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IMPORTANCE: Pediatric sepsis definitions have evolved, and some have proposed using the measure used in adults to quantify organ dysfunction, a Sequential Organ Failure Assessment (SOFA) score of 2 or more in the setting of suspected infection. A pediatric adaptation of SOFA (pSOFA) showed excellent discrimination for mortality in critically ill children but has not been evaluated in an emergency department (ED) population. OBJECTIVE: To delineate test characteristics of the pSOFA score for predicting in-hospital mortality among (1) all patients and (2) patients with suspected infection treated in pediatric EDs. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study took place from January 1, 2012, to January 31, 2020 in 9 US children’s hospitals included in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The data was analyzed from February 1, 2020, to April 18, 2022. All ED visits for patients younger than 18 years were included. EXPOSURES: ED pSOFA score was assigned by summing maximum pSOFA organ dysfunction components during ED stay (each 0-4 points). In the subset with suspected infection, visit meeting criteria for sepsis (suspected infection with a pSOFA score of 2 or more) and septic shock (suspected infection with vasoactive infusion and serum lactate level >18.0 mg/dL) were identified. MAIN OUTCOMES AND MEASURES: Test characteristics of pSOFA scores of 2 or more during the ED stay for hospital mortality. RESULTS: A total of 3 999 528 (female, 47.3%) ED visits were included. pSOFA scores ranged from 0 to 16, with 126 250 visits (3.2%) having a pSOFA score of 2 or more. pSOFA scores of 2 or more had sensitivity of 0.65 (95% CI, 0.62-0.67) and specificity of 0.97 (95% CI, 0.97-0.97), with negative predictive value of 1.0 (95% CI, 1.00-1.00) in predicting hospital mortality. Of 642 868 patients with suspected infection (16.1%), 42 992 (6.7%) met criteria for sepsis, and 374 (0.1%) met criteria for septic shock. Hospital mortality rates for suspected infection (599 502), sepsis (42 992), and septic shock (374) were 0.0%, 0.9%, and 8.0%, respectively. The pSOFA score had similar discrimination for hospital mortality in all ED visits (area under receiver operating characteristic curve, 0.81; 95% CI, 0.79-0.82) and the subset with suspected infection (area under receiver operating characteristic curve, 0.82; 95% CI, 0.80-0.84). CONCLUSIONS AND RELEVANCE: In a large, multicenter study of pediatric ED visits, a pSOFA score of 2 or more was uncommon and associated with increased hospital mortality yet had poor sensitivity as a screening tool for hospital mortality. Conversely, children with a pSOFA score of 2 or less were at very low risk of death, with high specificity and negative predictive value. Among patients with suspected infection, patients with pSOFA-defined septic shock demonstrated the highest mortality.

Objectives Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. Methods We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. Results Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. Conclusions In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

OBJECTIVE When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. METHODS Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. RESULTS There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 10/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. CONCLUSIONS Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

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

STUDY OBJECTIVE: The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. METHODS: We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. RESULTS: A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P.05 for both). CONCLUSION: Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.

Objective To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. Design A retrospective cohort study of pediatric ED visits in 2015. Setting Four pediatric EDs. Subjects Children aged four to 18 years with a long-bone fracture discharged from the ED. Methods A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. Results There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9–9.7%), B = 12.1% (95% CI = 10.5–14.0%), C = 16.9% (95% CI = 15.2–18.8%), D = 23.8% (95% CI = 21.7–26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12–18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. Conclusions For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.

Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics.In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains.Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals.Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.

* Abbreviations: aOR — : adjusted odds ratio CI — : confidence interval ED — : emergency department RR — : relative reduction Pain caused by long bone fractures is a common reason for opioid prescribing in the emergency department (ED) setting.1 Approximately 40% of opioid overdose deaths involve a prescription,2 and in response, opioid prescribing has declined in the last decade.3 We previously demonstrated racial and/or ethnic disparities in the ED management of pain among children with long bone fractures.4 We now perform this study to investigate whether racial and/or ethnic differences in provision of outpatient opioid prescriptions for children discharged from the ED with long bone fractures have attenuated over time. We performed a retrospective cross-sectional study of children aged 4 to

BACKGROUND AND OBJECTIVES Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020. METHODS Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement. RESULTS We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died. CONCLUSIONS We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.

