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OBJECTIVES Patients and families preferring languages other than English (LOE) often experience inequitable communication with their health care providers, including the underutilization of professional interpretation. This study had 2 aims: to characterize resident-perceived communication with families preferring LOE and to evaluate the impact of language preference on frequency of resident interactions with hospitalized patients and families. METHODS This was a cross-sectional study at a quaternary care children’s hospital. We developed a questionnaire for residents regarding their interactions with patients preferring LOE. We concurrently developed a communication tracking tool to measure the frequency of resident communication events with hospitalized patients. Data were analyzed with logistic and Poisson regression models. RESULTS Questionnaire results demonstrated a high level of resident comfort with interpretation, though more than 30% of residents reported “sometimes” or “usually” communicating with families preferring LOE without appropriate interpretation (response rate, 47%). The communication tracking tool was completed by 36 unique residents regarding 151 patients, with a 95% completion rate. Results demonstrated that patients and families preferring LOE were less likely to be present on rounds compared with their counterparts preferring English (adjusted odds ratio, 0.17; 95% confidence interval [CI], 0.07–0.39). Similarly, patients and families preferring LOE were less likely to receive a resident update after rounds (adjusted odds ratio, 0.29; 95% CI, 0.13–0.62) and received fewer resident updates overall (incidence rate ratio, 0.45; 95% CI, 0.30–0.69). CONCLUSIONS Hospitalized patients and families preferring LOE experience significant communication-related inequities. Ongoing efforts are needed to promote equitable communication with this population and should consider the unique role of residents.

OBJECTIVEPatients with limited English proficiency (LEP) benefit from the appropriate use of medical interpreters. A multidisciplinary quality improvement team sought to improve communication with patients with LEP within a pediatric emergency department (ED). Specifically, the team aimed to improve the early identification of patients and caregivers with LEP, the utilization of interpreter services for those identified, and documentation of interpreter use in the patient chart.METHODSUsing clinical observations and data review, the project team identified key processes for improvement in the ED workflow and introduced interventions to increase identification of language needs and offer interpreter services. These include a new triage screening question, an icon on the ED track board that communicates language needs to staff, an electronic health record (EHR) alert with information on how to obtain interpreter services, and a new template to prompt correct documentation in the ED provider’s note. Outcomes were tracked using statistical process control charts.RESULTSAll study measures met special cause for improvement during the 6-month study period and have been sustained during surveillance data collection. Identification rates for patients with LEP during triage increased from 60% to 77%. Interpreter utilization increased from 77% to 86%. The documentation of interpreter use increased from 38% to 73%.CONCLUSIONUsing improvement methods, a multidisciplinary team increased the identification of patients and caregivers with LEP in an ED. Integration of this information into the EHR allowed for the targeted prompting of providers to use interpreter services and to correctly document their use.

OBJECTIVES The aim of this study was to evaluate the effectiveness of clinical pathway implementation and quality improvement (QI) interventions to increase the percentage of infants with extremity fractures undergoing evaluation for suspected physical abuse, including skeletal survey (SS), and consultation with social work, and/or Child Protection Team. METHODS Charts were retrospectively reviewed to establish percentage of infants less than 12 months old with extremity fractures undergoing an SS and consultation during the prepathway (January 1, 2012 to December 31, 2013) and postpathway (January 1, 2014 to June 30, 2015) periods. Using an Ishikawa framework, key process drivers were identified and additional QI interventions (clinical decision support and provider education) were developed and implemented. Impact of QI interventions on study metrics during active QI (July 1, 2015 to June 30, 2016) and post-QI periods (July 1, 2016 to December 31, 2016) was monitored using statistical process control charts. Logistic regression assessed predictors of obtaining an SS, consultation use, and occult fracture detection. RESULTS Skeletal survey use pre- and postpathway averaged 40%, surpassing 60% on average during active QI and post-QI periods. Consultation performance averaged 46% pre- and postpathway, increasing to nearly 67% during active QI; consultation performance decreased during post-QI to 60%. A lack of trauma history and presence of femur or humerus fracture were associated with increased SS use and consultation (both P < 0.001). Overall 20% of SS revealed occult fractures.

Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Out-of-hospital cardiac arrest occurs frequently among people of all ages, including more than 6000 children annually. Pediatric cardiac arrest in the out-of-hospital setting is a stressful event for family, friends, caregivers, classmates, school personnel, and witnesses. Immediate bystander cardiopulmonary resuscitation and the use of automated external defibrillators are associated with improved survival in adults. There is some evidence in which improved survival in children who receive immediate bystander cardiopulmonary resuscitation is shown. Pediatricians, in their role as advocates to improve the health of all children, are uniquely positioned to strongly encourage the training of children, parents, caregivers, school personnel, and the lay public in the provision of basic life support, including pediatric basic life support, as well as the appropriate use of automated external defibrillators.

OBJECTIVE: The objective of the study was to describe the epidemiology, cranial computed tomography (CT) findings, and clinical outcomes of children with blunt head trauma after television tip-over injuries. METHODS: We performed a secondary analysis of children younger than 18 years prospectively evaluated for blunt head trauma at 25 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from June 2004 to September 2006. Children injured from falling televisions were included. Patients were excluded if injuries occurred more than 24 hours before ED evaluation or if neuroimaging was obtained before evaluation. Data collected included age, race, sex, cranial CT findings, and clinical outcomes. Clinically important traumatic brain injuries (ciTBIs) were defined as death from TBI, neurosurgery, intubation for more than 24 hours for the TBI, or hospital admission of 2 nights or more for the head injury, in association with TBI on CT. RESULTS: A total of 43,904 children were enrolled into the primary study and 218 (0.5%; 95% confidence interval [CI], 0.4% to 0.6%) were struck by falling televisions. The median (interquartile range) age of the 218 patients was 3.1 (1.9-4.9) years. Seventy-five (34%) of the 218 underwent CT scanning. Ten (13.3%; 95% CI, 6.6% to 23.2%) of the 75 patients with an ED CT had traumatic findings on cranial CT scan. Six patients met the criteria for ciTBI. Three of these patients died. All 6 patients with ciTBIs were younger than 5 years. CONCLUSIONS: Television tip-overs may cause ciTBIs in children, including death, and the most severe injuries occur in children 5 years or younger. These injuries may be preventable by simple preventive measures such as anchoring television sets with straps. Language: en

A previously healthy adolescent girl presented to the emergency department with new onset chest and right upper quadrant abdominal pain. Laboratory studies and imaging were consistent with myocarditis. She developed heart block after admission and required stabilization in the cardiac intensive care unit. Lyme serology returned positive, and her condition was diagnosed as Lyme disease-associated myocarditis.

Intranasal medication administration in the emergency care of children has been reported for at least 20 years and is gaining popularity because of ease of administration, rapid onset of action, and relatively little pain to the patient. The ability to avoid a needle stick is often attractive to practitioners, in addition to children and their parents. In time-critical situations for which emergent administration of medication is needed, the intranasal route may be associated with more rapid medication administration. This article reviews the use of intranasal medications in the emergency care of children. Particular attention will be paid to anatomy and its impact on drug delivery, pharmacodynamics, medications currently administered by this route, delivery devices available, tips for use, and future directions.

