Academic Pediatric Emergency Department Research Articles

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.

298 Factors Associated With Provider Shift Experience in an Academic Pediatric Emergency Department: A Novel Shift Satisfaction Score

Physician wellness is a multi-faceted construct involving engagement, fulfillment, and the absence of distress and burnout. While physician burnout negatively affects patient care, job satisfaction correlates with higher patient experience scores and is one subcategory of wellness linked to resource factors, clerical workload, efficiency, relationships, and control. This study focused on the intersection of provider satisfaction and the clinical work environment in the emergency department (ED). The objective was to use a novel shift satisfaction score to identify common themes impacting the on-shift wellness and experience of pediatric emergency medicine (PEM) providers. This descriptive study used an anonymous, electronic survey instrument with two questions developed via a modified Delphi method. Q1: Overall, how satisfied are you with your shift today? This was rated on a 7-point Likert scale. Q2: What are the main factors that you considered when rating your level of satisfaction with your shift today? This was an open-ended response. A voluntary response sampling of PEM workers (physicians, fellows, residents, nurses, and staff) at an academic pediatric trauma center was recruited via email listservs and QR codes at ED workstations. Data were collected and managed in REDCap and Excel. Qualitative analysis using inductive thematic coding was performed. Quantitative analysis with chi-squared testing to determine theme association with shift satisfaction employed a top-two-box model for binary outcomes. Univariate logistic regression was used to determine association of shift satisfaction with role. From Oct 2020 to May 2021, 372 unique responses were collected and analyzed. 250 respondents reported satisfaction on shift, while 120 respondents reported dissatisfaction. Physicians (OR 1.72, p=0.037) and paramedic/techs (OR 1.94, p=0.076) were associated with higher shift satisfaction than nurses, although only physicians reached significance. Themes related to teamwork, teaching/learning, and no comment were positively and significantly associated with higher shift satisfaction scores (score 6-7). Themes related to external team interactions (consultants, admitting teams), equipment/stocking, staffing, acuity/complex patients, code alert/death, and personal reasons were negatively and significantly associated with lower shift satisfaction scores (score 1-3). This pilot study identified work environment factors impacting provider shift satisfaction in a pediatric ED. Our findings imply that instituting practices that encourage quality team interactions, camaraderie, and opportunities for teaching and learning could positively impact satisfaction and wellness. In addition, attention to work environment improvements, such as staffing ratios and stocking issues, could mitigate on-shift dissatisfaction. Further, shift satisfaction level data can guide future research examining correlations with other operational dashboard metrics and provider-based interventions.

Association of Neighborhood Gun Violence With Mental Health–Related Pediatric Emergency Department Utilization

Many children and adolescents in the United States are exposed to neighborhood gun violence. Associations between violence exposure and children's short-term mental health are not well understood. To examine the association between neighborhood gun violence and subsequent mental health-related pediatric emergency department (ED) utilization. This location-based cross-sectional study included 128 683 ED encounters for children aged 0 to 19 years living in 12 zip codes in Philadelphia, Pennsylvania, who presented to an urban academic pediatric ED from January 1, 2014, to December 31, 2018. Children were included if they (1) had 1 or more ED visits in the 60 days before or after a neighborhood shooting and (2) lived within a quarter-mile radius of the location where this shooting occurred. Analysis began August 2020 and ended May 2021. Neighborhood violence exposure, as measured by whether a patient resided near 1 or more episodes of police-reported gun violence. ED encounters for a mental health-related chief complaint or primary diagnosis. A total of 2629 people were shot in the study area between 2014 and 2018, and 54 341 children living nearby had 1 or more ED visits within 60 days of a shooting. The majority of these children were Black (45 946 [84.5%]) and were insured by Medicaid (42 480 [78.1%]). After adjusting for age, sex, race and ethnicity, median household income by zip code, and insurance, children residing within one-eighth of a mile (2-3 blocks) of a shooting had greater odds of mental health-related ED presentations in the subsequent 14 days (adjusted odds ratio, 1.86 [95% CI, 1.20-2.88]), 30 days (adjusted odds ratio, 1.49 [95% CI, 1.11-2.03]), and 60 days (adjusted odds ratio, 1.35 [95% CI, 1.06-1.72]). Exposure to neighborhood gun violence is associated with an increase in children's acute mental health symptoms. City health departments and pediatric health care systems should work together to provide community-based support for children and families exposed to violence and trauma-informed care for the subset of these children who subsequently present to the ED. Policies aimed at reducing children's exposure to neighborhood gun violence and mitigating the mental symptoms associated with gun violence exposure must be a public health priority.