BACKGROUND Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

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

Study objective To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors. Methods This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries. Results The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support. Conclusion Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries.

The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse.A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs.Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer.A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

This article discusses the implications of health care reform on the pediatric emergency department (ED). The author briefly discusses the health care costs and outcomes in the United States in comparison to other developed nations. The article discusses the impact of the Affordable Care Act and insurance expansion on the pediatric ED. Then the article addresses the impacts of the growing patient financial responsibility on ED use. There will be a discussion of the development of pediatric accountable care organizations and how payment mechanisms are evolving, and the challenges the pediatric ED may face in these new payment strategies.

BACKGROUND: Penicillin allergy is reported in up to 10% of the general population; however, >90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction. METHODS: Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution’s quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre- and postpathway implementation. RESULTS: After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation. CONCLUSIONS: Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.

Obtaining informed consent for clinical research in the pediatric emergency department (ED) is challenging. Our objective was to understand the factors that influence parental consent for ED studies.This was a cross-sectional survey assessing parents' willingness to enroll their children into an ED research study. Parents reporting a willingness to enroll in ED studies were presented with two hypothetical scenarios, a low-risk and a high-risk study, and then asked about decision influencers affecting consent. Parents expressing a lack of willingness to enroll were asked which decision influencers impacted their consent decision.Among 118 parents, 90 (76%) stated they would be willing to enroll their child into an ED study; of these, 86 (96%) would consent for a low-risk study and 54 (60%) would consent for a high-risk study. Caucasian parents, and those with previous research exposure, were more likely to report willingness to participate. Those who would consent to the high-risk study cited "benefits that research would provide to future children" most strongly influenced their decision to agree.ED investigators should highlight the benefits for future children and inquire about parents' previous exposure to research to enhance ED research enrollment. Barriers to consent in non-Caucasian families should be further investigated.Obtaining consent for pediatric emergency research is challenging and this study identified factors influencing parental consent for research in EDs. Benefits for future children and parents' previous research experience were two of the most influential factors in parents' willingness to consent to ED research studies. These findings will help to improve enrollment in ED research studies and better our understanding of how to promote the health and well-being of pediatric patients.

OBJECTIVES Disparities in opioid prescribing in children can lead to underprescribing and poorly controlled pain. On the contrary, unnecessary overprescribing can increase the risk for misuse, abuse, and diversion. The primary objective of this study was to compare the demographics and clinical characteristics of children with an extremity fracture who did and did not receive an opioid prescription from a tertiary care children's hospital. METHODS This was a retrospective cohort study of children younger than 22 years with extremity fracture evaluated at a tertiary care children's hospital emergency department (ED) and surrounding satellite locations (3 EDs and 4 urgent cares), from January 1, 2017, to December 31, 2017. RESULTS There were 3325 patients younger than 22 years who were seen for evaluation of an extremity fracture. The overall median age of patients was 8 years (interquartile range [IQR], 4-11), and 1976 (59.4%) were male. Patients with extremity fractures who received opioid analgesics were older than those who did not receive opioids (median age of 10 years [IQR, 6-13 years] vs 7 years [IQR, 4-11 years], P < 0.001). There was a significant difference found between insurance types, specifically those patients receiving Medicaid and private insurance. Patients who received opioid analgesics had a higher initial pain score (7 [IQR, 4-9] vs 5 [IQR, 2-7], P < 0.001), were more likely to have an physician (MD/DO) provider (P < 0.001), and were more likely to present to the ED (P < 0.001). CONCLUSIONS Younger patients, patients with Medicaid insurance, patients treated by an advanced care provider, and patients who presented to an urgent care were less likely to receive opioid analgesics upon discharge. These findings demonstrate that more standardization and guidance on opioid prescribing are needed in pediatrics, to both adequately treat pain and reduce harms from overprescribing of opioid analgesics.

OBJECTIVES: To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS: We performed a 3-year retrospective cross-sectional study of children RESULTS: In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51–1.95]; Hispanic: 1.32 [1.16–1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14–1.76]; Hispanic: 1.38 [1.04–1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77–0.95]; Hispanic: aOR 0.86 [0.76–0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67–0.90]; Hispanic: aOR 0.80 [0.67–0.95]). CONCLUSIONS: There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.

