Academic Pediatric Emergency Department Research Articles

Implementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital: A Feasibility Study.

Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap. A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability. Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort. It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Predictors of Clinically Important Neuroimaging Findings in Children Presenting Pediatric Emergency Department.

The aim of the study is to evaluate predictors of clinically important neuroimaging results, that is, computed tomography and magnetic resonance imaging in children in an academic pediatric emergency department (PED) from 2015 to 2019. This study was conducted in an academic PED. The patient's demographic and clinical characteristics of PED visits and neuroimaging findings requested at the PED were recorded for January 1, 2015, to December 31, 2019. In addition, descriptive statistics and logistic regression analyses were conducted. We described and determined the predictors of clinically important neuroimaging findings in children. Clinically important neuroimaging findings were detected in patients with blurred vision (P = 0.001), ataxia (P = 0.003), unilateral weakness (P = 0.004), and altered level of consciousness (P = 0.026). Clinically important neuroimaging was found 9.4 times higher in patients with altered level of consciousness, 7.4 times higher in patients with focal weakness, 4.6 times higher in patients with blurred vision, and 3.5 times more in patients presenting with ataxia. Advanced neuroimaging, especially for selected patients in PED, can improve the quality of health care for patients. On the other hand, irrelevant neuroimaging findings can lead physicians away from prompt diagnosis and accurate management. According to our study, advanced neuroimaging can be performed in the early period for both diagnosis and early treatment, especially in selected patients with ataxia, blurred vision, altered consciousness, and unilateral weakness. In other cases, clinicians may find more supporting evidence.

“Let Us Take Care of the Medicine”: A Qualitative Analysis of Physician Communication When Caring for Febrile Infants

BackgroundGuidelines for the management of febrile infants emphasize patient-centered communication. Although patient-centeredness is central to high-quality health care, biases may impact physicians’ patient-centeredness. We aimed to 1) identify physicians’ assumptions that inform their communication with parents of febrile infants and 2) examine physicians’ perceptions of bias. MethodsWe recruited physicians from 3 academic pediatric emergency departments (EDs) for semistructured interviews. We applied a constant comparative method approach to conduct a thematic analysis of interview transcripts. Two coders followed several analytical steps: 1) discovery of concepts and code assignment, 2) identification of themes by grouping concepts, 3) axial coding to identify thematic properties, and 4) identifying exemplar excerpts for rich description. Thematic saturation was based on repetition, recurrence, and forcefulness. ResultsFourteen physicians participated. Participants described making assumptions regarding 3 areas: 1) the parent’s affect, 2) the parent’s social capacity, and 3) the physician’s own role in the parent-physician interaction. Thematic properties highlighted the importance of the physician’s assumptions in guiding communication and decision-making. Participants acknowledged an awareness of bias and specifically noted that language bias influenced the assumptions that informed their communication. ConclusionsED physicians described subjective assumptions about parents that informed their approach to communication when caring for febrile infants. Given the emphasis on patient-centered communication in febrile infant guidelines, future efforts are necessary to understand how assumptions are influenced by biases, the effect of such behaviors on health inequities, and how to combat this.

Analysis of a Medication Safety Intervention in the Pediatric Emergency Department

Strategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described. To describe implementation of MEDS in routine clinical practice and associated outcomes. This mixed-methods interrupted time series study of MEDS was conducted April 2021 to December 2022 in an academic pediatric ED using a hybrid type 1 design. Parents and guardians of children aged 90 days to 11.9 years who were discharged with acetaminophen, ibuprofen, or both were eligible for inclusion in the quantitative portion. Clinicians from a diversity of role groups (attending physician, resident, and nurse) were eligible for the qualitative portion. The study was conducted in 5 stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. During the intervention 1 phase, in-depth interviews were conducted until thematic saturation was reached; results were analyzed using thematic analysis. Interviews informed intervention 2 phase interventions. The primary outcome was any error (defined as dosing or frequency error) at a 48- to 72-hour follow-up phone call. There were 256 participants (median [IQR] child age, 1.7 [3.0-7.0] years; median [IQR] parent and guardian age, 36.0 [31.0-41.0] years; 200 females among parents and guardians [78.1%]) who consented and completed follow-up. At baseline, 44 of 68 participants (64.7%) made an error compared with 34 of 65 participants (52.3%) during intervention 1, 31 of 63 participants (49.X%) during intervention 2, and 34 of 60 participants (57.X%) during sustainability. After adjustment for language and health literacy, the adjusted odds ratio for error during the combined intervention phases was 0.52 (95% CI, 0.28-0.97) compared with baseline. This study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED.

