46 results on '"Hoyle JD"'
Search Results
2. Pediatric mental health emergencies: summary of a multidisciplinary panel.
- Author
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Hoyle JD Jr. and White LJ
- Published
- 2003
3. Training of residents for their role as flight physicians: a survey of emergency medicine training programs.
- Author
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Hoyle JD Jr., Loos SA, and Jones JS
- Published
- 2003
4. An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference.
- Author
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Kazi R, Hoyle JD Jr, Huffman C, Ekblad G, Ruffing R, Dunwoody S, Hover T, Cody S, and Fales W
- Subjects
- Child, Humans, Medication Errors prevention & control, Epinephrine, Retrospective Studies, Fentanyl, Emergency Medical Services, Asthma
- Abstract
Background: Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered., Objective: To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference., Methods: We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016-May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported., Results: During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3-48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57-100.0]) and glucagon (3/4 or 75% [95% CI 32.57-100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04-91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47-76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36-60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19-67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19-67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64-36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31-5.98])., Conclusions: Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.
- Published
- 2024
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5. Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results.
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Mahajan P, VanBuren JM, Tzimenatos L, Cruz AT, Vitale M, Powell EC, Leetch AN, Pickett ML, Brayer A, Nigrovic LE, Dayan PS, Atabaki SM, Ruddy RM, Rogers AJ, Greenberg R, Alpern ER, Tunik MG, Saunders M, Muenzer J, Levine DA, Hoyle JD, Lillis KG, Gattu R, Crain EF, Borgialli D, Bonsu B, Blumberg S, Anders J, Roosevelt G, Browne LR, Cohen DM, Linakis JG, Jaffe DM, Bennett JE, Schnadower D, Park G, Mistry RD, Glissmeyer EW, Cator A, Bogie A, Quayle KS, Ellison A, Balamuth F, Richards R, Ramilo O, and Kuppermann N
- Subjects
- Child, Fever complications, Fever diagnosis, Fever epidemiology, Humans, Infant, Procalcitonin, Urinalysis, Bacteremia complications, Bacteremia diagnosis, Bacteremia epidemiology, Bacterial Infections complications, Meningitis, Bacterial complications, Meningitis, Bacterial diagnosis, Meningitis, Bacterial epidemiology, Urinary Tract Infections epidemiology
- Abstract
It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis., Objective: To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results., Methods: Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results., Results: Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL., Conclusions: Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making., (Copyright © 2022 by the American Academy of Pediatrics.)
- Published
- 2022
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6. Methods Used to Obtain Pediatric Patient Weights, Their Accuracy and Associated Drug Dosing Errors in 142 Simulated Prehospital Pediatric Patient Encounters.
- Author
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Hoyle JD Jr, Ekblad G, Woodwyk A, Brandt R, Fales B, and Lammers RL
- Subjects
- Adult, Child, Child, Preschool, Humans, Infant, Medication Errors, Anaphylaxis, Burns, Emergency Medical Services, Heart Arrest
- Abstract
Background: Prehospital pediatric drug dosing errors occur at a high rate. Multiple factors contribute to these errors. The contribution of weight estimation errors to drug dosing errors is unknown. We describe methods used to obtain weights and resulting drug dosing errors. Methods: As part of a quality improvement study in 16 EMS agencies, we conducted four simulated pediatric scenarios: seizing, hypoglycemic infant, infant cardiac arrest, 18-month old burn and a 5-year old with anaphylactic shock. Crews used their regular drug bags and equipment. Simulations were observed by study team members with video review and scored on a standardized scoring sheet. Results: 142 scenarios were completed. Methods to obtain patient weights were: asking parent 17/142 (12.0%), patient age 35/142 (24.8%) and Broselow-Luten Tape (BLT) 89/142 (63.1%). There were 19 (13.4% 95% CI 8.5, 20.0) incorrect weight estimations resulting in 18 (12.7% 95% CI 8.2, 19.2) dosing errors (1 asking parent, 9 patient age and 8 BLT). Ten dosing errors were directly caused by weight estimation errors. In 41/89 (46.1% 95%CI 36.1, 56.4) BLT uses there was a near-miss error that did not result in a dosing error. One pound to kilogram conversion error occurred. Conclusions: BLT is the most frequently used method to obtain a patient weight. Drug dosing errors were most frequent with patient age, followed by BLT and asking the parent. System-based solutions-weight determination hierarchy, not using the BLT on seated patients, and more frequent training and practice with the BLT-are needed to improve drug-dosing accuracy.
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- 2022
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7. A Case of Delayed Presentation of Transposition of the Great Arteries.
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Welsh A and Hoyle JD Jr
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- Arteries, Child, Echocardiography, Female, Humans, Infant, Infant, Newborn, Oximetry, Pregnancy, Heart Defects, Congenital, Transposition of Great Vessels diagnostic imaging, Transposition of Great Vessels surgery
- Abstract
Intro: Transposition of the great arteries (TGA) is a rare cyanotic congenital heart defect (CHD) typically presenting the first month of life. Late presentations may occur in patients with associated cardiac anomalies allowing for mixing of oxygenated and deoxygenated blood, such as ventral septal defects or large atrial septal defects (ASD). We present a case of a late-presenting TGA with no ventral septal defect, and only small ASD and patent ductus arteriosus (PDA)., Case: A 2-month-old female infant presented to a rural emergency department with respiratory distress for 1 day. On arrival, she was cyanotic with only mild improvement in oxygen saturations on 15-L non-rebreather. Grade IV/VI murmur was noted, and prostaglandin E was started. She required intubation after becoming apneic and was transported to the local pediatric referral hospital. There, echocardiography showed dextro-type TGA, with 8-mm ASD with minimal gradient, small PDA with left to right flow, and ventral septal bowing. She underwent balloon septostomy and then atrial switch, which was well tolerated., Discussion: Our case is unique because of the patient's late presentation and prior lack of symptoms, given minimal levels of blood mixing though small ASD and PDA. Most TGA cases are now identified during prenatal ultrasound or with CHD screening pulse oximetry before discharge from the newborn nursery; however rare cases of late-presenting TGA may exist., Conclusion: Practitioners must maintain consideration of TGA, even after the newborn period, despite advances in newborn CHD screening in infants who present with new-onset respiratory distress without infection., Competing Interests: Disclosure: The authors have no potential conflicts of interest listed in the ICMJE. Neither the authors or their institutions have received grants, consulting fees or honoraria, support for meeting travel, fees for participation in review activities such as data monitoring boards or statistical analysis, payment for writing or reviewing the manuscript, and/or provision of writing assistance, medicines, equipment, or administrative support., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2021
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8. Radiographic Pneumonia in Febrile Infants 60 Days and Younger.
