Pediatric emergency care最新文献

Objectives: Pediatric emergency department (ED) visits for mental and behavioral health concerns are rising. Understanding psychosocial predictors of ED mental health visits among youth with elevated suicide risk may inform tailored interventions and/or targeted resource allocation, decreasing ED utilization. We examined the association between self-reported psychosocial risk factors among youth screened "at-risk" for suicide during a nonmental health index ED visit and subsequent ED mental health visits.

Methods: This single-center retrospective cohort study had an exploratory, hypothesis-generating design. We included youth aged 10 to 18 years who presented to the ED between July 2020 and June 2023 for a nonmental health concern, were identified as "at-risk" for suicide during universal screening, and completed a psychosocial risk questionnaire. Subsequent ED mental health visits were tracked for 6 months after the index encounter, through December 2023. Psychosocial factors were compared between youth with and without a subsequent mental health visit using χ 2 and Fisher exact tests. Multivariable logistic regression models assessed associations between risk factors and subsequent ED mental health visits.

Results: Of 740 youth, 88 (11.9%) had a subsequent ED mental health visit, most (69.3%) for suicidal ideation. Youth were female (70.9%), non-White (63.6%), Hispanic (50.7%), publicly insured (71.8%), and the median age was 15.2 years; many (48.9%) had no known mental health conditions. For the subgroup with prior ED mental health visit(s), the odds of a subsequent ED mental health visit were higher in youth who identified as sexual and gender minority (aOR: 3.05; 95% CI: 1.15, 8.09) and individuals who reported prior nonsuicidal self-injury (aOR 3.01; 95% CI: 1.05, 8.66).

Conclusions: Our results suggest a potential subpopulation, youth screened at-risk for suicide who identify as sexual and gender minority or report prior nonsuicidal self-injury, who may benefit from tailored interventions and/or resources to decrease subsequent ED utilization.

Objectives: Despite the ongoing mental health crisis among US youth and the critical role that pediatricians caring for children and adolescents in emergency departments (EDs) play, there are limited studies capturing these pediatricians' concerns, experiences, and needs.

Methods: National weighted survey data on mental health care were collected in 2022 from the American Academy of Pediatrics Pediatrician Life and Career Experience Study (PLACES) participants (response=67%). We analyzed responses from 115 pediatricians caring for children and adolescents in the ED. Participants reported perspectives on: (a) overall pediatric mental health concerns; (b) frequency of mental health presentations; (c) experience prescribing psychotropic medication; and (d) referral difficulty. We systematically examined open-ended responses on the most pressing mental health needs.

Results: Eighty-four percent of pediatricians caring for children and adolescents in the ED reported that mental health is a significant problem for youth in their community. Nearly all (98%) reported caring for children and adolescents with mental health conditions in the past month. Many reported daily encounters with pediatric patients experiencing mental health conditions, including anxiety, depression, and suicidal ideation. One in five reported prescribing psychotropic medication in the past year, none of whom reported being "very" comfortable doing so. One in five said resources to care for children and adolescents with mental health conditions were very or moderately available in their community. Open-ended responses (n=79) highlighted the urgent need for resources and solutions at the national level.

Conclusions: Pediatricians in the ED have significant concerns about child and adolescent mental health in their communities, and many see youth with anxiety, depression, and suicidal behavior daily. Findings underscore a need for more support for pediatricians in the ED and innovative solutions to improve child and adolescent mental health.

Background and objectives: Bladder catheterization (BC) is a routine procedure, but unsuccessful attempts due to inadequate bladder volume are common and stressful for children and caregivers. Physician-performed bladder point-of-care ultrasound (POCUS) improves BC success rates, but the effect of nurse-performed POCUS remains understudied.

Methods: We randomized children under 24 months of age to receive either nurse-performed POCUS before BC or standard blind BC in the pediatric emergency department to compare dry catheterization rates. A simplified POCUS technique using a single bladder measurement was employed to enhance efficiency and feasibility for nursing staff. We also compared caregiver satisfaction and procedural time between groups. Statistical comparisons used the Pearson χ 2 test for categorical variables and the Wilcoxon rank sum test for continuous variables. A P value of <0.05 was considered statistically significant. Univariate logistic regression estimated the odds of outcomes with POCUS versus standard care.

Results: In the POCUS group, the dry catheterization rate was 5% compared with 17% in the standard group (odds ratio=0.24, 95% CI=[0.09, 0.72]), indicating fewer dry BCs in the POCUS group. Caregivers of children in the POCUS group reported higher satisfaction ( P =0.02). There was no significant difference in the time from BC orders to initial BC attempt between groups.

Conclusions: Nurse-performed POCUS before BC reduces dry BCs and improves caregiver satisfaction without causing procedural delays. Incorporating nurse-performed POCUS into standard BC workflows may enhance patient care.

Objectives: Telemedicine use has surged since the COVID-19 pandemic, offering patients access to remote health care and the potential to reduce nonemergent emergency department (ED) visits. This study aims to describe postpandemic virtual urgent care (VUC) utilization, including VUC-to-ED referral rates and outcomes in children.

