Hospital Pediatric Emergency Department Research Articles

From Their Perspective: Pediatric Patients With Acute Mental Health Needs and Prolonged Emergency Department Stays.

The pediatric emergency department (PED) is experiencing a rising volume of patients with mental health concerns, leading to prolonged boarding times and delays in initiating active therapeutic plans. A paucity of research exists for the self-reported pediatric patient experience during such boarding. To inform more individualized and patient-centered PED care for patients boarding for mental health admission, by learning the prior trauma experiences and patient perspective on prolonged PED mental health stays. A convenience sample was collected at an urban hospital's PED among those boarding for mental health emergency greater than 24 hours. Demographic information, exposures to past trauma, and perceptions on and understanding of their care experience, were discussed. Descriptive and thematic content analysis were used for data analysis. A total of 99 youths were included in the study and the majority reported worsening mental health symptoms during PED boarding, notably increasing anxiety (72 [72.7%]). Patients were equivocal on efficacy of PED mental health intake on symptoms (41 [41.4%]). Personal suggestions were offered by these patients to guide the care of future children that would better mitigate their symptoms while boarding in the PED, such as group activities, electronics, and physical activity. Patients in mental health crisis boarding in the PED have already experienced stressful life events. By listening to the personal stories of this vulnerable population, the PED can improve care delivery and design a more therapeutic environment, especially as the need for acute mental health management continues to increase.

Revisits to a pediatric hospital emergency department for asthma attacks

Revisits to a pediatric hospital emergency department for asthma attacks

Experience with sedation and analgesia in a tertiary care hospital pediatric emergency department

Experience with sedation and analgesia in a tertiary care hospital pediatric emergency department

Shortening treatment duration for uncomplicated community acquired pneumonia to align with best practice guidelines in a large academic paediatric emergency department

Recommendations for antibiotic therapy for community acquired pneumonia recently changed from 10-day to 5-day duration. This quality improvement project aimed to change the practice of providers in an urban, free-standing children's hospital paediatric emergency department in the United States to match the updated recommendations. Improvement interventions included educational outreach, data sharing, on-site reminders, and audit-and-feedback. The project included analysis of ED return visits to monitor possible treatment failure. Interventions successfully increased 5-day antibiotic prescription rate from 3% to 85% within 12 months.

Continuous infusion of magnesium sulfate to treat acute severe asthma in a Brazilian pediatric emergency department

Purpose: Magnesium sulfate (MgSO4) emerged as an adjunctive therapy to help manage acute severe asthma refractory to the first-line therapy, such as oxygen, ipratropium, corticosteroids, and bronchodilators. Despite the known benefits of MgSO4, limited information is available regarding potential adverse effects (AEs). We aimed to investigate potential AEs and clinical response of intravenous MgSO4 by assessing vital signs and the modified Wood-Downes score (mWDS), a relevant clinical scoring system. Methods: This investigation constitutes a prospective, single-arm study, conducted from June 2022 through May 2023, in a pediatric emergency department of the quaternary public hospital in Brazil. This study included all children aged 3-14 years who visited the pediatric emergency department during the period and underwent a 6-hour continuous infusion of MgSO4 at 50 mg/kg/hour, against acute severe asthma, a case refractory to the first-line therapies. We evaluated the safety and efficacy of the infusion by using vital signs and the mWDS. Clinical response was defined as a reduction of at least 1 point in the scoring system.Results: We analyzed a total of 42 children including 24 boys (57.1%), whose mean age was 5.7 ± 2.4 years. The 6-hour continuous infusion of MgSO4 reduced mWDS from 3 (interquartile range, 3-4) to 2 (2-3) (P < 0.001) and resulted in the clinical response in 30 children (71.4%) without an AE. After the infusion, 13 of the 15 children (86.7%) classified as having moderate asthma exacerbation (mWDS, 4-6) were improved to having mild asthma exacerbation (mWDS, 1-3) (P < 0.001). The mean serum magnesium concentration after the infusion was 4.7 mg/dL. Pneumonia and viral infection did not predict the clinical response.Conclusion: This study indicates the safety and efficacy of the 6-hour continuous infusion of MgSO4 as a therapeutic option for acute severe asthma, which is refractory to the first-line therapy.

