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Objectives The aims of the study were (1) to determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level 1 trauma center emergency department (ED), (2) to identify variables associated with neck pain in this population, and (3) to report on aspects of care received in the ED including imaging and medication use. Methods This is a retrospective chart review of 652 patients presenting to a pediatric ED with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical examination, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion-related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine whether they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables. Results Of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging of the spine. They were also more likely to receive a referral and follow-up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic. Conclusions Neck pain is a common symptom in pediatric patients with mTBI, although it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. Although patients with neck pain were more likely to receive a referral and follow-up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.

Background Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018–2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7–18 years who present to our Level 1 emergency department/trauma center with a violent injury. Methods For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts. Results The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase. Conclusion(s) We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

The aim of this study was to prospectively investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs).Prospective cohort study of children age 0 to 18 years who activated the trauma team response between August 15, 2017, and February 12, 2019, at a large, urban pediatric emergency department (ED).The relationship between the lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) was investigated. Categorical variables were analyzed by χ 2 test, and continuous variables were analyzed by Student t test.A total of 148 pediatric trauma patients had somatic NIRS monitoring and met the inclusion criteria. Overall, 65.5% were male with a mean ± SD age of 10.9 ± 6.0 years. Injuries included 67.6% blunt trauma and 28.4% penetrating trauma with mortality of 3.4% (n = 5). Overall, the median lowest somatic NIRS value was 72% (interquartile range, 58%-88%; range, 15%-95%), and 43.9% of patients had a somatic NIRS value70%. The median somatic NIRS duration recorded was 11 minutes (interquartile range, 7-17 minutes; range, 1-105 minutes). Overall, 36.5% of patients required a LSI including 53 who required a lifesaving procedure, 17 required blood products, and 17 required vasopressors. Among procedures, requiring a thoracostomy was significant.Pediatric trauma patients with a somatic NIRS value70% had a significantly increased odds of requiring a LSI (odds ratio, 2.11; 95% confidence interval, 1.07-4.20). Somatic NIRS values70% had a sensitivity and specificity of 56% and 63%, respectively.Pediatric trauma patients with somatic NIRS values70% within 30 minutes of ED arrival have an increased odds of requiring LSIs. Among LSIs, pediatric trauma patients requiring thoracostomy was significant. The role of NIRS in incrementally improving the identification of critically injured children in the ED and prehospital setting should be evaluated in larger prospective multicenter studies.

The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown. We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one’s own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire. This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance a priori as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to

OBJECTIVES: Academic emergency departments (ED) rely on a steady flow of patients to provide residents with good clinical training. Understanding institutional volume patterns allows training directors to create a schedule that maximizes learning opportunities while also adequately staffing the ED. Our primary objective of this study was to utilize heat‐mapping software to optimize resident staffing in an academic ED. METHODS: Heat‐mapping tools within Microsoft Excel were utilized to overlay ED patient arrival patterns on top of the potential patients per hour based on published productivity data for trainees and historical averages for advanced practice providers at our institution. Time frames for under‐ and overstaffing were identified and color‐coded. This analysis informed a revised schedule template and the same heat‐mapping process was used to determine the appropriateness of the revised staffing template. RESULTS: The heat map for the original schedule template revealed understaffing in the morning and overstaffing the rest of the day. Informed by these findings, schedule adjustments were made. There was no net increase in the number of resident or advanced practice provider coverage hours. Prior to implementation, the ED was understaffed by 5% or more during 18.4% of operating hours. Following changes to the staffing template, only 5.9% of operating hours were understaffed (p

Introduction Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018-2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019-2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients. Methods Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months-18 years old, emergency severity index score 2-5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure. Results We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2. Conclusions This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

Objective The primary purpose of this study is to determine if there is an association between proximity to protective community assets and youth well-being following exposure to violence. Methods This study is a retrospective data analysis using existing data from 471 participants in a violence intervention program. Street addresses of participants were mapped using ArcMap version 10.8.1 mapping software and a buffer analysis was conducted to determine the association between victim well-being and proximity to green space. Results Living close to a green space is associated with decreased fatigue at 1000 ft (p=0.3), 1500 ft (p=0.01), and 2000ft (p=0.008). Proximity to green space is associated with increased overall psychosocial well-being at 1500ft (p=0.004) and 2000ft (p

