Type I Interferon in Children with Viral or Bacterial Infections.

BACKGROUND: Fever is one of the leading causes of consultation in the pediatric emergency department for patients under the age of 3 years. Distinguishing between bacterial and viral infections etiologies in febrile patients remains challenging. We hypothesized that specific host biomarkers for viral infections, such as type I-interferon (IFN), could help clinicians' decisions and limit antibiotic overuse. METHODS: Paxgene tubes and serum were collected from febrile children (n = 101), age from 7 days to 36 months, with proven viral or bacterial infections, being treated at pediatric emergency departments in France. We assessed the performance of an IFN signature, which was based on quantification of expression of IFN-stimulated genes using the Nanostring® technology and plasma IFN-α quantified by digital ELISA technology. RESULTS: Serum concentrations of IFN-α were below the quantification threshold (30 fg/mL) for 2% (1/46) of children with proven viral infections and for 71% (39/55) of children with bacterial infections (P < 0.001). IFN-α concentrations and IFN score were significantly higher in viral compared to bacterial infection (P < 0.001). There was a strong correlation between serum IFN-α concentrations and IFN score (p-pearson = 0.83). Both serum IFN-α concentration and IFN score robustly discriminated (Area Under the Curve >0.91 for both) between viral and bacterial infection in febrile children, compared to C-reactive protein (0.83). CONCLUSIONS: IFN-α is increased in blood of febrile infants with viral infections. The discriminative performance of IFN-α femtomolar concentrations as well as blood transcriptional signatures could show a diagnostic benefit and potentially limit antibiotic overuse. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov (NCT03163628).

Identifying Nonprovider Factors Affecting Pediatric Emergency Medicine Provider Efficiency.

OBJECTIVE: The aim of this study was to create a multivariable model of standardized relative value units per hour by adjusting for nonprovider factors that influence efficiency. METHODS: We obtained productivity data based on billing records measured in emergency relative value units for (1) both evaluation and management of visits and (2) procedures for 16 pediatric emergency medicine providers with more than 750 hours worked per year. Eligible shifts were in an urban, academic pediatric emergency department (ED) with 2 sites: a tertiary care main campus and a satellite community site. We used multivariable linear regression to adjust for the impact of shift and pediatric ED characteristics on individual-provider efficiency and then removed variables from the model with minimal effect on productivity. RESULTS: There were 2998 eligible shifts for the 16 providers during a 3-year period. The resulting model included 4 variables when looking at both ED sites combined. These variables include the following: (1) number of procedures billed by provider, (2) season of the year, (3) shift start time, and (4) day of week. Results were improved when we separately modeled each ED location. A 3-variable model using procedures billed by provider, shift start time, and season explained 23% of the variation in provider efficiency at the academic ED site. A 3-variable model using procedures billed by provider, patient arrivals per hour, and shift start time explained 45% of the variation in provider efficiency at the satellite ED site. CONCLUSIONS: Several nonprovider factors affect provider efficiency. These factors should be considered when designing productivity-based incentives.

Parents' Perspective on Trainees Performing Invasive Procedures: A Qualitative Evaluation.

OBJECTIVES: When obtaining informed permission from parents for invasive procedures, trainees and supervisors often do not disclose information about the trainee's level of experience. The objectives of this study were 3-fold: (1) to assess parents' understanding of both academic medical training and the role of the trainee and the supervisor, (2) to explore parents' preferences about transparency related to a trainee's experience, and (3) to examine parents' willingness to allow trainees to perform invasive procedures. METHODS: This qualitative study involved 23 one-on-one interviews with parents of infants younger than 30 days who had undergone a lumbar puncture. In line with grounded theory, researchers independently coded transcripts and then collectively refined codes and created themes. Data collection and analysis continued until thematic saturation was achieved. In addition, to triangulate the findings, a focus group was conducted with Yale School of Medicine's Community Bioethics Forum. RESULTS: Our analysis revealed 4 primary themes: (1) the invasive nature of a lumbar puncture and the vulnerability of the newborn creates fear in parents, which may be mitigated by improved communication; (2) parents have varying degrees of awareness of the medical training system; (3) most parents expect transparency about provider experience level and trust that a qualified provider will be performing the procedure; and (4) parents prefer an experienced provider to perform a procedure, but supervisor presence may be a qualifying factor for inexperienced providers. CONCLUSIONS: Physicians must find a way to improve transparency when caring for pediatric patients while still developing critical procedural skills.