- Author
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Florin TA, Ramilo O, Hoyle JD Jr, Jaffe DM, Tzimenatos L, Atabaki SM, Cohen DM, VanBuren JM, Mahajan P, and Kuppermann N
- Subjects
- Biomarkers, Fever etiology, Humans, Infant, Leukocyte Count, Prospective Studies, Bacteremia, Pneumonia diagnostic imaging
- Abstract
Objective: Few prospective studies have assessed the occurrence of radiographic pneumonia in young febrile infants. We analyzed factors associated with radiographic pneumonias in febrile infants 60 days or younger evaluated in pediatric emergency departments., Study Design: We conducted a planned secondary analysis of a prospective cohort study within 26 emergency departments in a pediatric research network from 2008 to 2013. Febrile (≥38°C) infants 60 days or younger who received chest radiographs were included. Chest radiograph reports were categorized as "no," "possible," or "definite" pneumonia. We compared demographics, Yale Observation Scale scores (>10 implying ill appearance), laboratory markers, blood cultures, and viral testing among groups., Results: Of 4778 infants, 1724 (36.1%) had chest radiographs performed; 2.7% (n = 46) had definite pneumonias, and 3.9% (n = 67) had possible pneumonias. Patients with definite (13/46 [28.3%]) or possible (15/67 [22.7%]) pneumonias more frequently had Yale Observation Scale score >10 compared with those without pneumonias (210/1611 [13.2%], P = 0.002) in univariable and multivariable analyses. Median white blood cell count (WBC), absolute neutrophil count (ANC), and procalcitonin (PCT) were higher in the definite (WBC, 11.5 [interquartile range, 9.8-15.5]; ANC, 5.0 [3.2-7.6]; PCT, 0.4 [0.2-2.1]) versus no pneumonia (WBC, 10.0 [7.6-13.3]; ANC, 3.4 [2.1-5.4]; PCT, 0.2 [0.2-0.3]; WBC, P = 0.006; ANC, P = 0.002; PCT, P = 0.046) groups, but of unclear clinical significance. There were no cases of bacteremia in the definite pneumonia group. Viral infections were more frequent in groups with definite (25/38 [65.8%]) and possible (28/55 [50.9%]) pneumonias than no pneumonias (534/1185 [45.1%], P = 0.02)., Conclusions: Radiographic pneumonias were uncommon, often had viruses detected, and were associated with ill appearance, but few other predictors, in febrile infants 60 days or younger., Competing Interests: Disclosure: O.R. reports personal fees from HuMabs, Abbvie, Janssen, Medimmune, and Regeneron, and grants from Janssen. All these fees and grants are not related to the current work. All remaining authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2021
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9. Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP.
- Author
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Cicero MX, Adelgais K, Hoyle JD, Lyng JW, Harris M, Moore B, and Gausche-Hill M
- Subjects
- Child, Humans, Emergency Medical Services
- Abstract
Background: Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect., Methods: We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: (1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, (2) what practices or technologies are known to enhance dosing safety, (3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and (4) what impact could standardization of medication formularies have on enhancing dosing safety. To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed., Results: After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting., Conclusion: These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services .
- Published
- 2021
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10. Dosing Errors Made by Paramedics During Pediatric Patient Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference.
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Hoyle JD Jr, Ekblad G, Hover T, Woodwyk A, Brandt R, Fales B, and Lammers RL
- Subjects
- Adult, Allied Health Personnel, Anaphylaxis therapy, Body Weight, Burns therapy, Child, Child, Preschool, Female, Heart Arrest therapy, Humans, Infant, Male, Michigan, Patient Simulation, Seizures therapy, Syringes, Emergency Medical Services, Epinephrine administration & dosage, Medication Errors, Vasoconstrictor Agents administration & dosage
- Abstract
Background: Drug dosing errors occur at a high rate for prehospital pediatric patients. To reduce errors, Michigan implemented a state-wide pediatric dosing reference (PDR), with doses listed in milliliters, the requirement that doses be drawn into a smaller syringe from a pre-loaded syringe using a stopcock, and dilution of certain drugs to different concentrations. Purpose: To evaluate the rate of medication errors, including errors of omission and commission, after implementation of a state-wide PDR. Methods: EMS crews from 15 agencies completed 4 validated, simulation scenarios: an infant seizing, an infant cardiac arrest, an 18-month-old with a burn, and 5-year-old with anaphylactic shock. Agencies were private, public, not-for-profit, for-profit, urban, rural, fire-based, and third service. EMS crews used their regular equipment and were required to carry out all the steps to administer a drug dose. Two evaluators scored crew performance via direct observation and video review. An error was defined as [Formula: see text]20% difference compared to the weight-appropriate dose. Descriptive statistics were utilized. Results: A total of 142 simulations were completed. The majority of crews were (58.3%) Emergency Medical Technician-Paramedic (EMTP)/EMTP. For the cardiac arrest scenario, 51/70 (72.9%; 95% CI: 60.9%, 82.8%) epinephrine doses were correct. There were 6 (8.6%, 95% CI: 2.0%, 15.1%) 10-fold overdoses and one (1.4%; 95% CI: -1.4%, 4.2%), 10-fold under dose. In the seizure scenario, 28/50 (56.0%; 95% CI: 42.2%, 69.8%) benzodiazepine doses were correct; 6/18 (33.3%; 95% CI: 11.5%, 55.1%) drug dilutions were incorrect resulting in dosing errors. Unrecognized air was frequently entrained into the administration syringe resulting in under doses. Overall, 31.2% (95% CI: 25.5%, 36.6%) of drug doses were incorrect. Obtaining an incorrect weight led to a drug dosing error in 18/142 (12.7%, 95% CI: 7.2%, 18.2%) cases. Errors of omission included failure to check blood sugar in the seizure scenario and failure to administer epinephrine and a fluid bolus in anaphylactic shock. Conclusion: Despite implementation of a PDR, dosing errors, including 10-fold errors, still occur at a high rate. Errors occur with dilution and length-based tape use. Further error reduction strategies, beyond a PDR and that target errors of omission, are needed for pediatric prehospital drug administration.
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- 2020
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11. Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age.
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Rogers AJ, Kuppermann N, Anders J, Roosevelt G, Hoyle JD Jr, Ruddy RM, Bennett JE, Borgialli DA, Dayan PS, Powell EC, Casper TC, Ramilo O, and Mahajan P
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- Biomarkers analysis, Biomarkers blood, Cohort Studies, Critical Illness epidemiology, Critical Illness therapy, Diagnostic Tests, Routine statistics & numerical data, Emergency Service, Hospital organization & administration, Emergency Service, Hospital statistics & numerical data, Female, Fever diagnosis, Fever epidemiology, Hospitalization statistics & numerical data, Humans, Infant, Infant, Newborn, Male, Practice Patterns, Physicians' statistics & numerical data, Prospective Studies, Diagnostic Tests, Routine methods, Fever therapy, Practice Patterns, Physicians' standards
- Abstract
Background: Febrile infants commonly present to emergency departments for evaluation., Objective: We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network., Methods: We enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28 days of age) and older (29-60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance., Results: Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%., Conclusions: The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29-60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization., (Copyright © 2019 Elsevier Inc. All rights reserved.)
- Published
- 2019
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12. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections.