Pediatric Patients Discharged After Transfer to a Pediatric Emergency Department: Opportunities for Telehealth?

Interemergency department pediatric transfers can be costly, involve risk, and may be disruptive to patients and families. Telehealth could be a way to safely reduce the number of transfers. We made an estimate of the proportion of transfers of pediatric patients to our emergency department (ED) that may have been avoidable using telehealth. This was a retrospective analysis of electronic health record data of all pediatric patients (younger than 19 years) who were transferred to a single urban, academic medical center pediatric emergency department (PED) (annual pediatric volume approximately 15,000) between June 1, 2016, and December 29, 2021. We defined transfers as potentially avoidable with telehealth (the primary outcome) when the encounter at the receiving ED resulted in ED discharge and 1) met our definition of low-resource intensity (had no laboratory tests, diagnostic imaging, procedures, or consultations) or 2) could have used initial ED resources with telehealth guidance. Among 4,446 PED patients received in transfer during the study period, 406 (9%) were low-resource intensity. Of the non-low-resource intensity encounters, as many as another 1,103 (24.8%) potentially could have been avoided depending on available telehealth and initial ED resources, ranging from 210 (4.7%) with only telehealth specialty consultation to 538 (7.4%) with imaging and telehealth specialty consultation, and up to 1,034 (23.3%) with laboratory, imaging, and telehealth specialty consultation. Our results suggest that depending on available telehealth and initial ED resources, between 9% and 33% of pediatric inter-ED transfers may have been avoidable. This information may guide health system design and PED operations when considering implementing pediatric telehealth.

A Video-Based Study of Emergency Medical Services Handoffs to a Pediatric Emergency Department

BackgroundEmergency medical services (EMS) to emergency department (ED) handoffs are important moments in patient care, but patient information is communicated inconsistently. ObjectiveThe aim of this study was to describe the duration, completeness, and communication patterns of patient handoffs from EMS to pediatric ED clinicians. MethodsWe conducted a video-based, prospective study in the resuscitation suite of an academic pediatric ED. All patients 25 years and younger transported via ground EMS from the scene were eligible. We completed a structured video review to assess frequency of transmission of handoff elements, handoff duration, and communication patterns. We compared outcomes between medical and trauma activations. ResultsWe included 156 of 164 eligible patient encounters from January to June 2022. Mean (SD) handoff duration was 76 (39) seconds. Chief symptom and mechanism of injury were included in 96% of handoffs. Most EMS clinicians communicated prehospital interventions (73%) and physical examination findings (85%). However, vital signs were reported for fewer than one-third of patients. EMS clinicians were more likely to communicate prehospital interventions and vital signs for medical compared with trauma activations (p < 0.05). Communication challenges between EMS clinicians and the ED were common; ED clinicians interrupted EMS or requested information already communicated by EMS in nearly one-half of handoffs. ConclusionsEMS to pediatric ED handoffs take longer than recommended and frequently lack important patient information. ED clinicians engage in communication patterns that may hinder organized, efficient, and complete handoff. This study highlights the need for standardizing EMS handoff and ED clinician education regarding communication strategies to ensure active listening during EMS handoff.

Pediatric Septic Shock Care Pathways in General Emergency Departments: A Qualitative Study Targeting How to Really Make it Work.

Many academic pediatric emergency departments (PEDs) have successfully implemented pediatric septic shock care pathways. However, many general emergency departments (GEDs), who see the majority of pediatric ED visits, have not. This study aims to compare the workflow, resources, communication, and decision making across these 2 settings to inform the future implementation of a standardized care pathway for children with septic shock in the GED. We used the critical incident technique to conduct semistructured interviews with 24 ED physicians, nurses, and technicians at one PED and 2 GEDs regarding pediatric septic shock care. We performed a thematic analysis using the Framework Method to develop our coding schema through inductive and deductive analyses. We continued an iterative process of revising the schema until we reached consensus agreement and thematic saturation. We identified the following 6 themes: (1) functioning like a "well-oiled machine" may be key to high performance; (2) experiencing the sequence of care for children with sepsis as invariant and predictable may be essential to high-quality performance; (3) resilience and flexibility are characteristic of high levels of performance; (4) believing that "the buck stops here" may contribute to more accountability; (5) continuous system learning is essential; and (6) computerized clinical decision support may not be optimized to drive decision-making at the point of care. Commentary from GED and PED participants differed across the 6 themes, providing insight into the approach for standardized care pathway implementation in GEDs. Pediatric septic shock workflow, decision making, and system performance differ between the PED and GEDs. Implementation of a standardized care pathway in GEDs will require a tailored approach. Specific recommendations include (1) improving shared situation awareness; (2) simulation for knowledge, skill, and team-based training; and (3) promoting a culture of continuous learning.

