Tertiary Care Pediatric Emergency Department Research Articles

Focused Cardiac Ultrasound Findings in Children Presenting With Shock to a Tertiary Care Hospital in Rwanda.

Shock remains a leading proximate cause of death in children. Children in sub-Saharan African (SSA) countries present with shock from a wide range of pathologies. Routine physiologic parameters may not reflect underlying physiology. No previous work has systematically described ultrasound findings in children with shock in an SSA country. We set out to perform focused cardiac ultrasound (FOCUS) on children with shock in Rwanda and describe the findings in this pilot study. In a prospective descriptive study, we trained pediatric residents to perform FOCUS on children presenting with shock to an urban tertiary care pediatric emergency department in Kigali, Rwanda. Images were transmitted via cellphone network and reviewed by experts. Primary outcome was expert's description of the FOCUS findings. Secondary outcomes included mortality at 48-hour, change in assessment and treatment after FOCUS, and agreement of FOCUS findings between residents and experts. Between January 2020 and April 2020, 25 subjects were enrolled by 8 residents. Eleven of 25 (44%) were newly diagnosed with acquired or congenital heart disease. The 48-hour mortality rate was higher in this group compared with those without heart disease (8 of 11 vs 1 of 14). The resident reported changing assessment and treatment based on FOCUS findings in 60% of patients (15 of 25). There was good to excellent agreements between residents and FOCUS experts on left ventricle function, pericardial effusion, and intravascular volume. In children presenting with signs and symptoms of shock in SSA, one could perform a screening FOCUS to distinguish between hypovolemic and cardiogenic shock.

Association of limited English proficiency and increased pediatric emergency department revisits.

Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits. This was a retrospective, cross-sectional study of patients 0 to 21years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted. There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference= 0.97, 95% confidence interval [CI]= 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR]= 1.15, 95% CI= 1.01 to 1.30) and in hospitalization (OR= 1.28, 95% CI= 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results. These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma

Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization. To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables. This post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo. Intravenous magnesium sulfate therapy (40-75 mg/kg). The association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis. Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect. Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with hospitalization were IV magnesium receipt from 2011 to 2016 (odds ratio [OR], 22.67; 95% CI, 6.26-82.06; P < .001) and from 2017 to 2019 (OR, 4.19; 95% CI, 1.99-8.86; P < .001), use of additional albuterol (OR, 5.94; 95% CI, 3.52-10.01; P < .001), and increase in PRAM score at disposition (per 1-U increase: OR, 2.24; 95% CI, 1.89-2.65; P < .001). In children with a disposition PRAM score of 3 or lower, receipt of IV magnesium therapy was associated with hospitalization (OR, 8.52; 95% CI, 2.96-24.41; P < .001). After adjustment for patient-level characteristics, receipt of IV magnesium therapy after initial asthma treatment in the ED was associated with subsequent hospitalization. This association also existed among children with mild asthma at ED disposition. Evidence of a benefit of IV magnesium regarding hospitalization may clarify its use in the treatment of refractory pediatric asthma. ClinicalTrials.gov: NCT01429415.

Replacing Computed Tomography with "Rapid" Magnetic Resonance Imaging for Ventricular Shunt Imaging.

Children with ventricular shunts undergo frequent neuroimaging, and therefore, radiation exposures, to evaluate shunt malfunctions. The objective of this study was to safely reduce radiation exposure in this population by reducing computed tomography (CT) and increasing "rapid" magnetic resonance imaging (rMRI-shunt) among patients warranting neuroimaging for possible shunt malfunction. This was a single-center quality improvement study in a tertiary care pediatric emergency department (ED). We implemented a multidisciplinary guideline for ED shunt evaluation, which promoted the use of rMRI-shunt over CT. We included patients younger than 18 years undergoing an ED shunt evaluation during 11 months of the preintervention and 25 months of the intervention study periods. The primary outcome was the CT rate, and we evaluated the relevant process and balancing measures. There were 266 encounters preintervention and 488 during the intervention periods with similar neuroimaging rates (80.7% versus 81.5%, P = 0.8.) CT decreased from 90.1% to 34.8% (difference -55.3%, 95% confidence interval [CI]: -71.1, -25.8), and rMRI-shunt increased from 9.9% to 65.2% (difference 55.3%, 95% CI: 25.8, 71.1) during the preintervention and intervention periods, respectively. There were increases in the mean time to neuroimaging (53.1 min; [95% CI: 41.6, 64.6]) and ED length of stay (LOS) (52.3 min; [95% CI: 36.8, 67.6]), without changes in total neuroimaging, 72-hour revisits, or follow-up neuroimaging. Multidisciplinary implementation of a standardized guideline reduced CT and increased rMRI-shunt use in a pediatric ED setting. Clinicians should balance the reduction in radiation exposure with ED rMRI-shunt for patients with ventricular shunts against the increased time of obtaining imaging and LOS.