A Blueprint for Pediatric Emergency Resource Reallocation During the COVID-19 Pandemic: An NYC Hospital Experience.

OBJECTIVE: We present a blueprint for the reallocation of pediatric emergency resources in response to the COVID-19 pandemic. METHODS: New York-Presbyterian Hospital - Weill Cornell Medical Center is an urban, quaternary, academic medical center, a level 1 trauma center, and a regional burn center located in New York City. The novel coronavirus (COVID-19) pandemic created a unique challenge for pediatric emergency medicine. As the crisis heightened for adult patients, pediatric emergency services experienced a significant decline in volume and acuity. RESULTS: We offer guidelines to modify physical space, clinical services, staffing models, and the importance of steady leadership. Pediatric emergency space was converted to adult COVID-19 beds, necessitating the repurposing of nonclinical areas for pediatric patients. Efficient clinical pathways were created in collaboration with medical and surgical subspecialists for expedited emergency care of children. We transitioned staffing models to meet the changing clinical demands of the emergency department by both reallocation of pediatric emergency medicine providers to telemedicine and by expanding their clinical care to adult patients. Concentrated communication and receptiveness by hospital and department leadership were fundamental to address the dynamic state of the pandemic and ensure provider wellness. CONCLUSIONS: Modification of physical space, clinical services, staffing models, and the importance of steady leadership enabled us to maintain outstanding clinical care for pediatric patients while maximizing capacity and service for adult COVID-19 patients in the emergency department.

The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey.

OBJECTIVE: The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey. METHODS: The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study. RESULTS: One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000). CONCLUSIONS: This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.

Pediatric Emergency Research Canada: Origins and Evolution.

OBJECTIVE: The objective of the study was to describe the origins, growth, and progress of a national research network in pediatric emergency medicine. METHODS: The success of Pediatric Emergency Research Canada (PERC) is described in terms of advancing the pediatric emergency medicine agenda, grant funding, peer-reviewed publications, mentoring new investigators, and global collaborations. RESULTS: Since 1995, clinicians and investigators within PERC have grown the network to 15 active tertiary pediatric emergency medicine sites across Canada. Investigators have advanced the research agenda in numerous areas, including gastroenteritis, bronchiolitis, croup, head injury, asthma, and injury management. Since the first PERC Annual Scientific meeting in 2004, the attendance has increased by approximately 400% to 152 attendees, 65 presentations, and 13 project/investigator meetings. More than $33 million in grant funding has been awarded to the network, and has published 76 peer-reviewed articles. In 2011, PERC's success was recognized with a Top Achievement Award in Health Research from Canadian Institutes of Health Research and the Canadian Medical Association Journal. CONCLUSIONS: Moving forward, PERC will continue to focus on the creation of new knowledge, the mentorship of new investigators and fellows in developing research projects, and promoting a pediatric emergency medicine-focused research agenda guided by the pooling of expertise from individuals across the nation. Through collaborations with networks across the globe, PERC will continue to strive for the conduct of high-quality, impactful research that improves outcomes in children with acute illness and injury.

Impact of scribes on emergency department patient throughput one year after implementation.

OBJECTIVES: Assess the impact of scribes on an academic emergency department's (ED) throughput one year after implementation. METHODS: A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre-defined study hours in a tertiary academic ED with both an adult and pediatric ED. An alternating-day pattern one year following scribe implementation ensured balance between the scribe and non-scribe groups in time of day, day of week, and patient complexity. RESULTS: Adult: Overall length of stay (LOS) was essentially the same in both groups (214 vs. 215min, p=0.34). In area A where staffing includes an attending and residents, scribes made a significant impact in treatment room time in the afternoon (190 vs 179min, p=0.021) with an increase in patients seen per hour on scribed days (2.00 vs. 2.13). There was no statistically significant changes in throughput metrics in area B staffed by an attending and a nurse practitioner/physician assistant, however scribed days did average more patients per hour (2.01 vs. 2.14). Pediatric: All throughput measurements were significantly longer when the treatment team had a scribe; however, patients per hour increased from 2.33 to 2.49 on scribed days. CONCLUSIONS: Overall patient throughput was not enhanced by scribes. Certain areas and staffing combinations yielded improvements in treatment room and door to provider time, however, scribes appear to have enabled attending physicians to see more patients per hour. This effect varied across treatment areas and times of day.