Strategic Surge Responses in the COVID-19 era: Operational Themes, Innovative Solutions and Lessons Learned by Three Freestanding Pediatric Emergency Departments.

The prolonged COVID-19 pandemic has created unique and complex challenges in operational and capacity planning for pediatric emergency departments, as initial low pediatric patient volumes gave way to unpredictable patient surges during Delta and Omicron variants. Compounded by widespread hospital supply chain issues, staffing shortages due to infection and attrition, and a concurrent pediatric mental health crisis, the surges have pushed pediatric emergency department leaders to re-examine traditionally defined clinical processes, and adopt innovative operational strategies. This study describes the strategic surge response and lessons learned by 3 major freestanding academic pediatric emergency departments in the western United States to help inform current and future pediatric pandemic preparedness.

Biomarkers and their association with bacterial illnesses in hypothermic infants

ObjectivesTo describe the association of biomarkers with serious bacterial infection (SBI; urinary tract infection [UTI], bacteremia and/or bacterial meningitis) in hypothermic infants presenting to the emergency department (ED). MethodsWe performed a cross sectional study in four academic pediatric EDs from January 2015 through December 2019, including infants ≤90 days old presenting with a rectal temperature of ≤36.4 °C. We constructed receiver operating characteristic (ROC) curves to evaluate the accuracy of blood biomarkers including white blood cell count (WBC), absolute neutrophil count (ANC) and platelets for identifying SBI, with exploratory analyses evaluating procalcitonin and band counts. ResultsAmong 850 included infants (53.5% males; median days of age 13 [IQR 5–58 days]), SBI were found in 55 (6.5%). For infants with SBI, the area under the curve (AUC; 95% confidence interval) for WBC was 0.70 (0.61–0.78) with sensitivity 0.64 (0.50–0.74) and specificity 0.77 (0.74–0.80). The AUC for ANC was 0.77 (0.70–0.84) with sensitivity 0.69 (0.55–0.81) and specificity 0.77 (0.74–0.8). For platelets, the AUC was 0.6 (0.52–0.67) with sensitivity 0.73 (0.59–0.84) and specificity 0.5 (0.46–0.53). Both the WBC and ANC were minimally accurate for identifying hypothermic infants with SBI. When looking at the accuracy of these biomarkers for identifying invasive bacterial infection (IBI; bacteremia and/or bacterial meningitis), ANC again showed minimal accuracy with an AUC of 0.70 (0.55–0.85). ConclusionsBiomarkers commonly used as part of an infectious workup are generally poor at identifying SBI in hypothermic infants. Our findings from this cohort of hypothermic infants are similar to those reported from febrile infants, suggesting similarities in the bioresponse to infection between hypothermic and febrile infants. Additional research is required to improve risk stratification for hypothermic infants, and to better guide evaluation and management.

Emergency Department-Attended Injuries Resulting from School-Based Violence in Baltimore Adolescents, 2019-2020.

Our objective is to describe violence-related injuries to early adolescents that occurred at school, resulting in emergency department (ED) evaluation. This retrospective cohort study at an urban academic pediatric ED in Baltimore, MD, identified patients 10-15 years old who presented with an injury from intentional, interpersonal violence that occurred at school between January 2019-December 2020. Descriptive statistics were used to summarize patient and event characteristics. Of 819 youth 10-15 years of age evaluated for a violence-related injury, school was the location in 115 cases (14.0%). All events occurred prior to the statewide stay at home order (March 30, 2020). School-injured youth had a mean age of 12.7 ± 1.7 years and were predominantly male (64.3%). Of the 115 cases, 75 (65.2%) involved an altercation with a peer, 26 (22.6%) involved a teacher or school staff, 6 (5.2%) involved a family member, 1 (0.9%) involved police, 6 (5.2%) involved an unknown party, and 1 (0.9%) involved an unrelated but known adult. All injured youth were discharged from the ED. School-based violence is a well-recognized cause of traumatic injuries to adolescents and may involve peers, teachers, or school staff.