Effect of the COVID-19 Pandemic on Patient Volumes, Acuity, and Outcomes in Pediatric Emergency Departments: A Nationwide Study.

The aim of this study was to quantify the effect of the COVID-19 pandemic on pediatric emergency department (ED) utilization and outcomes. This study is an interrupted-time-series observational study of children presenting to 11 Canadian tertiary-care pediatric EDs. Data were grouped into weeks in 3 study periods: prepandemic (January 1, 2018-January 27, 2020), peripandemic (January 28, 2020-March 10, 2020), and early pandemic (March 11, 2020-April 30, 2020). These periods were compared with the same time intervals in the 2 preceding calendar years. Primary outcomes were number of ED visits per week. The secondary outcomes were triage acuity, hospitalization, intensive care unit (ICU) admission, mortality, length of hospital stay, ED revisits, and visits for trauma and mental health concerns. There were 577,807 ED visits (median age, 4.5 years; 52.9% male). Relative to the prepandemic period, there was a reduction [-58%; 95% confidence interval (CI), -63% to -51%] in the number of ED visits during the early-pandemic period, with concomitant higher acuity. There was a concurrent increase in the proportion of ward [odds ratio (OR), 1.39; 95% CI, 1.32-1.45] and intensive care unit (OR, 1.20; 95% CI, 1.01-1.42) admissions, and trauma-related ED visits among children less than 10 years (OR, 1.51; 95% CI, 1.45-1.56). Mental health-related visits in children declined in the early-pandemic period (in <10 years, -60%; 95% CI, -67% to -51%; in children ≥10 years: -56%; 95% CI, -63% to -47%) relative to the pre-COVID-19 period. There were no differences in mortality or length of stay; however, ED revisits within 72 hours were reduced during the early-pandemic period (percent change: -55%; 95% CI, -61% to -49%; P < 0.001). After the declaration of the COVID-19 pandemic, dramatic reductions in pediatric ED visits occurred across Canada. Children seeking ED care were sicker, and there was an increase in trauma-related visits among children more than 10 years of age, whereas mental health visits declined during the early-pandemic period. When faced with a future pandemic, public health officials must consider the impact of the illness and the measures implemented on children's health and acute care needs.

Severe abrupt (thunderclap) non-traumatic headache at the pediatric emergency department - a retrospective study.

Adult abrupt severe non-traumatic headache (thunderclap) is often related to serious underlying etiologies such as subarachnoid hemorrhage. However, data are sparse regarding thunderclap headache in the pediatric population. The aim of the study was to evaluate the prevalence, characteristics and causes of thunderclap headache in the pediatric and adolescent population, aged 6-18 years, presenting to a pediatric emergency department. The electronic database of a tertiary care pediatric emergency department was searched for children presenting with acute headache during 2016-2018. Headache severity was defined by pain scales, either a visual analogue scale or by the Faces Pain Scale-Revised. Thunderclap headache was diagnosed in 19/2290 (0.8%) of the included patients, all of them with a pain score of 10/10. All the patients had a benign course. Primary headache was diagnosed in 15/19 (78.9%), six patients had migraine and eight were diagnosed with primary thunderclap headache. Four of the 19 patients were diagnosed with secondary headache: three with infectious causes and one with malignant hypertension. Thunderclap headache is rare among children and adolescents presenting to the emergency department. This headache is generally of a primary origin. Extensive evaluation is still needed to rule out severe diagnosis problems.