INTRODUCTION The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) pain crisis management recommend opioids within 60 minutes of emergency department (ED) registration and every 30 minutes thereafter until acute pain is managed. These guidelines are based on expert opinion without published, supporting data. OBJECTIVE To evaluate the association between timely ED opioid administration and hospitalization rates in children with SCD. METHODS Retrospective cohort of children presenting to a children's hospital ED with SCD pain between January 1, 2014, and April 30, 2018. Visits were extracted using ICD codes, chief complaints, and receipt of at least one opioid, and then reviewed to confirm the visit was an uncomplicated pain crisis. The primary outcome was hospitalization, yes or no. Generalized estimating equations were used to determine adjusted odds of hospitalization for the timely administration of initial and second doses of opioids. RESULTS Of the 902 eligible visits, 368 (40.8%) resulted in hospitalization. The mean (SD) age was 11.9 (± 5.2) years. The first opioid was administered within 60 minutes of arrival in 601 (66.6%) visits. The second opioid was administered within 30 minutes of the first in 84 (12.3%) visits. Receipt of the first opioid within 60 minutes of arrival was not associated with decreased hospitalization (1.30 [0.96-1.76]). However, receipt of the second dose within 30 minutes of the first was associated with decreased hospitalization (0.56 [0.33-0.94]). CONCLUSION This study suggests an association between children with SCD receiving a second dose within 30 minutes of the first opioid dose and decreased hospitalizations.

Supplemental Digital Content is available in the text., Introduction: Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017–2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s Methods: Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution. Results: We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital. Conclusions: We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.

Background: Suicide is the second leading cause of death in older children. Suicide has tripled in children 10-14 years and increased by 75% in adolescents 15-19 years from 2007-2017. Because children at risk for suicide may be difficult to detect, routine screening is necessary. The emergency department (ED) is an ideal location to perform screening because adolescents who use the ED engage in risky behaviors. However, during the pre-implementation period of this study only 1% of children >11 presenting to this ED …

Background Universal administration of the influenza vaccine is the best strategy for preventing morbidity and mortality. Vaccine administration in the emergency department (ED) is an innovative approach to improving vaccination rates. However, during the 2017–2018 influenza season only 75 influenza vaccines were administered, 0.2% of the total population in this tertiary care ED. Objectives We aimed to increase the number of influenza vaccines administered from 75 to 1000 in patients discharged from the ED between September 2018 and March 2019. Methods A multidisciplinary workgroup performed process mapping to identify potential barriers and solutions. The electronic health record was engineered to facilitate our key interventions: a required influenza vaccination screening question, scripted patient education, and an influenza vaccine nursing protocol with a clinical decision support tool. Interventions were tested using plan-do-study-act cycles. Process measures included percent screened and percent requested. The primary outcome was the number of influenza vaccines administered. The balancing measure was ED length of stay. Results 33,311 ED patients met inclusion criteria. In this population, influenza vaccination screening rates improved from 0 to 90% (figure 1) and 41% of children were found to be unvaccinated. 1323 children (4%) received the influenza vaccine (figure 2). Additionally, there was no change in ED LOS (139 min). Conclusions An efficient, nurse-driven workflow that screened for vaccination status, educated parents, and then provided the influenza vaccination to children during the ED visit significantly increased the number of children receiving the influenza vaccine from 75 to 1323 without extending length of stay.

Objective Controversy exists regarding which febrile children with sickle cell disease (SCD) should receive a chest x-ray (CXR). Our goal is to provide data informing the decision of which febrile children with SCD presenting to the emergency department (ED) require a CXR to evaluate for acute chest syndrome (ACS). Methods Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED at one of two academic children's hospitals with fever ≥38.5°C between January 1, 2010, and December 31, 2012. Demographic characteristics, respiratory symptoms, and laboratory results were abstracted. The primary outcome was the presence of ACS. Binary recursive partitioning was performed to determine predictive factors for a diagnosis of ACS. Results A total of 185 (10%) of 1,837 febrile ED visits met ACS criteria. The current National Heart, Lung, and Blood Institute (NHLBI) consensus criteria for obtaining a CXR (shortness of breath, tachypnea, cough, or rales) identified 158 (85%) of ACS cases, while avoiding 825 CXRs. Obtaining a CXR in children with NHLBI criteria or chest pain and in children without those symptoms but with a white blood cell (WBC) count ≥18.75 × 109/L or a history of ACS identified 181 (98%), while avoiding 430 CXRs. Conclusion Children with SCD presenting to the ED with fever and shortness of breath, tachypnea, cough, rales, or chest pain should receive a CXR due to high ACS rates. A higher WBC count or history of ACS in a child without one of those symptoms may suggest the need for a CXR. Prospective validation of these criteria is needed.

