Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis.

Importance: Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes. Objective: To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis. Design, Setting, and Participants: This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024. Exposure: The number of minutes from emergency department arrival to antibiotic administration. Main Outcomes and Measures: The primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome. Results: A total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes. Conclusions and Relevance: In this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.

Characteristics and Outcomes of Culture-Positive and Culture-Negative Pediatric Sepsis.

OBJECTIVES: To compare the outcomes of pediatric severe sepsis and septic shock among patients with culture-positive and culture-negative sepsis and to determine if there are differentiating markers of disease severity between these 2 populations during their initial presentation and emergency department (ED) stay. STUDY DESIGN: Retrospective cohort study of patients ≤21 years of age who presented to the ED of a single children's hospital with severe sepsis or septic shock from June 1, 2017 to June 5, 2019. RESULTS: There were 235 patients who met criteria for severe sepsis or septic shock. Of these, 139 (59.1%) had culture-negative sepsis and 96 (40.9%) had culture-positive sepsis. In the adjusted multivariable model, children with culture-negative sepsis had more intensive care unit (ICU)-free days than those with culture-positive sepsis (27.3 vs 24.1; adjusted median differences [aMD] -2.6 [-4.4, -0.8]). There were no differences in mortality or hospital-free days. On initial presentation, there were no differences in fever, hypothermia, tachycardia, tachypnea, or hypotension between the 2 groups. There were no differences in proportion of patients receiving the following interventions: intravenous (IV) antibiotics, IV fluids, vasoactive medications, CPR, intubation, or time from arrival to provision of these interventions. CONCLUSIONS: Culture-negative sepsis constitutes a substantial proportion of pediatric severe sepsis and septic shock. In this study, patients with culture-negative and culture-positive sepsis presented similarly on arrival to the ED and received similar treatments while there. Patients with culture-negative sepsis had more ICU-free days than those with culture-positive sepsis, although differences in hospital length of stay (LOS) and mortality were not observed.

Improving Discharge Safety in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement. METHODS: At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates. RESULTS: Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates. CONCLUSIONS: The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock.

STUDY OBJECTIVE: To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock. METHODS: This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure. RESULTS: Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

Reducing Pediatric Emergency Department Prescription Errors.

BACKGROUND: Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines. METHODS: From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing. RESULTS: Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased. CONCLUSION: QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.

Pediatric sepsis screening in US hospitals.

Sepsis is a major cause of morbidity and mortality in children. While adverse outcomes can be reduced through prompt initiation of sepsis protocols including fluid resuscitation and antibiotics, provision of these therapies relies on clinician recognition of sepsis. Recognition is challenging in children because early signs of shock such as tachycardia and tachypnea have low specificity while hypotension often does not occur until late in the clinical course. This narrative review highlights the important context that has led to the rapid growth of pediatric sepsis screening in the United States. In this review, we (1) describe different screening tools used in US emergency department, inpatient, and intensive care unit settings; (2) highlight details of the design, implementation, and evaluation of specific tools; (3) review the available data on the process of integrating sepsis screening into an overall sepsis quality improvement program and on the effect of these screening tools on patient outcomes; (4) discuss potential harms of sepsis screening including alarm fatigue; and (5) highlight several future directions in sepsis screening, such as novel tools that incorporate artificial intelligence and machine learning methods to augment sepsis identification with the ultimate goal of precision-based approaches to sepsis recognition and treatment. IMPACT: This narrative review highlights the context that has led to the rapid growth of pediatric sepsis screening nationally. Screening tools used in US emergency department, inpatient, and intensive care unit settings are described in terms of their design, implementation, and clinical performance. Limitations and potential harms of these tools are highlighted, as well as future directions that may lead to a more precision-based approach to sepsis recognition and treatment.

Exclusion of SARS-COV-2 From Two Maine Overnight Camps July-August 2020.

