preparation for a clinical trial of therapeutic agents for children with moderate-to-severe blunt traumatic brain injuries (TBIs) in emergency departments (EDs), we conducted this feasibility study to 1) determine the number and clinical characteristics of eligible children, 2) determine the timing of patient and guardian arrival to the ED, and 3) describe the heterogeneity of TBIs on computed tomography (CT) scans. METHODS: We conducted a prospective observational study at 16 EDs of children ≤ 18 years of age presenting with blunt head trauma and Glasgow Coma Scale (GCS) scores of 3-12. We documented the number of potentially eligible patients, timing of patient and guardian arrival, patient demographics and clinical characteristics, severity of injuries, and cranial CT findings. RESULTS: We enrolled 295 eligible children at the 16 sites over 6 consecutive months. Cardiac arrest and non-survivable injuries were the most common characteristics that would exclude patients from a future trial. Most children arrived within 2 hours of injury, but most guardians did not arrive until 2-3 hours after the injury. There was a substantial range in types of TBIs, with subdural hemorrhages being the most common. CONCLUSION: Enrolling children with moderate-to-severe TBI into time sensitive clinical trials will require large numbers of sites, meticulous preparation and coordination, and will prove challenging to obtain informed consent given the timing of patient and guardian arrival. The Federal Exception from Informed Consent for Emergency Research will be an important consideration for enrolling these children. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved. Language: en

Author(s): Moore, Brian; Shah, Manish I; Owusu-Ansah, Sylvia; Gross, Toni; Brown, Kathleen; Gausche-Hill, Marianne; Remick, Katherine; Adelgais, Kathleen; Lyng, John; Rappaport, Lara; Snow, Sally; Wright-Johnson, Cynthia; Leonard, Julie C; AMERICAN ACADEMY OF PEDIATRICS, Committee on Pediatric Emergency Medicine and Section on Emergency Medicine EMS Subcommittee; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, Emergency Medical Services Committee; EMERGENCY NURSES ASSOCIATION, Pediatric Committee; NATIONAL ASSOCIATION OF EMERGENCY MEDICAL SERVICES PHYSICIANS, Standards and Clinical Practice Committee; NATIONAL ASSOCIATION OF EMERGENCY MEDICAL TECHNICIANS, Emergency Pediatric Care Committee; Pediatric Readiness in Emergency Medical Services Systems; POLICY STATEMENT; Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children

There is a global variation in policies that define clear indications for pediatric intensive care unit (PICU) admissions. In resource-limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments. Design: The consensus recommendations were developed by a multidisciplinary consensus task force comprised of international experts in pediatric critical care, emergency medicine, trauma, critical care, and health policy stakeholders during the 2016 annual INDUSEM WORLD CONGRESS in Bengaluru, India. Measurements and Main Results: A task force steering committee completed a global literature search about PICU admission criteria development, reviewed PICU admission guidelines published by a variety of professional organizations worldwide, and performed a literature review of relevant publications. The objectives of this task force is to provide a framework for validated approach to determine appropriateness of intensive care unit (ICU) admission in India (resource-limited setting) based on (a) prioritization modeling; (b) general clinical criteria; (c) clinical and objective parameters; and (d) other criteria. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, the current standard of care, and expert opinion in the context of the Indian health system. The general subject was addressed in sections: admission criteria and benefits of different levels of care. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion: Although these are consensus recommendations, the subjects addressed encompass complex ethical and medicolegal aspects of patient care that affect daily clinical practice. The scarcity of high-quality evidence made it difficult to answer all the questions asked related to ICU admission. Despite these limitations, the members of the task force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission process. This publication is designed to assist in future development of health policies to ensure effective resource allocation, maximize healthcare benefits, and improve access to quality care for children.