63 Translational Research Capacity in Canadian Pediatric Emergency Departments Participating in the Precision Medicine for Improving the Diagnosis of Pediatric Appendicitis in the Emergency Department (PRIMED) Study

Abstract Background Pediatric clinical and translational research are essential to acquire effective diagnostic and treatment options for children, but they are underfunded and under prioritized in comparison to research focused on treatments for adults. The Precision Medicine for Improving the Diagnosis of Pediatric Appendicitis in the Emergency Department (PRIMED) study aimed to characterize the proteomic and metabolic bio-profiles of children with appendicitis and to investigate these bio-profiles as a clinical prediction tool. Objectives In this current work, we aimed to evaluate translational research capacity at Canadian pediatric Emergency Departments (EDs) and to describe some of the challenges experienced in the implementation of the PRIMED study and various strategies used to improve local research capacity. Design/Methods Participating sites provided basic demographic and administrative data along with laboratory- and human-resource availability during enrolment for the PRIMED study. Data was summarized using descriptive statistics. Eleven pediatric EDs participated in the PRIMED study. Results Six study hospitals (54.5%) used on-site clinical laboratories to process research samples; the remaining hospitals (5/11, 45.5%) required access to research facilities, of which two (18.2%) were off-site. Fewer than two thirds of the study sites (7/11, 63.6%) had any laboratory that would process samples 24 hours per day. Four study sites (36.4%) only enrolled patients during business hours and over half of the sites (6/11, 54.5%) were unable to collect samples for the entire 17:00 to 21:00 peak when the greatest number of pediatric patients present to the ED (Figure 1). There was no nighttime coverage for patient enrollment and sample collection and only three study sites (3/11, 27.3%) had enrollment hours that captured over 75% of the potential study participants. Over half (6/11, 54.5%) of the PRIMED study sites developed novel processes to enable study success, for example creating graduate student on-call schedules and hiring bioscience trained site coordinators to perform sample processing requirements. Conclusion Despite site-specific efforts to overcome resource barriers, the gap in translational research capacity at academic pediatric emergency departments remains a significant concern. University research institutes and pediatric hospitals should invest in infrastructure and human resources to increase after-hours clinical and translational research capacity to optimize child health and wellness outcomes.

Esophageal Bougienage for Management of Lodged Esophageal Coins: Safe, Effective, Efficient, and Underused.

The aims of the study are to evaluate outcomes of esophageal bougienage for management of lodged esophageal coins and to assess the extent of bougienage usage and barriers among emergency providers. We performed a retrospective chart review of pediatric patients with single lodged esophageal coins presenting to our single academic pediatric emergency department between November 2012 and December 2018. We compared procedural outcomes, complications, length of stay (LOS), and cost between those managed with bougienage and with endoscopy. We further surveyed emergency physicians to assess the extent of bougienage usage and barriers to utilization across different institutions. We identified 205 patients with single lodged esophageal coins presenting during our study window. One hundred forty-seven patients ultimately underwent bougienage with 97% success and no major complications. Fifty-six patients were managed by endoscopy with 100% success and one major complication. Bougienage had significantly lower LOS (median 2.18 vs 11.92 hours, P < 0.001) and hospital charges (median $3533 vs $12,679, P < 0.001) compared with endoscopy. We received 242 completed surveys representing 38 states from primarily academic pediatric emergency physicians. The majority of respondents (90%) used specialist consult with only 4.5% performing bougienage. A total of 36.4% of respondents had never heard of the procedure and only 16.1% had ever performed it. Barriers to usage included lack of provider training (95.6%), perceived risk of complications (94.4%), and perceived lack of success (80.5%). Bougienage is safe and effective with significant LOS and cost benefits compared with endoscopy. Despite these advantages, the procedure is underused, because of lack of provider education and concerns regarding safety, efficacy, and both family and specialist preference, which are not supported by current literature. These data support the need for broader education regarding the bougienage technique, as well as larger prospective studies of its safety and outcomes.