Methods: We performed a retrospective cohort study of patients under 21 years presenting to the ED within 72 hours following a VUC visit from March 1, 2021, through February 28, 2023, using the electronic medical record. We reviewed demographic data and examined ED care and disposition for patients VUC physician-referred compared with those who self-referred.

Results: We analyzed 4676 completed VUC patient visits. Patients who preferred English, were non-Hispanic, and had commercial insurance were more likely to complete their VUC visit, with a rate of 72%. Among all patients who completed a VUC visit, 5.9% were referred to the ED by a VUC physician with a 19% admission rate, whereas 5% of patients self-referred with a 6% admission rate. On logistic regression analysis, only insurance status was significant; patients with Medicaid had twice the odds of a self-referred visit.

Conclusions: This study demonstrated low referral rates from VUC to ED. Despite modifications to improve VUC access, disparities in VUC utilization persist. Patients with Medicaid are more likely to self-refer to the ED, although they have lower rates of admission when self-referred. Future qualitative studies are needed to optimize VUC as an equitable health care resource.

Objective: Children with medical complexity (CMC) may bypass emergency departments (EDs) close to home to seek care at hospitals with more specialized pediatric services. However, few studies have examined ED choice for CMC or how this differs by rurality. This work describes rural-urban differences in ED care and bypass patterns, examines associations between ED bypass and visit outcomes, and identifies factors associated with ED bypass.

Methods: We analyzed 2012 to 2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire. Bypass was defined as a driving time of ≥5 minutes than time to the closest ED. We used logistic regression to identify factors associated with ED bypass and examine associations between bypass and rates of inter-facility transfer, index hospital admission, and in-hospital mortality.

Results: In total, 82,747 CMC experienced 284,374 ED visits. Rural-residing CMC were more often insured by Medicaid, more likely to travel >30 minutes, and less likely to bypass their closest EDs (26.9% vs. 43.7% for urban-residing CMC). In adjusted regression models, ED bypass was associated with significantly increased odds of admission (OR=2.19, 95% CI: 1.51-3.16) but not with interfacility transfer or mortality. Chronic condition primary diagnosis was associated with increased odds of bypass, and Medicaid coverage was associated with decreased odds of bypass for both rural-residing and urban-residing CMC.

Conclusions: Rural-residing and urban-residing CMC differed in where they sought ED care and in their ED bypass patterns. These findings illustrate several factors that may be associated with ED choice for CMC and can inform clinical improvement efforts for this population.

Objective: To identify demographic, social, and legislative risk factors that may contribute to increased incidence of ballistic injuries among children presenting to Le Bonheur Children's Hospital (LBCH) in Memphis, Tennessee. Memphis has the highest incidence of violent crime per capita in the United States. Tennessee, where Memphis is located, became a permit-less carry state on July 1, 2021.

Methods: We conducted a retrospective cohort study of firearm-related injuries among pediatric patients (0 to 18 y) who presented to Le Bonheur Children's Hospital (LBCH)-a tertiary care hospital and ACS-verified Level 1 Pediatric Trauma Center-from January 1, 2010, through December 31, 2023. Variables collected included age, sex, race, mortality, school zoning type (in-person, virtual, hybrid), Social Vulnerability Index (SVI) (based on patient residence), and first firearm injury (in the event patients experienced more than one). Statistical analyses were performed using the T test, χ 2 test, univariate and multivariate Poisson regression, and backward elimination.

Results: From 2010 to 2023, we collected 1512 charts featuring 1471 individual subjects; 79.13% were males, 78.11% were Black, and 56.8% were 14 to 18 years old. The number of pediatric firearm injuries increased from 153 patients in September 2018 to February 2020, to 377 patients between March 2020 and August 2021 during the pandemic, when schools closed and most students attended school online remotely. Black males, adolescents aged 14 to 18 years, and residing in a high-risk SVI area were associated with a higher risk of firearm injury. Passage of the permit-less carry legislation was associated with a 23.78% increase in firearm injuries. Black race and male sex were significant risk factors for firearm injury, while a low-risk SVI was protective.

Conclusions: This study shows that adolescents living in areas with high SVI who are Black and male are more likely to suffer firearm injuries. Because there is widespread poverty in Memphis and increased access to guns, firearm injuries will continue to be a major public health issue for this demographic. Research on this topic should lead to tangible efforts to improve these risk factors and reduce the number of firearm injuries.

Objective: Pneumonia is a common infection in childhood. We tested the utility of initial clinical assessment tools and of early laboratory markers for predicting severe disease among children admitted with pneumonia.

Methods: This was a retrospective cohort study of previously healthy children admitted to a children's hospital with pneumonia from June 2017 to June 2021. We tested the predictive utility of the Canadian Triage and Acuity Scale (CTAS) score and of the pediatric assessment triangle (PAT) upon first patient contact. We also evaluated the predictive value of elevated WBC, ANC, CRP, lower serum albumin, and phosphorus drawn in the ED, with severe pneumonia defined as concurrent sepsis, need for pleural drainage, or intensive care during index admission. Analyses were bivariate.