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.

Patients with palliative needs in a tertiary hospital emergency department in 2021 - retrospective chart review

Introduction: Children with complex chronic diseases and life-limiting conditions require a differentiated and adapted medical approach. OBJECTIVES: Characterise the affluence and management of children, followed by an in-hospital pediatric palliative care support team, who presented to a tertiary hospital pediatric emergency department in 2021. Methods: A one-year retrospective analysis of emergency episodes was performed by consulting medical records. Episodes were categorized, data were recorded anonymously, and descriptive statistical analysis was carried out. Results: Of the 58 pediatric patients monitored by the team, 66% resorted to the emergency department in 2021, leading to 85 admissions (average: two per patient; 82% classified as urgent, very urgent, or immediate). The most frequent admission reasons were respiratory symptoms. Hospitalization was required in 45%: 3 patients transferred from another hospital in the pediatric intensive care unit, 32 to the pediatric ward, and the remaining in the observation service. Blood tests, cultures and imaging tests were performed in 45%, 48% and 46% respectively, and antibiotics instituted in 44%. Twenty-three children (61%) admitted to the emergency department had an orally discussed advanced care plan. No patients died in the emergency department or the intensive care unit. One died at home with support from the team and three in the ward. Discussion: The reduced emergency department visits per patient and the frequent hospitalization needed when recurring reflects the effectiveness of a differentiated multidisciplinary team, domiciliary care and caregiver training. Establishing an advanced care plan and an emergency approach protocol is fundamental for individualized care delivery.

Patterns of healthcare use among children with immigrant and non-immigrant backgrounds in 2019 and 2020: evidence from the CRIAS cohort study in the metropolitan area of Lisbon, Portugal

BackgroundInternational migrant families may face various barriers in the access and use of health services. Evidence on immigrant children’s health care or prevention facilities’ utilisation patterns is scarce in Portugal. Therefore, the objectives of this study were to compare health services use between immigrant and non-immigrant children in the Metropolitan Area of Lisbon in 2019–2020 with the aim of informing public policies towards equitable access to, and use of health services.MethodsThe CRIAS (Health Trajectories of Immigrant Children) prospective cohort study enrolled 420 children (51.6% immigrant) born in 2015 and attending primary health care (PHC) services in 2019. We compared primary health care facilities and hospital paediatric emergency department (ED) utilisation patterns in the public National Health Service, together with reported private practitioners use, between immigrant and non-immigrant children in 2019 and 2020. The Pearson chi-squared test, Fisher-Freeman-Halton Exact test, two-proportion z-test and Mann‒Whitney U test were used to examine the differences between the two groups.ResultsIn 2019, no significant differences in PHC consultations attendance between the two groups were observed. However, first-generation immigrant children (children residing in Portugal born in a non-European Union country) accessed fewer routine health assessments compared to non-immigrant children (63.4% vs. 79.2%). When children were acutely ill, 136 parents, of whom 55.9% were parents of non-immigrant children, reported not attending PHC as the first point of contact. Among those, nearly four times more non-immigrant children sought healthcare in the private sector than immigrant children (p < 0.001). Throughout 2019, immigrant children used ED more often than non-immigrant children (53.5% vs. 40.4%, p = 0.010), as their parents reported difficulties in accessing PHC. In 2020, during the COVID-19 pandemic, fewer immigrant children accessed PHC compared to non-immigrant children (70% vs. 80%, p = 0.018). Both non-immigrant and immigrant children reduced ED use by 2.5 times, with a higher decrease among immigrant children (46% vs. 34%). In both 2019 and 2020, over 80% of immigrant and non-immigrant children used ED for conditions classified as having low clinical priority.ConclusionBeyond identifying health care use inequalities between immigrant and non-immigrant children, the study points to urgent needs for public policy and economic investments to strengthen PHC for all children rather than for some.

