Pediatric emergency care最新文献

Objective: Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs.

Methods: Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported.

Results: Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening.

Conclusions: Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

Background: 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.

Objectives: 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.

Methods: 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.

Results: 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.

Discussion: 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.

Objectives: The Emergency Department Work Index (EDWIN) is a validated overcrowding score shown to correlate well with staff assessment of adult emergency department (ED) overcrowding and the potential need for diversion. It derives from the number of staffed ED beds, attending physicians on duty, patients within each triage category, and admitted patients. To date, no study has validated EDWIN in a pediatric community ED setting. We aim to determine if EDWIN correlates with established overcrowding measures and provider perception of overcrowding within a freestanding, community-based pediatric ED.

Methods: In this prospective observational study at a freestanding, community-based pediatric ED, EDWIN was calculated hourly over 8 weeks throughout the year. EDWIN was compared with other objective and previously established ED metrics of overcrowding, including rates of patients who left without being seen (LWBS), average time from arrival to ED room, average length of stay (LOS), ED occupancy rates, and number of patients in the waiting room. Furthermore, EDWIN was compared with provider perception of overcrowding by surveying providers 6 times a day during the study period using novel, real-time, longitudinal, electronic health record-based survey distribution methodology. Spearman correlation coefficients were calculated to characterize the associations between EDWIN vs provider perception and EDWIN vs ED metrics. ANOVA and Tukey HSD were used to compare means of ED metrics of overcrowding across EDWIN severity categories.

Results: Five hundred eleven provider perception survey responses were collected from July 2022 through January 2023. EDWIN directly correlated with all measures of overcrowding, including provider perception of crowdedness (rho = 0.67), LWBS rates (rho = 0.44), average time from arrival to ED room (rho = 0.74), average LOS (rho = 0.70), ED occupancy rates (rho = 0.68), and number of patients in the waiting room (rho = 0.65). All findings were statistically significant ( P < 0.05).

Conclusions: Our findings suggest that EDWIN is an accurate tool to measure overcrowding in a freestanding, community-based pediatric ED.

Objectives: Expedited partner therapy (EPT) is a partner treatment strategy for sexually transmitted infections (STIs) including gonorrhea and chlamydia as well as trichomoniasis in some states. The process allows healthcare providers to write prescriptions for STI treatment among partners of infected patients without a previous medical evaluation. The Centers for Disease Control (CDC) has recommended EPT as a useful option to facilitate partner treatment, particularly male partners of women with chlamydia or gonorrhea infections. Our institution implemented EPT in 2016 after Ohio legislation was passed to authorize its use. We aim to describe the implementation process and descriptive outcomes of EPT adoption in a pediatric emergency department.

Methods: This study describes use of the electronic health record for implementation of EPT in our institution. We conducted a retrospective review of EPT utilization from implementation. Electronic records from the implementation date of January 1, 2017, through December 31, 2021, were reviewed. We describe basic demographics and overall uptake of the intervention. Fisher exact tests were used for categorical variables and two-sample t -tests for continuous variables.

Results: There was a total of 3275 positive test results and 739 EPT prescriptions written. Adolescent patients who received prescriptions for EPT were more likely to be female (78.7% of all EPT prescriptions, P = 0.007) and older than other patients (average age 17.7 vs 17.4 years, P = 0.004). There was no significant difference in race, insurance, or ethnicity among adolescent patients receiving and not receiving EPT. The percentage of positive STI tests associated with an EPT prescription ranged between 11.4% and 18.2%. Metronidazole was the most prescribed EPT medication.

Conclusions: The use of the electronic health record provides a platform for implementation of EPT. Our study highlights a potential strategy for increasing treatments of STIs through EPT prescribing in the emergency department setting.

Objective: Our aim is to emphasize the varied presentation of acute disseminated encephalomyelitis (ADEM) to help health care professionals improve recognition of the disease in a timely manner, thereby allowing for the selection of an appropriate treatment regimen. Therefore, this may avoid neurocognitive consequences and the ultimate fatality of the patient.

Patients and methods: This is a retrospective case series involving 7 cases of children presenting to the Pediatric Emergency Department of Hackensack University Medical Center who were ultimately diagnosed with ADEM.

Results: In many of the cases, a preceding viral-like illness with nonspecific symptomatology made it difficult to accurately establish an initial diagnosis. Ultimately, the neurologic symptoms spontaneously resolved or improved with administration of high-dose steroids.

Conclusions: Children presenting to the emergency department with nonspecific symptoms associated with any neurological deficits should undergo further investigation using magnetic resonance imaging and lumbar puncture to rule out rare yet possibly fatal diseases such as ADEM.

Objectives: General emergency medicine (EM) physicians provide most pediatric emergency care in the United States, yet EM physicians feel underprepared to manage pediatric emergencies. Pediatric emergency medicine (PEM) education during EM residency is variable, and learner preferences regarding educational experiences have not been widely explored through a qualitative lens. We aimed to better describe EM physicians' PEM educational needs and preferred teaching methods.

Methods: In 2021, as part of a survey querying senior EM residents and recent graduates from 8 diverse EM programs regarding perceived preparedness for PEM emergencies, educational needs and content delivery methods were assessed using 2 free-text questions. Qualitative analysis included deidentification and iterative coding of the data with double coding of 100% of the comments. We performed conventional content analysis of responses to identify emerging themes.

Results: The overall response rate for the survey was 53% (N = 129 out of 242 eligible participants) with 84 distinct free-text responses. Major themes included: 1) desire for education regarding neonates, infants, and critically ill children, especially airway management and 2) need for help translating lessons from PEM rotations to community EM practice. Respondents desired more autonomy during training. Their preferred PEM educational modality was simulation, and they appreciated online clinical pathways for just-in-time decision support.

Conclusions: This qualitative study of EM physicians proximal to training adds to a prior needs assessment by describing in detail desired pediatric content and preferred delivery. The findings can be used to better inform the development of PEM curricula for this group of EM physicians.

Background: Intranasal fentanyl (INF) has gained popularity in pediatric emergency departments (EDs) as an effective alternative to intravenous morphine for treating acute moderate to severe pain. Intranasal fentanyl eliminates the need for invasive access, making it advantageous for patients with minor injuries. Our study aims to provide a comprehensive evaluation of the available evidence regarding the effectiveness and safety of INF administration in pediatric emergency wards, particularly compared with other treatment options described in the literature.

Methods: A thorough search strategy identified randomized controlled trials assessing INF in the pediatric emergency ward. Eligible studies were independently screened, and relevant data were extracted. The analysis used pooled risk ratio (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous ones. Randomized controlled trials' quality was assessed using the Cochrane Risk of Bias Assessment Tool 2.

Results: In our study, 8 randomized controlled trials involving 806 patients, INF demonstrated superior effectiveness in reducing pain compared with other comparators at the 15- to 20-minute mark (SMD, -0.23; 95% confidence interval, -0.37 to -0.08; P = 0.002). However, no significant differences were found at the 30- and 60-minute time points (SMDs, -0.16; 95% CI, -0.50, 0.19; P = 0.37; and -0.16; 95% CI, -0.50 to 0.19; P = 0.78) except when excluding one study to resolve heterogeneity at the 30-minute mark (RR, -0.02; 95% CI, -0.24 to 0.20; P = 0.87). Intranasal fentanyl also exhibited a better adverse outcome profile, with a lower risk of total adverse events and nausea/vomiting (RR, 0.66; 95% CI, 0.48-0.91; P = 0.01; and RR, 0.43; 95% CI, 0.30-0.63; P > 0.001) compared with other analgesics. However, no significant differences were observed for dizziness and hallucination (RR, 0.43; 95% CI, 0.30-0.63; P = 0.68; and RR, 0.43; 95% CI, 0.30-0.63; P = 0.35).

Conclusions: Our study assessed the effectiveness of INF compared with other analgesics in pain reduction. Intranasal fentanyl demonstrated superior pain reduction at the 15- to 20-minute point but showed no significant differences at 30 and 60 minutes. Intranasal fentanyl also had a more favorable adverse event profile, with a lower risk of nausea and vomiting than other analgesics. However, no significant differences were observed in dizziness and hallucination between the groups.