E-learning to teach medical students about acute otitis media: A randomized controlled trial

Acute otitis media (AOM) is extremely prevalent among children but its diagnosis remains challenging. Our primary objective was to measure the impact of an e-learning module on medical students' accuracy in diagnosing paediatric AOM. This randomized controlled trial was performed at a single tertiary care paediatric emergency department (ED). Medical students on their paediatric rotation were randomized to a locally developed e-learning module or a small-group lecture on AOM. They then had to examine at least 10 ears of patients at risk for AOM. The primary outcome was diagnostic accuracy and secondary outcomes included knowledge test scores and learning modality preference. Between May 2017 and September 2018, 201 medical students were randomized. Eighty-three evaluated at least 10 ears and were included in the primary analysis. Diagnostic accuracies (76.5% for the e-learning group versus 76.4% for the lecture group, difference of 0.1%; 95%CI: -6.2 to 6.4%) and post-test scores (difference of 0.5/20 points; 95%CI: -0.8 to 1.2/20 points) were similar between the groups. Sixty-two per cent of participants preferred the e-learning module to the lecture, while 15% had no preference. Diagnostic accuracy for AOM was similar between students exposed to an e-learning module or a small-group lecture. E-learning was the preferred learning modality.

Utility of MyHEARTSMAP in Youth Presenting to the Emergency Department with Mental Health Concerns

To evaluate the utility of a digital psychological self-assessment tool, MyHEARTSMAP (scores on 10 sections: home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources), in youth presenting to the pediatric emergency department (ED) with a mental health concern. We conducted a prospective cohort study in 2 tertiary care pediatric EDs from December 2017 to October 2019. Youth 10-17years old triaged for a mental health concern were screened and enrolled to complete MyHEARTSMAP on a mobile device. A clinician blinded to the MyHEARTSMAP assessment conducted their own assessment which was used as the reference standard. Utility was quantified as the sensitivity and specificity of MyHEARTSMAP in detecting psychiatric, social, youth health, and functional concerns. Among 379 eligible youth, 351 were approached and 233 (66.4%) families were enrolled. Sensitivity for youth MyHEARTSMAP self-assessments ranged from 87.4% in the youth health domain to 99.5% in the psychiatric domain for identifying any concern, and 33.3% in the social domain to 74.6% in the psychiatric domain for severe concerns. Specificity ranged from 66.7% in the psychiatric domain to 98.2% in the youth health domain for no or only mild concerns. Youth and guardian MyHEARTSMAP assessments are sensitive for detecting psychosocial concerns requiring follow-up beyond pediatric ED evaluation. Specificity for no or only mild concerns was high in the nonpsychiatric domains.

Evaluation of bedside sonography performed by emergency physicians to detect intussusception in children in the emergency department.

The aim of our study was to evaluate the test characteristics of point-of-care ultrasound (POCUS) performed by emergency physicians with varying levels of experience among children having undergone diagnostic radiology ultrasound for intussusception in a pediatric emergency department (PED). This was a subanalysis of a prospective cohort study conducted at a tertiary care PED. The study population was a sample of children younger than 5years old who required an abdominal ultrasound for suspected intussusception. Participating physicians had varying levels of POCUS experience. They received a 1-hour didactic and practical training session on intussusception ultrasound. All POCUS was performed following the initial physical examination and prior to further radiologic evaluation. The final outcome was determined by radiologic evaluation performed by a pediatric radiologist. Test characteristics were calculated for POCUS compared with the criterion standard of ultrasound read by a pediatric radiologist. A secondary analysis compared test characteristics of POCUS performed by physicians with different level of POCUS training. A total of 131 children were evaluated by POCUS, of whom 45 (34%) had an intussusception. Twenty-four physicians performed between one and 25 POCUS procedures. POCUS identified 39 of 45 intussusception cases, with a sensitivity of 0.87 (95% confidence interval [CI]= 0.74 to 0.94). A normal or inconclusive POCUS was reported for 83 of the 86 negative studies, with a specificity of 0.97 (95% CI= 0.90 to 0.99). When excluding the 28 patients for whom the physician reported an inconclusive examination, the sensitivity improved to 0.98 (95% CI= 0.97 to 1.00) and the specificity to 0.94 (95% CI= 0.85 to 0.99). The accuracy of diagnosis using POCUS was 42 of 43 (98%) for experienced sonographers in comparison to 81 of 88 (92%) for novices. This study demonstrated a very good sensitivity and specificity of POCUS for intussusception in children when performed by multiple emergency physicians with varying POCUS experience.

Oropharyngeal Carriage of Kingella kingae and Transient Synovitis of the Hip in Young Children: A Case-control Study.