Reduction of False-positive Blood Culture Rates Using a Passive Blood Diversion Device in an Urban Academic Pediatric Emergency Department

Background Blood cultures contaminated with common commensals during collection contribute to antibiotics overuse, return visits to the Emergency Department (ED), and increased overall medical costs. There are published quality improvement projects aimed at implementing best practices to reduce false positive blood culture (FPBC) rates in adults, but literature is lacking in pediatrics, and few studies include the use of passive diversion devices designed to remove an aliquot of blood likely to contain skin flora. FPBC rates in our pediatric ED range from 0.45% to 5.63%. Our FPBC institutional goal is Methods In an urban, academic, freestanding pediatric hospital, the ED has 35,000 patient encounters and obtains 2800 blood cultures annually. In each study period, passive blood diversion devices were bundled with collection supplies. Education with best practices for technique, use of the device, and instructions to record device non-use were provided. Positive blood culture results were reviewed by the Infection Preventionist to determine true infection versus FPBC. Results In the first study period, 341 blood cultures were drawnwith an overall FPBC rate of 1.5%. The rate of FPBC when the device not used was 10.5% (4 of 38). In the second study period, 905 blood cultures were drawn with an overall FPBC rate of 0.22%. The rate of FPBC when the device not used was 6.06% (2 of 33). Zero FPBCs occurred with device use in each study period (0 of 303) and (0 of 874). Conclusions This significant reduction (by Fisher's exact test p = 0.0001) suggests that employing a passive blood diversion device in addition to targeted education may decrease FPBCs; antibiotics overuse, costs, and return visits in the pediatric ED setting.

Pediatric Emergency Imaging Studies in Academic Radiology Departments: A Nationwide Survey of Staffing Practices.

Particularly for pediatric patients presenting with acute conditions or challenging diagnoses, identifying variation in emergency radiology staffing models is essential in establishing a standard of care. We conducted a cross-sectional survey among radiology departments at academic pediatric hospitals to evaluate staffing models for providing imaging interpretation for emergency department imaging requests. We conducted an anonymous telephone survey of academic pediatric hospitals affiliated with an accredited radiology residency program across the United States. We queried the timing, location, and experience of reporting radiologists for initial and final interpretations of emergency department imaging studies, during weekday, overnight, and weekend hours. We compared weekday with overnight, and weekday with weekend, using Fisher's exact test and an α of 0.05. Surveying 42 of 47 freestanding academic pediatric hospitals (89%), we found statistically significant differences for initial reporting radiologist, final reporting radiologist, and final report timing between weekday and overnight. We found statistically significant differences for initial reporting radiologist and final report timing between weekday and weekend. Attending radiologist involvement in initial reports was 100% during daytime, but only 33.3% and 69.0% during overnight and weekends. For initial interpretation during overnight and weekend, 38.1% and 28.6% use resident radiologists without attending radiologists, and 28.6% and 2.4% use teleradiology. All finalized reports as soon as possible during weekdays, but only 52.4% and 78.6% during overnight and weekend. A minority of hospitals use 24-hour in-house radiology attending radiologist coverage. During overnight periods, the majority of academic pediatric emergency departments rely on resident radiologists without attending radiologist supervision or outside teleradiology services to provide initial reports. During weekend periods, over a quarter rely on resident radiologists without attending radiologist supervision for initial reporting. This demonstrates significant variation in staffing practices at academic pediatric hospitals. Future studies should look to determine whether this variation has any impact on standard of care.

Transfers From a Pediatric Urgent Care to an Academic Pediatric Emergency Department.