OBJECTIVES: Summer camp can positively affect self-esteem and social skills. Most United States summer camps did not open during 2020 because of concerns about severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Our objective is to describe exclusion strategies successfully used by 2 summer camps in Maine. METHODS: Before camp arrival, all attendees were asked to quarantine at home for 14 d and perform a daily symptom checklist. Salivary specimens were submitted by mail for SARS-COV-2 PCR testing 4 d before arrival, and again 4 d after arrival. At camp, multiple layers of nonpharmaceutical interventions (NPIs) were used. RESULTS: A total of 717 (96.7%) prospective attendees underwent remotely supervised saliva collection; 4 were positive and did not come to camp. Among the 20 who did not submit a sample, 3 did not come to camp; the other 17 underwent screening and a rapid antigen test for SARS-COV-2 immediately upon arrival and before reporting to communal living spaces; all were negative. All campers and staff were re-tested by salivary polymerase chain reaction 4 d after arrival, and all were negative. CONCLUSIONS: We demonstrate that it is possible to safely operate overnight camps during a pandemic, thus supporting the continued physical and socioemotional growth of children, using multiple layers of NPIs.

Pediatric sepsis survival in pediatric and general emergency departments.

OBJECTIVE: Understanding differences in mortality rate secondary to sepsis between pediatric and general emergency departments (EDs) would help identify strategies to improve pediatric sepsis care. We aimed to determine if pediatric sepsis mortality differs between pediatric and general EDs. METHODS: We performed a nationally representative, retrospective cohort study using the 2008-2017 Nationwide Emergency Department Sample (NEDS) to examine visits by patients less than 19 years old with a diagnostic code of severe sepsis or septic shock. We generated national estimates of study outcomes using NEDS survey weights. We compared pediatric to general EDs on the outcomes of ED mortality and hospital mortality. We determined adjusted mortality risk using logistic regression, controlling for age, gender, complex care code, and geographic region. RESULTS: There were 54,129 weighted pediatric ED visits during the study period with a diagnosis code of severe sepsis or septic shock. Of these visits, 285 died in the ED (0.58%) and 5065 died during their hospital stay (9.8%). Mortality risk prior to ED disposition in pediatric and general EDs was 0.31% and 0.72%, respectively (adjusted odds ratio (aOR), 95% confidence interval (CI): 0.36 (0.14-0.93)). Mortality risk prior to hospital discharge in pediatric and general EDs was 7.5% and 10.9%, respectively (aOR, 95% CI: 0.55 (0.41-0.72)). CONCLUSIONS: In a nationally representative sample, pediatric mortality from severe sepsis or septic shock was lower in pediatric EDs than in general EDs. Identifying features of pediatric ED care associated with improved sepsis mortality could translate into improved survival for children wherever they present with sepsis.

Utility of specific laboratory biomarkers to predict severe sepsis in pediatric patients with SIRS.

OBJECTIVE: To identify the association between readily available laboratory biomarkers and the development of severe sepsis in children presenting to the emergency department (ED) with systemic inflammatory response syndrome (SIRS). METHODS: In this retrospective cohort study, ED patient encounters from June 2018 to June 2019 that triggered an automated sepsis alert based on SIRS criteria were analyzed. Encounters were included if the patient had any of the following laboratory tests sent within 6 h of ED arrival: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lactic acid, and procalcitonin. For each of the biomarkers, a receiver operating characteristic (ROC) curve was created for our primary outcome, severe sepsis within 24 h of ED disposition, and our secondary outcome, severe sepsis with a positive bacterial culture. For each ROC curve, we calculated the area under the curve (AUC) with 95% confidence intervals (95% CI) and created cutoff points to achieve 90% sensitivity and 90% sensitivity for the primary and secondary outcomes. RESULTS: During the study period, 4349/61,195 (7.1%) encounters triggered an automated sepsis alert. Of those, 1207/4349 (27.8%) had one of the candidate biomarkers sent within 6 h of ED arrival and were included in the study. A total of 100/1207 (8.3%) met criteria for severe sepsis within 24 h of arrival, and 41/100 severe sepsis cases (41%) were deemed culture-positive. Procalcitonin had the highest AUC for identifying severe sepsis [0.62 (95% CI 0.52-0.73)] while ESR and CRP had the highest AUC for culture-positive sepsis [0.68 (95% CI 0.47-0.89) and 0.67 (95% CI 0.53-0.81), respectively]. At 90% sensitivity for detecting severe sepsis, all of the biomarker threshold values fell within that laboratory test's normal range. At 90% specificity for severe sepsis, threshold values were as follows: procalcitonin 2.72 ng/mL, CRP 16.79 mg/dL, ESR 79.5 mm/h and lactic acid 3.6 mmol/L. CONCLUSION: Our data indicate that CRP, ESR, lactic acid, and procalcitonin elevations were all specific, but not sensitive, in identifying children in the ED with SIRS who go on to develop severe sepsis.