Background Although oral rehydration therapy is recommended for children with acute gastroenteritis (AGE) with none to some dehydration, intravenous (IV) rehydration is still commonly administered to these children in high-income countries. IV rehydration is associated with pain, anxiety, and emergency department (ED) revisits in children with AGE. Objectives We sought to better understand the factors associated with IV rehydration in children with AGE in order to inform knowledge translation strategies. Design/Methods This was a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) randomized, controlled trials of oral probiotics in children with AGE-associated diarrhea. Eligible children were aged 3–48 months and reported >3 watery stools in a 24-hour period. The primary outcome was administration of IV rehydration at the index ED visit. We used mixed-effects logistic regression model to explore univariable and multivariable relationships between IV rehydration and a prioririsk factors. Results From the parent study sample of 1848 participants, 1846 had data available for analysis: mean (SD) age of 19.1 ± 11.4 months, 45.4% females. 70.2% (1292/1840) vomited within 24 hours of the index ED visit and 34.1% (629/1846) received ondansetron in the ED. 13.0% (240/1846) were administered IV rehydration at the index ED visit, and 3.6% (67/1842) were hospitalized. Multivariable predictors of IV rehydration were Clinical Dehydration Scale (CDS) score [compared to none: mild to moderate (OR: 8.1, CI: 5.5–11.8); severe (OR: 45.9, 95% CI: 20.1–104.7), P Conclusion Higher CDS scores, antiemetic use, previous healthcare visits and country were independent predictors of IV rehydration which was also associated with increased ED revisits. Knowledge translation focused on optimizing the use of antiemetics (i.e. for those with dehydration) and reducing the geographic variation in IV rehydration use may improve the ED experience and reduce ED-revisits.

* Abbreviations: ANC — : absolute neutrophil count CBC — : compete blood count CRP — : C-reactive protein CSF — : cerebrospinal fluid ED — : emergency department IBI — : invasive bacterial infection PCT — : procalcitonin Clinicians caring for young febrile infants have struggled with risk stratification algorithms for invasive bacterial infections (IBIs) (bacteremia and/or bacterial meningitis) for decades1–5 because of the tension between not wanting to miss infants with IBIs yet not wanting to over-test and over-treat these vulnerable infants.6,7 Risk stratification algorithms using compete blood counts (CBCs) with or without cerebrospinal fluid (CSF) data, developed in the 1980s and 1990s, have several limitations: (1) laboratory thresholds were not derived by statistical methods, resulting in suboptimal test accuracies; (2) algorithm precision was limited by the relatively few infants with IBIs; (3) the epidemiology of IBIs has changed in the past decades8–10 with an increase in Escherichia coli and a decrease in group B Streptococcus infections due to perinatal screening; (4) algorithm specificity has been insufficient to limit the use of lumbar punctures, empirical antibiotics, and hospitalizations; and (5) newer biomarkers, including C-reactive protein (CRP) and particularly procalcitonin (PCT), are substantially more sensitive than the CBC for detecting infants with these infections.7,11,12 In a well-conducted retrospective case-control analysis from 11 emergency departments (EDs) between 2011 … Address correspondence to Nathan Kuppermann, MD, MPH, Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, 2315 Stockton Blvd, PSSB Suite 2100, Sacramento, CA 95817. E-mail: nkuppermann{at}ucdavis.edu

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.

Pediatric early warning scores in an emergency department may be used in routine patient evaluation of illness severity and resource allocation, thereby positively impacting quality and safety in pediatric care. This prospective nursing study assessed the feasibility and reliability of pediatric early warning scores in a busy, inner-city, level 1 trauma center pediatric emergency department. The pediatric early warning scores demonstrated high interrater reliability (degree of agreement among scorers) (intraclass correlation coefficient = 0.91) and intrarater reliability (multiple repetitions by a single scorer) (intraclass correlation coefficient = 0.90).

Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.