Despite limited evidence, cannabidiol-rich cannabis extracts have been popularly used in pediatrics. With increased use, it is critical to determine basic pharmacokinetic parameters of cannabidiol in these extracts in the pediatric population. The objective of this study was to determine the disposition of oral cannabidiol cannabis extracts and drug interactions in children with pediatric epilepsy. We conducted a prospective observational study evaluating the disposition of oral cannabidiol in children (

Background Electronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes. Methods A data dictionary, and subsequent data model, were developed describing EHR data sources to include all processes of care within the emergency department (ED). ED visit data were deidentified and XML files were created and submitted to a central data coordinating center for inclusion in the registry. Automated data quality control occurred prior to submission through an application created for this project. Data quality reports were created for manual data quality review. Results The Pediatric Emergency Care Applied Research Network (PECARN) Registry, representing four hospital systems and seven EDs, demonstrates that ED data from disparate health systems and EHR vendors can be harmonized for use in a single registry with a common data model. The current PECARN Registry represents data from 2,019,461 pediatric ED visits, 894,503 distinct patients, more than 12.5 million narrative reports, and 12,469,754 laboratory tests and continues to accrue data monthly. Conclusion The Registry is a robust harmonized clinical registry that includes data from diverse patients, sites, and EHR vendors derived via data extraction, deidentification, and secure submission to a central data coordinating center. The data provided may be used for benchmarking, clinical quality improvement, and comparative effectiveness research.

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

Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days.A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded.Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4-3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received3 days of opioids were younger (P0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications.Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.

Objective To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. Study design This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. Results Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. Conclusions In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.

Objective To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival. Study design This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set. Results Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set. Conclusions This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.

Introduction: Although over half of US states have legalized marijuana for medical indications, there is limited research in use in the pediatric population. The objective was to evaluate t...

IMPORTANCE: Computed tomographic (CT) scanning is the standard for the rapid diagnosis of intracranial injury, but it is costly and exposes patients to ionizing radiation. The Pediatric Emergency Care Applied Research Network (PECARN) rules for identifying children with minor head trauma who are at very low risk of clinically important traumatic brain injury (ciTBI) are widely used to triage CT imaging. OBJECTIVE: To examine whether optimal classification trees (OCTs), which are novel machine-learning classifiers, improve on PECARN rules’ predictive accuracy. DESIGN, SETTING, AND PARTICIPANTS: A secondary analysis of prospective, publicly available data on emergency department visits for head trauma used by the PECARN group to develop their tool was conducted to derive OCT-based prediction rules for ciTBI in a development cohort and compare their predictive performance vs the PECARN rules in a validation cohort among children who were younger than 2 years and 2 years or older. Data on 42 412 children with head trauma and without severely altered mental status who were examined between June 1, 2004, and September 30, 2006, were gathered from 25 emergency departments in North America participating in PECARN. Data analysis was conducted from September 15, 2016, to December 18, 2018. MAIN OUTCOMES AND MEASURES: The outcome was ciTBI, with predictive performance measured by estimating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for the OCT and the PECARN rules. The OCT and PECARN rules’ performance was compared by estimating ratios for each measure. RESULTS: Of the 42 412 children (15 996 [37.7%] girls) included in the analysis, 10 718 were younger than 2 years (25.3%; mean [SD] age, 11.6 [0.6] months) and 31 694 were 2 years or older (74.7%; age, 9.1 [4.9] years). Compared with PECARN rules, OCTs misclassified 0 vs 1 child with ciTBI in the younger and 10 vs 9 children with ciTBI in the older cohort, and correctly identified more children with very low risk of ciTBI in the younger (7605 vs 5701) and older (20 594 vs 18 134) cohorts. In the validation cohorts, compared with the PECARN rules, the OCTs had statistically significantly better specificity (in the younger cohort: 69.3%; 95% CI, 67.4%-71.2% vs 52.8%; 95% CI, 50.8%-54.9%; in the older cohort: 65.6%; 95% CI, 64.5%-66.8% vs 57.6%; 95% CI, 56.4%-58.8%), positive predictive value (odds ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively), and positive likelihood ratio (risk ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively). There were no statistically significant differences in the sensitivity, negative predictive value, and negative likelihood ratio between the 2 sets of rules. CONCLUSIONS AND RELEVANCE: If implemented, OCTs may help reduce the number of unnecessary CT scans, without missing more patients with ciTBI than the PECARN rules.