Patient transfers from outpatient urgent care centers are common occurrences in a pediatric emergency department (ED). A previous study done at our institution evaluated the clinical appropriateness of transfers from general urgent care centers into our pediatric ED, showing that a significant proportion (27%) of such transfers were discharged home with minimal ED resource utilization. This study investigated the hypothesis that transfers to a pediatric ED from a pediatric urgent care have higher rates of ED resource utilization when compared with patients transferred from general urgent care centers. A retrospective chart review was completed during an 11-month period on all patients transferred from a pediatric urgent care center to the pediatric ED. Demographic, diagnoses, reason for transfer, ED resource utilization, ED disposition, and 72-hour ED return data were collected from the electronic medical record. Each encounter was classified as acute or nonacute based on previously established resource utilization criteria. This data were then compared with findings from a prior study of transfers from all urgent care centers to our institution's pediatric ED. A total of 240 patients met the inclusion criteria. Of these, 160 (66.7%) were discharged from the ED. Twenty-six (10.8%) of the transferred patients met the nonacute transfer criteria. The odds of nonacute transfer from pediatric urgent care were 0.66 times lower than from general urgent care (odds ratio, 0.34; 95% confidence interval, 0.18-0.93). A significantly lower proportion of transfers from the pediatric urgent care center were classified as nonacute, as compared with transfers from general urgent care centers. This suggests that the pediatric urgent care model may help to reduce the number of nonacute ED visits, thus producing cost savings and better patient care.

Outcomes of Patients with Sepsis in a Pediatric Emergency Department after Automated Sepsis Screening

To determine the effect of an automated sepsis screening tool on treatment and outcomes of severe sepsis in a pediatric emergency department (ED). Retrospective cohort study of encounters of patients with severe sepsis in a pediatric ED with a high volume of pediatric sepsis cases over a 2-year period. The automated sepsis screening algorithm replaced a manual screen 1year into the study. The primary outcome was the proportion of patients treated for sepsis while in the ED. Secondary outcomes were time from ED arrival to first intravenous (IV) antibiotic and first IV fluid bolus, volume of fluid administered in the ED, 30-day mortality, intensive care unit-free days, and hospital-free days. In year 1 of the study, 8910 of 61 026 (14.6%) of encounters had a manual sepsis screen; 137 patients met criteria for severe sepsis. In year 2, 100% of 61 195 encounters had an automated sepsis screen and there were 136 cases of severe sepsis. There was a higher proportion of patients with severe sepsis who had an active malignancy and indwelling central venous catheter in year 2. There were no differences in the proportion of patients treated for sepsis in the ED, time to first IV antibiotic or first IV fluid bolus, fluid volume delivered in the ED, hospital-free days, intensive care unit-free days, or 30-day mortality after implementation of the automated screening algorithm. An automated sepsis screening algorithm introduced into an academic pediatric ED with a high volume of sepsis cases did not lead to improvements in treatment or outcomes of severe sepsis in this study.

Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative.

There were 3 study periods: baseline (April 2009-March 2010), improvement (July 2012-December 2013), and operational (January 2014-December 2018). All patients undergoing RSI were eligible. We collected data using a structured video review. We compared key processes and outcomes with statistical process control charts. We collected data for 615 of 643 (96%) patient encounters with RSI performed: 114 baseline (12 months), 105 improvement (18 months), and 396 operational (60 months). Key characteristics were similar, including patient age. Statistical process control charts indicated sustained improvement of all 6 key processes and the primary outcome measure (oxyhemoglobin desaturation) throughout the 5-year operational period. Improvements in RSI safety were sustained 5 years after a successful improvement initiative, with further improvement seen in several key processes. Further research is needed to elucidate the factors contributing to sustainability.

Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation.

Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). This was a retrospective, observational study of RSI. An academic PED. A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be<2years old (32% vs 17%; P=.002) and to have neurologic (29% vs 17%; P=.005), respiratory (16% vs 4%; P<.001), or urinary (5% vs 1%; P=.004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.

Does Intravenous Acetaminophen Reduce Opioid Requirement in Pediatric Emergency Department Patients With Acute Sickle Cell Crises?

We evaluated the ability of intravenous (IV) acetaminophen to reduce the amount of opioid medication administered in pediatric patients with sickle cell disease (SCD) having vasoocclusive crisis (VOC) in an emergency department (ED) setting. This was a prospective, randomized, double-blind placebo-controlled trial at an academic urban pediatric ED. Participants included patients with SCD, aged 4 to 16years, with VOC pain. All patients received a 0.1mg/kg dose of IV morphine, 0.5mg/kg ketorolac, or both. Patients were randomized to receive either 15mg/kg IV acetaminophen or placebo. Patients were reassessed every 30minutes to see whether additional opioid doses were indicated to a maximum of three doses. The total morphine given, pain scores, rates of admissions, 72-hour return visits, and adverse events were assessed for each group. Of 71 subjects randomized, 35 patients in the acetaminophen group and 36 patients in the control group were analyzed. Baseline characteristics and initial pain scores were similar in both groups. The mean total amount of morphine given was 8.6mg (95% confidence interval [CI]= 6.5 to 10.8) in the acetaminophen group and 8.0mg (95% CI= 5.9 to 10.2) in the placebo group. The mean total cumulative morphine dosing was 0.2mg/kg (95% CI= 0.1 to 0.2 mg/kg) in the acetaminophen group and 0.2mg/kg (95% CI= 0.1 to 0.2mg/kg) in the control group. The mean pain score at time of disposition was 5.5 (95% CI= 4.3 to 6.6) in the acetaminophen group and 5.2 (95% CI= 4.2 to 6.3) in the placebo group. There were no clinical or statistically significant differences between the rates of admission, 72-hour return visits, or adverse events. In this study, patients who received IV acetaminophen did not receive less morphine than patients in the placebo group. Disposition pain scores for the two groups were also equivalent. We conclude that IV acetaminophen, when used in addition to morphine for pediatric sickle cell VOC pain, does not provide an opioid-sparing effect. Further searches for adjunctive nonaddictive pain medicines are indicated.

