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Our emergency department updated our care algorithm to provide evidence-based, standardized care to 0- to 60-day-old febrile neonates. Specifically, we wanted to increase the proportion of visits for which algorithm-adherent care was provided from 90% to 95% for infants 0-28 days, and from 67% to 95% for infants 29-60 days, by June 30, 2020., Methods: Our emergency medicine team outlined our theory for improvement and used multiple plan-do-study-act cycles to test interventions aimed at key drivers. Interventions included constructing an updated care algorithm, clinician, and nurse education, integrating an updated opt-out order set, and streamlined discharge instructions. Our primary outcome was the proportion of patient encounters in which clinicians ordered algorithm-adherent care. In addition, our quality improvement team manually reviewed all failures to determine the reasons for failure and inform further interventions., Results: We evaluated 2,248 visits between January 2018 and October 2021. Algorithm-adherent care for 29- to 60-day-old infants improved from 67% to 92%. Algorithm-adherent care for 0- to 28-day infants improved from 90% to 96%. We sustained these improvements for 22 months. Failure to adhere to the algorithm in the 29- to 60-day-old infant group was primarily due to clinicians not ordering procalcitonin., Conclusions: Using quality improvement methods, we successfully increased algorithm-adherent evaluation of febrile neonates 0-60 days old in our pediatric emergency departments. Education and opt-out order sets were keys to implementing our new algorithm., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Factors predictive of research career interest among pediatric emergency medicine (PEM) fellows are not known. We sought to determine the prevalence and determinants of interest in research careers among PEM fellows., Methods: We performed an electronically distributed national survey of current PEM fellows. We assessed demographics, barriers to successful research, and beliefs about research using 4-point ordinal scales. The primary outcome was the fellow-reported predicted percentage of time devoted to clinical research 5 years after graduation. We measured the association between barriers and beliefs and the predicted future clinical research time using the Spearman correlation coefficient., Results: Of 458 current fellows, 231 (50.4%) submitted complete responses to the survey. The median predicted future clinical research time was 10% (interquartile range, 5%-20%). We identified no association between sex, residency type, and previous research exposure and predicted future research time. The barrier that most correlated with decreased predicted clinical research time was difficulty designing a feasible fellowship research project (Spearman coefficient [ρ], 0.20; P = 0.002). The belief that most correlated with increased predicted clinical research time was excitement about research (ρ = 0.69, P < 0.001)., Conclusions: Most fellows expect to devote a minority of their career to clinical research. Excitement about research was strongly correlated with career research interest.

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.

This article is the first in a 7-part series (Table 1) that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated on program completion. This overview article provides a framework for the series.

Objectives: (1) To develop an automated eligibility screening (ES) approach for clinical trials in an urban tertiary care pediatric emergency department (ED); (2) to assess the effectiveness of natural language processing (NLP), information extraction (IE), and machine learning (ML) techniques on real-world clinical data and trials., Data and Methods: We collected eligibility criteria for 13 randomly selected, disease-specific clinical trials actively enrolling patients between January 1, 2010 and August 31, 2012. In parallel, we retrospectively selected data fields including demographics, laboratory data, and clinical notes from the electronic health record (EHR) to represent profiles of all 202795 patients visiting the ED during the same period. Leveraging NLP, IE, and ML technologies, the automated ES algorithms identified patients whose profiles matched the trial criteria to reduce the pool of candidates for staff screening. The performance was validated on both a physician-generated gold standard of trial-patient matches and a reference standard of historical trial-patient enrollment decisions, where workload, mean average precision (MAP), and recall were assessed., Results: Compared with the case without automation, the workload with automated ES was reduced by 92% on the gold standard set, with a MAP of 62.9%. The automated ES achieved a 450% increase in trial screening efficiency. The findings on the gold standard set were confirmed by large-scale evaluation on the reference set of trial-patient matches., Discussion and Conclusion: By exploiting the text of trial criteria and the content of EHRs, we demonstrated that NLP-, IE-, and ML-based automated ES could successfully identify patients for clinical trials., (© The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: To assess the efficacy of oral dexamethasone or nebulized dexamethasone sodium phosphate in children with mild croup., Methods: Double-blind, placebo-controlled study of 264 children between 6 months and 6 years of age with symptoms of croup for fewer than 48 hours. Patients were excluded if they received racemic epinephrine or corticosteroid treatment. Other exclusion criteria included corticosteroid treatment during the 14 days prior to enrollment or complicating medical condition. Subjects randomly received oral dexamethasone (0.6 mg/kg), nebulized dexamethasone sodium phosphate (160 microg), or placebo. Telephone follow-up was obtained on days 1, 2, 3, 4, and 7., Main Outcome Measures: The primary outcome measure was treatment failure, defined as receiving corticosteroid or racemic epinephrine treatment during the 7 days after enrollment in the study. Secondary outcome measures included seeking additional care and the parental assessments of the patients' condition obtained during follow-up (worse, same, better, or gone)., Results: Eighty-five patients received oral dexamethasone, 91 received nebulized dexamethasone, and 88 received placebo. There were 3 treatment failures in the oral dexamethasone-treated group, 12 in the nebulized dexamethasone-treated group, and 10 in the placebo-treated group (P =.05). Ten children in the oral dexamethasone-treated group sought additional care compared with 27 and 29 in the nebulized dexamethasone-treated and placebo-treated groups, respectively (P =.002). Parents of children in the oral dexamethasone-treated group reported greater improvement on day 1 (P<.001) compared with the nebulized dexamethasone-treated and placebo-treated groups., Conclusions: Children with mild croup who receive oral dexamethasone treatment are less likely to seek subsequent medical care and demonstrate more rapid symptom resolution compared with children who receive nebulized dexamethasone or placebo treatment.

