Pediatric emergency care最新文献

Objectives: To measure the association between overall workload and patient and family experience (PFE) in a pediatric emergency department (ED). Our secondary objective was to assess the construct validity of total ED Relative Value Units (RVUs) as an overall ED workload measure.

Methods: We performed a retrospective study from January 2022 to August 2023 using data from a large, urban, academic pediatric ED with approximately 85,000 patient visits annually. PFE was measured by surveys distributed to all patients discharged from ED. The association of overall ED workload with PFE was assessed using multivariate ordinal logistic regression. We examined the construct validity of total ED RVUs by replacing this measure with National Emergency Department Overcrowding Scale (NEDOCS) in the logistic regression model.

Results: Of 126,336 discharged visits, 7128 (5.6%) completed surveys. We found a statistically significant association between ED workload and PFE. For each 10 RVUs added to ED workload, the odds of more positive PFE decreased by 9% (95% CI: 8%-9%). The adjusted odds ratio of NEDOCS demonstrated a less pronounced association in the same direction; an increase of 10 points in NEDOCS was associated with 6% (95% CI: 5%-6%) decrease in the likelihood of higher PFE ratings.

Conclusions: High ED workload, as measured by overall RVUs, was significantly associated with negative PFE. Similar results were found when we substituted NEDOCS for overall RVUs. Our findings suggest that overall RVUs may be a useful measure of ED workload and might provide a quantitative target for quality improvement.

Objectives: Despite the existence of evidence-based guidelines from the Centers for Disease Control and Prevention, studies have demonstrated the need for improvement in the evaluation and treatment of adolescents and young adults with a possible sexually transmitted infection (STI) presenting for care in pediatric emergency departments (PEDs) and general emergency departments (EDs) in the United States. We created an implementation strategy plan for our PED designed to improve STI care for patients.

Methods: Using the Tailored Implementation in Chronic Diseases (TICD) determinants framework, we identified, prioritized, and investigated determinants of implementation success of our initiative. We then conducted stakeholder interviews to refine and design an implementation strategy plan that addressed identified barriers and facilitators.

Results: The resulting implementation strategy included: (1) a standardized STI care protocol; (2) electronic health record (EHR) enhancements, including smart phrases and tailored order sets; (3) staff training materials and academic detailing sessions for physicians and nurses; (4) an adolescent-friendly discharge instruction handout; (5) an EHR-based referral system to an adolescent health clinic; (6) visual aids to support accurate STI sample collection'and (7) an evaluation plan to assess protocol uptake, documentation quality, treatment accuracy, and follow-up linkage.

Conclusions: This TICD-informed, stakeholder-driven approach may serve as a model for EDs aiming to enhance STI care delivery for adolescent and young adult patients.

Background: Blunt cerebrovascular injury (BCVI), defined as an injury occurring to the carotid and/or vertebral arteries, occurs in ~1% of pediatric blunt trauma patients and is associated with morbidity and mortality. Our objective was to evaluate the sensitivity and specificity of the McGovern score, a pediatric-specific screening tool for BCVI, and describe the effect of its implementation on the use of additional imaging for BCVI and the detection of BCVI.

Methods: This was a retrospective cohort study of patients below 16 years old presenting with blunt trauma to the Pediatric Emergency Department of a tertiary care level 1 pediatric trauma center pre- (July 1, 2020, to November 30, 2021) and post- (December 1, 2021, to December 31, 2022) implementation of McGovern scoring into the clinical decision algorithm for blunt trauma. Patient characteristics, diagnostic studies used [including computed tomography angiography (CTA) or magnetic resonance angiography (MRA) of the neck vessels], and outcomes (BCVI, stroke, mortality), were obtained from the medical record and compared pre-McGovern versus post-McGovern score implementation.