349 The Physical Examination Is Unreliable in Determining the Location of the Ankle Physis in Healthy Children

Pediatric ankle injuries are a common presentation to the emergency department (ED). The Salter-Harris classification defines a type 1 fracture of the distal fibula as tenderness overlying the physis of the distal fibula without radiographic evidence of a fracture. Our primary objective was to establish the reliability of physical examination performed by pediatric emergency physicians in determining the location of the physis of the distal fibula as compared to a criterion standard using ultrasound. This was a prospective, observational, single-site study of a convenience sample of pediatric patients aged 4 to 10 years old. It was performed at an urban academic pediatric ED between March 2019 and April 2020. Otherwise healthy children presenting to the ED for reasons other than lower extremity injury were eligible to participate. A pediatric emergency physician or fellow performed a physical examination of the patient’s distal fibula and marked the location of the physis based on his or her examination with a marker. After this, the study investigator (an ultrasound fellow) scanned the distal fibula, established the location of the physis on ultrasound, and used an invisible ink pen to mark the location of the physis. Using an ultraviolet light, the investigator measured the distance between the clinician’s estimated position and the actual sonographic position of the physis. Because the distal fibular physis measures only 3 mm on average, a clinically accurate position was defined a priori as a marked point located within a 5 mm distance of the sonographic marking. We compared the accuracy rate of physical examination to ultrasound landmarking using proportions as well as means with 95% confidence intervals (CI). Using a simulation assuming the participation of at least 15 physicians assessing multiple patients, we calculated a sample size of 90 patients to detect a difference in 70% versus 50% physician accuracy with at least 80% power. Enrolment was stopped early due to the novel coronavirus pandemic, so we were unable to recruit our target sample size of 90 participants. We enrolled 71 patients, of whom 52 (73%) were male. The mean age was 6.7 years and the mean weight was 25.5 kg. Participating pediatric emergency physicians included 18 staff physicians and 2 fellows. The assessments were performed by staff physicians in 60 (85%) patients and by fellows in 11 (15%) patients. Each physician examined a mean of 3.6 patients (range 1-15). The physis of the distal fibula was correctly identified in only 24 patients, yielding an accuracy rate of 34% (95% CI 23%-46%). The mean distance between the physician’s estimated position of the physis and the sonographic position was 7.4 mm (95% CI 6.4-8.4 mm). In a sensitivity analysis where the remaining 19 patient examinations would have all been accurate, the probability of accurate identification was 48% (95 CI 37%-59%). We found that pediatric emergency physicians were only 34% accurate with their physical examination in identifying the physis of the distal fibula. This calls into question the utility of the definition of a type 1 Salter-Harris fracture given that the physical examination is unreliable in identifying the location of the physis of the distal fibula.

Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department.

The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation–associated events and desaturation among these patients.Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years.The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups (P < .01), respectively. There was a lower proportion of tracheal intubation–associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1–5) for the VL group and 2 (range, 1–8) for the DL group (P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9–10.4, P < 0.01).Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation–associated events.

77 MANAGEMENT OF PEDIATRIC POST-CONCUSSIVE HEADACHES: A NATIONAL SURVEY OF ABORTIVE THERAPIES USED IN THE EMERGENCY DEPARTMENT

Abstract Background The incidence of children presenting to an Emergency Department (ED) following concussion has increased markedly in recent decades. Headache is the most commonly associated symptom and recent guidelines emphasize the importance of analgesia, yet evidence to inform treatment of post-concussive headache (PCH) is completely lacking. Objectives This study sought to characterize abortive therapies used to treat PCH among physicians in academic pediatric EDs and to determine whether duration of symptoms and/or headache intensity influence treatment strategies. Design/Methods A scenario-based electronic survey was sent to physician members of the Pediatric Emergency Research Canada (PERC) database. Participants were asked questions regarding management when presented with cases of an adolescent presenting to the ED with PCH refractory to appropriate doses of acetaminophen and ibuprofen. Scenarios differed only by duration of symptoms (48-hours versus 1-month post-injury), as well as headache intensity (moderate versus severe). Descriptive statistics are reported. Results Survey response rate was 63% (n/N=137/219). At 48 hours post-injury, 93% of physicians reported that they would initiate treatment for a headache rated as severe. The most commonly selected medications to treat PCH were metoclopramide (72%), an intravenous bolus of normal saline (47%) and non-steroidal anti-inflammatories (NSAIDS; 35%). There was wide variability among second line strategies for refractory pain following first-line treatment. When presented with PTH pain rated moderate in severity, 63% of respondents would change their management compared to severe pain, with 66% no longer offering pharmacologic treatment in the ED and most frequently selecting oral NSAIDS (58%) when electing to initiate treatment. Medication selection was unchanged when presented with a patient reporting severe PCH at 1 month compared to 48-hours post-injury. Conclusion Most physicians would treat pediatric PCH in the ED for a patient reporting severe pain, however, pain rated as moderate was less likely to receive abortive treatment. Metoclopramide was the most frequently selected medication for analgesia for severe pain. Future research should aim to establish the efficacy of this and comparative treatments for PTH in children.

Pediatric Ice Pop Administration to Improve Patient Experience Scores.

ObjectiveTo assess the impact on patient experience scores of giving an ice pop (Popsicle, Good Humor-Breyers, Oakland, CA) to patients in a pediatric emergency department (ED).Patients and MethodsA prospective two-center trial was conducted at a tertiary academic pediatric ED and a community ED from January 1, 2018, through March 31, 2018. The intervention arm gave an ice pop to all eligible patients 0 to 14 years of age on even-numbered days versus conventional practice on odd-numbered days. Press Ganey top box scores were then compared.ResultsOf 4574 pediatric (0 to 14 years of age) patient visits, patient experience surveys were delivered to 1346 families (29.4%) and 152 were returned (11.3%). Eighty-four surveys were returned for even-numbered day visits and 68 for odd-numbered day visits. There was a significant increase in patient experience scores associated with ice pop administration days for questions that asked about doctor’s concern for comfort 70.2% versus 57.4% (P=.05), doctor’s courtesy 76.2% versus 61.8% (P=.04), and doctor taking time to listen 72.6% versus 57.4% (P=.03).ConclusionA low-cost intervention resulted in significantly increased patient experience scores in select domains. Popsicle administration was a simple intervention which was easily instituted in both academic and community ED settings. Further study should explore the durability of the effect.

Comparison of Ultrasound-Marked Versus Standard Lumbar Puncture Success in Infants.

The aim of this study was to compare ultrasound (US)-marked versus standard lumbar puncture success in infants. This was a prospective cohort study at an academic pediatric emergency department. Standard lumbar puncture success in a retrospective control was compared with success in a US-marked group. Spinal US was performed with infants in the sitting and lateral decubitus position to identify the interspinous space with the most cerebrospinal fluid. The optimal position was determined, and this space was marked. The proceduralist performed the lumbar puncture at the level of the markings. The primary outcome was a successful lumbar puncture by the first provider, defined as a collection of cerebrospinal fluid with less than 1000 red blood cells/mm3. Secondary outcomes were successful lumbar puncture after attempts by more than 1 provider and collection of any spinal fluid. Between June 2017 and April 2019, we enrolled 284 infants younger than 12 months, 210 in the retrospective standard group and 74 in the prospective US-marked group. Baseline characteristics of both groups were similar. The primary outcome showed no difference between US-marked group and control (38% vs 36%; difference: 1.6% [95% confidence interval (CI), -14.7 to 10.7]). Secondary outcomes showed no significant success differences by more than 1 provider (51% vs 39%; difference: 12.8% [95% CI, -25.7 to 0.3]) or in obtaining any spinal fluid (82% vs 79%; difference: 3.9% [95% CI -13.3 to 7.5]). There were no differences in success between US-marked and standard lumbar punctures in infants by different providers.