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Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC, Nigrovic LE, Muenzer J, Linakis JG, Grisanti K, Jaffe DM, Hoyle JD Jr, Greenberg R, Gattu R, Cruz AT, Crain EF, Cohen DM, Brayer A, Borgialli D, Bonsu B, Browne L, Blumberg S, Bennett JE, Atabaki SM, Anders J, Alpern ER, Miller B, Casper TC, Dean JM, Ramilo O, and Mahajan P
- Subjects
- Age Factors, Bacteremia metabolism, Bacteremia microbiology, Biomarkers metabolism, Emergency Service, Hospital, Female, Humans, Infant, Infant, Newborn, Leukocyte Count, Male, Meningitis, Bacterial metabolism, Meningitis, Bacterial microbiology, Predictive Value of Tests, Prospective Studies, Risk Factors, Urinalysis, Urinary Tract Infections metabolism, Urinary Tract Infections microbiology, Bacteremia diagnosis, Clinical Decision Rules, Fever microbiology, Meningitis, Bacterial diagnosis, Urinary Tract Infections diagnosis
- Abstract
Importance: In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs., Objective: To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs., Design, Setting, and Participants: Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018., Exposures: Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis., Main Outcomes and Measures: Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis., Results: We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia., Conclusions and Relevance: We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.
- Published
- 2019
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13. Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger.
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Powell EC, Mahajan PV, Roosevelt G, Hoyle JD Jr, Gattu R, Cruz AT, Rogers AJ, Atabaki SM, Jaffe DM, Casper TC, Ramilo O, and Kuppermann N
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- Escherichia coli, Humans, Infant, Infant, Newborn, Prospective Studies, Bacteremia epidemiology, Escherichia coli Infections epidemiology, Meningitis, Bacterial epidemiology, Streptococcal Infections epidemiology, Urinary Tract Infections epidemiology
- Abstract
Study Objective: To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN)., Methods: We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia., Results: Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis., Conclusion: The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)
- Published
- 2018
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14. Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures.
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Badawy MK, Dayan PS, Tunik MG, Nadel FM, Lillis KA, Miskin M, Borgialli DA, Bachman MC, Atabaki SM, Hoyle JD Jr, Holmes JF, and Kuppermann N
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- Adolescent, Brain Injuries, Traumatic complications, Brain Injuries, Traumatic diagnostic imaging, Child, Child, Preschool, Female, Head Injuries, Closed complications, Head Injuries, Closed diagnostic imaging, Humans, Male, Patient Discharge, Prevalence, Prospective Studies, Recurrence, Seizures complications, Seizures diagnostic imaging, Time Factors, Tomography, X-Ray Computed, Brain Injuries, Traumatic epidemiology, Emergency Service, Hospital, Neuroimaging methods, Seizures epidemiology
- Abstract
Objectives: Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with posttraumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBIs) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED., Methods: This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children < 18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions, and recurrent seizures within 1 week. Patients discharged from the ED were contacted by telephone 1 week to 3 months later., Results: Of 42,424 children enrolled, 536 (1.3%, 95% confidence interval [CI] = 1.2%-1.4%) had PTS. A total of 466 of 536 (86.9%, 95% CI = 83.8%-89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI = 12.3%-19.1%), of whom 20 (27.8%, 95% CI = 17.9%-39.6%) underwent neurosurgical intervention and 15 (20.8%, 95% CI = 12.2%-32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and five (1.1%, 95 CI = 0.4%-2.5%) had recurrent seizures; four of five presented with Glasgow Coma Scale scores < 15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p = 0.006) and longer duration of PTS (p < 0.001)., Conclusions: Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBIs on CT, however, are at low risk of short-term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT-negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED., (© 2017 by the Society for Academic Emergency Medicine.)
- Published
- 2017
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15. A Modified Delphi Study for Development of a Pediatric Curriculum for Emergency Medicine Residents.
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Mitzman J, King AM, Fastle RK, Hopson LR, Hoyle JD Jr, Levasseur KA, Mitchell MS, O'Neill JC, Pazderka PA, Perry MA, Reynolds M, Shah PG, Skarbek-Borowska S, Way DP, and Stanley RM
- Abstract
Objectives: Emergency medicine (EM) trainees are expected to learn to provide acute care for patients of all ages. The American Council for Graduate Medical Education provides some guidance on topics related to caring for pediatric patients; however, education about pediatric topics varies across residency programs. The goal of this project was to develop a consensus curriculum for teaching pediatric emergency care., Methods: We recruited 13 physicians from six academic health centers to participate in a three-round electronic modified Delphi project. Participants were selected on the basis of expertise with both EM resident education and pediatric emergency care. The first modified Delphi survey asked participants to generate the core knowledge, skills, and experiences needed to prepare EM residents to effectively treat children in an acute care setting. The qualitative data from the first round was reformulated into a second-round questionnaire. During the second round, participants used rating scales to prioritize the curriculum content proposed during the first round. In round 3, participants were asked to make a determination about each curriculum topic using a three-point scale labeled required, optional, or not needed., Results: The first modified Delphi round yielded 400 knowledge topics, 206 clinical skills, and 44 specific types of experience residents need to prepare for acute pediatric patient care. These were narrowed to 153 topics, 84 skills, and 28 experiences through elimination of redundancy and two rounds of prioritization. The final lists contain topics classified by highly recommended, partially recommended, and not recommended. The partially recommended category is intended to help programs tailor their curriculum to the unique needs of their learners as well as account for variability between 3- and 4-year programs and the amount of time programs allocate to pediatric education., Conclusion: The modified Delphi process yielded the broad outline of a consensus core pediatric emergency care curriculum.
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- 2017
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16. Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics.
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Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, and Fales W
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- Child, Cross-Sectional Studies, Health Care Surveys, Humans, Patient Safety, Surveys and Questionnaires, United States, Emergency Medical Services standards, Emergency Medical Technicians standards, Medication Errors prevention & control
- Abstract
Background: Pediatric drug dosing errors occur at a high rate in the prehospital environment., Objective: To describe paramedic training and practice regarding pediatric drug administration, exposure to pediatric drug dose errors and safety culture among paramedics and EMS agencies in a national sample., Methods: An electronic questionnaire was sent to a random sample of 10,530 nationally certified paramedics. Descriptive statistics were calculated., Results: There were 1,043 (9.9%) responses and 1,014 paramedics met inclusion criteria. Nearly half (43.0%) were familiar with a case where EMS personnel delivered an incorrect pediatric drug dose. Over half (58.5%) believed their initial paramedic program did not include enough pediatric training. Two-thirds (66.0%) administered a pediatric drug dose within the past year. When estimating the weight of a pediatric patient, 54.2% used a length-based tape, while 35.8% asked the parent or guardian, and 2.5% relied on a smart phone application. Only 19.8% said their agency had an anonymous error-reporting system and 50.7% believed they could report an error without fear of disciplinary action. For solutions, 89.0% believed an EMS-specific Broselow-Luten Tape would be helpful, followed by drug dosing cards in milliliters (83.0%) and changing content of standardized pediatric courses to be more relevant (77.7%)., Conclusion: This national survey demonstrated a significant number of paramedics are aware of a pediatric dosing error, safety systems specific to pediatric patients are lacking, and that paramedics view pediatric drug cards and eliminating drug calculations as helpful. Pediatric drug-dosing safety in the prehospital environment can be improved.
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- 2017
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17. Emergency Medical Dispatchers Can Obtain Accurate Pediatric Weights from 9-1-1 Callers.