The impact of emergency department (ED) treatment on outcomes of sickle cell disease (SCD) acute pain hospitalizations is not well described. We investigated whether length of stay (LOS) and change in health-related quality of life (HRQL) are affected by initial opioid dose and time to administration. We conducted secondary analyses of data from the randomized-controlled Magnesium for children in Crisis (MAGiC) trial. The primary outcome was LOS. Secondary outcome was change in HRQL, assessed using PedsQL SCD Pain and Hurt and Pain Impact Domains measured in ED and at discharge. Independent variables were (1) time to first IV opioid, (2) total initial opioid dose (mg/kg/hr of morphine equivalents administered between ED and first study drug), and (3) Time to first oral opioid. Spearman correlations determined the associations with LOS. Using two-sample t-tests, we compared mean change in HRQL scores between IV opioid initiated within 60 and60 min, opioid doses in the highest and lowest tertiles, and oral opioid initiated within 24 and24 hr. Two hundred and four patients participated at 8 sites. Mean (SD) age was 13.6 (4.7) years. Earlier initiation of oral opioids was strongly correlated with shorter LOS (r = 0.61, P 0.01). Higher initial opioid dose was weakly correlated with longer LOS (r = 0.34, P 0.01). Higher initial opioid doses (6 vs -2.2; P = 0.01) and oral opioids initiated within 24 hr (5.7 vs -1.7, P = 0.04) were associated with larger mean change in HRQL at discharge. Prospective trials evaluating the impact of ED care on outcomes of pain hospitalizations could improve SCD pain treatment. Am. J. Hematol. 91:1175-1180, 2016. © 2016 Wiley Periodicals, Inc.

Enrollment of patients in sickle cell intervention trials has been challenging due to difficulty in obtaining consent from a legal guardian and lack of collaboration between emergency medicine and hematology. We utilized education and preconsent in a pediatric multisite sickle cell intervention trial to overcome these challenges. Overall, 48 patients were enrolled after being preconsented. Variable Institutional Review Board policies related to preconsent validity and its allowable duration decreased the advantages of preconsent at some sites. The utility of preconsent for future intervention trials largely depends on local Institutional Review Board policies. Preeducation may also benefit the consent process, regardless of site differences.

OBJECTIVES Urgent medical evaluation is recommended for patients with sickle cell disease (SCD) and fever. Clear recommendations exist regarding certain aspects of treatment, but other areas lack evidence. We determined practice variation for children with SCD presenting with fever to the emergency department (ED). METHODS Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED with fever greater than or equal to 38.5°C in the ED or preceding 24 hours. Visits from 3 sickle cell centers were included. Outcomes included blood culture, complete blood count, antibiotic treatment, chest x-ray, urinalysis, electrolytes, and hospital disposition. Differences greater than 10% were considered clinically meaningful. RESULTS The population included 14,454 visits, of which 4143 (29%) were febrile and met all inclusion criteria. A complete blood count and blood culture were obtained at 94% of visits, and antibiotics were given at 91%, with no differences among sites. Meaningful differences existed for disposition, with 52%, 43%, and 99% of patients admitted to the inpatient units at hospitals A, B, and C, respectively. Differences were seen in obtaining a urinalysis (33%, 17%, and 21%), electrolytes (2%, 50%, and 12%), and chest x-rays for patients 2 years and older (78%, 77%, 64%) for hospitals A, B, and C, respectively. CONCLUSIONS Significant variation exists in the proportion of children who receive a urinalysis, electrolytes, chest x-ray, and, most importantly, admission to the hospital. These examples of practice variation represent potential opportunities to define best care practices for children with SCD presenting to the ED for fever.

OBJECTIVES Today's emergency department (ED) providers spend a significant amount of time on medical record documentation, decreasing clinical productivity. One proposed solution is to utilize medical scribes who assist with documentation. We hypothesized that scribes would increase provider productivity and increase provider satisfaction without affecting patient experience or nursing satisfaction. METHODS We conducted an observational pre-post study comparing ED prescribe and postscribe clinical productivity metrics for 18 pediatric emergency medicine physicians, two general pediatricians, and two nurse practitioners working in the 12-bed nonurgent area of the pediatric ED. Productivity metrics included patients per hour (pts/hr), work relative value units per hour (wRVUs/hr), and visit duration measured for 1 year pre- and postscribe implementation. Cross-sectional satisfaction surveys were administered to patient families, providers, and nurses during the initial scribe rollout. RESULTS Overall, 24,518 prescribe and 27,062 postscribe visits were analyzed. Following scribe implementation, overall provider efficiency increased by 0.24 pts/hr (11.98%, p

Background Academic institutions rely on resident physicians to adequately staff emergency departments while residency programs need a steady flow of patients in order to provide trainees with a good clinical experience. Feedback from end-of-rotation evaluations suggest that residents feel competition for patients during some shifts and overworked during others. To investigate this, we utilized heat-mapping software to determine the degree of over- and under-staffing by hour of the day in the ED. Objective Utilize heat-mapping to develop an evenly-distributed staffing model in the ED at a tertiary care children's hospital Design/Methods Heat-mapping software within Excel (Microsoft Corp, Seattle, WA) was utilized to overlay ED patient arrival patterns from June 2017-May 2018 on top of the potential patients per hour based on national estimates for trainees. Time-frames for under- and over-staffing were identified. A new schedule matrix was implemented in October 2018 and the same heat-mapping process was used to determine appropriateness of the staffing matrix. Given the visual nature of the study, results are presented descriptively. Results Analysis of the heat-map revealed that the current schedule matrix significantly under-staffed in the morning between 7-11am and over-staffed the rest of the day. A heat map representing usual staffing from October to December 2017 is shown in figure 1 and highlights the mismatch. Changes were made to the staffing matrix informed by the findings which resulted in more appropriate staffing during morning hours and evening hours for the months of October to December 2018 (figure 2). Conclusion(s) Novel use of heat-mapping software has the potential to successfully match ED patient arrival patterns to an appropriate resident staffing matrix. Future directions include incorporation of variable productivity to account for fatigue as the shift progresses.