Background Pediatric emergency care research networks have evolved substantially over the past two decades. Some networks are specialized in specific areas (e.g., sedation, simulation) while others study a variety of medical and traumatic conditions. Given the increased collaboration between pediatric emergency research networks, the logical next step is the development of a research priorities agenda to guide global research in emergency medical services for children (EMSC). Objectives An international group of pediatric emergency network research leaders was assembled to develop a list of research priorities for future collaborative endeavors within and between pediatric emergency research networks. Methods Before an in-person meeting, we used a modified Delphi approach to achieve consensus around pediatric emergency research network topic priorities. Further discussions took place on May 15, 2018, in Indianapolis, Indiana, at the Academic Emergency Medicine (AEM) consensus conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." Here, a group of 40 organizers and participants met in a 90-minute "breakout" session to review and further develop the initial priorities. Results We reached consensus on five clinical research priorities that would benefit from collaboration among the existing and future emergency networks focused on EMSC: sepsis, trauma, respiratory conditions, pharmacology of emergency conditions, and mental health emergencies. Furthermore, we identified nonclinical research priorities categorized under the domains of technology, knowledge translation, and organization/administration of pediatric emergency care. Conclusion The identification of pediatric emergency care network research priorities within the domains of clinical care, technology, knowledge translation and organization/administration of EMSC will facilitate and help focus collaborative research within and among research networks globally. Engagement of essential stakeholders including EMSC researchers, policy makers, patients, and their caregivers will stimulate advances in the delivery of emergency care to children around the globe.

Despite the fact that emergency care can impact health of populations, the global epidemiology of emergencies in children and adults is unknown and substantial variation exists in emergency infrastructure among different nations, especially among the low and middle income countries. Various research networks which are etiology specific or subspecialty specific, including emergency care based networks have positively impacted the health of populations. However, emergency departments (ED) in low and middle income counties are underrepresented in most international networks. Creation of a global ED based research network will help generate generalizable evidence that can then be translated into locally relevant evidence-based guidelines, nurture future researchers in emergency medicine, standardize training/education and improve patient outcomes by reducing variation in clinical care.

The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally, organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine (MD) in Emergency Medicine (EM) as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3-year superspeciality course (in PEM) after completion of MD/Diplomate of National Board (DNB) Pediatrics or MD/DNB in EM. The National Board of Examinations (NBE) that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program - DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG-ACEE-India) gives its recommendations for starting 3-year DM/DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.

Objectives Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma. Methods This was a planned subanalysis of a prospective, multicenter observational study of children ( 50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention. Results Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled in the parent study. Intra-abdominal injuries undergoing acute intervention were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI = 32% to 34%) patients with clinician suspicion 1% se comparo con la presencia de cualquier variable en la regla de prediccion para la identificacion de ninos con LIA con necesidad de una intervencion urgente. Resultados Los clinicos documentaron su sospecha en 11.919 (99%) de los 12.044 pacientes incluidos en el estudio original. La LIA con necesidad de intervencion urgente se diagnostico en 203 (2%) pacientes. Las TC abdominales se obtuvieron en el SU en 2.302 de los 2.667 pacientes (86%, IC95% = 85% a 88%) incluidos con sospecha clinica ≥1%; y en 3.016 de los 9.252 pacientes (33%, IC95% = 32% a 34%) con sospecha clinica

Background Low-income African-American adolescents use preventive medical services less frequently than their White counterparts, indicating a need for effective interventions targeting this group. Puff City is a Web-based, asthma management program for urban adolescents that has been evaluated in high school settings with promising results. The objective of this pilot was to assess the feasibility of initiating Puff City (treatment) in an emergency department setting, thereby informing the conduct of an individual randomized trial to evaluate its effectiveness compared to a generic, Web-based program (control) in preventing subsequent emergency department (ED) visits. Methods Teens aged 13–19 years presenting with acute asthma to two urban EDs within the study period were eligible. Subsequent ED visits were collected using the electronic medical record. A priori indication of a potential intervention effect was p 3 of 4 sessions and 90% completed the 12-month survey. At 12 months, the treatment group showed a trend toward fewer ED visits than controls (33.8 versus 46.4%), p = 0.15. Conclusions Results indicate the feasibility of enrolling at-risk adolescents in ED settings and set the stage for a large, pragmatic trial using a technology-based intervention to reduce the burden of pediatric asthma. Trial registration ClinicalTrials.gov, NCT01695031