Planning for disasters involving children in Australia: A practical guide.

Children comprise 19% of the Australian population. Children are at risk of higher morbidity and mortality in disaster events than adults; however, there is a paucity of paediatric-specific disaster preparedness in Australia. Paediatric disaster plans should be developed, tested and renewed regularly. Plans need to address unaccompanied and unidentified children, medical and psychosocial needs and family reunification. Specific management is required for chemical, biological and radiological events.

Alternatives to ward admission from the emergency department.

There is ever-increasing pressure on hospital resources in general and emergency departments (ED) in particular. At the same time, there is increasing recognition that traditional inpatient ward-based care is not necessary for the majority of children presenting to the ED with acute illness, and that there are patient, family and hospital benefits to pursuing other options. Here, we describe alternative pathways for children presenting to the ED, including short stay and observational medicine, hospital-in-the-home and non-admission enhanced care, in other words, additional management practices or pathways for children who are discharged from the ED. We discuss the principles, models and practical considerations involved in each of these.

Essentials of Pediatric Emergency Medicine Fellowship: Part 4: Beyond Clinical Education.

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the skills beyond clinical training required of pediatric emergency medicine physicians including teaching, leadership, teamwork, and communication.

Essentials of Pediatric Emergency Medicine Fellowship: Part 6: Program Administration.

This article is the sixth in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article provides a broad overview of administering and supervising a PEM fellowship program. It explores 3 topics: the principles of program administration, committee management, and recommendations for minimum time allocated for PEM fellowship program directors to administer their programs.

Prospective cohort study of children with suspected SARS-CoV-2 infection presenting to paediatric emergency departments: a Paediatric Emergency Research Networks (PERN) Study Protocol.

INTRODUCTION: Relatively limited data are available regarding paediatric COVID-19. Although most children appear to have mild or asymptomatic infections, infants and those with comorbidities are at increased risk of experiencing more severe illness and requiring hospitalisation due to COVID-19. The recent but uncommon association of SARS-CoV-2 infection with development of a multisystem inflammatory syndrome has heightened the importance of understanding paediatric SARS-CoV-2 infection. METHODS AND ANALYSIS: The Paediatric Emergency Research Network-COVID-19 cohort study is a rapid, global, prospective cohort study enrolling 12 500 children who are tested for acute SARS-CoV-2 infection. 47 emergency departments across 12 countries on four continents will participate. At enrolment, regardless of SARS-CoV-2 test results, all children will have the same information collected, including clinical, epidemiological, laboratory, imaging and outcome data. Interventions and outcome data will be collected for hospitalised children. For all children, follow-up at 14 and 90 days will collect information on further medical care received, and long-term sequelae, respectively. Statistical models will be designed to identify risk factors for infection and severe outcomes. ETHICS AND DISSEMINATION: Sites will seek ethical approval locally, and informed consent will be obtained. There is no direct risk or benefit of study participation. Weekly interim analysis will allow for real-time data sharing with regional, national, and international policy makers. Harmonisation and sharing of investigation materials with WHO, will contribute to synergising global efforts for the clinical characterisation of paediatric COVID-19. Our findings will enable the implementation of countermeasures to reduce viral transmission and severe COVID-19 outcomes in children. TRIAL REGISTRATION NUMBER: NCT04330261.

Impact of novel coronavirus Disease-19 (COVID-19) pandemic in Italian pediatric emergency departments: a national survey.

BACKGROUND: Coronavirus Disease-19 (COVID-19) has rapidly become a pandemic emergency, distressing health systems in each affected country. Preparation strategies for managing this pandemic have been keys to face the COVID-19 surge all over the world and all levels of care. MATERIALS AND METHODS: During the epidemic, the Italian society of pediatric emergency-urgency (SIMEUP) promoted a national survey aiming to evaluate preparedness and response of pediatric emergency departments (PED) critical in ensuring optimal management of COVID-19 cases. RESULTS: Our results suggest that Italian PED have promptly set a proactive approach to the present emergency. 98.9% of the hospitals have defined special pathways and assistive protocols concerning the management of pediatric COVID-19 cases. The highest percentage of application of the measures for preventive and protective for COVID-19 concerned the use of personal protective equipments. CONCLUSIONS: Results show that the following measures for pediatric patients, admitted in PED, have been promptly implemented throughout the whole country: eg. use of protective devices, pre-triage of patients accessing the hospital. Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision algorithm and clear plans for the interventional platform teams, we can ensure optimal health care workers and patients' safety.