BACKGROUND: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool’s predictive validity for alcohol misuse and alcohol use disorders (AUDs). METHODS: Participants (N = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up. RESULTS: Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year (P = .0002), 2 years (P CONCLUSIONS: The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen.

Prehospital pediatric airway management is difficult and controversial. Options include bag-mask ventilation (BMV), endotracheal tube (ETT), and laryngeal mask airway (LMA). Emergency Medical Services personnel report difficulty assessing adequacy of BMV during transport. Capnography, and capnograph tracings in particular, provide a measure of real-time ventilation currently used in prehospital medicine but have not been well studied in pediatric patients or with BMV. Our objective was to compare pediatric capnographs created with 3 airway modalities.This was a prospective study of pediatric patients requiring ETT or LMA ventilation during elective surgical procedures. Data were collected during BMV using 2 bag types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag type repeated. Ten- to 14-second capnographs were reviewed by 2 blinded anesthesiologists who were asked to assess ventilation and identify the airway and bag type used. Descriptive statistics, κ, and risk ratios were calculated.Twenty-nine patients were enrolled. Median age was 4.4 years (2 months to 16.8 years). One hundred sixteen capnographs were reviewed. Reviewers were unable to differentiate between airway modalities and agreed on adequacy of ventilation 77% of the time (κ = 0.6, P.001). Bag-mask ventilation was rated inadequate more frequently than ETT or LMA ventilation. There were no difference between ETT and LMA ventilation and no difference between the 2 bag types.Capnographs are generated during BMV and are virtually identical to those produced with ETT or LMA ventilation. Attention to capnographs could improve outcomes during emergency treatment and transport of critically ill pediatric patients requiring ventilation with any of these airway modalities.

Background Improving Diagnosis in Healthcare calls for improved training in diagnostic reasoning and establishing non-judgmental forums to learn from diagnostic errors arising from heuristic-driven reasoning. Little is known about pediatric providers’ familiarity with heuristics or the culture surrounding forums where diagnostic errors are discussed. This study aimed to describe pediatric providers’ familiarity with common heuristics and perceptions surrounding public discussions of diagnostic errors. Methods We surveyed pediatric providers at a university-affiliated children’s hospital. The survey asked participants to identify common heuristics used during clinical reasoning (five definitions; four exemplar clinical vignettes). Participants answered questions regarding comfort publicly discussing their own diagnostic errors and barriers to sharing them. Results Seventy (30.6% response rate) faculty completed the survey. The mean number of correctly selected heuristics was 1.60/5 [standard deviation (SD)=1.13] and 1.01/4 (SD=1.06) for the definitions and vignettes, respectively. A low but significant correlation existed between correctly identifying a definition and selecting the correct heuristic in vignettes (Spearman’s ρ=0.27, p=0.02). Clinicians were significantly less likely to be “pretty” or “very” comfortable discussing diagnostic errors in public vs. private conversations (28.3% vs. 74.3%, p Conclusions Pediatric providers demonstrated limited familiarity with common heuristics leading to diagnostic error. Greater years in practice is associated with more comfort discussing diagnostic errors, but negative peer and personal perceptions of diagnostic performance are common barriers to discussing errors publicly.

Introduction\ud Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn.\ud \ud Methods\ud A prospective cross-sectional study of 500 children (0–16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015–2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities.\ud \ud Results\ud Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver.\ud \ud Conclusion\ud A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.

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 AND OBJECTIVES: Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. METHODS: Retrospective cohort study of previously healthy infants aged RESULTS: Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%–99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5–111), use in Canada was 11.5 (95% CI: 3.7–36), use in the United States was 6.8 (95% CI: 2.3–19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4–4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0–12.2), use in Canada was 4.9 (95% CI 1.9–12.6), use in Spain and Portugal was 2.4 (95% CI 0.6–9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7–4.7). CONCLUSIONS: More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.