Vaccine Hesitancy in Central Switzerland: Identifying and Characterizing Undervaccinated Children in a Pediatric Emergency Department.

Vaccinations play an important role in the prevention of potentially fatal diseases. Vaccine hesitancy has become an important problem both in the public discourse and for public health. We aimed to identify and characterize this potentially unvaccinated or incompletely vaccinated group of children presenting to the pediatric emergency department (PED) of the tertiary children's hospital in central Switzerland, a region that has anecdotally been claimed as a hotspot for vaccine hesitancy. All patients presenting to the PED (N = 20,247) between September 2018 and September 2019 were screened for their vaccination status and categorized as incomplete, unvaccinated, or fully vaccinated in a retrospective cohort study. Some 2.6% (n = 526) visits to the PED were not or incompletely vaccinated according to age, or their vaccination status was unknown. Most of the children in the cohort were not critically ill, and the minority had to be hospitalized. Undervaccinated patients were overrepresented in rural areas. Of all cohort visits, 18 (3.4%) patients received opportunistic vaccination in the PED. No cases of vaccine-preventable diseases were observed. In summary, incompletely vaccinated and unvaccinated status was less frequent than initially expected. The PED may play a role in increasing vaccination coverage by providing opportunistic vaccinations.

Vertebral Fractures in Pediatric Suicidal Jumpers: A Retrospective Study with Epidemiological and Clinical Analysis before and after the COVID-19 Pandemic

Background: From the beginning of the COVID-19 pandemic, reports in the literature confirm a significant increase in suicide attempts in children and adolescents. At the Bambino Gesù Pediatric Hospital Emergency Department (Rome, Italy), there was a dramatic increase in suicidal jumpers. Many of these presented vertebral fractures. Methods: This retrospective study includes all suicidal jumpers with vertebral fractures treated from April 2017 to March 2023. We collected and compared data from three years before to three years after the pandemic, analyzing vertebral fractures. Results: From April 2019 to March 2020, 141 cases of suicide attempt arrived at the emergency department. Five of these were suicidal jumpers without vertebral fractures. From April 2020 to March 2023, 362 cases of suicide were hospitalized and 19 were suicidal jumpers; 12 reported vertebral fractures (mean age 14 years). Seven patients were treated by percutaneous pedicle fixation. Three patients needed an open spinal surgery by posterior approach. One case with cervical fractures was treated by Halo-Vest. Conclusions: This is the first report that shows a sharp increase in vertebral body fractures due to suicide jumping attempts in children and adolescents. This could be a new epidemiological phenomenon persisting or even increasing over time in the pediatric population as a consequence of the COVID-19 pandemic.

Faringoamigdalitis y estreptococo, ¿enemigo o colonizador?

Introduction: the main etiology of acute pharyngotonsillitis (AAT) is viral, and among the bacterial etiology, Streptococcus pyogenes is a non-negligible colonizer of the healthy pediatric population. The aim of this study is to know how the rapid streptococcal diagnostic test (RDT) is used in pediatric emergency departments in order to optimize its use, reduce the overdiagnosis of streptococcal AAP and the prescription of antibiotics. Material and methods: we collected retrospective information on the number of RDTs performed on patients seen in the Pediatric Emergency Department of a tertiary hospital, from January 2022 to January 2023 (both inclusive). Information was also collected on the number of patients who underwent more than one RDT and the time elapsed. Results: during the 13 months studied, a total of 1610 TDRs were performed (43% in &lt; 5 years). More than one TDR was performed in 89 patients (53% in &lt; 5 years) and 40% of these were performed in the first 40 days. Discussion: microbiological tests for Streptococcus pyogenes are not able to differentiate between active infection and healthy carrier state. According to the results of our study there seems to be an inadequate use of RDTs; most tests are performed in &lt; 5 years, where streptococcal etiology is less frequent and healthy carrier status predominant. This leads to overdiagnosis of FAAE, antibiotic overtreatment, occurrence of adverse effects and bacterial resistance.