Background: Although the accuracy of focused abdominal sonography for trauma (FAST) in adults has been demonstrated, results of this technique in children have been conflicting with few comparisons against computed tomography (CT), the imaging gold standard., Methods: A total of 160 hemodynamically stable pediatric trauma victims referred for abdominal CT initially underwent rapid screening sonography looking for free fluid. Both studies were interpreted in blinded fashion., Results: Forty-four of the 160 patients had an intraabdominal injury on CT, 24 (55%) of which had normal screening sonography. Fifteen of the 44 (34%) had no free fluid on either modality. Accuracy of sonography compared with CT was 76% with a negative predictive value 81%., Conclusions: Sonography for free fluid alone is not reliable to exclude blunt intraabdominal injury in hemodynamically stable children given the considerable percentage of injured patients without free fluid. J Pediatr Surg 36:565-569., (Copyright 2001 by W.B. Saunders Company.)

This study was undertaken to determine the time interval for changes in end-tidal CO2, oxygen saturation (SaO2), heart rate (HR), and blood pressure (BP) in response to an acute airway obstruction or hypopharyngeal extubation in a hyperoxemic model. Complete and partial airway obstructions were simulated with complete and partial cross-clamping of an endotracheal (ET) tube in five anesthetized, nonparalyzed, mechanically ventilated Yorkshire minipigs with initial PAo2 of > 400 mm Hg. Placement of the ET tube into the hypopharynx was performed to simulate accidental extubation. Both sidestream (SS) and mainstream (MS) capnography were used. Continuous pulse oximetry monitored SaO2, femoral arterial catheter monitored systolic BP, and electrocardiograph monitored HR. The time intervals for the capnograph wave to flatten and for the monitor to display zero were recorded after each airway alteration. The time interval to a change in the initial HR of 10 beats/min, a change of initial systolic BP of 10 mm Hg, and a change of initial SaO2 of 5% were recorded. Experiments were carried out for 180 seconds, and 25 trials were performed. HR, systolic BP, and SaO2 did not change for the 180-second duration of the trials. Complete obstruction produced a flattening of the SS and MS waveform in 8 +/- 2 seconds and 6 +/- 2 seconds, respectively. The SS and MS monitors displayed zero in 19 +/- 1 seconds and 68 +/- 7 seconds, respectively. Partial obstruction did not produce flattening of the wave or a monitor displaying zero. Hypopharyngeal extubation produced a flattening of the SS and MS waveform in 7 +/- 1 seconds and 7 +/- 2 seconds, respectively. The SS and MS monitors displayed zero in 18 +/- 3 seconds and 76 +/- 16 seconds, respectively. Continuous end-tidal CO2 capnography detects acute airway obstruction and hypopharyngeal extubation more rapidly than does pulse oximetry or vital sign monitoring in a hyperoxemic porcine model.

Study Objective: To identify the frequency of violence and the perception of safety in pediatric emergency departments., Study Design: Descriptive, cross-sectional survey of directors of pediatric EDs with fellowship programs., Setting: University-based urban pediatric EDs., Participants: Forty-seven pediatric ED directors were surveyed, with 94% responding., Results: More than three-fourths of those responding reported one or more verbal threats per week; 77% reported one or more physical attacks on staff per year; and 25% reported actual injury to staff. No pediatric EDs had weapon detectors; 7% had city police stationed there; and 54% had 24-hour security stationed in the pediatric ED. The majority reported that their staff members practice with at least occasional fear (55%) and had documented this concern (82%). Perception of safety was associated with the incidence of verbal threats (P < .006), physical attacks (P < .03), injury to staff or patient (P < .01), and the frequency with which security was needed (P < .001). Pediatric EDs with 50,000 or more visits per year were more likely to have multiple physical attacks on staff (relative risk, 2.89; 95% confidence interval, 1.33-6.26; P < .004). More verbal threats were reported in pediatric EDs with longer waiting times (P < .001). Fewer than half of the pediatric EDs with reported injuries had 24-hour security., Conclusion: Pediatric EDs are not immune to the problem of violence. Efforts must be directed to increase safety through better security, more efficient patient care, and aggression management training.

To better characterize methemoglobinemia in children, we reviewed the charts of 17 patients who were admitted to a children's hospital over the last 10 years. Two distinct groups were identified: (1) The endogenous group (n = 9) included patients with methemoglobinemia associated with an intercurrent illness. (2) The exogenous group (n = 8) included patients with methemoglobinemia secondary to drug exposure. Despite similar initial methemoglobin levels in the endogenous (mean, 29%) and exogenous (mean, 28%) groups, children in the endogenous group had more acidosis (serum bicarbonate levels of 5.9 vs 19.1 mmol/L and arterial pH of 7.01 vs 7.35). All the children in the exogenous group with methemoglobinemia secondary to an accidental ingestion stayed only 1 day in the hospital, while children in the endogenous group were admitted for an average of 19 days. Children with methemoglobinemia secondary to a drug exposure have a more benign illness with a shorter duration than children with methemoglobinemia associated with an intercurrent illness. It appears that the absolute level of methemoglobin is not as important as the underlying cause in determining both the course and severity of illness.