Transient synovitis of the hip affects mostly preschool children, and its etiology is unknown. Kingella kingae has been identified recently as a common etiologic agent of osteoarticular infections (OAI) in young children and could potentially be associated to transient synovitis of the hip. The main objective of this study was to evaluate the association between transient synovitis of the hip and oropharyngeal carriage of K. kingae among preschool children. This was a prospective case-control study conducted at a tertiary care pediatric emergency department. Cases were children between 6 and 71 months of ages with a diagnosis of transient synovitis of the hip. For each transient synovitis case, an age-matched control was recruited among children presenting for a trauma. A second control group included children with any OAI. The independent variable was the presence of oropharyngeal K. kingae identified by a specific polymerase chain reaction assay. The primary analysis was the association between oropharyngeal K. kingae carriage and final diagnosis. A total of 73 children were included in the study. Among them, 25 had a transient synovitis, 16 an OAI, and 22 controls. Baseline demographics were similar between the groups. There was no difference in oropharyngeal carriage of K. kingae for children with transient synovitis (5/25; 0.20) in comparison to controls (3/22; 0.14), while it was higher for children with OAI (10/16; 0.63). There is no association between oropharyngeal K. kingae and transient synovitis of the hip among preschool children.

Predictors of epinephrine undertreatment in anaphylaxis—the experience of a busy North American tertiary care pediatric emergency department

Anaphylaxis, a potentially fatal allergic reaction with an increasing incidence and severity continues to be underdiagnosed and undertreated.1 Intramuscular (IM) epinephrine is the first-line treatment in any age group,1 and delay in administration is associated with a higher risk of fatality.2 Rates of epinephrine under treatment in the outpatient setting and in the emergency department (ED) range between 25% and 60%,3-6 even following intervention programs.6 Predictors for epinephrine undertreatment have been poorly studied.

The impact of COVID-19 on a tertiary care pediatric emergency department.

The restrictive measures required to face the recent outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may impact patterns of healthcare utilization. Our aim was to provide an insight into the change in the use of a pediatric emergency department (ED) during the SARS-CoV-2 pandemic. The medical records of the children seen in our pediatric ED during March and April 2020 were retrospectively reviewed. Consequently, these were compared to the medical records of 2018 and 2019 from the same time period and from other control periods (January–February 2019 and 2020, and July–August 2018 and 2019). The total number of ED visits declined by 73% from 2019 to 2020 (3051 vs 818). Significant variations were observed in the distribution of children between triage categories: the proportion of patients who was given a green-code showed a 0.59-fold decrease in comparison to 2019 (95% CI 0.5–0.69), while a relative increase in the proportion of yellow codes was observed (OR 1.46, 95% CI 1.2–1.78).Conclusion: Quarantine measures significantly impacted on the total number of patients and on the reasons for visiting them in our pediatric ED. This substantial decrease in pediatric care may either be due to lower rates of acute infections because of social distancing, or to parents’ or caregivers’ reticence to risk exposure to SARS-CoV-2 in a health-care setting.What is known:• A recent outbreak of a novel coronavirus responsible for a severe acute respiratory syndrome is spreading globally.• Restrictive measures may impact patterns of healthcare utilization, as observed in other previous outbreaks.What is new:• This study shows significant variations in the distribution of children among triage categories during the COVID-19 pandemic.• Discharge diagnosis was significantly different as well, in particular a relative increase in the proportion of children presenting with traumatic injuries and a decrease of viral infections were observed.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00431-020-03909-9.

684. The impact of rapid molecular respiratory testing on provider and parental decision making for children with respiratory illness evaluated in an ED setting