Study objective To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). Methods We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. Results Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections ( E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. Conclusion The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

The main objective of this study was to describe the epidemiology of return visits (RVs) in well-appearing infants to an urban emergency department (ED) who were evaluated for serious bacterial infection (SBI) at their index ED visit.We conducted a retrospective chart review on infants aged 90 days and younger who were evaluated for SBI at their initial ED visit from 2003 through 2009. A parent database of all febrile infants evaluated for SBI was queried to identify patients who had an RV within 7 days of the index visit. We collected demographic variables including age, sex, and past medical history as well as laboratory test results including white blood cell count, blood, urine, and cerebrospinal fluid cultures and viral studies.Of eligible febrile infants, 10.8% (350/3220) had an RV to the ED within 7 days. The prevalence of SBI in the RV cohort was 6.0% (21/350), which included 1.7% (6/350) bacteremia, 3.7% (13/350) urinary tract infection, and 0.6% (2/350) combined urinary tract infection and bacteremia. The blood culture contamination rate was 88%.Infants aged 90 days or younger who are evaluated for SBI have high RV rates. A substantial number of RVs are due to contaminated blood cultures. Future studies should be conducted to identify predictors for false-positive blood cultures.

INTRODUCTION Empiric parenteral ampicillin has traditionally been used to treat listeria and enterococcal serious bacterial infections (SBI) in neonates 28 days of age or younger. Anecdotal experience suggests that these infections are rare. Existing data suggest an increasing resistance to ampicillin. Guidelines advocating the routine use of empiric ampicillin may need to be revisited. OBJECTIVE This study aimed to describe the epidemiology and ampicillin sensitivity of listeria and enterococcal infections in neonates 28 days of age and younger who presented to 2 pediatric emergency departments (ED) in Michigan. METHODS We conducted a 2-center, retrospective chart review (2006-2010) of neonates 28 days of age or younger who were evaluated for SBI in the ED. We abstracted and compared relevant demographic, historical and physical details, laboratory test results, and antibiotic sensitivity patterns to ampicillin from the eligible patient records. RESULTS We identified SBI in 6% (72/1192) of neonates 28 days of age or younger who were evaluated for SBI, of which 0.08% (1/1192) neonates had enterococcal bacteremia and 0.08% (1/1192) neonates had listeria bacteremia. A total of 1.4% (15/1192) of patients had enterococcal urinary tract infection (UTI). Urinalysis is less helpful as a screening tool for enterococcal UTI when compared with Escherichia coli UTI (P < 0.001). Seventy-three percent (11/15) of urine isolates had an increase of minimal inhibitory concentrations, which indicate gradual development of resistance to ampicillin. CONCLUSIONS Listeria is an uncommon cause of neonatal SBI in febrile neonates who presented to the ED. Empiric use of ampicillin may need to be reconsidered if national data confirm very low listeria and enterococcal prevalence and high ampicillin resistance patterns.

Objectives There is no perfectly sensitive or specific test for identifying young, febrile infants and children with occult serious bacterial infections (SBIs). Studies of procalcitonin (PCT), a 116-amino-acid precursor of the hormone calcitonin, have demonstrated its potential as an acute-phase biomarker for SBI. The objective of this study was to compare performance of serum PCT with traditional screening tests for detecting SBIs in young febrile infants and children. Methods This was a prospective, multicenter study on a convenience sample from May 2004 to December 2005. The study was conducted in four emergency departments (EDs): one pediatric ED and three EDs with pediatric units, all with academic faculty on staff. A total of 226 febrile children 36 months old or younger who presented to the four participating EDs and were evaluated for SBI by blood, urine, and/or cerebral spinal fluid (CSF) cultures were included. Results The test characteristics (with 95% confidence intervals [CIs]) of the white blood cell (WBC) counts including neutrophil and band counts were compared with PCT for identifying SBI. Thirty children had SBIs (13.3%, 95% CI = 8.85 to 17.70). Four (13.3%) had bacteremia (including one with meningitis), 18 (60.0%) had urinary tract infections (UTIs), and eight (26.6%) had pneumonia. Children with SBIs had higher WBC counts (18.6 × 109 ± 8.6 × 109 cells/L vs. 11.5 × 109 ± 5.3 × 109 cells/L, p

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.