OBJECTIVE: To determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) two-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network (PECARN) pediatric emergency departments. This article describes the study methodology, sample characteristics and baseline outcomes of the NIAAA two-question screen. METHODS: Participants included 12–17 year olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA two-question screen and other measures of alcohol, drug use and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was re-administered the NIAAA two-question screen one week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA two-question screen. RESULTS: There were 4,834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across gender and age. Forty-six percent of participants identified as White and 26% identified as Black. Approximately one-quarter identified as Hispanic. Using the NIAAA two-question screen algorithm, approximately 8% were classified as low risk, 12% as moderate risk and 4% as highest risk. Alcohol use was less likely to be reported by Black participants, non-Hispanic participants and those less than 16 years old. DISCUSSION: This study successfully recruited a large, demographically diverse sample, in order to establish rates of the NIAAA screen risk categories across age, gender, ethnicity and race within pediatric emergency departments.

BACKGROUND AND OBJECTIVES:In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED.METHODS:This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site.RESULTS:Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [CI] 2.4%–2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; CI 0.36–0.53), Hispanic (aOR 0.65; CI 0.53–0.81), and other NH (aOR 0.68; CI 0.52–0.87) children remained less likely to receive antibiotics for viral ARTIs.CONCLUSIONS:Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias.

OBJECTIVES: We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma. METHODS: Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were RESULTS: We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P < .05) but modestly (2.3%–3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%–1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%–4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%–6.2%). CONCLUSIONS: The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.

BACKGROUND AND OBJECTIVES: Up to 30% of children who have concussion initially evaluated in the emergency department (ED) display delayed symptom resolution (DSR). Greater initial symptom severity may be an easily quantifiable predictor of DSR. We hypothesized that greater symptom severity immediately after injury increases the risk for DSR. METHODS: We conducted a prospective longitudinal cohort study of children 8 to 18 years old presenting to the ED with concussion. Acute symptom severity was assessed using a graded symptom inventory. Presence of DSR was assessed 1 month later. Graded symptom inventory scores were tested for association with DSR by sensitivity analysis. We conducted a similar analysis for post-concussion syndrome (PCS) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Potential symptoms characteristic of DSR were explored by using hierarchical cluster analysis. RESULTS: We enrolled 234 subjects; 179 (76%) completed follow-up. Thirty-eight subjects (21%) experienced DSR. Initial symptom severity was not significantly associated with DSR 1 month after concussion. A total of 22 subjects (12%) had PCS. Scores >10 (possible range, 0–28) were associated with an increased risk for PCS (RR, 3.1; 95% confidence interval 1.2–8.0). Three of 6 of the most characteristic symptoms of DSR were also most characteristic of early symptom resolution. However, cognitive symptoms were more characteristic of subjects reporting DSR. CONCLUSIONS: Greater symptom severity measured at ED presentation does not predict DSR but is associated with PCS. Risk stratification therefore depends on how the persistent symptoms are defined. Cognitive symptoms may warrant particular attention in future study. Follow-up is recommended for all patients after ED evaluation of concussion to monitor for DSR.

Background The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. Objective Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). Methods This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. Results Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. Conclusions We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Objective Retrospective studies have shown home oxygen to be a safe alternative to hospitalization for some patients with bronchiolitis living at high altitudes. We aimed to prospectively describe adverse events, follow-up, duration of home oxygen, factors associated with failure, and caregiver preferences. Methods This was a prospective observational study of hypoxemic bronchiolitis patients ages 3 to 18 months who were discharged from a tertiary care pediatric emergency department on home oxygen over three winters (2011-2014). Caregivers were contacted on postdischarge days ~3, 7, 14, and 28 while on oxygen. Caregivers not reached by phone were sent a survey and their primary care physicians were contacted. Records of admitted subjects were reviewed. Outcome measures included hospital readmission, positive pressure ventilation (noninvasive or intubation), outpatient follow-up, duration of home oxygen therapy, and caregiver satisfaction. Results A total of 274 patients were enrolled. Forty-eight (17.5%) were admitted and 225 (82.1%) were discharged on oxygen. The median age was 8 months. Eighteen subjects were lost to follow-up. A total of 196 (87.1%) were successfully treated with outpatient oxygen, and 11 (4.9%) failed outpatient therapy and were hospitalized. Only one hospitalized patient required invasive ventilation. The median duration of home oxygen was 7 days. Child noncompliance was the most common problem (reported by 14%). The median caregiver comfort level with home oxygen was 9 of 10. Eighty-eight percent of caregivers would again choose home oxygen over admission. Conclusions This study confirms that outpatient oxygen therapy can reduce hospitalizations due to bronchiolitis in a relatively high-altitude setting, with low failure and complication rates. Caregivers are comfortable with home oxygen and prefer it to hospitalization.