Intranasal Fentanyl to Reduce Pain and Improve Oral Intake in the Management of Children With Painful Infectious Mouth Lesions.

Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions. This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 μg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05. Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group. Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.

Pediatric Emergency Physicians' Comfort Level Providing Urgent Care for Adults on Telemedicine During the COVID-19 Pandemic: Experience at an Academic Medical Center.

Objective: Our objectives were to assess the comfort level of pediatric emergency physicians (PEPs) providing urgent care to adult patients on telemedicine (APOTM) when redeployed during the coronavirus disease 2019 (COVID-19) pandemic, how it changed over time, and what resources were helpful. Materials and methods: We conducted a retrospective pre-post cross-sectional survey of PEPs providing urgent care to APOTM with COVID-19 symptoms during the COVID-19 surge from March 12, 2020, to June 12, 2020 (the "care period") at two academic pediatric emergency departments in New York City. A retrospective chart review was also conducted. We include data on demographics of PEPs and adult patients; comfort level of PEPs providing urgent care to APOTM with COVID-19 symptoms pre- and post-three-month care period and effective resources.Results: Sixty-five PEPs provided urgent care to 1515 APOTM with COVID-19 symptoms during the care period. Pre-pandemic, 22/43 (51%) of responders feared caring for APOTM; 6/43 (14%) were comfortable. At the end of the care period, 25/42 (58%) of the responders stated they were comfortable caring for these patients. Factors associated with increased comfort level were: increased volume of patients over time, treatment algorithms, group support via electronic communication, and real-time back-up by a general emergency medicine (GEM) physician. Reduced medicolegal liability was also cited.Conclusion: With minimal additional training and resources, PEPs can increase their comfort to provide urgent care to APOTM with COVID-19 symptoms. As future pandemics may disproportionately affect certain patient populations (adults versus pediatrics), interventions such as treatment algorithms, group support via emails and texts, and sub-specialty backup should be incorporated into redeployment plans for urgent care telemedicine programs. Future research is needed to determine the adaptability of other medical specialties to cross-cover a different specialty from their own if needed.

Reducing Pediatric Emergency Department Prescription Errors.

Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines. From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing. Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased. QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.

The Concise Assessment of Leader Management Tool: Evaluation of Healthcare Provider Leadership During Real-Life Pediatric Emergencies.

Resuscitation events in pediatric critical and emergency care are high risk, and strong leadership is an important component of an effective response. The Concise Assessment of Leadership Management (CALM) tool, designed to assess the strength of leadership skills during pediatric crises, has shown promising validity and reliability in simulated settings. The objective of this study was to generate further validity and reliability evidence for the CALM by applying it to real-life emergency events. A prospective, video-based study was conducted in an academic pediatric emergency department. Three reviewers independently applied the CALM tool to the assessment of pediatric emergency department physicians as they led both a cardiac arrest and a sepsis event. Time to critical event (epinephrine, fluid, and antibiotic administration) was collected via video review. Based on Kane's framework, we conducted fully crossed, person × event × rater generalizability (G) and decision (D) studies. Interrater reliability was calculated using Gwet AC 2 and intraclass correlation coefficients. Time to critical events was correlated with CALM scores using Spearman coefficient. Nine team leaders were assessed in their leadership of 2 resuscitations each. The G coefficient was 0.68, with 26% subject variance, 20% rater variance, and no case variance. Thirty-three percent of the variance (33%) was attributed to third-order interactions and unknown factors. Gwet AC 2 was 0.3 and intraclass correlation was 0.58. The CALM score and time to epinephrine correlated at -0.79 ( P = 0.01). The CALM score and time to fluid administration correlated at -0.181 ( P = 0.64). This study provides additional validity evidence for the CALM tool's use in this context if used with multiple raters, aligning with data from the previous simulation-based CALM validity study. Further development may improve reliability. It also serves as an exemplar of the rigors of conducting validity work within medical simulation.