Medical errors are a leading cause of morbidity and mortality in healthcare. Pediatric patients receiving care in the acute or emergency setting may be especially susceptible to medical error and subsequent harm. Here we review the most common types of medical errors in pediatric emergency medicine – those related to medication, laboratory evaluation, communication, and diagnosis. Diagnostic errors are perhaps the most common but least studied type of error, though there has been recent interest in further quantifying, characterizing and preventing such error. Active research focuses on the systems issues and cognitive biases that likely play a role in this process.

Background: Augmented reality is increasingly being investigated for its applications to medical specialties as well as in medical training. Currently, there is little information about its applicability to training and care delivery in the context of emergency medicine. Objective: The objective of this article is to review current literature related to augmented reality applicable to emergency medicine and its training. Methods: Through a scoping review utilizing Scopus, MEDLINE, and Embase databases for article searches, we identified articles involving augmented reality that directly involved emergency medicine or was in an area of education or clinical care that could be potentially applied to emergency medicine. Results: A total of 24 articles were reviewed in detail and were categorized into three groups: user-environment interface, telemedicine and prehospital care, and education and training. Conclusions: Through analysis of the current literature across fields, we were able to demonstrate that augmented reality has utility and feasibility in clinical care delivery in patient care settings, in operating rooms and inpatient settings, and in education and training of emergency care providers. Additionally, we found that the use of augmented reality for care delivery over distances is feasible, suggesting a role in telehealth. Our results from the review of the literature in emergency medicine and other specialties reveal that further research into the uses of augmented reality will have a substantial role in changing how emergency medicine as a specialty will deliver care and provide education and training.

To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies.We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics.Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication,1% pain medication,1% assisted ventilation,1% seizure medication,1% an advanced airway, and1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old.Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

OBJECTIVES To describe the types and severity of reported laboratory errors in pediatric emergency departments. METHODS Retrospective review of incident reports classified as laboratory errors from July 2007 to June 2008 within the Pediatric Emergency Care Applied Research Network. Laboratory testing errors recorded included: delayed results or lost specimen, unlabeled specimens, wrong patient, failure to label specimen correctly, and other. The severity of laboratory-related incidents was characterized using the National Coordinating Council for Medication Error Reporting and Prevention severity classification system. Contributing factors were classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems-based. RESULTS A total of 335 (42.2%) laboratory reports were related to events in the preanalytic phase. Involved staff personnel were identified in 345 of the reports (43.5%). Nurses were identified in 179 (22.6%) and physicians in 38 (4.8%). The majority of laboratory errors [408 (51.5%)] were not associated with harm; 138 (17.4%) patients were harmed by the error; 136 (98.6%) patients were temporarily harmed and required treatment, and 1 (0.7%) patient was hospitalized or had their hospitalization prolonged with the event. Human factors 657 (82.8%) were the most common contributing factor. CONCLUSIONS Laboratory errors are a common cause of safety events in the pediatric ED. Most events are preanalytic and involve problems with specimens that are improperly collected, mislabeled, or lost. Although most events were not associated with harm, there is potential for significant injury.