BackgroundRapid respiratory testing (RRT) can decrease ancillary testing, length of stay and antibiotic use for hospitalized children. Less is known regarding the impact of RRT in the emergency department (ED).Our objectives were to determine if RRT impacts ED provider clinical decision making, family acceptance, and subsequent healthcare visitation for children with influenza-like illness (ILI).MethodsRandomized controlled trial of children 1 month-18 years of age presenting to a tertiary care pediatric ED with ILI. All children received a nasopharyngeal swab and RRT and were randomized to the intervention group (RRT result given to clinicians/families) or control group (results not available unless obtained clinically). Outcomes included provider decision-making (anti-infective prescribing, ED diagnostic testing, disposition), family acceptance of RRT (willingness to undergo future testing) and repeat healthcare visits (clinic or ED). Providers in the intervention group were surveyed after RRT results were available, and families in both arms were contacted 1 and 10 days later.ResultsThere were 920 ED visits from 908 enrolled children; 629 (68%) families from both arms and 443 (96%) providers from the intervention arm completed surveys. Most providers (33%) were ED trained and < 5 years post-training (37%). Clinical decisions were changed in 17% of visits based on RRT results, most commonly by ED trained physicians, advanced practice providers, and those < 5 years post-training (Table). The most common decision changes were antiviral use and avoidance of diagnostic tests (Figure). Families were more willing to undergo future RRT if they were in the intervention group, or if RRT results were available in 20 minutes. In the control arm, 22 families (7%) stated they would not have sought additional medical visits if RRT results were available. In the intervention group, 20 families (6.7%) reported that the RRT influenced how their child received care, and 14 families (17%) sought additional care due to RRT results.Figure. Provider Clinical Decision Making Based on Results of Rapid Respiratory Testing, n = 443 Characteristics of providers and patients by provider decision type ConclusionRRT impacts clinical decision making for 1 in 5 ED visits, specifically antiviral prescribing and reduced diagnostic testing. Most families were in favor of RRT, which impacts additional health care visits after the ED encounter.Disclosures Suchitra Rao, MD, BioFire (Grant/Research Support) Molly Lamb, PhD, BioFire (Grant/Research Support) Rakesh Mistry, MD, MSCE, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

Frequency, Timing, Risk Factors, and Outcomes of Desaturation in Infants With Acute Bronchiolitis and Initially Normal Oxygen Saturation

Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them. To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization. This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020. After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home. The primary outcome was desaturation (ie, Spo2 < 90%) during the first 36 hours. Of 239 infants enrolled, with a median (interquartile range [IQR]) age of 3.9 (1.5-6.5) months, 116 (48.5%) were boys and desaturation occurred in 165 infants (69.0%). Median (IQR) time to desaturation was 3.6 (1.8-9.4) hours. The rate of desaturation was similar between infants hospitalized and those discharged home (137 of 200 infants [68.5%] vs 28 of 39 infants [71.8%]; difference, -3.3%; 95% CI, -18.8% to 12.2%; P = .85). A more severe initial clinical presentation with moderate or severe retractions was the only independent risk factor associated with desaturation (odds ratio, 2.73; 95% CI, 1.49 to 5.02; P = .001). Of 39 infants discharged home, 22 infants (56.4%) experienced major desaturations. However, infants with desaturations, including those with major desaturations, had rates of rehospitalization similar to those of infants without desaturations (8 of 28 infants [28.5%] vs 3 of 11 infants [27.3%]; difference, 1.2%; 95% CI, -29.9% to 32.5; P > .99). These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.

Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits.

Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits. This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables. We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission. In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.

Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department

While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. ClinicalTrials.gov Identifier: NCT01429415.

Children's Hospital Management in the COVID-19 Era: The Reorganization of a Tertiary Care Pediatric Emergency Department in Northern Italy.

In the Veneto Region, an exponential spread of patients affected by 2019 novel Coronavirus disease (COVID-19) has been observed after February 21st. Since then, we have been evaluating children suspected or confirmed for SARS-CoV-2 infection. A protocol for pediatric hospital reorganization and children management has been developed, since the beginning of the epidemic. A pre-triage area has been created at the immediate entrance of the pediatric emergency room, for all uncritical pediatric patients. According to the epidemiologic and clinical risk factors, all children/adolescents have been addressing to one of the four different pathways created. The strict application of this protocol has been leading to quickly identification, isolation, and management of all positive children, preventing SARS-CoV-2 intrahospital spread.

Abstract 224: Videographic Assessment of Pediatric Endotracheal Intubation in the Covid-19 Era: A Report From the Videography in Pediatric Resuscitation Collaborative