A Randomized Trial of Incentivization to Maximize Retention For Real-Time Symptom and Activity Monitoring Using Ecological Momentary Assessment in Pediatric Concussion

To determine the incentivization strategy that maximizes patient adherence to report symptoms and activity via ecological momentary assessment (EMA) following pediatric concussion. Concussion is a common pediatric injury. Traditionally, outcome assessment has occurred at discrete points-in-time, days or weeks apart, relying on patient's subjective recall of symptoms and activity. EMA is a behavioral measurement approach that allows for reporting of real-time symptoms and behaviors in real-life settings. While feasible in adolescents, the ideal strategy to maximize responsiveness from the emergency department (ED) setting is unknown. This was a randomized controlled trial of patients age 13-18 with concussion presenting to an urban, academic pediatric ED within 5 days of injury. Patients were randomized to one of 4 incentive-based arms: 2 dynamic (loss-based and streak) and 2 flat-rate (monetary and electronic device). Through the ReCoUPS app, patients reported symptoms 3 times per day and cognitive activity once each evening for 3 weeks. Physical activity (step count) and sleep were monitored using a FitBit (which was kept by the participant in the electronic device flat-rate arm). The primary outcome was proportion of prompts to which patients responded. Secondary outcomes included daily symptom change and time to symptom resolution. Thirty participants were enrolled, median age 15.5 years, 60% female. Median proportion completed was 81% in the loss-based arm, 59% in the streak accrual arm, 50% in the FitBit-received arm, and 57% monetary flat rate arm. Retention was higher in the dynamic compared to the flat arms (68% v. 54%, p = 0.065). There was no significant difference between morning, afternoon, and evening symptoms. Sixty-four percent of participants had symptom resolution during the 3-week follow-up. Dynamic incentivization showed higher rates of response to tri-daily symptom prompts compared with flat-fee incentivization. This data shows tracking concussed youth using EMA from ED is feasible using a dynamic incentivization strategy.

Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success.

Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.

The physical examination is unreliable in determining the location of the distal fibular physis.

Salter-Harris type 1 (SH1) fractures of the distal fibula are acute orthopedic injuries with tenderness over the physis without radiographic evidence of fracture. Our primary objective was to establish the accuracy of the physical examination performed by pediatric emergency medicine (PEM) physicians in determining the location of the distal fibular physis compared to a criterion standard of ultrasound. This was a prospective, observational study at an urban academic pediatric emergency department of a convenience sample of children aged 4 to 10years old between March 2019 and March 2020. A PEM physician or fellow examined the patient's distal fibula and marked the location of the physis with a marker. A study investigator scanned the distal fibula to establish the location of the physis on ultrasound and measured the distance between the clinician's estimated position and the actual sonographic position. We a priori defined a clinically accurate position as a distance of ≤5mm. We compared the accuracy rate of physical examination to ultrasound landmarking using proportions with 95% confidence intervals (CI). We enrolled 71 patients, of whom 52 (73%) were male. The mean age was 6.7years and the mean weight was 25.5kg. Participating PEM physicians included 18 attending physicians and 2 fellows. The distal fibular physis was correctly identified in 24 patients, yielding an accuracy rate of 34% (95% CI 23%-46%). The mean distance between the physician's estimated position and the sonographic position was 7.4mm (95% CI 6.4-8.4mm). PEM physicians were unable to accurately identify the distal fibular physis on physical examination.

Characteristics of pediatric emergency department visits for youth 10-15 years old with injuries due to interpersonal violence

This retrospective cohort study at an urban academic pediatric emergency department (ED) in the United States identified all visits for youth 10-15 years of age for injury due to intentional interpersonal violence between January 2019 and December 2020. Demographic and clinical data were abstracted, including circumstances of the event. Data analysis included a comparison of pre-pandemic visits to pandemic visits after a statewide stay-at-home order was issued (March 30, 2020). Of 2780 10-15 year old youth evaluated for any injury, 819 (29.5%) had intentional/violence-related injuries. Most patients were male (53.1%), Black/African-American (84.1%), and were enrolled in a public insurance plan (75.0%). Although peer-violence related injuries comprised a substantial proportion (19.2%), the majority resulted from family violence (54.7%), which may include child maltreatment or physical fighting. Most injuries occurred at home (53.9%). Alcohol, drugs and weapons were significantly more likely to be involved in violent events during the pandemic in comparison to pre-pandemic (12.5 vs 5.0%, 11.4% vs 3.0%, 30.4% vs 8.5%; p < 0.001). Our findings support the need for ED-based efforts to screen and intervene for family and peer violence and other contributory factors (including personal, family and peer alcohol, drug and weapons access) when youth present with intentional injuries, which can be critical to preventing future violence.