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Chassee T, Reischmann D, Mancera M, and Hoyle JD Jr
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- Allied Health Personnel, Child, Child, Preschool, Drug Dosage Calculations, Female, Humans, Infant, Male, Body Weight, Emergency Medical Dispatcher statistics & numerical data, Emergency Medical Services statistics & numerical data
- Abstract
Background: Prehospital pediatric drug dosing errors affect 56,000 U.S. children annually. An accurate weight is the first step in accurate dosing. To date, the accuracy of Emergency Medical Dispatcher (EMD) obtained weights has not been evaluated. We hypothesized that EMD could obtain accurate pediatric weights., Methods: We used a convenience sample of patients 12 years and younger that were transported by EMS to one children's hospital. EMD obtained patient weight (DW) from the 9-1-1 caller. Paramedics reported their estimate of the patient's weight on arrival to the hospital (PW). The DW and PW were compared to the hospital scale weight (HW) for accuracy., Results: A total of 197 patients were included. Parent/guardians were the most frequent 9-1-1 callers (74%). The most frequent method utilized by paramedics to obtain patient weight was to ask a family member. For 0-2 year olds, the mean differences between HW and DW/PW were 0.239kg (SD 3.117)/ -0.374 (SD 2.528). For 3-7 year olds, the mean differences between HW and DW/PW were 0.041kg (SD 4.684)/1.007 (SD 2.466). For 8-11 year olds the mean difference between HW and DW/PW was 2.768 kg (SD 10.926)/ 1.919 (SD 6.909)., Conclusion: EMD were able to obtain pediatric patient weights with relative accuracy for patients 0-7 year old. Using this EMD-obtained weight to carry out a drug dose calculation would be unlikely to result in a clinically significant dose error in the vast majority of cases. Communicating an EMD-obtained weight to EMS crews en route to a pediatric patient offers additional preparation time for drug calculations, which could improve accuracy.
- Published
- 2016
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18. Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.
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Tunik MG, Powell EC, Mahajan P, Schunk JE, Jacobs E, Miskin M, Zuspan SJ, Wootton-Gorges S, Atabaki SM, Hoyle JD Jr, Holmes JF Jr, Dayan PS, and Kuppermann N
- Subjects
- Adolescent, Child, Child, Preschool, Emergency Service, Hospital statistics & numerical data, Female, Glasgow Coma Scale, Head Injuries, Closed diagnostic imaging, Head Injuries, Closed therapy, Humans, Male, Skull Fracture, Basilar diagnostic imaging, Skull Fracture, Basilar therapy, Time Factors, Tomography, X-Ray Computed, Treatment Outcome, Head Injuries, Closed diagnosis, Skull Fracture, Basilar diagnosis
- Abstract
Study Objective: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma., Methods: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT)., Results: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT., Conclusion: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge., (Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)
- Published
- 2016
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19. Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger.
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Mahajan P, Kuppermann N, Mejias A, Suarez N, Chaussabel D, Casper TC, Smith B, Alpern ER, Anders J, Atabaki SM, Bennett JE, Blumberg S, Bonsu B, Borgialli D, Brayer A, Browne L, Cohen DM, Crain EF, Cruz AT, Dayan PS, Gattu R, Greenberg R, Hoyle JD Jr, Jaffe DM, Levine DA, Lillis K, Linakis JG, Muenzer J, Nigrovic LE, Powell EC, Rogers AJ, Roosevelt G, Ruddy RM, Saunders M, Tunik MG, Tzimenatos L, Vitale M, Dean JM, and Ramilo O
- Subjects
- Bacteremia blood, Bacterial Infections blood, Bacterial Infections complications, Biomarkers blood, Case-Control Studies, Diagnostic Tests, Routine, Emergency Service, Hospital, Female, Fever blood, Genetic Markers, Humans, Infant, Infant, Newborn, Male, Meningitis, Bacterial blood, Meningitis, Bacterial complications, Meningitis, Bacterial diagnosis, Microarray Analysis methods, Prospective Studies, RNA genetics, Statistics, Nonparametric, Urinary Tract Infections blood, Urinary Tract Infections complications, Urinary Tract Infections diagnosis, Bacterial Infections diagnosis, Fever microbiology, RNA blood
- Abstract
Importance: Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach., Objective: To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections., Design, Setting, and Participants: Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type., Exposure: RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections., Main Outcomes and Measures: Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores., Results: Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43)., Conclusions and Relevance: In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice., Competing Interests: Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Mejias reports receiving personal fees from Abbvie, Novartis, and Janssen and grants from Gilead, Alios, and Janssen. Dr Ramilo reports receiving personal fees from HuMabs, Abbvie, Janssen, Medimmune, and Regeneron and grants from Janssen. All these fees and grants were not related to the current work. No other disclosures were reported.
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- 2016
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20. Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma.
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Borgialli DA, Mahajan P, Hoyle JD Jr, Powell EC, Nadel FM, Tunik MG, Foerster A, Dong L, Miskin M, Dayan PS, Holmes JF, and Kuppermann N
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- Adolescent, Brain Injuries complications, Brain Injuries, Traumatic, Child, Child, Preschool, Emergency Service, Hospital, Female, Head Injuries, Closed complications, Hospitalization, Humans, Infant, Male, Prospective Studies, ROC Curve, Tomography, X-Ray Computed, Glasgow Coma Scale, Head Injuries, Closed diagnosis
- Abstract
Objective: The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma., Methods: This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes., Results: We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI., Conclusions: The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI., (© 2016 by the Society for Academic Emergency Medicine.)
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- 2016
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21. Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma.