Management in the paediatric wards facing novel coronavirus infection: a rapid review of guidelines and consensuses.

OBJECTIVES: Relevant guidelines and consensuses for COVID-19 contain recommendations aimed at optimising the management in paediatric wards. The goal of this study was to determine the quality of those recommendations and provide suggestions to hospital managers for the adjustment of existing hospital prevention and control strategies, and also to offer recommendations for further research. DESIGN: A rapid review of the guidelines and consensuses for the management in paediatric wards facing COVID-19. METHODS: PubMed, EMBASE, the Cochrane Library, UpToDate, China National Knowledge Infrastructure, the Wanfang database and relevant websites such as medlive.cn, dxy.cn, the National Health and Health Commission and the China Center for Disease Control and Prevention were systematically searched through late May 2020. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was then used to assess the quality of the selected articles and summarise the relevant evidence concerning management in paediatric wards. RESULTS: A total of 35 articles were included, composed of 3 consensus guidelines, 25 expert consensuses and 7 expert opinions. Of the 35 papers, 24 were from China, 2 from the USA, 1 from Spain, 1 from Brazil, 1 from Saudi Arabia and 6 from multinational cooperative studies. Scores for the six domains of the AGREE II tool (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence) were 98.57%, 53.57%, 17.92%, 69.62%, 26.96% and 50.35%, respectively. Recommendations for nosocomial infection and control, human resource management as well as management of paediatric patients and their families were summarised. CONCLUSIONS: Due to the outbreak of COVID-19, the quality of rapid guidelines and consensuses for the management in paediatric wards affected by COVID-19 is unsatisfactory. In the future, it will be necessary to develop more high-quality guidelines or consensuses for the management in paediatric wards to deal with nosocomial outbreaks in order to fully prepare for emergency medical and health problems.

Impact of Medical Scribes on Provider Efficiency in the Pediatric Emergency Department.

OBJECTIVES: Today's emergency department (ED) providers spend a significant amount of time on medical record documentation, decreasing clinical productivity. One proposed solution is to utilize medical scribes who assist with documentation. We hypothesized that scribes would increase provider productivity and increase provider satisfaction without affecting patient experience or nursing satisfaction. METHODS: We conducted an observational pre-post study comparing ED prescribe and postscribe clinical productivity metrics for 18 pediatric emergency medicine physicians, two general pediatricians, and two nurse practitioners working in the 12-bed nonurgent area of the pediatric ED. Productivity metrics included patients per hour (pts/hr), work relative value units per hour (wRVUs/hr), and visit duration measured for 1 year pre- and postscribe implementation. Cross-sectional satisfaction surveys were administered to patient families, providers, and nurses during the initial scribe rollout. RESULTS: Overall, 24,518 prescribe and 27,062 postscribe visits were analyzed. Following scribe implementation, overall provider efficiency increased by 0.24 pts/hr (11.98%, p < 0.001) and 0.72 wRVUs/hr (20.14%, p < 0.001). The largest efficiency increase (0.36 pts/hr, 0.96 wRVUs/hr) occurred in January-March, when ED census peaked. Patient visit duration was 53 minutes in both the prescribe and the postscribe periods. During initial scribe implementation, 80% of parents of patients without a scribe rated the visit as very good/great compared to 84% with a scribe (p = 0.218). Of the 34 providers surveyed, 88% preferred working with a scribe. A majority of providers (82%) felt that their skills were used more effectively when working with a scribe, decreasing their likelihood of experiencing burnout. Of the 43 nurses surveyed, 51% preferred scribes and 47% were indifferent. CONCLUSIONS: Medical scribes increased ED efficiency without decreasing patient satisfaction. Providers strongly favored the use of scribes, while nurses were indifferent. The next steps include a cost analysis of the scribe program.

Research priorities for European paediatric emergency medicine.