Magnesium, a vasodilator, anti-inflammatory, and pain reliever, could alter the pathophysiology of sickle cell pain crises. We hypothesized that intravenous magnesium would shorten length of stay, decrease opioid use, and improve health-related quality of life (HRQL) for pediatric patients hospitalized with sickle cell pain crises. The Magnesium for Children in Crisis (MAGiC) study was a randomized, double-blind, placebo-controlled trial of intravenous magnesium vs normal saline placebo conducted at 8 sites within the Pediatric Emergency Care Applied Research Network (PECARN). Children 4 to 21 years old with hemoglobin SS or Sβ(0) thalassemia requiring hospitalization for pain were eligible. Children received 40 mg/kg of magnesium or placebo every 8 hours for up to 6 doses plus standard therapy. The primary outcome was length of stay in hours from the time of first study drug infusion, compared using a Van Elteren test. Secondary outcomes included opioid use and HRQL. Of 208 children enrolled, 204 received the study drug (101 magnesium, 103 placebo). Between-group demographics and prerandomization treatment were similar. The median interquartile range (IQR) length of stay was 56.0 (27.0-109.0) hours for magnesium vs 47.0 (24.0-99.0) hours for placebo (P = .24). Magnesium patients received 1.46 mg/kg morphine equivalents vs 1.28 mg/kg for placebo (P = .12). Changes in HRQL before discharge and 1 week after discharge were similar (P > .05 for all comparisons). The addition of intravenous magnesium did not shorten length of stay, reduce opioid use, or improve quality of life in children hospitalized for sickle cell pain crisis. This trial was registered at www.clinicaltrials.gov as #NCT01197417.

BACKGROUND: Penicillin allergy is commonly reported in the pediatric emergency department (ED). True penicillin allergy is rare, yet the diagnosis results from the denial of first-line antibiotics. We hypothesize that all children presenting to the pediatric ED with symptoms deemed to be low-risk for immunoglobulin E-mediated hypersensitivity will return negative results for true penicillin allergy. METHODS: Parents of children aged 4 to 18 years old presenting to the pediatric ED with a history of parent-reported penicillin allergy completed an allergy questionnaire. A prespecified 100 children categorized as low-risk on the basis of reported symptoms completed penicillin allergy testing by using a standard 3-tier testing process. The percent of children with negative allergy testing results was calculated with a 95% confidence interval. RESULTS: Five hundred ninety-seven parents completed the questionnaire describing their child’s reported allergy symptoms. Three hundred two (51%) children had low-risk symptoms and were eligible for testing. Of those, 100 children were tested for penicillin allergy. The median (interquartile range) age at testing was 9 years (5–12). The median (interquartile range) age at allergy diagnosis was 1 year (9 months–3 years). Rash (97 [97%]) and itching (63 [63%]) were the most commonly reported allergy symptoms. Overall, 100 children (100%; 95% confidence interval 96.4%–100%) were found to have negative results for penicillin allergy and had their labeled penicillin allergy removed from their medical record. CONCLUSIONS: All children categorized as low-risk by our penicillin allergy questionnaire were found to have negative results for true penicillin allergy. The utilization of this questionnaire in the pediatric ED may facilitate increased use of first-line penicillin antibiotics.

Enrollment of patients in sickle cell intervention trials has been challenging due to difficulty in obtaining consent from a legal guardian and lack of collaboration between emergency medicine and hematology. We utilized education and preconsent in a pediatric multisite sickle cell intervention trial to overcome these challenges. Overall, 48 patients were enrolled after being preconsented. Variable Institutional Review Board policies related to preconsent validity and its allowable duration decreased the advantages of preconsent at some sites. The utility of preconsent for future intervention trials largely depends on local Institutional Review Board policies. Preeducation may also benefit the consent process, regardless of site differences.

BACKGROUND:The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors' practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines.METHODS:A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations.RESULTS:A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis—antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms—physician visit (45.6%), antibiotics (10%), and symptom resolution (25%).CONCLUSIONS:Directors’ self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.