Results: A total of 1189 patients were included in the study; 664 preimplementation of the McGovern scoring and 525 postimplementation. Median age was 6 years (IQR 2 to 11), and 668 (56%) were trauma activations (leveled traumas), with no significant differences in patient characteristics between the 2 cohorts. Imaging for BCVI was performed in 13 (2.0%) patients in the preimplementation group and 27 (5.0%) patients in the postimplementation group (P=0.003). BCVI was detected in 12/1189 patients overall (1.0%); 2 in the preimplementation group (0.3%), and 10 (1.9%) in the postimplementation group (P=0.007). In the postimplementation group, the sensitivity of the McGovern score was 90% while the specificity was 96.7%.

Conclusions: The implementation of the McGovern score into the pediatric trauma decision algorithm was associated with the detection of an increased number of BCVIs compared to the preimplementation group, with good sensitivity and specificity, but a significant increase in the use of imaging.

Objectives: The aim of this study was to investigate differences in utilization of diagnostic imaging between the adult and pediatric trauma teams when caring for adolescent trauma patients.

Methods: This was a retrospective observational study from 2015 to 2019 comparing pediatric trauma team activations for patients ages 12 to 14 and adult trauma team activations for patients ages 15 to 17 at a single institution verified as both a level I adult and a level I pediatric trauma center. Data were collected from a prospective trauma registry and manual chart review of the electronic medical records. The primary outcome was the frequency of whole body computed tomography (WBCT) and computed tomography (CT) imaging of individual body regions.

Results: We identified 191 adult and 100 pediatric trauma team cases, with similar proportions transferred from outside hospitals (40% vs. 43%). Among patients presenting directly from the scene, WBCT use was significantly higher in the adult trauma team group (64% vs. 12%; RR: 5.21; 95% CI: 2.57-10.58), as was CT of all individual body regions. For transferred patients, the adult trauma team more often performed WBCT and individual CT scans, excluding head CT. CT imaging rates before transfer did not differ between groups. No significant differences were observed in injury severity scores, altered mental status, length of stay, or missed injuries.

Conclusions: Among adolescents with similar injury severity, the adult trauma team more frequently utilizes WBCT and regional CT than the pediatric team. However, CT use before transfer from outside hospitals without dedicated pediatric trauma teams was similar across age groups.

Objectives: Describe the interactions of young people killed by firearms with the pediatric health care system, with a focus on emergency department care. Characterize victims' risk factors for firearm violence as documented in the medical record.

Methods: Subjects were identified by querying the Gun Violence Archive (GVA) for individuals aged 13 to 30 who were fatally shot in Washington, D.C. between January 1, 2018 and December 31, 2022. GVA victims were matched to medical records within our pediatric hospital system. Records were analyzed for demographics, violence risk factors, and health care utilization.

Results: A total of 352 patients met inclusion criteria. The most common risk factors ascertained from medical record review were accidental injury (70.5%), violent injury (45.4%), and involvement with the juvenile justice system (32.9%). Individuals with greater than 5 risk factors comprised only 9.4% of our population but accounted for more than a quarter of the total risk factors documented, including 46.8% of child abuse cases, 31.2% of firearm injuries, 25% of juvenile justice cases, and the majority of mental and behavioral health risk factors (89.4% of behavioral issues, 55.2% of mood problems, and 54.1% of ADHD cases). Conversely, thirty-eight subjects (10.8%) had no documented risk factors. Subjects visited our ED multiple times (mean 5.74 visits) and the majority (70.1%) visited an outpatient clinic.

Conclusions: Young victims of firearms had a range of risk factors for firearm violence and multiple interactions with our pediatric hospital system before death. Each interaction represents an opportunity to screen and intervene. This work also points to the opportunity to change the inequitable systems responsible for these risk factors. Further work must be done to evaluate which risk factors are most predictive and how they develop over time.

Objectives: High-flow nasal cannula (HFNC) use in bronchiolitis has increased substantially with wide variability, likely due to the lack of objective means of predicting clinical outcomes. Our objective was to identify features associated with care escalation for infants started on HFNC in the Emergency Department (ED), thereby assisting in disposition of patients and optimizing the utilization of limited resources.