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Atabaki SM, Hoyle JD Jr, Schunk JE, Monroe DJ, Alpern ER, Quayle KS, Glass TF, Badawy MK, Miskin M, Schalick WO, Dayan PS, Holmes JF, and Kuppermann N
- Subjects
- Adolescent, Brain Injuries, Traumatic diagnostic imaging, Child, Child, Preschool, Emergency Service, Hospital, Emergency Treatment methods, Female, Head Injuries, Closed diagnostic imaging, Humans, Infant, Prospective Studies, Tomography, X-Ray Computed, Brain Injuries, Traumatic diagnosis, Decision Support Techniques, Head Injuries, Closed diagnosis
- Abstract
Objective: Children with minor head trauma frequently present to emergency departments (EDs). Identifying those with traumatic brain injuries (TBIs) can be difficult, and it is unknown whether clinical prediction rules outperform clinician suspicion. Our primary objective was to compare the test characteristics of the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules to clinician suspicion for identifying children with clinically important TBIs (ciTBIs) after minor blunt head trauma. Our secondary objective was to determine the reasons for obtaining computed tomography (CT) scans when clinical suspicion of ciTBI was low., Methods: This was a planned secondary analysis of a previously conducted observational cohort study conducted in PECARN to derive and validate clinical prediction rules for ciTBI among children with minor blunt head trauma in 25 PECARN EDs. Clinicians recorded their suspicion of ciTBI before CT as <1, 1-5, 6-10, 11-50, or >50%. We defined ciTBI as 1) death from TBI, 2) neurosurgery, 3) intubation for more than 24 hours for TBI, or 4) hospital admission of 2 nights or more associated with TBI on CT. To avoid overfitting of the prediction rules, we performed comparisons of the prediction rules and clinician suspicion on the validation group only. On the validation group, we compared the test accuracies of clinician suspicion > 1% versus having at least one predictor in the PECARN TBI age-specific prediction rules for identifying children with ciTBIs (one rule for children <2 years [preverbal], the other rule for children >2 years [verbal])., Results: In the parent study, we enrolled 8,627 children to validate the prediction rules, after enrolling 33,785 children to derive the prediction rules. In the validation group, clinician suspicion of ciTBI was recorded in 8,496/8,627 (98.5%) patients, and 87 (1.0%) had ciTBIs. CT scans were obtained in 2,857 (33.6%) patients in the validation group for whom clinician suspicion of ciTBI was recorded, including 2,099/7,688 (27.3%) of those with clinician suspicion of ciTBI of <1% and 758/808 (93.8%) of those with clinician suspicion >1%. The PECARN prediction rules were significantly more sensitive than clinician suspicion >1% of ciTBI for preverbal (100% [95% confidence interval {CI} = 86.3% to 100%] vs. 60.0% [95% CI = 38.7% to 78.9%]) and verbal children (96.8% [95% CI = 88.8% to 99.6%] vs. 64.5% [95% CI = 51.3% to 76.3%]). Prediction rule specificity, however, was lower than clinician suspicion >1% for preverbal children (53.6% [95% CI = 51.5% to 55.7%] vs. 92.4% [95% CI = 91.2% to 93.5%]) and verbal children (58.2% [95% CI = 56.9% to 59.4%] vs. 90.6% [95% CI = 89.8% to 91.3%]). Of the 7,688 patients in the validation group with clinician suspicion recorded as <1%, CTs were nevertheless obtained in 2,099 (27.3%). Three of 16 (18.8%) patients undergoing neurosurgery had clinician suspicion of ciTBI <1%., Conclusions: The PECARN TBI prediction rules had substantially greater sensitivity, but lower specificity, than clinician suspicion of ciTBI for children with minor blunt head trauma. Because CT ordering did not follow clinician suspicion of <1%, these prediction rules can augment clinician judgment and help obviate CT ordering for children at very low risk of ciTBI., (© 2016 by the Society for Academic Emergency Medicine.)
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- 2016
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22. Pediatric Prehospital Medication Dosing Errors: A Mixed-Methods Study.
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Hoyle JD Jr, Sleight D, Henry R, Chassee T, Fales B, and Mavis B
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- Adolescent, Child, Child, Preschool, Female, Focus Groups, Humans, Infant, Infant, Newborn, Male, Michigan, Risk Factors, Allied Health Personnel, Emergency Medical Services standards, Medication Errors prevention & control, Medication Errors statistics & numerical data
- Abstract
Prehospital dosing errors affect approximately 56,000 US children yearly. To decrease these errors, barriers, enablers and solutions from the paramedic (EMT-P) and medical director (MD) standpoint need to be understood. We conducted a mixed-methods study of EMT-P and MDs in Michigan utilizing focus groups (FG). FGs were held at EMS agencies and state EMS conferences. Questions focused on the drug dose delivery process, barriers and enablers to correct dosing and possible solutions to decrease errors. Responses were coded by the research team for themes and number of response mentions. Participants completed a pre-FG survey on pediatric experience and agency characteristics. There were 35 EMT-P and 9 MD participants: 43% of EMT-Ps had been practicing > 10 years, 11% had been practicing < 1 year; and 25% reported they had not administered a drug dose to a child in the last 12 months. EMT-Ps who were "very comfortable" with their ability to administer a correct drug dose to infants, toddlers, school-aged, and adolescents were: 5%, 7%, 10%, and 54%, respectively. FGs identified themes of: difficulty obtaining weight, infrequent pediatric encounters, infrequent/inadequate pediatric training, difficulties with drug packaging, drug bags that were not "EMS friendly," difficulty with drug calculations, and lack of dosing aids. Simplification of dose delivery, an improved length based tape for EMS, pediatric checklists, and dose cards in mL were given as solutions. This mixed-methods study identified barriers and potential solutions to reducing prehospital pediatric drug dosing errors. Solutions should be thoroughly tested prior to implementation.
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- 2016
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23. Antitoxin Treatment of Inhalation Anthrax: A Systematic Review.
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Huang E, Pillai SK, Bower WA, Hendricks KA, Guarnizo JT, Hoyle JD, Gorman SE, Boyer AE, Quinn CP, and Meaney-Delman D
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- Administration, Intravenous, Animals, Anti-Bacterial Agents therapeutic use, Antibodies, Monoclonal, Humanized, Antigens, Bacterial immunology, Bioterrorism, Drug Therapy, Combination, Humans, Immunoglobulins, Intravenous therapeutic use, Mass Casualty Incidents, Rabbits, Anthrax drug therapy, Antibodies, Monoclonal therapeutic use, Antitoxins therapeutic use, Immunoglobulin G therapeutic use, Respiratory Tract Infections drug therapy
- Abstract
Concern about use of anthrax as a bioweapon prompted development of novel anthrax antitoxins for treatment. Clinical guidelines for the treatment of anthrax recommend antitoxin therapy in combination with intravenous antimicrobials; however, a large-scale or mass anthrax incident may exceed antitoxin availability and create a need for judicious antitoxin use. We conducted a systematic review of antitoxin treatment of inhalation anthrax in humans and experimental animals to inform antitoxin recommendations during a large-scale or mass anthrax incident. A comprehensive search of 11 databases and the FDA website was conducted to identify relevant animal studies and human reports: 28 animal studies and 3 human cases were identified. Antitoxin monotherapy at or shortly after symptom onset demonstrates increased survival compared to no treatment in animals. With early treatment, survival did not differ between antimicrobial monotherapy and antimicrobial-antitoxin therapy in nonhuman primates and rabbits. With delayed treatment, antitoxin-antimicrobial treatment increased rabbit survival. Among human cases, addition of antitoxin to combination antimicrobial treatment was associated with survival in 2 of the 3 cases treated. Despite the paucity of human data, limited animal data suggest that adjunctive antitoxin therapy may improve survival. Delayed treatment studies suggest improved survival with combined antitoxin-antimicrobial therapy, although a survival difference compared with antimicrobial therapy alone was not demonstrated statistically. In a mass anthrax incident with limited antitoxin supplies, antitoxin treatment of individuals who have not demonstrated a clinical benefit from antimicrobials, or those who present with more severe illness, may be warranted. Additional pathophysiology studies are needed, and a point-of-care assay correlating toxin levels with clinical status may provide important information to guide antitoxin use during a large-scale anthrax incident.
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- 2015
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24. Antimicrobial Treatment for Systemic Anthrax: Analysis of Cases from 1945 to 2014 Identified Through a Systematic Literature Review.