The Effect of Stress Ball Use Applied by Emergency Nurses During Swabbing Procedure on the Pain and Fear Levels of Children Admitted to the Pediatric Emergency Service With the Suspicion of COVID-19: A Randomized Controlled Trial

IntroductionThis study aimed to determine the effect of stress ball use during the swabbing procedure on the pain and fear levels of children admitted to the pediatric emergency department with the suspicion of coronavirus disease 2019. Children with suspected coronavirus disease 2019 were recruited by convenience sampling from the pediatric emergency department of a university hospital in a city in Turkey. MethodsThis study used a random controlled experimental design and had a calculated sample size of 60. There were 30 participants in both the control and experimental groups. The stress ball intervention was applied to the children in the experimental group during the swabbing process, and no intervention was made to the children in the control group during the procedure. The pain and fear levels of the children in the control and experimental groups were measured during the swabbing process. “Descriptive Characteristics Form for Parents and Children,” “Wong-Baker Faces Pain Rating Scale,” “Children’s Fear Scale,” and “Stress Ball” were used in data collection. Chi-square, Mann-Whitney U, and Friedman tests were used in the analysis. ResultsAlthough there was no statistically significant difference between the groups in terms of pain and fear level mean scores before the procedure, a statistically significant difference was found between the groups during and after the procedures (P < .05). DiscussionGiving a stress ball to children aged 4 to 10 years during the swabbing procedure was determined to reduce the pain and fear levels during and after the procedures. It is recommended that stress ball use be applied during the swabbing procedure for children.

Validation of the Turkish version of the pediatric early warning score

Aim: The pediatric early warning score (PEWS) identifies pediatric patients at risk for clinical deterioration and can helpless-experienced providers get a sense of which patients may need escalation of care. The purpose of the study was to adapt the PEWS into Turkish and evaluate its validity in pediatric patients admitted to the emergency. &#x0D; Material and Methods: This study was conducted between May and October 2022 on 228 patients aged 17 and under in the pediatric emergency department of a tertiary care hospital. In the pilot phase of the study, scoring of the first 30 patients was performed by three nurses in the emergency department. In the second phase, the validity of the PEWS scale was evaluated. Validity of the scoring system in predicting admission was assessed using area under the receiver operating characteristics (ROC) curve (AUC), sensitivity, and specificity, positive predictive value (PPV) and negative predictive value (NPV).&#x0D; Results: The mean age of the children was 6.37 ± 4.72 years. Phase I demonstrated good inter-rater reliability (kappa = 0.75). In phase II, 22 patients (9.6%) were admitted to the intensive care unit (ICU) during the study period. AUC for predicting was 0.948 (95% CI: 0.915–0.981). According to ROC curve analysis, a cut-off value for PEWS score was found to be 4 (PEWS &gt;4) for admitted to the ICU. Sensitivity and specificity in predicting ICU admission with the cut-off PEWS ≥4 was 86.36% and 90.78%, respectively (PPV, 50%; NPV, 90.48%). The sensitivity and specificity in predicting admission with a cut-off of PEWS ≥1 was 100% and 59.22%, respectively (PPV, 20.75%; NPV, 100%).&#x0D; Conclusion: The Turkish version of PEWS can be helpful in assessing patient status in pediatric emergency department with acceptable validity and can serve as a potentially screening tool for prediction of ICU admission.

Efficacy of Single Titanium Elastic Nail in the Treatment of Child Femur Fractures.