Results: During the study period, 554 children admitted with pneumonia were included in the analysis [median age, 25.5 mo (IQR: 14.3 to 63.0); 58.3% males]. Seventy-four (13.3%) had severe pneumonia.Severe pneumonia was diagnosed in 17% of children classified as CTAS 2 (emergent), 13% with CTAS 3 (urgent), 13% with CTAS 4 (less urgent), and 0% with CTAS 5 (nonurgent). Among children with an abnormal PAT, 20% had severe pneumonia versus 5% among those with a normal PAT. The receiver operating characteristic area under the curve (95% CIs) was 0.73 (0.66-0.80) for serum albumin, 0.66 (0.61-0.72) for CRP, 0.61 (0.58-0.66) for phosphorus, 0.58 (0.51-0.64) for ANC, and 0.55 (0.49-0.62) for WBC. The AUC for PAT was 0.71 (95% CI: 0.65-0.77) and for CTAS was 0.56 (95% CI: 0.49-0.62).

Conclusions: For the prediction of severe pediatric pneumonia, no single marker offered robust utility. CTAS showed no clear utility, while PAT was comparable to albumin, the best-performing laboratory marker. Hypoalbuminemia was marginally superior to elevated CRP. The remaining laboratory markers had at best moderate accuracy in isolation.

Objective: Children in the emergency department (ED) experience distress due to many factors, such as pain. Although ketamine has analgesic and sedative effects, its parenteral administration causes pain and anxiety. It is notable that ketamine can be administered intranasally for analgesia. We hypothesized that the administration of intranasal (IN) ketamine for analgesia before intramuscular ketamine injection would diminish the injection pain without any adverse effect.

Methods: This study was a randomized, double-blind, placebo-controlled clinical trial conducted in the ED. The IN ketamine group received a dose of 1.5 mg/kg intranasally diluted to 1 mL, while the placebo group received 1 mL of sterile water. Injection pain was assessed using the FLACC scale (0 to 10), encompassing the face, leg, activity, cry, and consolability. Sedation time and adverse effects were also assessed.

Result: Eighty-four patients were enrolled. While the median (IQR) injection pain score in the placebo group was 10 (10 to 10), it was 1 (0 to 5) in the intervention group ( P <0.001). The sedation time in the control group was 80.9±33.6 minutes and 86.4±19.8 in the intervention arm ( P= 0.07). After excluding intraoral procedures, 7 (16.7%) and 2 (4.2%) patients had vomiting in the intervention and placebo groups, respectively. In addition, 3 (7%) patients of the IN-ketamine group had hypoventilation that was resolved with simple airway maneuvers.

Conclusion: Although IN ketamine demonstrated efficacy in reducing injection-related pain, its adverse event profile may limit its practicality in routine settings.

Introduction: Children have unacceptably low rates of COVID-19 and influenza vaccine uptake. Given limited access to primary care for many children, pediatric emergency departments (PEDs) are novel settings for COVID-19 and influenza vaccine administration.

Objective: Our study tested whether viewing a brief educational video would be associated with an increase in COVID-19 and influenza vaccine readiness among adult caregivers for themselves and their children.

Methods: This study consisted of a convenience sample of 339 caregivers accompanying pediatric patients to a university-based PED from 1/13/2022 to 5/11/2022. Participants completed a pre-intervention survey through iPad that gathered information concerning demographics, COVID-19 beliefs, and vaccine attitudes and readiness. Participants watched a novel 3-minute educational video created by the study team addressing risks and benefits of vaccine-preventable illnesses and immunizations. Information in the video was delivered by local medical professionals and tailored to our community. Participants were then resurveyed with only the questions about vaccine attitudes and vaccine readiness. Pre-intervention/post-intervention attitude changes were assessed using the Wilcoxon signed-rank test.

Results: Participants were 69% Hispanic and 16% Native American, with a median age of 34 years; 30% resided in rural areas. Post-intervention, COVID-19 vaccine acceptability as reported by caregivers increased on a 5-point agreement scale for both themselves ( P =0.0017) and their children ( P =0.0038). Participants were also more likely to be willing to talk to a pediatric emergency medicine doctor about influenza vaccine administration for their children after the intervention ( P =0.012).

Conclusions: A brief video-based intervention featuring locally relevant content in a PED targeted at caregivers was associated with improvement in some measures of vaccine readiness as reported by caregivers for both themselves and their children. Similar interventions could be modeled specifically for individual community characteristics and combined with vaccine administration to substantially impact morbidity and mortality from vaccine-preventable diseases.

Persistent jaundice in a newborn infant past 2 weeks of age requires timely evaluation for cholestasis or unconjugated hyperbilirubinemia. Untreated biliary atresia may result in death within a year of age and is the most common cause of death in children with liver disease. It is also the most common indication for liver transplantation in children when Kasai hepatic portoenterostomy fails. Ultrasound is the primary initial imaging modality for suspected biliary atresia, primarily looking for absence of the gallbladder and the triangular cord sign, with a thickened echogenic anterior wall of the right portal vein (EARPV measuring >4 mm). We report a case in which point-of-care ultrasound was used to evaluate suspected biliary atresia and expedite care, with the diagnosis subsequently confirmed by liver biopsy and surgery.