OBJECTIVES: To determine the test-retest reliability, concurrent, convergent, and discriminant validity of a recently devised screen (“Newton screen”) for alcohol and cannabis use/misuse, and its predictive validity at follow up. STUDY DESIGN: Adolescents, 12-17 years old (N=4,898), treated in one of 16 participating pediatric emergency departments (PEDs) across the United States were enrolled in a study as part of a larger study within the Pediatric Emergency Care Applied Research Network (PECARN). Concurrent and predictive validity (at 1, 2, and 3-year follow-up) were assessed in a random subsample with a structured Diagnostic and Statistical Manual of Mental Disorders (DSM)-based interview. Convergent validity was assessed with the Alcohol Use Disorders Identification (AUDIT), a widely used alcohol screening measure. RESULTS: The sensitivity of the Newton screen for alcohol use disorder (AUD) at baseline was 78.3% with a specificity of 93.0%. The cannabis use question had a baseline sensitivity of 93.1% and specificity of 93.5% for cannabis use disorder (CUD). Predictive validity analyses at 1, 2, and 3 years revealed high specificity but low sensitivity for alcohol and high specificity and moderate sensitivity for cannabis. CONCLUSION: The Newton screening instrument may be an appropriate brief screening tool for use in the busy clinical environment. Specificity was high for both alcohol and cannabis, but sensitivity was higher for cannabis than alcohol. Like other brief screens, more detailed follow-up questions may be necessary to definitively assess substance misuse risk and need for referral to treatment.

Background Suspected ingestions are a common chief complaint to the emergency department although the majority of ingestions by children are insignificant. Objective Assess the utility of screening laboratory tests and Electrocardiograms (ECGs) in unintentional asymptomatic pediatric poisonings. Methods Retrospective chart review at a tertiary care children's hospital and a regional poison center of patients less than 12 years of age using ICD-9 codes from January 2005 through December 2008. Laboratory or ECG results requiring intervention and/or direct treatment, a non-RPC subspecialty consultation, and/or prolonged Emergency Department stay was considered changed management. Results Five hundred ninety five suspected ingestions met our criteria. The median age was 2.6 years (IQR 1.6, 3.0 years) and 56% were male. One laboratory test or ECG was obtained in 233 patients (39%). Of 24 screening ECGs, 32 complete blood counts and 34 blood gases, none were clinically significant. Fifty-two patients received screening metabolic panels, 3 were abnormal and 2 changed management (anion gap metabolic acidosis with unsuspected salicylate ingestions). None of the 127 (21%) screening acetaminophen levels changed management. Two of sixty-five (13%) screening salicylate levels changed management. Three screening urine toxicology tests on patients with altered mental status were positive without ingestion history. No patient under the age of 12 years with normal vital signs and normal mental status had positive screening tests. Conclusions Screening laboratory tests and ECGs were of limited utility and rarely changed management despite being ordered in a significant number of patients. Screening tests are rarely indicated in unintentional overdoses in children who are asymptomatic.

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

Objective To examine emergency department (ED) staff's knowledge of traumatic stress in children, attitudes toward providing psychosocial care, and confidence in doing so, and also to examine differences in these outcomes according to demographic, professional, and organizational characteristics, and training preferences. Study design We conducted an online survey among staff in ED and equivalent hospital departments, based on the Psychological First Aid and Distress-Emotional Support-Family protocols. Main analyses involved descriptive statistics and multiple regressions. Respondents were 2648 ED staff from 87 countries (62.2% physicians and 37.8% nurses; mean years of experience in emergency care was 9.5 years with an SD of 7.5 years; 25.2% worked in a low- or middle-income country). Results Of the respondents, 1.2% correctly answered all 7 knowledge questions, with 24.7% providing at least 4 correct answers. Almost all respondents (90.1%) saw all 18 identified aspects of psychosocial care as part of their job. Knowledge and confidence scores were associated with respondent characteristics (eg, years of experience, low/middle vs high-income country), although these explained no more than 11%-18% of the variance. Almost all respondents (93.1%) wished to receive training, predominantly through an interactive website or one-off group training. A small minority (11.1%) had previously received training. Conclusions More education of ED staff regarding child traumatic stress and psychosocial care appears needed and would be welcomed. Universal education packages that are readily available can be modified for use in the ED.