Background: Minoritized patients are disproportionately represented in low-acuity emergency department (ED) visits in the United States in part caused by lack of timely access to primary and urgent care. However, there is also the possibility that implicit bias during triage could contribute to disproportionate representation of minority groups in low-acuity ED visits. Triage discordance, defined as when ED resources used are different from initial triage score predictions, can be used as a proxy for triage accuracy. Recent data suggest that discordant triage may be common, although little is known about the interaction with race, ethnicity, and language for care.

Objectives: This study aims to determine the prevalence of discordant triage among moderate- and low-acuity pediatric ED encounters and the interaction with patient race, ethnicity, and language for care.

Methods: We performed a retrospective analysis of pediatric ED encounters from 2019 with Emergency Severity Index (ESI) scores of 3, 4, or 5 at an academic referral hospital. The primary outcome was triage discordance, encompassing overtriage (ESI 3 and 4) and undertriage (ESI 4 and 5). Logistic and multinomial regressions were used to assess discordant triage by race, ethnicity, and language group.

Results: Triage discordance occurred in 47% (n = 18,040) of encounters. Black and Hispanic patients had higher likelihood of undertriage for ESI 5 (adjusted odds ratio 1.21, 95% confidence interval [CI] 1.01-1.46 and 1.27, 95% CI 1.07-1.52, respectively), and Black patients were more likely to be overtriaged in ESI 3 (1.18, 95% CI 1.09-1.27). Those with a language other than English for care had higher proportions of overtriage for ESI 3 (1.08, 95% CI 1.04-1.12) and undertriage for ESI 5 (1.23, 95% CI 1.11-1.37).

Conclusions: We found high rates of triage discordance in our pediatric ED, with significant associations with race, ethnicity, and language for care. Future research should evaluate the source of triage discordance and develop quality improvement efforts to improve equitable care.

Objectives: During the COVID-19 pandemic, there was a marked shift toward telesimulation in medical education. Limited studies exist comparing the effectiveness of online and offline simulation education. The goals of this study are to evaluate active learners' perceived effectiveness of telesimulation versus in situ simulation and to identify potential shortcomings of existing online teaching platforms.

Methods: Through participant evaluations after a simulation, we compared telesimulation using the Virtual Resus Room (VRR) to in situ simulation in the domains of (1) self-efficacy, (2) fidelity, (3) educational value, and (4) teaching quality. Study subjects included medical and pharmacy residents and medical students completing their pediatric emergency medicine rotation at two children's hospitals as well as nurses, nurse practitioners, and physician assistants who were recently hired and orienting to their new roles in the emergency department. Learners used a modified Michigan Standard Simulation Experience Scale to evaluate either a telesimulation or in situ simulation case. Survey responses were compared using Wilcoxon rank sum tests with Bonferroni correction for multiple comparisons.

Results: In overall assessment, in situ simulation was rated higher than telesimulation. There were significant differences noted related to perceived realism, utility in training device-related skills, and utility in training team-building skills. All P values were less than 0.0036. There were no significant differences between simulation types in perception of physical examination fidelity, instructor adequacy, or self-efficacy.

Conclusions: Telesimulation using the VRR is comparable to in situ simulation in learners' perception of improvement in self-efficacy and of teaching quality for pediatric emergency medicine topics. However, participants felt less able to practice tactile and communication skills virtually. Further innovation is needed to improve learners' experience with fidelity and educational value.

Abstract: Early recognition of septic shock and its treatment are key factors for limiting progression to multiple organ dysfunction and death. Lactate, a byproduct of metabolic pathways, is usually elevated in tissue hypoperfusion and shock and is associated with poor prognosis in sepsis. As a biomarker, it may help the clinician in risk stratification, and the identification and treatment of sepsis. In this article, we provide an update on lactate's pathophysiology and role in diagnosis, treatment, and prognosis in children with sepsis and septic shock.