Introduction: Endotracheal intubation (ETI) of critically ill children is a high acuity, low frequency procedure in the pediatric emergency department that presents unique challenges to both pediatric and general acute care providers. COVID-19 and the associated requirements for PPE use, limitations of in-room personnel, communication difficulties, and reorganization of equipment have created new complexities. Objective: To use video review to compare intubator training level, first-attempt ETI success and presence of hypoxia during ETI attempts in the pediatric emergency department in the pre-COVID and COVID era. Methods: This is a retrospective multi-center case series of videorecordings of endotracheal intubations at the four tertiary care pediatric emergency departments comprising the VIPER Collaborative. All children undergoing emergent ETI between 1/1/2019-6/1/2020 in whom videorecordings were available were included for analysis. Data on patient age and intubator background was collected. Outcomes were first-attempt intubation success and hypoxia, defined as SpO2 &lt;90%. Data was compared before (PRE) and after (POST) implementation of COVID-19 airway protocols, which each PED adopted in March 2020. Univariate analysis comparing PRE and POST for both outcomes was done by c2 testing. Multivariate analysis with a generalized estimating equation to control for clustering by site was done to determine the independent association between PRE and POST and outcomes. Results: Between 1/1/2019 and 6/1/2020, a total of 272 patients underwent ETI (239 PRE, 33 POST). Overall first attempt success was 155/239 (65%) in PRE and 28/33 (85%) in POST (p=0.02). Hypoxia was noted in 15% of PRE patients and in 12% of POST patients. Analysis of the training level of the intubator was notable for a significant increase in the number of intubations performed by anesthesiologists (55% POST vs. 13% PRE, p&lt;0.001). In multivariate analysis controlling for intubator background, the POST phase was associated with greater first attempt success (AOR 2.4, 95% CI 1.6 – 3.7). Conclusion: Pediatric ETI in the COVID-19 era is associated with increased first attempt success when compared to the pre-COVID era.

Virtual Reality to Reduce Procedural Pain During IV Insertion in the Pediatric Emergency Department: A Pilot Randomized Controlled Trial.

The objective of this study was to evaluate the feasibility of using virtual reality (VR) for distraction during intravenous (IV) insertion in the pediatric emergency department (ED) and of conducting a full-scale randomized controlled trial. Children aged 8 to 17 years old attending a tertiary care pediatric ED were randomized to interactive VR or an attention control (video on a tablet) for distraction during their IV insertion. Feasibility was determined by recruitment rates, acceptability of the intervention, response rates to outcome measures, and safety or technical problems. Satisfaction questionnaires and pain, fear, and distress scores were completed by the child, caregiver, nurse, and research assistant. Immersion in the intervention was rated by the child. Heart rate was measured. Children were recruited between February 2018 and May 2019. A total of 116 children were screened and 72.3% of eligible children were enrolled. Overall, 60 children were randomized to either VR (n=32) or attention control (n=28). Children, caregivers, and nurses were highly satisfied with both distraction methods. There were no significant safety, technical, or equipment issues. There was minimal disruption to clinical workflow in both groups due to study protocols. There was a clinically significant reduction in pain in the VR group. There was no significant difference in fear or distress. Children reported higher immersion in the VR environment. Heart rate increase from baseline was higher in the VR group. Our data support the feasibility of using VR for distraction during IV insertion and of conducting a full-scale randomized controlled trial. Identifying eligible patients and minimizing the number of outcome measures will be important considerations for future research.

Pediatric emergency care in a low-income country: Characteristics and outcomes of presentations to a tertiary-care emergency department in Mozambique.

An effective pediatric emergency care (PEC) system is key to reduce pediatric mortality in low-income countries. While data on pediatric emergencies from these countries can drive the development and adjustment of such a system, they are very scant, especially from Africa. We aimed to describe the characteristics and outcomes of presentations to a tertiary-care Pediatric Emergency Department (PED) in Mozambique. We retrospectively reviewed PED presentations to the "Hospital Central da Beira" between April 2017 and March 2018. Multivariable logistic regression was used to identify predictors of hospitalization and death. We retrieved 24,844 presentations. The median age was 3 years (IQR 1-7 years), and 92% lived in the urban area. Complaints were injury-related in 33% of cases and medical in 67%. Data on presenting complaints (retrieved from hospital paper-based registries) were available for 14,204 (57.2%) records. Of these, respiratory diseases (29.3%), fever (26.7%), and gastrointestinal disorders (14.2%) were the most common. Overall, 4,997 (20.1%) encounters resulted in hospitalization. Mortality in the PED was 1.6% (62% ≤4 hours from arrival) and was the highest in neonates (16%; 89% ≤4 hours from arrival). A younger age, especially younger than 28 days, living in the extra-urban area and being referred to the PED by a health care provider were all significantly associated with both hospitalization and death in the PED at the multivariable analysis. Injuries were a common presentation to a referral PED in Mozambique. Hospitalization rate and mortality in the PED were high, with neonates being the most vulnerable. Optimization of data registration will be key to obtain more accurate data to learn from and guide the development of PEC in Mozambique. Our data can help build an effective PEC system tailored to the local needs.