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Pillai SK, Huang E, Guarnizo JT, Hoyle JD, Katharios-Lanwermeyer S, Turski TK, Bower WA, Hendricks KA, and Meaney-Delman D
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- Administration, Intravenous, Antitoxins therapeutic use, Drug Therapy, Combination trends, Global Health, Humans, Anthrax drug therapy, Anti-Bacterial Agents administration & dosage, Drug Therapy, Combination methods
- Abstract
Systemic anthrax is associated with high mortality. Current national guidelines, developed for the individualized treatment of systemic anthrax, outline the use of combination intravenous antimicrobials for a minimum of 2 weeks, bactericidal and protein synthesis inhibitor antimicrobials for all cases of systemic anthrax, and at least 3 antimicrobials with good blood-brain barrier penetration for anthrax meningitis. However, in an anthrax mass casualty incident, large numbers of anthrax cases may create challenges in meeting antimicrobial needs. To further inform our understanding of the role of antimicrobials in treating systemic anthrax, a systematic review of the English-language literature was conducted to identify cases of systemic anthrax treated with antimicrobials for which a clinical outcome was recorded. A total of 149 cases of systemic anthrax were identified. Among the identified 59 cases of cutaneous anthrax, 33 were complicated by meningitis (76% mortality), while 26 simply had evidence of the systemic inflammatory response syndrome (4% mortality); 21 of 26 (81%) of this latter group received monotherapy. Subsequent analysis regarding combination antimicrobial therapy was restricted to the remaining 123 cases of more severe anthrax (overall 67% mortality). Recipients of combination bactericidal and protein synthesis inhibitor therapy had a 45% survival versus 28% in the absence of combination therapy (p = 0.07). For meningitis cases (n = 77), survival was greater for those receiving 3 or more antimicrobials over the course of treatment (3 of 4; 75%), compared to receipt of 1 or 2 antimicrobials (12 of 73; 16%) (p = 0.02). Median parenteral antimicrobial duration was 14 days. Combination bactericidal and protein synthesis inhibitor therapy may be appropriate in severe anthrax disease, particularly anthrax meningitis, in a mass casualty incident.
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- 2015
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25. Emergency department practice variation in computed tomography use for children with minor blunt head trauma.
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Stanley RM, Hoyle JD Jr, Dayan PS, Atabaki S, Lee L, Lillis K, Gorelick MH, Holubkov R, Miskin M, Holmes JF, Dean JM, and Kuppermann N
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- Child, Child, Preschool, Hospitals, Pediatric statistics & numerical data, Hospitals, Teaching statistics & numerical data, Humans, Infant, Multivariate Analysis, Prospective Studies, Risk Assessment, Skull diagnostic imaging, Emergency Service, Hospital statistics & numerical data, Head Injuries, Closed diagnostic imaging, Practice Patterns, Physicians' statistics & numerical data, Tomography, X-Ray Computed statistics & numerical data
- Abstract
Objective: To describe factors associated with computed tomography (CT) use for children with minor blunt head trauma that are evaluated in emergency departments., Study Design: Planned secondary analysis of a prospective observational study of children <18 years with minor blunt head trauma between 2004 and 2006 at 25 emergency departments. CT scans were obtained at the discretion of treating clinicians. We risk-adjusted patients for clinically important traumatic brain injuries and performed multivariable regression analyses. Outcome measures were rates of CT use by hospital and by clinician training type., Results: CT rates varied between 19.2% and 69.2% across hospitals. Risk adjustment had little effect on the differential rate of CT use. In low- and middle-risk patients, clinicians obtained CTs more frequently at suburban and nonfreestanding children's hospitals. Physicians with emergency medicine (EM) residency training obtained CTs at greater rates than physicians with pediatric residency or pediatric EM training. In multivariable analyses, compared with pediatric EM-trained physicians, the OR for CT use among EM-trained physicians in children <2 years was 1.24 (95% CI 1.04-1.46), and for children >2 years was 1.68 (95% CI 1.50-1.89). Physicians of all training backgrounds, however, overused CT scans in low-risk children., Conclusions: Substantial variation exists in the use of CT for children with minor blunt head trauma not explained by patient severity or rates of positive CT scans or clinically important traumatic brain injuries., (Copyright © 2014 Elsevier Inc. All rights reserved.)
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- 2014
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26. Epidemiology of blunt head trauma in children in U.S. emergency departments.
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Quayle KS, Powell EC, Mahajan P, Hoyle JD Jr, Nadel FM, Badawy MK, Schunk JE, Stanley RM, Miskin M, Atabaki SM, Dayan PS, Holmes JF, and Kuppermann N
- Subjects
- Accidents statistics & numerical data, Adolescent, Athletic Injuries epidemiology, Bicycling injuries, Child, Child, Preschool, Emergency Service, Hospital, Glasgow Coma Scale, Head Injuries, Closed diagnostic imaging, Head Injuries, Closed etiology, Humans, Infant, Prospective Studies, Tomography, X-Ray Computed statistics & numerical data, United States epidemiology, Head Injuries, Closed epidemiology
- Abstract
Among more than 43,000 children treated in 25 emergency departments for blunt head trauma, traumatic brain injury was identified on CT scan in 7% of the patients. Falls were the most frequent injury mechanism for children under the age of 12 years.
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- 2014
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27. Sweet solutions and needle-related pain in infants.
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Michiels EA and Hoyle JD Jr
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- Humans, Dietary Sucrose administration & dosage, Needles adverse effects, Pain prevention & control, Sweetening Agents administration & dosage
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- 2014
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28. Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury.
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Anders JF, Adelgais K, Hoyle JD Jr, Olsen C, Jaffe DM, and Leonard JC
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- Adolescent, Child, Child, Preschool, Emergency Medical Services organization & administration, Female, Hospital Administration, Humans, Injury Severity Score, Male, Outcome Assessment, Health Care, Treatment Outcome, Cervical Vertebrae injuries, Patient Transfer statistics & numerical data, Spinal Injuries therapy, Time-to-Treatment, Transportation of Patients statistics & numerical data, Trauma Centers
- Abstract
Background: Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries., Objectives: The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries., Methods: The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data., Results: The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR] = 1.89, 95% confidence interval [CI] = 1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent., Conclusions: Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers., (© 2013 by the Society for Academic Emergency Medicine.)
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- 2014
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29. Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma.
- Author
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Hoyle JD Jr, Callahan JM, Badawy M, Powell E, Jacobs E, Gerardi M, Melville K, Miskin M, Atabaki SM, Dayan P, Holmes JF, and Kuppermann N
- Subjects
- Adolescent, Child, Child, Preschool, Dose-Response Relationship, Drug, Female, Follow-Up Studies, Glasgow Coma Scale, Humans, Infant, Injections, Intravenous, Male, Prospective Studies, Trauma Centers, Trauma Severity Indices, Conscious Sedation methods, Head Injuries, Closed diagnostic imaging, Hypnotics and Sedatives administration & dosage, Tomography, X-Ray Computed methods
- Abstract
Objective: 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., Methods: 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., Results: 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., Conclusions: 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.
- Published
- 2014
- Full Text
- View/download PDF
30. Characteristics of the pediatric patients treated by the Pediatric Emergency Care Applied Research Network's affiliated EMS agencies.