OBJECTIVE:No study has evaluated the association between state endorsement of American Academy of Pediatrics (AAP) and American Public Health Association (APHA) national guidelines and unnecessary exclusion decisions. We sought to determine the rate of unnecessary exclusion decisions by child care directors in a state that endorses AAP/APHA guidelines and to identify factors that are associated with higher unnecessary exclusion decisions.METHODS:A telephone survey was administered to directors in metropolitan Milwaukee, Wisconsin. Directors were randomly sampled from a list of 971 registered centers. Director, center, and neighborhood characteristics were obtained. Directors reported whether immediate exclusion was indicated for 5 vignettes that featured children with mild illness that do not require exclusion by AAP/APHA guidelines. Weighted data were summarized by using descriptive statistics. Regression analysis was used to identify factors that were associated with directors' exclusion decisions.RESULTS:A total of 305 directors completed the survey. Overall, directors would unnecessarily exclude 57% of children. More than 62% had never heard of the AAP/APHA guidelines. Regression analysis showed fewer exclusions among more experienced compared with less experienced directors, among larger centers compared with smaller centers, and among centers that were located in areas with a higher percentage of female heads of household. Centers with ≤10% children on state-assisted tuition excluded more.CONCLUSIONS:High rates of inappropriate exclusion persist despite state endorsement of AAP/APHA guidelines. Focused initial and ongoing training of directors regarding AAP/APHA guidelines may help to reduce high rates of unnecessary exclusions.

Background A previous study reported increased dissatisfaction with hospital care for children with sickle cell disease (SCD); however, its small size excluded determining whether race and chronic disease explained the difference. Procedure At hospital discharge, parents of children with SCD completed a survey assessing satisfaction with their child's hospital care. Results were compared to three years of satisfaction surveys for children with asthma or admitted to a general pediatrician's service collected as quality improvement for the hospital. The primary outcome was parent reported dissatisfaction with care. A chi-square was used to compare dissatisfaction between SCD and each comparison group. Results Parents of 639 children were included, 34 children with SCD, 124 with asthma, and 481 general pediatric patients. Parents of children with SCD were more often dissatisfied with their child's care compared to children with asthma (32.4% vs. 16.9%, P

Emergency department (ED) visits by children with sickle cell disease (SCD) are often classified as urgent based on resource utilization. This classification may not accurately reflect the potentially preventable nature of SCD visits. We sought to determine the proportion of SCD crisis-related pediatric ED visits that are possibly preventable.We reviewed 2 years of ED visits with a diagnosis of SCD with crisis at a hospital with an established sickle cell program. Criteria for preventable visits were predefined by pediatric hematologists. Non-pain-related chief complaints requiring emergent evaluation or painful episodes preceded by 2 opioid doses were considered not preventable; others were potentially preventable.The study included 603 visits by 187 patients; 33% were potentially preventable. Overall, 29% of visits were emergent based on non-pain-related emergent complaints. Of the remaining pain-related visits, 26% were preceded by 2 or more doses of opioids at home. Visits by children with asthma were 0.58 times as likely to be preventable, due to more non-pain-related emergent chief complaints (32%) and more children (36%) taking 2 or more opioid doses.Approximately two thirds of SCD crisis-related pediatric ED visits are not immediately preventable; that percentage is higher in children with asthma.

OBJECTIVE: To better understand parental decisions to seek care for their children and physician perceptions of parents' decisions to seek nonurgent emergency-department care. PATIENTS AND METHODS: In-depth interviews of 26 parents of children and 20 primary care physicians of the same children presenting for nonurgent care at a children's hospital emergency department were completed. Parent accounts of events that preceded the emergency-department visit were coded and qualitatively analyzed for themes. Physician evaluations of the accounts of events and parental decisions were ascertained through interviews with primary care physicians, who also described their practice characteristics. The parent/physician analyses allowed for an investigation of all aspects of the child's care and were designed to reveal differences between parent and physician beliefs. RESULTS: Parents believed that they acted appropriately, and physicians approved of parents' decisions. Four main themes emerged: (1) immediate reassurance that their children are safe from harm is critical to parents' decisions; (2) primary care offices lack specific tests and treatments that parents and physicians believe may be necessary, regardless of whether they are actually needed; (3) discrepancies exist between physician and parent perceptions of adequate communication and access; and (4) nonurgent emergency-department visits are not perceived as a significant enough breach in continuity of care by physicians and parents to warrant any concern. CONCLUSIONS: When individual interviews were evaluated, neither parents nor primary care physicians saw nonurgent emergency-department visits as a significant enough problem to warrant any change in physician care practices or parent care-seeking behavior.

Background Rehospitalization rates are increasingly used as quality indicators for a variety of illnesses, including sickle cell disease. While one small, single center study suggested outpatient follow-up with a pediatric hematologist was associated with fewer rehospitalizations, no study has examined the effect of post-discharge outpatient follow-up on rehospitalization rates across ages and beyond a single site. Procedure This is a retrospective cohort study using Wisconsin Medicaid claims data for hospitalized children and adults with sickle cell disease from 2003 to 2007. The primary outcomes were rehospitalization at both 14 and 30 days after an index hospitalization for sickle cell pain crisis (ICD-9-CM codes 28242, 28262, 28264, 28269). Univariate survival analyses were performed based on outpatient visit, severe disease, asthma, and age. The Cox proportional hazards model was used for multivariate analyses yielding hazard ratios for the association between outpatient visits and subsequent rehospitalization rates. Results Of the 408 patients included, 42 (10.2%) patients were rehospitalized within 14 days and 70 (17.1%) were rehospitalized within 30 days. Multivariate analysis showed that an outpatient visit is associated with lower rates of both 30-day rehospitalization (Hazard Ratio (HR) 0.442; 95%CI: 0.330–0.593) and 14-day rehospitalization (HR 0.226; 95%CI: 0.124–0.412), with the majority of 30-day rehospitalizations occurring within 14 days. Conclusions For sickle cell disease, post-discharge planning should emphasize early follow-up to prevent subsequent hospitalization and improve care quality. Pediatr Blood Cancer 2012; 58: 406–409. © 2011 Wiley Periodicals, Inc.

Sickle-cell disease is not a reportable condition, making it difficult to ascertain the number of affected individuals. We estimated the number of people with sickle-cell disease for the United States and each individual state, adjusting for increased mortality. US Census population data for each of the 50 states plus the District of Columbia were obtained. The published prevalence of sickle-cell disease for blacks and Hispanics of either Mexican or non-Mexican ancestry was applied. Analysis revealed 89,079 (95% confidence interval: 88,494―89,664) people with sickle-cell disease in the United States, 80,151 black and 8928 Hispanic. The state with the highest sickle-cell population was New York with 8308, followed by Florida with 7539, and Texas with 6765 people with sickle-cell disease. This study provides important information for researchers and policymakers attempting to better plan for the care of the sickle-cell population.

A previous study reported increased dissatisfaction with hospital care for children with sickle cell disease (SCD); however, its small size excluded determining whether race and chronic disease explained the difference.At hospital discharge, parents of children with SCD completed a survey assessing satisfaction with their child's hospital care. Results were compared to three years of satisfaction surveys for children with asthma or admitted to a general pediatrician's service collected as quality improvement for the hospital. The primary outcome was parent reported dissatisfaction with care. A chi-square was used to compare dissatisfaction between SCD and each comparison group.Parents of 639 children were included, 34 children with SCD, 124 with asthma, and 481 general pediatric patients. Parents of children with SCD were more often dissatisfied with their child's care compared to children with asthma (32.4% vs. 16.9%, P0.05) and general pediatric patients (32.4% vs. 14.6%, P0.05). Among all children, dissatisfaction was higher in families with minority children (21.1% vs. 12.6%); this difference did not exist among children with asthma. Among African-American children, a higher proportion of parents of children with SCD believed their child was treated differently because of race than children with asthma (45.5% vs. 2.8%, P0.01) or general pediatric patients (45.5% vs. 8.3%, P0.01).Parents of children with SCD report increased dissatisfaction with care. While dissatisfaction was higher in minority families, the high rate of parental concern about race as a reason for families of children with SCD is not seen in African-American families of children with asthma.

There is currently no standardized approach to emergency department (ED) and inpatient treatment of an acute pain event for patients with sickle cell disease (SCD). In addition, how the initial treatment of a pain event influences the outcome of that pain event is not well described. In surgical patients, aggressive pre-operative and peri-operative pain management is associated with improved pain outcomes post-operatively. Furthermore, in post-operative patients, using oral opioids alone or in combination with intravenous (IV) opioids is shown to provide better pain control, decreased IV opioid consumption, less side effects and higher patient satisfaction. In SCD, it is not known whether more aggressive opioid treatment at presentation to ED care or earlier initiation of oral opioids after hospitalization is associated with improved outcomes. Thus, we sought to determine the impact of the following treatment-related aspects of acute pain events on length of hospital stay: 1) total opioid dose at presentation, 2) time to initiation of first IV opioid at presentation, and 3) time to initiation of first oral opioid after hospitalization. We hypothesized that increased total initial dose of opioids, more rapid initiation of IV opioids in the ED, and earlier initiation of oral opioids after hospitalization would be associated with shorter length of hospital stay. We conducted a secondary analysis of data from the randomized controlled Magnesium for children in Crisis (MAGiC) trial. The MAGiC trial was a double-blind randomized controlled trial of IV magnesium versus saline placebo added to standard treatment for pediatric pain events. All patients had HbSS or HbSβ0 thalassemia to be eligible. The primary outcome, length of stay, was a composite endpoint of actual discharge or 12 hours after administration of last IV opioid, whichever came first. Patients were defined as having severe disease if a history of acute chest syndrome and/or 3 or more pain hospitalizations in the prior 3 years existed. A priori, all pain events were considered severe as the need for hospitalization indicated failure of outpatient therapy. Our primary variables of interest were: 1) Total initial opioid dose: total mg/kg/hr of morphine equivalents administered between first opioid in ED through start of study drug, 2) Time to first IV opioid: total hours between ED arrival and first IV opioid, 3) Time to first oral opioid: total hours between ED arrival and start of first oral opioid after hospitalization. Spearman correlations were used to determine the association between the above variables and length of stay and between length of stay and rehospitalization within 7 days to determine the consequence of earlier discharge. A total of 204 patients were enrolled at 8 sites. Mean (SD) age was 13.6 (4.7) years, 51.5% were female, 88.2% had severe disease and 60.3% were taking hydroxyurea. The primary MAGiC trial analysis found IV magnesium had no impact on length of stay. The mean total initial dose of opioid was 0.043 (0.029) mg/kg/hr that was administered over a median of 8.5 (IQR 6.4-13.1) hours. Higher total initial opioid dose was correlated with shorter length of stay (r=0.34, p Earlier initiation of oral opioids was strongly associated with shorter length of stay without associated increased rehospitalizations. Higher doses of opioids during the initial management of a pain event also contributed to shorter length of stay, however, more rapid initiation of IV opioids did not alter length of stay. These data suggest that higher initial doses of opioids in the ED and earlier introduction of oral opioids after hospitalization may improve outcomes of pain events. Prospective trials designed to evaluate the impact of initial ED care on outcomes of hospitalizations for pain events and trials aimed at standardizing inpatient treatment for pain events are needed and could ultimately lead to improved outcomes for pain in children with SCD. Disclosures Brandow: NIH, ASH: Research Funding. Panepinto:NKT Therapeutics, Inc: Consultancy; HRSA, NIH: Research Funding. Brousseau:NIH: Research Funding.

Background The National Heart, Lung, and Blood Institute Consensus Expert Panel recommends emergency department evaluation for all patients with sickle cell disease who develop a fever. However, it is unclear what recommended components are present in institutional care plans for their patients with sickle cell disease and what variation exists in the evaluation of patients who present with sickle cell disease and fever across institutions. There are few studies evaluating this practice variation and little evidence concerning the appropriate work-up of these children. Our objective was to describe areas where significant practice variation exists in the care of children with sickle cell disease presenting with fever to established sickle cell centers. Methods We undertook a retrospective cross-sectional study of the actual care received at three comprehensive sickle cell centers at pediatric hospitals to understand the diagnostic evaluation, treatment and disposition of children ages 3 months to 21 years presenting to the emergency department with sickle cell disease and fever. Chart reviews were performed on all visits of children presenting with a diagnosis of sickle cell disease to the emergency department of one of the three participating sites between January 1, 2008 and December 31, 2012. All charts were reviewed, and any chart with a documented fever ≥ 38.5°C, either at home or in the emergency department, was included for analysis. Data abstraction included laboratory and radiographic evaluation as well as antibiotic use and disposition. All children pretreated with an antibiotic within the past 24 hours were excluded from the analysis as this could alter the diagnostic evaluation and disposition of these patients. Descriptive statistics were used to determine the percent of children who received a chest radiograph, blood culture, complete blood count, urinalysis, electrolytes, treatment with an antibiotic, and disposition of hospital admission. Due to the large sample sizes, relatively small differences in proportions were determined to be statistically significant; however, differences of less than 10 percent were not considered to necessarily be indicative of clinically meaningful differences in evaluation or treatment, and therefore differences smaller than 10% were reported as similar. Results Analysis to date reveals complete evaluation of 1251 visits [673 at the Children's Hospital of Wisconsin (CHW), 368 at Children's National Medical Center (CNMC), and 210 at Children's Hospital of Philadelphia (CHOP)]. The median age of the children at these visits was 3.4 years (interquartile range of 1.4 - 7.7). Analysis of diagnostic testing revealed approximately 98 percent of patients received a complete blood count and a blood culture, with no difference between sites. Ninety-three percent of patients were treated with an antibiotic, which also showed no meaningful difference across sites. Analysis of disposition revealed significant differences between sites, with 49%, 47%, and 100% of patients admitted to the inpatient units at CHW, CNMC and CHOP, respectively. Likewise, significant differences were seen in obtaining chest radiographs: 81%, 92%, and 29% at CHW, CNMC and CHOP, respectively. The percent of patients who received a urinalysis ranged from a high of 39% at CNMC to a low of 18% at CHOP. Electrolytes were obtained from 3%, 48% and 1% of patients at CHW, CNMC and CHOP, respectively. Conclusion Consistent with NHLBI guidelines, essentially all children with sickle cell disease presenting to the emergency department with fever receive a complete blood count, blood culture and antibiotics. These equal proportions suggest similar treatment guidelines across sites. There is significant variation between sites in the proportion of children who receive a chest x-ray, urinalysis, electrolytes and perhaps most importantly, admission to the hospital. These examples of practice variation may represent potential areas for quality improvement efforts to better define best care practices for children with sickle cell disease presenting to the emergency department for fever. Disclosures: No relevant conflicts of interest to declare.