Methods: This is a retrospective cohort study from 3 free-standing children's hospitals of infants younger than or equal to 12 months with bronchiolitis who were initiated on HFNC in the ED between 2/1/2018 and 3/1/2020. The primary outcome was escalation of care within the first 24 hours after HFNC initiation [transfer to pediatric intensive care unit (PICU) and/or initiation of noninvasive positive pressure ventilation (NIPPV) or mechanical ventilation (MV)]. A clinical prediction model was developed using multivariable logistic regression.

Results: We included 738 infants with a mean age of 5.4 months (SD 3.4), of which 73 (10%) experienced care escalation within the first 24 hours. Fever, tachypnea, tachycardia, and hypoxemia were associated with escalation, whereas historical features, physical examination findings, and response to ED therapies were not. A prediction model consisting of the highest ED respiratory rate and the lowest oxygen saturation yielded an AUC of 0.75, with a sensitivity of 57.9% and specificity of 82.2% (based on an optimal predicted probability threshold of 7.9%).

Conclusions: Hypoxemia and tachypnea predicted early escalation of care in infants with bronchiolitis with moderate performance. This model may have promise to assist with management decisions; however, it requires prospective validation.

Objective: Abdominal pain is a common pediatric presentation in the emergency department (ED), and acute appendicitis (AA) is the most common surgical diagnosis. This study describes the management of suspected AA in a tertiary Australian pediatric ED.

Methods: A single-center prospective observational study was performed between November 2022 and May 2023. Children aged 5 to 15 years presenting to the ED with acute abdominal pain and clinician suspicion of AA were included. Clinical gestalt was measured using a 5-point Likert Scale before and after blood tests. Diagnosis of AA was confirmed on histopathology, and non-AA was confirmed with follow-up at 30 to 60 days.

Results: The study enrolled 481 children; AA was diagnosed in 146 (30.6%). Patients with AA were older (11.1 vs. 10.0 y) and more likely to be male (69.2% vs. 48.1%) compared with those without AA. Blood tests were performed in 449 (93.3%) children, with higher rates in AA cases (100% vs. 90.4%). Gestalt improved with blood test results, with overall diagnostic accuracy increasing from 65.9% pre-blood tests to 88.5% post-blood tests. Ultrasound (US) was performed in 361 (75.1%) children with a diagnostic accuracy of 90.6% and was frequently used even in patients deemed low-risk post-blood tests (65.7%). One hundred and fifty (31.2%) of suspected AA cases underwent surgery, with 3 negative appendectomies and 1 ovarian cystectomy without appendectomy. Median (IQR) hospital length of stay was significantly longer for AA cases than non-AA cases [50.8 (35.3 to 95.0) h vs. 7.1 (4.6 to 16.8) h].

Conclusions: This study reviews the management and outcomes of suspected AA in a high-volume Australian ED. It shows the importance of blood tests in improving diagnostic accuracy of clinician gestalt and highlights the potential overuse of US in low-risk patients. Future research should explore a more structured diagnostic approach to increase diagnostic accuracy, optimize resource utilization, and improve patient outcomes.

Objective: In the United States, firearm-related injuries are the leading cause of death in individuals aged 0 to 24 years and lead to substantial cost burden, mortality, and morbidity. This study identifies trends of pediatric firearm injury at this level I pediatric trauma center, which may inform violence prevention and firearm safety intervention at the local level.

Methods: This study is a retrospective review of the pediatric trauma registry at a level 1 pediatric trauma center of children (0 to 17.9 y) who presented between January 1, 2013 and December 31, 2022. Age, sex, race, ethnicity, number of GSWs, location of injury, disposition, intention, mortality, insurance status, length of stay, zip code of residence, location of shooting, hospital charges, and recidivism for firearm injury, police officer-related interactions, or violence-related events were reviewed and analyzed.

Results: There were 585 patient charts reviewed over the 10-year period. The rate of pediatric firearm injuries increased by almost 5 folds and fatality rates tripled from 2013 to 2022. The victims were predominantly male (82.9%), black (75.3), non-Hispanic (88.5%), and Medicaid holder/uninsured (86.3%). Assault accounted for 67% of all GSWs and 13.5% returned with an assault or violence-related concern; 6.4% returned for a GSW-related injury over the study period. The rate of firearm injuries increased from 9.09 (per 100,000) pre-COVID to 17.93 (per 100,000) post-COVID with a rate of 16.74 (per 100,000) while in the peak of the pandemic.