Pediatric head trauma is a common occurrence. There is mounting evidence that even patients with minor head injury require limits on school activities and/or removal from sports and play to help speed recovery and limit morbidity. The objective of this study was to determine whether discharge instructions given to children who had sustained head injuries included information regarding activity restrictions, activity time constraints, and/or specifics of follow-up care.This was a retrospective chart review of patients aged 2 to 18 years evaluated and treated for head injury during a 4-month period at a level I trauma center (volume ∼23,000 pediatric patients per year). Included were those children seen, evaluated, and diagnosed with any of the following: mild head injury, concussion, minor head trauma, or mild traumatic brain injury (mTBI). Subjects were excluded if there was a positive acute head injury computed tomography finding (other than findings of a simple linear skull fracture) or if the subject required admission.Among the 204 patients meeting eligibility, 95.1% received instruction to follow up with a physician, 82.8% received anticipatory guidance regarding expected symptoms, 15.2% received specific restriction time from sports, and 21.5% were removed from sports. Of these patients, 113 patients were determined "likely" to have sustained an mTBI. Patients with sports-related mTBI received return-to-sports restrictions (χ2 = 11.225, P0.008) and to remove the child from play (χ2 = 9.781, P0.004) as discharge instructions significantly more than did patients with motor vehicle accident or other mechanisms of injury.Children sustaining head injury were inadequately instructed to restrict athletic activities upon discharge. This is particularly true for patients who sustain an mTBI from non-sports-related activity.

OBJECTIVES: Variables used in prediction rules and clinical guidelines should show acceptable agreement when assessed by different observers. Our objective was to determine the interobserver agreement of patient history and physical examination variables used to assess children undergoing emergency department (ED) evaluation for a first seizure not provoked by a known precipitant such as fever or trauma (ie, an unprovoked seizure). METHODS: We conducted a prospective cohort study of children aged 28 days to 18 years evaluated for unprovoked seizures at 6 tertiary care EDs. We excluded patients if previously evaluated for a similar event. Two clinicians independently completed a clinical assessment before neuroimaging. We determined agreement for each clinical variable by using the unweighted κ statistic. RESULTS: A total of 217 paired observations were analyzed; median patient age was 53.5 months, and 38% were younger than 2 years. Agreement beyond chance was at least moderate (κ ≥ 0.41) for 21 of 31 (68%) variables for which κ could be calculated. κ was ≥0.41 for 7 of 11 (64%) general history variables, all 8 seizure-specific history variables (including seizure focality), and 6 of 12 (50%) physical examination variables. Agreement beyond chance was substantial or better (κ ≥ 0.61) for 2 of 11 (18%) general history variables, for 5 of 8 (63%) seizure-specific history variables, and for 2 of 12 (17%) physical examination variables. CONCLUSIONS: For children with first unprovoked seizures evaluated in the ED, clinicians frequently assess findings from seizure-specific history with substantial agreement beyond chance. Those clinical variables that have been associated with the presence of intracranial abnormalities and show reliability between assessors, such as seizure focality and the presence of any focal neurological finding, may be more useful in the ED assessment of children with first unprovoked seizures.

Objectives: Determine prevalence of participation and under-immunization rate in a regional immunization registry (IR) among patients presenting to a university pediatric emergency department (PED). Rate of agreement between parental report and documented immunization status was also measured. Methods: A convenience sample of parents of patients younger than 11 years registered in the PED were approached with a short questionnaire. When informed consent was obtained, the Central New York (CNY) IR was accessed via computer to see if the child was in the registry and to ascertain if their immunizations were up-to-date (UTD). Rate of agreement between parental report and immunization status documented in the IR was calculated. Results: 698 (97%) of 720 patients consented to participate. Of these, 235 (34%, 95% CI, 30-37) were enrolled in the IR. Eighty-five (36%, 95% CI, 30-42) enrolled patients were under age 2. Sixty-seven (29%, 95% CI, 23-34) were from private group practices, 146 (62%, 95% CI, 56-68) were from university/ community health center clinics and the source of primary care for 22 patients (9%) was unknown. Only 67 (29%, 95% CI, 23-34) parents of children in the IR were aware that they were enrolled. Of IR patients, 225 (96%, 95% CI, 93-98) stated they were UTD, while only 143 (61%, 95% CI, 55-67) were documented to be so. Conclusions: A significant number of patients seen in the PED were in the CNY IR. More than one-half of the parents of enrolled children did not recall that they had previously registered their child. Only 61% of patients were UTD, whereas parents reported that almost all were. In the PED, use of an IR would create an opportunity for intervention in a large number of patients who were not UTD.

Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children.We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14.Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate.Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.

WHAT'S KNOWN ON THIS SUBJECT: Previous studies have revealed misconceptions among pediatric patients, their families, and athletic coaches surrounding concussion. Little is known about pediatric primary care and emergency medicine providers' attitudes and beliefs about diagnosis and management of this mild traumatic brain injury. WHAT THIS STUDY ADDS: Although pediatric primary care and emergency medicine providers regularly care for concussion patients and value their role in management, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. abstract To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network. METHODS: A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried. RESULTS: There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval (CI): 86%- 95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 "not a barrier" to 5 "significant barrier" was used to assess providers' barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%-23%), inadequate time to educate 15% (95% CI: 12%-24%), and not my role to educate 1% (95% CI: 0.4%-5%). Ninety-six percent (95% CI: 91%-98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%-100%) of providers without discharge instructions specifi ct o concussion believed these resources would be helpful. CONCLUSIONS: Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have ade- quate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and pa- tient information could help enhance and standardize concussion manage- ment. Pediatrics 2012;130:1120-1125

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

Cases of pertussis, a potentially life-threatening illness in infants younger than 6 months of age, are at a 40-year high. Children frequently present to emergency departments for initial evaluation. Quick recognition of the illness allows rapid triage, isolation, and prevention of nosocomial transmission. A retrospective, case−control chart review was conducted of pediatric emergency department patients (0 to 18 years of age) presenting between January 1, 2003, and December 31, 2004. Analysis focused on the exploration of medical history and physical examination variables as predictors using laboratory verification of the presence of pertussis as a binary outcome variable. Infants younger than 2 months who have a cough or choking associated with cyanosis, as well as a cough and rhonchi on physical examination, have a high likelihood of pertussis and should be identified in triage, isolated immediately, and tested for pertussis. This may lead to appropriate therapy for this population and decrease the transmission of pertussis to other patients and staff in the pediatric emergency department.

Objective. To investigate the potential for pediatric emergency department (ED) triage nurses to apply a topical anesthetic (ie, eutectic mixture of local anesthetic) for intravenous catheter (IV) insertion. Methods. Prospective cross-sectional survey over a 2-month period, with post hoc application of internally developed prediction rules. Eligible patients were children presenting to the ED triage area of an urban children's hospital. Results. A total of 2596 (86.7% of eligible children) had a triage nursing prediction performed. Nurse prediction of IV insertion had a sensitivity of 72% (95% CI: 66,78), a specificity of 90% (88,91), and a positive predictive value (PPV) of 49% (44,54). Objective factors such as high-risk medical history (chronic neurologic, hematologic, cardiac, endocrine, or gastrointestinal illness) and high-risk chief complaint (gastrointestinal illness, skin infection, and previous seizure) were incorporated into a predictive score used to predict IV insertion independently with a sensitivity of 33% (27,39) and a PPV of 43% (44,54). Addition of the objective predictors to nursing prediction increased the sensitivity to 76% (70,81) with a PPV of 43% (38,47). Of the patients, 95% received an IV insertion ≤45 minutes after triage, 89% ≤60 minutes after triage. Of the IV insertions, 68% were placed in the dorsum of the hand. Conclusions. The prediction of an experienced triage nurse can identify most patients requiring an IV in a pediatric ED. Incorporation of objective criteria other than nursing prediction into this decision process can decrease the amount of wasted product at the expense of less sensitive identification. The timing of IV insertion in our ED would allow for full medication effect of the currently marketed topical anesthetics in the majority of ED patients. topical anesthetic, intravenous cannulation, children, eutectic mixture of local anesthetic.