Objective This study aimed to prospectively determine the etomidate dose associated with adequate sedation and few significant respiratory events for procedures of short duration in children. Methods This is a prospective cohort study in an urban pediatric emergency department of patients 4 to 18 years requiring sedation and analgesia for painful procedures of short duration. Patients received fentanyl 1 μg/kg followed by intravenously administered etomidate 0.1 to 0.2 mg/kg as a loading dose. An additional dose of etomidate 0.1 mg/kg was intravenously administered if needed. The level of sedation was determined by The Children's Hospital of Wisconsin Sedation Score. The primary outcome was to determine the etomidate dose associated with an adequate level of sedation and procedural completion. Results Sixty patients were enrolled. The most frequent procedure was fracture reduction (50/60, 83.3%). Procedures were successfully completed for 59 (98.3%) of 60 patients. The initial dose of etomidate associated with adequate sedation was 0.2 mg/kg intravenously administered for 33 (66.7%) of 50 patients requiring fracture reduction and for 6 (60.0%) of 10 patients receiving a procedure other than fracture reduction. Respiratory depression was noted in 9 (16.4%) of 55 patients, and oxygen desaturation was noted in 23 (39.0%) of 59 patients. Of 58 patients, 21 (36.2%) experienced a respiratory adverse event requiring brief intervention including oxygen supplementation, stimulation, and/or airway repositioning. No patient experienced a significant adverse respiratory event, defined as positive pressure ventilation. Median time to discharge-ready was 21 minutes. Conclusions For short-duration painful emergency department procedures, etomidate 0.2 mg/kg intravenously administered after fentanyl was associated with effective sedation, successful procedural completion, and readily managed respiratory adverse events in children.

Appropriate interpretation is imperative for families with limited English proficiency (LEP). We compared throughput times for ED visits involving families with LEP based on type of interpretation provided: in-person interpretation, remote telephonic interpretation or bilingual providers. This study is a secondary analysis of a prospective study of caretaker satisfaction with different interpreter modalities. We queried the medical record for event time stamps, clinical factors and disposition. The in-person cohort (116 min) had a significantly shorter total throughput time than telephonic (141 min) and bilingual provider (153 min) cohorts (P < 0.0001), due to a difference in time seen by provider to disposition. Time seen by provider to disposition remained statistically significantly shorter for the in-person cohort when compared to telephonic interpretation when controlling for potential confounders such as admission rate (P = 0.006). In-person interpretation significantly decreased ED throughput times and may be an important consideration in the choice of interpreter modality.

OBJECTIVES: The American Academy of Pediatrics published bronchiolitis clinical practice guidelines in 2014 recommending against the routine use of bronchodilators, chest radiographs, or respiratory viral testing in children with a clinical diagnosis of bronchiolitis. Our aim in this project was to align care with the American Academy of Pediatrics clinical practice guidelines by decreasing the overuse of these interventions. METHODS: This study included patients who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. The team used a multidisciplinary kickoff event to understand the problem and develop interventions, including sharing provider-specific data and asking providers to sign a pledge to reduce use. We used a novel, real-time data dashboard to collect and analyze data. RESULTS: Special cause variation on control charts indicated improvement for all outcomes for inpatients during the intervention season. Pre- and postanalyses in which we compared baseline to intervention values for all admitted patients and patients who were discharged from the emergency department or urgent care revealed a significant reduction in the ordering of chest radiographs (from 22.7% to 13.6%; P ≤ .001), respiratory viral testing (from 12.5% to 9.8%; P = .001), and bronchodilators (from 17.5% to 10.3%; P = .001) without changes in balancing measures (eg, hospital readmission within 7 days [1.7% (preanalysis) and 1.0% (postanalysis); P = .21]) for bronchiolitis. CONCLUSIONS: This multidisciplinary improvement initiative resulted in a significant reduction in use for bronchiolitis care at our institution. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases.