Things Are Not Always What They Seem: Two Cases of Child Maltreatment Presenting With Common Pediatric Chief Complaints.

We describe 2 cases of child maltreatment who presented as common pediatric conditions: preseptal cellulitis and gastroenteritis. The first case is an 8-year-old girl who presented with progressive right eye pain, swelling, and discharge. She was initially treated for preseptal cellulitis, but eye cultures ultimately grew Neisseria gonorrhoeae. Further investigation revealed sexual abuse by a male family member. The second case is a 2-year-old previously healthy girl who presented with 6 hours of emesis, lethargy, and abdominal pain. Initially attributed to viral gastroenteritis, her serum blood urea nitrogen and creatinine were above what was expected for her clinical course, and she later developed signs of peritonitis. She was ultimately found to have a large bladder wall defect secondary to inflicted blunt abdominal trauma. These cases are presented to emphasize the need for pediatricians to consider child abuse even when patients present with common pediatric complaints.

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods.

BACKGROUND AND OBJECTIVES: Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS: We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS: The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS: Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.