- Author
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Lerner EB, Dayan PS, Brown K, Fuchs S, Leonard J, Borgialli D, Babcock L, Hoyle JD Jr, Kwok M, Lillis K, Nigrovic LE, Mahajan P, Rogers A, Schwartz H, Soprano J, Tsarouhas N, Turnipseed S, Funai T, and Foltin G
- Subjects
- Child, Female, Humans, Male, Retrospective Studies, United States, Emergency Medical Services organization & administration
- Abstract
Objective: To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies., Methods: We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics., Results: Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old., Conclusions: Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.
- Published
- 2014
- Full Text
- View/download PDF
31. Improving dementia diagnosis and management in primary care: a cohort study of the impact of a training and support program on physician competency, practice patterns, and community linkages.
- Author
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Lathren CR, Sloane PD, Hoyle JD, Zimmerman S, and Kaufer DI
- Subjects
- Adult, Cohort Studies, Dementia epidemiology, Disease Management, Female, Humans, Male, Middle Aged, Pilot Projects, Primary Health Care methods, Clinical Competence standards, Dementia diagnosis, Dementia therapy, Physician's Role, Primary Health Care standards, Residence Characteristics
- Abstract
Background: Primary care physicians routinely provide dementia care, but may lack the clinical skills and awareness of available resources to provide optimal care. We conducted a community-based pilot dementia training intervention designed to both improve clinical competency and increase utilization of local dementia care services., Methods: Physicians (N = 29) and affiliated staff (N = 24) participated in a one-day training program on dementia screening, diagnosis and management that included direct engagement with local support service providers. Questionnaires about their dementia care competency and referral patterns were completed before and 6 months after the training intervention., Results: Physicians reported significantly higher overall confidence in their dementia care competency 6 months post-training compared to pre-training. The largest reported improvements were in their ability to educate patients and caregivers about dementia and making appropriate referrals to community care services. Participants also reported markedly increased use of cognitive screening tools in providing care. Community service providers recorded approximately 160 physician-initiated referrals over a 2 year-period post-training, compared to few beforehand., Conclusions: Combining a targeted physician practice-based educational intervention with community service engagement improves dementia care competency in clinicians and promotes linkages between clinical and community dementia care providers.
- Published
- 2013
- Full Text
- View/download PDF
32. Medication dosing errors in pediatric patients treated by emergency medical services.
- Author
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Hoyle JD, Davis AT, Putman KK, Trytko JA, and Fales WD
- Subjects
- Age Factors, Child, Child, Preschool, Confidence Intervals, Female, Health Care Surveys, Humans, Male, Michigan, Retrospective Studies, Safety Management, Emergency Medical Services statistics & numerical data, Medication Errors statistics & numerical data, Patient-Centered Care statistics & numerical data, Pediatrics statistics & numerical data, Safety statistics & numerical data
- Abstract
Background: Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients., Objective: To characterize medication dosing errors in children treated by EMS., Methods: We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone., Results: There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%., Conclusions: Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors.
- Published
- 2012
- Full Text
- View/download PDF
33. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?
- Author
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Holmes JF, Borgialli DA, Nadel FM, Quayle KS, Schambam N, Cooper A, Schunk JE, Miskin ML, Atabaki SM, Hoyle JD, Dayan PS, and Kuppermann N
- Subjects
- Adolescent, Child, Child, Preschool, Female, Glasgow Coma Scale, Head Injuries, Closed diagnostic imaging, Head Injuries, Closed therapy, Humans, Magnetic Resonance Imaging, Male, Neurologic Examination methods, Outcome Assessment, Health Care, Prospective Studies, Tomography, X-Ray Computed, Watchful Waiting, Head Injuries, Closed diagnosis, Hospitalization
- Abstract
Study Objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results., Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention., Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%)., Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary., (Copyright © 2010. Published by Mosby, Inc.)
- Published
- 2011
- Full Text
- View/download PDF
34. Factors associated with cervical spine injury in children after blunt trauma.
- Author
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Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, Adelgais KM, Anders J, Borgialli D, Donoghue A, Hoyle JD Jr, Kim E, Leonard JR, Lillis KA, Nigrovic LE, Powell EC, Rebella G, Reeves SD, Rogers AJ, Stankovic C, Teshome G, and Jaffe DM
- Subjects
- Accidents statistics & numerical data, Adolescent, Case-Control Studies, Child, Emergency Service, Hospital statistics & numerical data, Female, Glasgow Coma Scale, Humans, Infant, Injury Severity Score, Logistic Models, Male, Risk Factors, Cervical Vertebrae injuries, Wounds, Nonpenetrating complications
- Abstract
Study Objective: Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma., Methods: We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity., Results: We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses., Conclusion: We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation., (Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)
- Published
- 2011
- Full Text
- View/download PDF
35. Pain intervention for infant lumbar puncture in the emergency department: physician practice and beliefs.
- Author
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Hoyle JD Jr, Rogers AJ, Reischman DE, Powell EC, Borgialli DA, Mahajan PV, Trytko JA, and Stanley RM
- Subjects
- Anesthesia methods, Anesthesia statistics & numerical data, Anesthetics, Local therapeutic use, Emergency Medicine, Emergency Service, Hospital, Health Care Surveys, Humans, Infant, Newborn, Lidocaine therapeutic use, Midwestern United States, Pain etiology, Pediatrics, Spinal Puncture adverse effects, Analgesia methods, Analgesia statistics & numerical data, Attitude of Health Personnel, Pain drug therapy, Physicians psychology, Spinal Puncture methods
- Abstract
Objectives: The objectives were to characterize physician beliefs and practice of analgesia and anesthesia use for infant lumbar puncture (LP) in the emergency department (ED) and to determine if provider training type, experience, and beliefs are associated with reported pain intervention use., Methods: An anonymous survey was distributed to ED faculty and pediatric emergency medicine (PEM) fellows at five Midwestern hospitals. Questions consisted of categorical, yes/no, descriptive, and incremental responses. Data were analyzed using descriptive statistics with confidence intervals (CIs) and odds ratios (ORs)., Results: A total of 156 of 164 surveys (95%) distributed were completed and analyzed. Training background of respondents was 52% emergency medicine (EM), 30% PEM, and 18% pediatrics. Across training types, there was no difference in the belief that pain treatment was worthwhile (overall 78%) or in the likelihood of using at least one pain intervention. Pharmacologic pain interventions (sucrose, injectable lidocaine, and topical anesthetic) were used in the majority of LPs by 20, 29, and 27% of respondents, respectively. Nonpharmacologic pain intervention (pacifier/nonnutritive sucking) was used in the majority of LPs by 67% of respondents. Many respondents indicated that they never used sucrose (53%), lidocaine (41%), or anesthetic cream (49%). Physicians who thought pain treatment was worthwhile were more likely to use both pharmacologic and nonpharmacologic pain interventions than those who did not (93% vs. 53%, OR = 10.98, 95% CI = 4.16 to 29.00). The number of LPs performed or supervised per year was not associated with pain intervention use. Other than pacifiers, injectable lidocaine was the most frequently reported pain intervention., Conclusions: Provider beliefs regarding infant pain are associated with variation in anesthesia and analgesia use during infant LP in the ED. Although the majority of physicians hold the belief that pain intervention is worthwhile in this patient group, self-reported pharmacologic interventions to reduce pain associated with infant LP are used regularly by less than one-third. Strategies targeting physician beliefs on infant pain should be developed to improve pain intervention use in the ED for infant LPs., (© 2011 by the Society for Academic Emergency Medicine.)