Study objective Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. Methods We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity. Results We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. Conclusion We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

Health care systems are increasingly incorporating quality improvement (QI) methods that were traditionally being used in the manufacturing industry to reduce errors, costs, and variation in care and to improve access, safety, and finally value (quality/cost) of medical care. Many pediatric emergency medicine providers who are directly responsible for improving quality at the institutional level are not formally trained in QI methodology. For QI methods to be relevant, one needs to present the application of these methods in the context of care that is provided on a day-to-day basis. This article attempts to provide a glossary of commonly used quality frameworks, terms, and tools (the “learning curve”) followed by a couple of examples of clinical issues that are being addressed by formal/informal QI techniques (the “curveball”).

Objectives: The issue of multiple family members presenting to the emergency department (ED) for care during a single visit is unique to pediatric EDs (PEDs). The epidemiology of such multiple-patient visits (MPVs) has not been well characterized. The aims of this study were to describe patient characteristics, Emergency Severity Index (ESI) triage categories, length of stay, ED disposition, and payer characteristics of such MPV and to compare these characteristics to that of the overall ED visits (OEVs). Methods: We conducted a retrospective chart review of MPVs to an inner-city PED from June to December 2006. We collected patient demographics, ESI triage categories, ED disposition, length of stay, and payer characteristics. Descriptive methods and comparative methods were used to summarize the sample characteristics and compare group differences, respectively. Results: Multiple-patient visit constituted 2.2% (1166/52,491) of the total ED visits with a total of 2511 patients. The majority (88%; 1025/ 1166) of such visits were with 2 patients in a family. Ninety-one percent (2285/2511) of patients presented for medical complaints. Compared with the OEV, MPV belonged significantly more to ESI triage category 5 (51.2% vs 28.6%) and less to ESI triage category 3 (10.0% vs 24.6%; X 2 = 775.4; P < 0.01). A significantly higher percentage of MPV patients belonged to Medicaid Health Maintenance Organization compared with the OEV patients (72.4% vs 47.6%; P < 0.01). Only 3.3% of MPV patients required hospital admission. Conclusions: In our inner-city PED, most of the MPVs are for medical complaints, belong to a lower acuity, and have a low hospital admission rate.

Objectives: Wait times and length of stay (LOS) measure efficiency of care in pediatric emergency departments (PEDs). Our hospital introduced a rapid assessment program (RAP) wherein patients will be seen by a physician within 29 minutes of arrival to the PED. Our primary objective was to evaluate the impact of this RAP on total LOS and compare it with the pre-RAP period. The secondary objective was to compare door-to-physician times and admission frequencies. Methods: We conducted an observational study of randomly selected visits before (in 2004) and after (in 2005) RAP in a PED. Data were acquired retrospectively from charts. We compared total LOS (time from arrival at triage to discharge), boarding time (time from the decision to admit to transfer to inpatient bed), door-to-physician time (arrival at triage to first evaluation by physician), and admission frequencies. Results: Data from 990 visits (in 2004) and 1010 visits (in 2005) indicated similar age, sex, seasonal distribution, and weekday distribution. The total median LOS decreased by 37 minutes with RAP (103 [interquartile range {IQR}, 57-187] minutes in 2005 vs 140 [IQR, 78-234] minutes in 2004, P < 0.001) but only among lower triage categories. Median door-to-physician time decreased by 20 minutes with RAP (15 [IQR, 7-29] minutes in 2005 vs 35 [IQR, 18-72] minutes in 2004, P < 0.001) among lower triage categories. The LOS was reduced both in admitted and discharged patients with no difference in the boarding times or admission frequencies. Conclusions: In our PED, a RAP reduced the total LOS of patients with lower acuity of illness.