Conclusions: This level 1 trauma center has seen an overall increase in pediatric GSW injuries and fatalities in 10 years.

Objectives: Succinylcholine and rocuronium are neuromuscular blocking agents used in the emergency department (ED) during rapid sequence intubation (RSI). Very few studies have been conducted to determine which agent is preferred for children. This study analyzed outcomes of death, post-traumatic stress disorder (PTSD) and malignant hyperthermia for children administered succinylcholine versus rocuronium for RSI in the ED.

Methods: This retrospective, propensity-matched study utilized the TriNetX database. Cohorts included children less than or equal to 17 years of age, given a paralytic agent plus etomidate or ketamine during intubation in the ED from 2004 to 2024. Cohorts were further stratified by the administration of succinylcholine or rocuronium. The outcomes measured were death, PTSD, and malignant hyperthermia. Propensity matching was done for demographics and pre-existing conditions.

Results: Before propensity matching, 2095 pediatric patients were identified. After propensity matching, 706 patients were identified in each cohort. After propensity matching, children administered succinylcholine had a lower rate of death (5.7% vs. 8.9%, RR: 0.65, 95% CI [0.43-0.93], P =0.019) but no significant difference in PTSD (2.6% vs. 3.7%, RR: 0.71, 95% CI [0.32-1.68], P =0.399). There was no significant difference in malignant hyperthermia. Subgroup analysis suggests that succinylcholine and etomidate were the best combination of drugs for RSI.

Conclusions: Mortality rates were lower for children administered succinylcholine for RSI when compared with rocuronium. This study demonstrates a potential association between succinylcholine use and favorable RSI outcomes in the ED, though further prospective studies are needed.

Background: Pediatric ocular trauma is the leading cause of monocular blindness and comprises 7% of injuries. Prompt treatment is mandatory but may vary by facility type. This study investigates factors influencing treating facility, comparing level 1 and level 2 verified pediatric trauma centers (PTC) with other trauma centers (non-PTC).

Methods: The National Trauma Data Bank 2019 was examined for ages 1 to 18 years with ICD10 ocular trauma diagnoses. Descriptive statistics compared patients of PTCs versus non-PTCs. Logistic regression was used to examine the association between treatment at PTC and type of ocular injury, adjusting for age, race, ethnicity, sex, socioeconomic status, injury severity score (ISS), and suspicion of child abuse. A second logistic regression model evaluated the association between direct transfer from emergency department (ED) to operating room (OR) and injury type, and adjusted for confounders. End points included surgical intervention and discharge disposition.

Results: Of 645 patients with ocular trauma, 67.6% were male, 14% were Hispanic. Median age was 10 years at PTC versus 13 years non-PTC ( P =0.001). Two hundred eighty-two (44%) were treated in PTC. There was no difference in proportion with ISS >15 or mechanism of ocular injury. One hundred forty-six patients were taken directly to OR from ED, with no difference between PTC and non-PTC. The most common diagnoses for patients taken directly to OR were eye or adnexa contusion and laceration, globe or adnexal open wound, and orbital wall fractures. There was no association between type of injury and treatment at PTC versus non-PTC. 71 abuse reports were noted, of which 23 (32.4%) were treated in PTCs, compared with 48 (67.6%) treated at non-PTCs ( P =0.036). Logistic regression examination of direct to OR admission revealed only Hispanic ethnicity was significantly associated ( P =0.03).

Conclusions: Pediatric ocular traumas are treated at both PTCs and non-PTCs at a similar rate and level of severity. Younger children and more Hispanic children tended to be treated at PTCs. More abuse reports were noted in non-PTCs. Hispanic ethnicity was noted to be inversely associated with direct transfer to OR from ED. This study should form the background from which evaluation of outcomes can begin, to clarify the optimal treatment pathways for pediatric ocular trauma, and if there are disparities in outcomes.

Type of study: Retrospective cross-sectional study.