OBJECTIVE: Research in European Paediatric Emergency Medicine (REPEM) network is a collaborative group of 69 paediatric emergency medicine (PEM) physicians from 20 countries in Europe, initiated in 2006. To further improve paediatric emergency care in Europe, the aim of this study was to define research priorities for PEM in Europe to guide the development of future research projects. DESIGN AND SETTING: We carried out an online survey in a modified three-stage Delphi study. Eligible participants were members of the REPEM network. In stage 1, the REPEM steering committee prepared a list of research topics. In stage 2, REPEM members rated on a 6-point scale research topics and they could add research topics and comment on the list for further refinement. Stage 3 included further prioritisation using the Hanlon Process of Prioritisation (HPP) to give more emphasis to the feasibility of a research topic. RESULTS: Based on 52 respondents (response rates per stage varying from 41% to 57%), we identified the conditions 'fever', 'sepsis' and 'respiratory infections', and the processes/interventions 'biomarkers', 'risk stratification' and 'practice variation' as common themes of research interest. The HPP identified highest priority for 4 of the 5 highest prioritised items by the Delphi process, incorporating prevalence and severity of each condition and feasibility of undertaking such research. CONCLUSIONS: While the high diversity in emergency department (ED) populations, cultures, healthcare systems and healthcare delivery in European PEM prompts to focus on practice variation of ED conditions, our defined research priority list will help guide further collaborative research efforts within the REPEM network to improve PEM care in Europe.

Referring Hospital Characteristics Associated With Potentially Avoidable Emergency Department Transfers.

OBJECTIVE: Many emergency department (ED) transfers of children may be avoidable. Identifying hospital-level variables associated with avoidable transfers may guide system-level interventions to improve pediatric emergency care. We sought to examine hospital characteristics associated with ED transfers deemed "probably avoidable" in a large state Medicaid program. METHODS: We performed a retrospective cohort study using 2009 to 2013 claims data for Pennsylvania Medicaid beneficiaries. We categorized all ED transfers of children < 17 years old as "probably avoidable," "possibly avoidable", or "unavoidable" based on ultimate disposition and procedures (including subspecialty consultations) at the receiving ED. Using descriptive statistics and multivariable regression, we examined hospital characteristics associated with probably avoidable transfers. RESULTS: Among 2,839,379 pediatric visits to EDs across 158 Pennsylvania hospitals, 20,304 resulted in transfer. Among these, 3,764 (18.5%) were categorized as probably avoidable and 6,091 (30.0%) as possibly avoidable transfers. In adjusted analysis, compared to hospitals with no pediatric-specific capabilities, probably avoidable transfers were less likely from referring hospitals with pediatric-specific EDs and no other pediatric-specific capabilities (adjusted odds ratio [aOR] = 0.38, 95% confidence interval [CI] = 0.21-0.71) and from referring hospitals with pediatric-specific EDs and inpatient capabilities (aOR = 0.36, 95% CI = 0.20-0.64). Probably avoidable transfers were more likely from referring hospitals in large metropolitan areas (aOR = 2.64, 95% CI = 1.46-4.80) compared to those in rural areas. CONCLUSIONS: Among pediatric emergency transfers in a large state Medicaid program with a nearly 20% probably avoidable transfer rate, there was significant hospital-level variation in the proportion of probably avoidable transfers. Transfers from hospitals in large metropolitan areas and transfers from hospitals without pediatric-specific capabilities had increased odds of being probably avoidable transfers, such that these hospitals may represent targets for interventions to reduce these transfers.

[Pediatric emergency medicine specialty: Welcome!] / Especialidad de Emergentología Pediátrica: ¡Bienvenida!

Pediatric Emergency Medicine has developed around the world as a subspecialty of pediatrics. There is plenty of data reflecting a growing need for its services. The subspecialty was initiated in the United States and Argentina, together with other Latin American countries, followed the same path. Nevertheless, there is yet much to be done. It is necessary to strengthen its promotion and to stimulate research and teaching activities in order to continue improving the quality of care delivered to the pediatric population, their families and society as a whole.

La Emergentología Pediátrica se ha desarrollado en el mundo como una subespecialidad de la pediatría durante las últimas décadas. Los registros muestran una creciente necesidad de sus servicios. Esta orientación tuvo su empuje inicial en Estados Unidos de América y nuestro país ha continuado por el mismo camino, así como muchos otros países latinoamericanos. Aun así, habrá que intensificar su promoción y trabajar en el desarrollo de la investigación y la docencia relacionadas con el área para promover el bienestar de los niños, sus familias y de la sociedad en general.