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Objective: To design a risk map (RM) as a tool for identifying and managing risks in the paediatric emergency department and to assess the impact of the improvement actions developed based on the identified risks in terms of the level of risk to patient safety., Methodology: A multidisciplinary working group reviewed the entire care process by applying the Failure Mode and Effects Analysis (FMEA) tool. Project phases: (1) RM 2017 and planning of improvement actions; (2) Development and implementation of improvement actions; (3) RM 2019; (4) Analysis: evolution of the RM and impact of improvement actions., Results: A total of 106 failure modes (FMs) were identified in the 2017 RM (54.7% high- or very high risk). We applied prioritization criteria to select the improvement actions to plan. Nineteen improvement actions were planned, with assigned responsible parties and deadlines, to address 46 priority FMs. One hundred percent were implemented. In the 2019 RM, we identified 110 FMs (48.2% high risk) and found an overall reduction of the risk level of 20%. Analysing the 46 priority FMs that had been addressed by the 19 planned improvement actions, we found that 60% had changed from high to medium risk level and that the risk level had decreased, both overall (-27.8%) and by process., Conclusion: The FMEA is a useful tool to identify risks, analyse the impact of improvement strategies and monitor the risk level of a complex clinical care department. The improvement actions developed succeeded in reducing the level of risk in the processes in our unit, improving patient safety., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Background: The main objective was to determine the clinical or analytical factors that independently predict risk of serious bacterial infection (RSBI) in immunocompetent patients older than 90 days given a diagnosis of fever and for whom neutropenia was an incidental finding. The secondary objective was to describe the prevalence of serious bacterial infections (SBIs)., Methods: This is a 3-year-long, multicenter, prospective analytical and observational study carried out at 6 pediatric emergency departments. Data for epidemiological, clinical, and analytical variables were collected., Results: One hundred forty patients with febrile neutropenia (60.7% mild, 39.3% moderate to severe) were recruited. Serious bacterial infection incidence was 15.0% (95% confidence interval [CI], 9-21): 1 Invasive Bacterial Infection (Staphylococcus epidermidis bacteremia), 10 urinary tract infections, 8 pneumonias, and 2 cellulitis. Median total neutrophil counts per microliter showed no statistically significant differences (P = 0.512; 1000 [750-1200] in SBI patients vs 1100 [800-1300] in non-SBI patients). Higher RSBI was observed in patients with neutrophils less than 20% relative to total leukocytes (SBI, 15, 26.3%) than in those with neutrophils of 20% or greater (SBI, 6, 7.2%) (odds ratio, 4.6; 95% CI, 1.7-12.7). In patients with greater than 5000 leukocytes/μL, a percentage of neutrophils less than 20% was related to a greater RSBI with a trend toward statistical significance (odds ratio, 6.1; 95% CI, 0.7-51.1; P = 0.066). The clinical variables did not show a significant association with RSBI., Conclusions: None of the clinical or analytical variables assessed were associated with the RSBI. However, according to a post hoc analysis, in patients with greater than 5000 leukocytes/μL, a neutrophil percentage less than 20% could be an independent risk factor for SBI. A thorough physical examination and basic diagnostic tests (urinalysis and chest x-ray) may help to establish a diagnosis of SBI in the vast majority of cases., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Thirty-eight million patients with injuries are treated in Emergency Departments every year, 90% of them being in the form of unintentional injuries (UIs). There are currently no global records of its management in Spain, or the risk factors that may be associated with them. The objective of this study is to describe the management of UIs in Spanish paediatric emergency departments, and to analyse factors related to the presence of serious injuries., Material and Methods: A sub-study of a prospective multicentre observational study conducted over 12months in 11hospitals of the Spanish Paediatric Emergency Research Group (RiSEUP-SPERG), including children from 0 to 16years of age consulting for UIs. Epidemiological data, circumstances of the injury, and data on emergency care and discharge destination were recorded on the 13th day of each month., Results: A total of 10,175 episodes were recorded, of which 1,941 were UIs (19.1%), including 1,673, of which 257 (15.4%) were severe. The most frequent complementary test was simple radiography (60.0%), and the most frequent procedure was limb immobilisation (38.6%). A significant relationship was found between presenting with a severe UI and age >5 years (OR2.24; 95%CI: 1.61-3.16), history of fracture (OR2.05; 95%CI: 1.22-3.43), or sports activity as a mechanism of injury (OR1.76; 95%CI: 1.29-2.38), among others., Conclusion: In Spain, most UIs are not serious. X-rays and immobilisation of extremities are the most frequently performed tests and procedures. Severe UIs were associated with individual factors, such as age >5years or history of fracture, and with sports activity as a mechanism associated with severity. It is vital to implement measures to improve the prevention of these injuries and to support the training of caregivers through educational programmes., (Copyright © 2020 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To analyse the clinical and epidemiological characteristics of children who are attended in Emergency Departments (EDs) for an unintentional injury in Spain., Methods: Multicentre case series with prospective data collection conducted during 12 months in the ED of 11 hospitals belonging to the Spanish Paediatric Emergency Research Group. Data were collected between September 2014 and January 2015, continuing for one year in all paediatric EDs, and included children between 0 and 16 years old seen for an unintentional injury., Results: A total of 10,175 episodes were recorded during the study, of which 1,941 were due to unintentional injuries (19.1%, 95% CI: 18.3%-19.8%), and 1,673 of these were included in the study. Falling, direct injuries, and injuries due to sports activities represented more than 80%, with significant variations in the injuries mechanism observed in different age groups. More than occurred at home or school. About 40% of the unintentional injuries were not witnessed by an adult. The most frequent diagnosis was limb trauma (63.0%), with a fracture being observed in 242 (14.4% of unintentional injuries). As regards fractures, 34 (2.0%) were admitted to hospital, with 21 (61.8%) for surgical reduction of the fracture. No deaths were recorded in the first 24h., Conclusions: Unintentional injuries constitute a very common reason for consultation in EDs in Spain. The circumstances surrounding the unintentional injuries should be considered, in order to develop preventive measures and to improve the training of people involved in the care of these children., (Copyright © 2018. Publicado por Elsevier España, S.L.U.)