ACADEMIC EMERGENCY MEDICINE 2011; 18:140–144 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objectives were to characterize physician beliefs and practice of analgesia and anesthesia use for infant lumbar puncture (LP) in the emergency department (ED) and to determine if provider training type, experience, and beliefs are associated with reported pain intervention use. Methods: An anonymous survey was distributed to ED faculty and pediatric emergency medicine (PEM) fellows at five Midwestern hospitals. Questions consisted of categorical, yes/no, descriptive, and incremental responses. Data were analyzed using descriptive statistics with confidence intervals (CIs) and odds ratios (ORs). Results: A total of 156 of 164 surveys (95%) distributed were completed and analyzed. Training background of respondents was 52% emergency medicine (EM), 30% PEM, and 18% pediatrics. Across training types, there was no difference in the belief that pain treatment was worthwhile (overall 78%) or in the likelihood of using at least one pain intervention. Pharmacologic pain interventions (sucrose, injectable lidocaine, and topical anesthetic) were used in the majority of LPs by 20, 29, and 27% of respondents, respectively. Nonpharmacologic pain intervention (pacifier/nonnutritive sucking) was used in the majority of LPs by 67% of respondents. Many respondents indicated that they never used sucrose (53%), lidocaine (41%), or anesthetic cream (49%). Physicians who thought pain treatment was worthwhile were more likely to use both pharmacologic and nonpharmacologic pain interventions than those who did not (93% vs. 53%, OR = 10.98, 95% CI = 4.16 to 29.00). The number of LPs performed or supervised per year was not associated with pain intervention use. Other than pacifiers, injectable lidocaine was the most frequently reported pain intervention. Conclusions: Provider beliefs regarding infant pain are associated with variation in anesthesia and analgesia use during infant LP in the ED. Although the majority of physicians hold the belief that pain intervention is worthwhile in this patient group, self-reported pharmacologic interventions to reduce pain associated with infant LP are used regularly by less than one-third. Strategies targeting physician beliefs on infant pain should be developed to improve pain intervention use in the ED for infant LPs.

To assess parental perception of urgency of illness and compare this with an emergency department (ED) physician's assessment of the same.A prospective study was conducted on convenience sample of parents/legal guardians of 800 patients presenting to the pediatric ED. Parents and physicians were asked to classify the urgency of their child's illness.For this study, we grouped the urgency of illness as "urgent" (care needed within 24 hours) and "nonurgent" (care could safely wait until the next day). Ninety-four percent of parents considered their child's illness as urgent and 6% as nonurgent. Of the patients whose parents perceived the illness as nonurgent, 31% were assessed by physicians as requiring urgent attention.In our study, there was a significant discrepancy between the parental perceptions of urgency of illness and the ED physician assessment of the same. A significant proportion of children whose visits are perceived as nonurgent do require urgent care.

Fever is the most common complaint for a child to visit hospital. Under the aegis of INDO-US Emergency and Trauma Collaborative, Pediatric Emergency Medicine chapter of Academic College of Emergency Experts in India developed evidence-based consensus for evaluation and management of febrile child in emergency department. An extensive literature search and further online communication of the group led to the development of a detailed approach for the evaluation and management of individual conditions associated with fever. To develop an approach to individual conditions presenting with fever, that is, best suited to the epidemiology prevalent in India. The algorithmic approach given by the group describes in details the evaluation and management of specialized and individual conditions like fever and immunocompromised state, fever with localizing signs that include fever with seizures, cough, ear discharge, loose stools, rash and dysuria; fever without localization with epidemiological evidence supporting diagnosis such as malaria, enteric fever and dengue; and fever without any localization and no epidemiological evidence supporting the diagnosis.

Objectives: The objective was to describe the perspective of research personnel on issues of informed consent in a time-sensitive clinical study under emergency circumstances. Methods: The authors convened concurrent focus groups of research staff and investigators involved in a pharmacokinetic study of lorazepam for status epilepticus (SE). Moderators led discussion with openended questions on selected issues of parental consent, communication and understanding, patient assent, and comparison to other types of studies. Focus group transcripts were analyzed to identify themes and subthemes from the discussions. Results: Most themes and subthemes were identified in both research staff and investigator focus groups. Focus group discussion points were categorized into three main themes: barriers to and enablers of informed consent, barriers to and enablers of actual enrollment, and overall ethical concerns about the research. Many of the issues identified were unique to emergency research. Conclusions: From the perspectives of research staff and investigators enrolling patients in a time-sensitive emergency department study, the authors identified several areas of concern that should be addressed when planning future emergency studies. ACADEMIC EMERGENCY MEDICINE 2009; 16:763‐770 a 2009 by the Society for Academic Emergency