- Published
- 2011
- Full Text
- View/download PDF
36. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
- Author
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Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, and Wootton-Gorges SL
- Subjects
- Algorithms, Biomechanical Phenomena, Brain Injuries diagnostic imaging, Brain Injuries mortality, Child, Child, Preschool, Decision Trees, Emergency Medicine methods, Humans, Intubation, Intratracheal statistics & numerical data, Patient Admission statistics & numerical data, Patient Selection, Pediatrics methods, Predictive Value of Tests, Prospective Studies, Risk Assessment standards, Risk Factors, Severity of Illness Index, Brain Injuries etiology, Craniocerebral Trauma complications, Craniocerebral Trauma diagnosis, Decision Support Techniques, Risk Assessment methods, Tomography, X-Ray Computed adverse effects, Tomography, X-Ray Computed statistics & numerical data
- Abstract
Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary., Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights)., Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations., Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated., Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.
- Published
- 2009
- Full Text
- View/download PDF
37. Incidental discovery of radiopaque pills on abdominal CT in a patient with abdominal pain.
- Author
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Judge BS and Hoyle JD Jr
- Subjects
- Abdominal Pain diagnostic imaging, Adolescent, Female, Humans, Tablets, Radiography, Abdominal, Stomach diagnostic imaging, Tomography, X-Ray Computed
- Abstract
We present a case in which a young female ingested several tablets of an over-the-counter cough and cold remedy over the course of a week. Pill fragments were identifiable and incidentally discovered when a CT scan of the abdomen was performed to evaluate the cause of her abdominal pain. Discovery of radiopaque pills on diagnostic imaging studies warrants further history and appropriate testing to rule out a life-threatening ingestion.
- Published
- 2008
- Full Text
- View/download PDF
38. Comparative study of airway management techniques with restricted access to patient airway.
- Author
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Hoyle JD Jr, Jones JS, Deibel M, Lock DT, and Reischman D
- Subjects
- Cohort Studies, Emergency Medical Services, Emergency Medical Technicians, Humans, Manikins, Physicians, Prospective Studies, Airway Resistance, Intubation, Intratracheal methods
- Abstract
Objective: To determine which airway endotracheal tube (ET), Combitube (CT), or Laryngeal Mask Airway (LMA) has the shortest time to successful ventilation in three nontraditional prehospital airway scenarios., Methods: Prospective randomized cohort study of emergency medicine (EM) residents, faculty EM physicians, and paramedics (EMT-P). Subjects were instructed to place an airway in a mannequin in three scenarios: mannequin supine under a table with head abutting a wall, mannequin sitting upright with access from behind, and mannequin lying on its side with access facing the mannequin. The number of airway placement attempts and time to successful ventilation were recorded., Results: Twenty-five resident physicians, 9 faculty physicians, and 22 EMT-Ps participated. No significant difference was found between the different airways in the number of attempts to successfully ventilate. EMT-Ps demonstrated significantly faster times to successful ventilation for all scenarios versus physicians (e.g., supine scenario with ET, EMT-P median time 57 seconds, physician median time 96 seconds) except for the mannequin lying on its side where there was no significant difference. The time to ventilation for all scenarios was less with the LMA versus ET or CT versus ET, except in the sitting scenario where ET and CT were comparable., Conclusions: In this mannequin model of restricted airway access, LMA resulted in significantly faster times to ventilation versus ET and CT in all but one scenario. Further consideration and study using airways other than ET are warranted for situations with restricted access to the patient's airway.
- Published
- 2007
- Full Text
- View/download PDF
39. Treatment of pediatric and adolescent mental health emergencies in the United States: current practices, models, barriers, and potential solutions.
- Author
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Hoyle JD Jr and White LJ
- Subjects
- Adolescent, Adult, Child, Emergencies, Emergency Medical Services statistics & numerical data, Health Services Accessibility, Humans, Mental Disorders diagnosis, Mental Disorders epidemiology, Mental Health Services statistics & numerical data, United States epidemiology, Suicide Prevention, Emergency Medical Services organization & administration, Emergency Service, Hospital statistics & numerical data, Mental Disorders therapy, Mental Health Services organization & administration
- Abstract
Mental illness significantly impairs the lives of 10% of all children and adolescents in the United States (National Institute of Mental Health. Brief Notes on the Mental Health of Children and Adolescents. Bethesda, MD: National Institute of Mental Health, 1999). Of the myriad mental health problems afflicting children, an alarming number are known to have grim outcomes. Some illnesses continue into adulthood, while others may culminate in death during adolescence. Despite the serious consequences of children's mental health problems, early treatment can improve or control these conditions. Even with this knowledge, seemingly little effort is geared toward removing barriers to treatment for these diseases that plague our children. As a part of its five-year plan, Emergency Medical Services for Children (EMSC) has collaborated with the National Association of EMS Physicians (NAEMSP) to examine childhood and adolescent mental health emergencies--particularly their presentation and management within the emergency medical services system. This document presents a critical review of current practices and models for treatment of children and adolescents that includes identification of barriers to mental health treatment and recommendations for their resolution.
- Published
- 2003
- Full Text
- View/download PDF
40. The Beverly Hills Club disaster.
- Author
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Hoyle JD
- Subjects
- Hospitals, Kentucky, Disaster Planning, Fires
- Published
- 1977
41. Tornadoes! Prepare for the unpredictable.
- Author
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Hoyle JD
- Subjects
- Hospital Design and Construction, Kentucky, Radio, Safety, United States, Weather, Disasters, Hospital Administration
- Published
- 1977
42. Students learn about the health care system.
- Author
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Connelly T Jr and Hoyle JD
- Subjects
- Attitude of Health Personnel, Community Health Services, Delivery of Health Care, Hospital Departments, Hospitals, Community, Kentucky, Personnel, Hospital, Schools, Health Occupations, Students, Health Occupations, Allied Health Personnel education, Curriculum, Inservice Training
- Published
- 1975
43. GALLSTONE ILEUS. CASE REPORT.
- Author
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HOYLE JD
- Subjects
- Cholelithiasis, Diagnosis, Differential, Gallstones, Geriatrics, Ileus, Intestinal Obstruction, Surgical Procedures, Operative, Water-Electrolyte Balance
- Published
- 1965
44. Diagnosis of early breast cancer.
- Author
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KLOPP CT, HOYLE JD, and BLADES BB
- Subjects
- Humans, Breast Neoplasms
- Published
- 1952
- Full Text
- View/download PDF
45. Multiple aorto-intestinal fistulas secondary to swallowed foreign body.
- Author
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HOYLE JD
- Subjects
- Humans, Digestive System, Foreign Bodies, Intestinal Fistula, Respiratory System
- Published
- 1949
46. Hyperparathyroidism.
- Author
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Hoyle JD
- Subjects
- Adult, Female, Humans, Male, Hyperparathyroidism diagnosis, Hyperparathyroidism therapy
- Published
- 1966
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