Objectives: To describe epidemiological characteristics, types of injury, prognosis and medical management of bicycle-related Paediatric Emergency Department (ED) visits and to identify potential preventive measures., Patients and Methods: This multicentred, observational prospective study included all children between 3 and 16 years of age treated for bicycle-related injuries in the Emergency Departments of 15 Spanish Hospitals belonging to the «Unintentional Paediatric Injury Workshop» of the Spanish Paediatric Emergency Society between the 1(st) of June 2011 and the 31(st) of May 2012. Characteristics of all ED visits, as well as epidemiological data and accident-related information, were collected., Results: A total of 846 patients were included in the study, with a male predominance (72.9%) and a median age of 9.6 ± 3.6 years. Head injury was the third most common injury (22.3%) and the main cause of admission to the Pediatric Intensive Care Unit (PICU) (68.4%). More than three-quarters (77.9%) of the patients did not wear a helmet, which was significantly associated to a higher incidence of head injury and admission to PICU. Older children (OR 1.063) and bicycle injuries involving motor vehicles (OR 2.431) were identified as independent risk factors for worse outcomes., Conclusions: Since helmet use reduces up to 88% of central nervous system lesions secondary to head injury, promotion of its use should be the main preventive measure, followed by restriction of bike-riding to cycling areas., (Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

Introduction: Perianal dermatitis due to group A beta-hemolytic streptococcus is a rare diagnosis in pediatrics. Clinical manifestations include erythema, edema, and perianal pruritus associated with vulvovaginitis or balanitis, painful defecation, constipation, anal fissures, purulent discharge, and/or rectal bleeding., Material and Methods: A descriptive, observational, prospective study was conducted between May, 2004 and April, 2005. In children presenting to the emergency room with erythema, edema, and perianal pruritus, a rapid streptococcal antigen test and bacterial cultures of their perianal secretions were obtained. Patients with a positive result in the rapid test were treated with oral phenoxymethylpenicillin (40-50 mg/kg/day) for 10 days, after which clinical and bacteriological evaluations were conducted., Results: Of the 24 patients presenting with erythema, edema, and perianal pruritus, 19 patients (12 boys and 7 girls), aged between 6 months and 4 years (median age: 30 months), tested positive for group A beta-hemolytic streptococcus. Nine patients also presented with constipation, 5 with anal fissures, 4 with rectal bleeding, 2 with vulvovaginitis, and 1 with streptococcal pharyngoamygdalitis. Outcome was favorable in 85 % of the patients, and perianal isolation of group A beta-hemolytic streptococcus was negative after treatment in 95 %., Conclusions: In patients presenting with erythema, edema, and perianal pruritus, perianal streptococcal dermatitis should be ruled out. The rapid test for streptococcal antigen detection is a quick and reliable method for this diagnosis. The antibiotic of choice is oral penicillin.

Necrotizing fasciitis is a severe infection, with systemic involvement and tissue necrosis. The clinical course is rapid and often fatal. Although this entity is uncommon, early recognition and treatment is essential to improve prognosis. Necrotizing fasciitis should be suspected when there are symptoms of toxicity and there is severe pain, frequently out of proportion to the clinical findings. In addition, in the last few years the incidence of invasive disease due to Streptococcus pyogenes in children has increased. Treatment is based on life support, aggressive debridement, and antimicrobial therapy. Intravenous immunoglobulin (IVIG) as adjunctive therapy seems useful and reduces mortality. The case of an infant with necrotizing fasciitis of four extremities is presented.

The intraosseous infusion is an easy technique to learn. The chosen places for infusion are: proximal tibia, distal tibia and distal femur. We have used this technique on thirteen occasions in emergency situations. In all cases, access was achieved in less than one minute. Saline, glucose and Ringer's solutions, sodium bicarbonate, blood, calcium chloride, epinephrine, atropine, succinylcholine, dopamine, dobutamine, isoproterenol, lidocaine and anticonvulsants may be infused. The doses are the same as those used in parenteral access and its efficacy is similar to that of a central venous line. Complications are rare. The most frequent is subcutaneous, and occasionally subperiosteal infiltration. Osteomyelitis appeared in 0.6% of the cases. The intraosseous infusion provides rapid, easy and safe vascular access in emergency situations. Therefore, we believe that this technique should be chosen in pediatric patients.