To describe the patterns of referral and use of resources for patients with psychiatric-related visits presenting to pediatric emergency departments (EDs) in a pediatric research network.We conducted a retrospective chart review of a random sample of patients (approximately 10 charts per month per site) who presented with psychiatric-related visits in 2002 to 4 pediatric EDs in the Pediatric Emergency Care Applied Research Network. Emergency department resource use variables evaluated included the use of consultation services, restraints, and laboratory tests as well as ED length of stay.We reviewed 462 patient visits with a psychiatric-related ED diagnosis. Mean (SD) age was 12.8 (3.7) years, 52% were male, and 49% were African American. The most common chief complaints were suicidality (47%), aggression/agitation (42%), and anxiety/depression (27%), alone or in combination. Ninety percent of patients (range across sites, 83%-94%) had a mental health consult in the ED, 5% were restrained (range, 3%-9%), and 35% had a laboratory test performed (range, 15%-63%). Mean (SD) ED length of stay was 5.1 (5.4) hours, and 52% were admitted (93% to a psychiatric bed, including transfers to separate psychiatric facilities).Children with psychiatric-related visits seem to require substantial ED resources. Interventions are needed to reduce the burden on the ED by increasing the linkage to mental health services, particularly for suicidal youths.

Objective: There is a paucity of literature in the United States regarding preparedness for a bioterrorist attack on children. The main objective of this study was to assess the self-reported level of bioterrorism preparedness of pediatricians practicing in Michigan. Methods: We conducted a survey that was mailed to 1000 pediatricians practicing in Michigan from July through December 2006. Survey questions were designed to evaluate the overall level of preparedness, as defined by the American Academy of Pediatrics, in dealing with a possible biological event and to describe key demographic variables. Results: Of the 590 pediatricians who responded (59%), a majority (80%) were general pediatricians, whereas 20% were pediatric subspecialists. Sixty percent of responders believe terrorism is a threat, with biological agents (52%; 95% confidence interval (CI), 48.00-56.12) as the most likely cause of an event. Half of the pediatricians who responded had a workplace disaster plan, but only 12% feel their preparedness for a biological attack/event was good. Sixty-six percent (392/590) were not currently Pediatric Advanced Life Support certified, 38% (95% CI,34.63-42.51) have never attended a lecture based on bioterrorism, 85% (95% CI, 82.00-87.78) have never participated in a bioterrorism training exercise, and 89% (95% CI, 87.00-91.95) do not provide disaster-oriented anticipatory guidance to their patients. Seventy-six percent (95% CI, 73.10-79.98) of all responders indicated their desire for more bioterrorism training, with 42% preferring diagnostic algorithms and 37% (95% CI, 32.79-40.59) preferring a prepared lecture on video format. Conclusions: Surveyed pediatricians in Michigan consider bioterrorism a significant threat but are overwhelmingly underprepared to deal with an event. There is a perceived need for a coordinated educational program to improve level of preparedness.

The widespread use of highly effective and safe vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae has impacted the epidemiology of serious bacterial illness in the febrile child. Because of the resultant decline in the incidence of invasive pneumococcal disease, one needs to reconsider the evaluation and management of the febrile child. In particular, for well-appearing febrile children who are vaccinated, routine screening for occult bacterial infections with or without empiric treatment can no longer recommended. At the same time, early evidence suggests that infections due to nonvaccine serotypes are increasing along with selected invasive diseases such as complicated pneumonia. Therefore, although likely to evolve, the optimal management strategy for the well-appearing, immunized, febrile child may be screening for urinary tract infections and observation with adequate follow-up. Continued surveillance of disease due to nonvaccine serotypes is essential.

Background Although young age is considered a risk factor for adverse events related to procedural sedation and analgesia (PSA), data in very young children (