Femoral shaft fractures in childhood constitute an important part of emergency visits to orthopedic clinics. The aim of this study was to investigate the efficacy and reliability of a method in the treatment of simple fractures in the middle of the femoral diaphysis in patients with multiple injuries or in the treatment of cases with a medullary canal that is too narrow for two nails, with a single stretch nail thicker than half the diameter of the canal. Between July 2002 and November 2006, examinations were made of 11 femoral fractures in 11 patients who were admitted to the pediatric emergency department of Tepecik Training and Research Hospital with a diagnosis of femoral fracture and who were hospitalized and treated with a single flexible intramedullary titanium nail. In the follow-up, no problem was found in terms of union and length difference in any of the cases, except for a10º varus deformity present after surgery in one case. Elastic intramedullary nailing is an effective method in the treatment of simple femoral fractures in children. A single elastic nail provides adequate stability following open reduction with minimal incision in patients whose short operating time must be kept short such as those with head trauma, thoracic trauma, or intra-abdominal pathology, or patients with a narrow medullary canal where two flexible nails cannot pass. We think that it is a feasible method because it causes minimal soft tissue damage.

Implementing Point-of-Care Ultrasound for Acute Scrotal Pain in the Pediatric Emergency Department: Screening Testicular Torsion and Patient Flow Analysis.

Testicular torsion (TT) is a pediatric surgical emergency that requires prompt treatment. This study investigated the feasibility of point-of-care ultrasound (POCUS) for diagnosing TT in the pediatric emergency department (ED). We retrospectively reviewed the medical records of patients, aged 18 years or younger, who visited a university-affiliated hospital pediatric ED with acute scrotal pain without trauma history and underwent diagnostic ultrasounds between January 2010 and October 2022. This study included 731 patients (median age: 9 years), Of these, 315 (43%) were in the POCUS-performed group: 188 in the POCUS-only group, and 127 in the POCUS-and-RADUS group. The other 416 patients (56.9%) were in the RADUS-only group. In total, 45 patients (6.2%) were diagnosed with TT (19 in the POCUS-performed group and 26 in the RADUS-only group). The sensitivity, specificity, and positive and negative predictive values of POCUS for diagnosing TT were 94.7%, 92.9%, 46.2%, and 99.6%, respectively. The median time to perform POCUS was shorter than RADUS (23 versus 61 minutes, P < .001). The POCUS-performed group had a shorter ED length of stay than the RADUS-only group (93 versus 170 minutes, P < .001). Among the patients diagnosed with TT, performing POCUS first did not significantly delay the ED process, including time to operation (250 versus 205 minutes, P = .142). For patients with acute scrotal pain, evaluation performed by pediatric emergency physicians using POCUS performs well in screening TT, and can decrease length of stay in the ED.

Ambulatory Management of Urinary Tract Infections in Children: Experience of the Pediatric Medical Emergency Department in Rabat

The aim of the study is to describe the clinical epidemiological characteristics and bacteriological profile of UTIs in infants and children, to determine the main risk factors for the occurrence of UTIs, and to identify the causes of UTIs urinary tract infections, to compare the interest of CRP and let procalcitonin assays for the diagnosis of febrile urinary tract infections as well as the interest of imaging (renal scintigraphy and ultrasound of the urinary tree) in the diagnosis of febrile urinary tract infections. This observational study of a cohort of 169 patients (children aged more than 28 days, 119 girls and 40 boys) conducted in the pediatric emergency department of the children's hospital of the university hospital of Rabat over a period of 6 months. The diagnosis of UTIs is based on the detection of germs in the urine, either indirectly by urine dipstick or by urine culture. However, the interpretation of microbiological results can be tricky: an inappropriate urine collection technique, particularly in neonates and young children, is a pitfall that the clinician must take into account to avoid misdiagnosing UTI, usually by over-diagnosis. The location of high UTI involving the renal parenchyma or low UTI limited to the bladder, which determines the morbidity of the infection, the therapeutic management and the imaging work-up, remains a matter of debate. DMSA renal scintigraphy, the reference examination in the case of high UTI, cannot be recommended as a first-line examination because of its cost and the practical difficulties of performing it. Biological markers of inflammation (leucocytosis, CRP, procalcitonin) do not always allow the diagnosis of ANP to be made with certainty.