To describe bottled water use and beliefs and attitudes about water among parents of children from different racial/ethnic groups.Cross-sectional survey.Urban/suburban emergency department.Parents of children treated between September 2009 and March 2010.The respondents completed a questionnaire in English or Spanish, describing their use of bottled water and tap water for their children and rating their agreement with a series of belief statements about bottled water and tap water. Logistic regression was used to evaluate the association between bottled water use and beliefs and demographic characteristics with odds ratios (ORs).A total of 632 surveys were completed (35% white, 33% African American, and 32% Latino respondents). African American and Latino parents were more likely to give their children mostly bottled water; minority children were exclusively given bottled water 3 times more often than non-Latino white children (24% vs 8%, P .01). In logistic regression analysis, the following factors were independently associated with mostly bottled water use: belief that bottled water is safer (OR, 2.4), cleaner (OR, 2.0), better tasting (OR, 2.8), or more convenient (OR, 1.7). After other factors were adjusted for, race/ethnicity, household income, and prior residence outside the United States were not associated with bottled water use.Minority parents are more likely to exclusively give bottled water to their children. Disparities in bottled water use are driven largely by differences in beliefs and perceptions about water. Interventions to reduce bottled water use among minority families should be based on knowledge of the factors that are related to water use in these communities.

Abstract 1365 Poster Board I-387 Background Although sickle cell disease is a genetic disease diagnosed by state newborn screening programs, it is not a reportable condition. Therefore it is difficult to ascertain the actual number of affected individuals living with sickle cell disease in the United States. One NIH estimate puts the number between 50,000 and 75,000 while the Sickle Cell Disease Association of America estimates the number to be “over 70,000”. Without accurate estimates, clinicians, health services researchers, and policy makers are all working with incomplete information when determining the extent of the cost and health consequences of sickle cell disease. Our objective was to estimate the number of people with sickle cell disease for the United States as a whole and for each individual State, adjusting for the increased mortality of sickle cell disease. Methods Census estimates by age and race/ethnicity were obtained for both the United States as a whole and for each individual State from the US Census website. The prevalence of sickle cell disease for blacks was uniformly applied to the U.S. and individual states using a rate of 289 black children with sickle cell disease per 100,000 live births. Based on previously published prevalence rates for Hispanics, prevalence rates of 89.8 Hispanic children of non-Mexican ancestry with sickle cell disease per 100,000 live births and 3.14 Hispanic children of Mexican ancestry with sickle cell disease per 100,000 live births were calculated. We did not include sickle cell disease for whites or Asians in our estimate. Year 2005 was used as the baseline year for all calculations. Consistent with previous literature, at age 0, 60% of children with sickle cell disease were classified as having HgbSS/SB0 and 40% of children were classified as having HgbSC/SB+. These proportions were altered towards higher proportions of HbSC/SB+ with increasing age based on the increased mortality of the more severe forms of sickle cell disease. To adjust for mortality, we analyzed the data based on age and sickle cell type, and used published mortality data for different sickle cell genotypes to calculate survival of the population to a given age. A population multiplier was then used to adjust population estimates for the difference in population across age groups and differences in population patterns by race/ethnicity. Results Analysis revealed an estimate of 89,079 (95% CI: 88,494 – 89,664) people with sickle cell disease in the United States, of which 80,151 are black and 8,928 Hispanic. The South, with a sickle cell population of 47,354 people, comprised more than 53% of all people with sickle cell disease in the United States. The five states with the highest estimated number of people with sickle cell disease were New York with 8,308; Florida with 7,539; Texas with 6,765; California with 6,474; and Georgia with 5,890. These five states comprised more than 43% of the total sickle cell population for the nation. Finally, the increased mortality for HgbSS/SB0 leads to an alteration in the relative percentages of sickle cell genotypes, with HgbSS/SB0 comprising 60% of people with sickle cell disease at birth, half of the sickle cell population at slightly over 30 years old, and only 25% of the sickle cell population by 60 years old. Conclusion This study reveals that the sickle cell population in the United States is higher than previously reported, with almost 90,000 people with sickle cell disease. In addition, differential mortality increases the percentage of people with HbSC/SB+, such that after 40 years of age they represent the majority of the sickle cell population. The population estimates for the country as well as the individual states provide important information with regard to allocation of resources for this chronic disease which primarily affects lower income, underserved individuals. Disclosures No relevant conflicts of interest to declare.