The effect of visual and/or auditory distraction techniques on children's pain, anxiety and medical fear in invasive procedures: A randomized controlled trial

PurposeThis study was conducted to determine the effects of visual and/or auditory distraction techniques applied to children aged 7–12 during invasive procedures on pain, anxiety, and medical fear. MethodsThis single-blinded, randomized controlled trial was carried out in the pediatric emergency department of a public hospital between November 2021 and March 2022. In the study, 144 children were assigned to three different intervention groups, in which a kaleidoscope, music, and virtual reality were applied during invasive procedures, and the control group in which the standard invasive procedure was applied, by using the stratified block randomization method. The data were collected using a Personal Information Form, Wong-Baker Faces Pain Rating Scale, Children's Anxiety Meter-State, and Child Medical Fear Scale. ResultsIn the study, the levels of pain, anxiety, and medical fear after the invasive procedure were lower in the intervention groups than in the control group. In addition, there was no difference between the three different distraction techniques in terms of reducing pain and medical fear, but the virtual reality application was more effective in reducing the level of anxiety. ConclusionVisual and/or auditory distraction techniques are effective methods that can be used by nurses in pediatric healthcare to reduce invasive procedure-related pain, anxiety, and medical fear. Implications for practiceThis study provides evidence that can guide the use of non-pharmacological methods such as distraction to prevent the traumatic effects of invasive procedures in children.

Brief resolved unexplained event: Severity-associated factors at admission in the pediatric emergency ward

ObjectiveA brief resolved unexplained event (BRUE) is a recent clinical entity that has now replaced the term “infant discomfort”. Despite the availability of recent recommendations, identification of patients requiring further examination remains difficult. MethodWe aimed to identify factors associated with severe pathology and/or recurrence by studying the medical files of 767 patients admitted to the pediatric emergency department of a French university hospital for a BRUE. ResultsOverall, 255 files were studied; 45 patients had a recurrence and 23 patients had a severe diagnosis. The most frequently found etiology was gastroesophageal reflux in the benign diagnosis group and apnea or central hypoventilation in the severe diagnosis group. Prematurity (p = 0.032) and time since last meal >1 h (p = 0.019) were the main factors associated with severe disease. Most of the routine examination results remained non-contributive to the etiology. ConclusionAs prematurity is a factor associated with severe diagnosis, special attention should be given to this population, without subjecting them to multiple tests, since the main complication was found to be apnea or central hypoventilation. Prospective research is needed to establish the usefulness and prioritization of diagnostic tests for infants who are at “high risk” of experiencing a BRUE.

Mental health emergency admissions in the paediatric emergency department.

To evaluate the demographic characteristics, diagnoses and length of stay of mental health emergency attendance to the paediatric emergency department (ED), to determine the burdens these patients brought to the paediatric ED and to the national economy by examining hospital costs. This retrospective observational study was conducted in a tertiary hospital's paediatric ED in Turkey. Data were obtained from the electronic medical record system from January 2018 to January 2020. A total of 142 admissions were included of whom 60% were female. The mean age was 15.2 ± 1.8 years, 50% of cases were suicide attempts and 19% were alcohol intoxications. The majority (85.9%) of patients were discharged from the emergency observation unit. Among the diagnostic groups, the mean age was higher in patients with a history of substance abuse. There was a female predominance among patients who were admitted due to suicide attempts. Among the diagnostic groups, the duration of hospital stay and cost of hospitalization were higher in patients who were followed up with a diagnosis of suicide attempt. Mental health problems are frequent in the paediatric ED. We determined that the most common cause of attendance in paediatric emergencies was suicide attempts, and the length of hospital stay and hospital cost were higher in this diagnostic group. Although further research is necessary to determine national trends in paediatric mental health problems in the paediatric ED, screening strategies and early detection and interventions in primary healthcare may allow more effective care for childhood mental health problems.

Editorial introductions.

Editorial introductions.