Prediction of patient disposition: comparison of computer and human approaches and a proposed synthesis.

OBJECTIVE: To compare the accuracy of computer versus physician predictions of hospitalization and to explore the potential synergies of hybrid physician-computer models. MATERIALS AND METHODS: A single-center prospective observational study in a tertiary pediatric hospital in Boston, Massachusetts, United States. Nine emergency department (ED) attending physicians participated in the study. Physicians predicted the likelihood of admission for patients in the ED whose hospitalization disposition had not yet been decided. In parallel, a random-forest computer model was developed to predict hospitalizations from the ED, based on data available within the first hour of the ED encounter. The model was tested on the same cohort of patients evaluated by the participating physicians. RESULTS: 198 pediatric patients were considered for inclusion. Six patients were excluded due to incomplete or erroneous physician forms. Of the 192 included patients, 54 (28%) were admitted and 138 (72%) were discharged. The positive predictive value for the prediction of admission was 66% for the clinicians, 73% for the computer model, and 86% for a hybrid model combining the two. To predict admission, physicians relied more heavily on the clinical appearance of the patient, while the computer model relied more heavily on technical data-driven features, such as the rate of prior admissions or distance traveled to hospital. DISCUSSION: Computer-generated predictions of patient disposition were more accurate than clinician-generated predictions. A hybrid prediction model improved accuracy over both individual predictions, highlighting the complementary and synergistic effects of both approaches. CONCLUSION: The integration of computer and clinician predictions can yield improved predictive performance.

Outcomes of Patients with Sepsis in a Pediatric Emergency Department after Automated Sepsis Screening.

OBJECTIVE: To determine the effect of an automated sepsis screening tool on treatment and outcomes of severe sepsis in a pediatric emergency department (ED). STUDY DESIGN: Retrospective cohort study of encounters of patients with severe sepsis in a pediatric ED with a high volume of pediatric sepsis cases over a 2-year period. The automated sepsis screening algorithm replaced a manual screen 1 year into the study. The primary outcome was the proportion of patients treated for sepsis while in the ED. Secondary outcomes were time from ED arrival to first intravenous (IV) antibiotic and first IV fluid bolus, volume of fluid administered in the ED, 30-day mortality, intensive care unit-free days, and hospital-free days. RESULTS: In year 1 of the study, 8910 of 61 026 (14.6%) of encounters had a manual sepsis screen; 137 patients met criteria for severe sepsis. In year 2, 100% of 61 195 encounters had an automated sepsis screen and there were 136 cases of severe sepsis. There was a higher proportion of patients with severe sepsis who had an active malignancy and indwelling central venous catheter in year 2. There were no differences in the proportion of patients treated for sepsis in the ED, time to first IV antibiotic or first IV fluid bolus, fluid volume delivered in the ED, hospital-free days, intensive care unit-free days, or 30-day mortality after implementation of the automated screening algorithm. CONCLUSIONS: An automated sepsis screening algorithm introduced into an academic pediatric ED with a high volume of sepsis cases did not lead to improvements in treatment or outcomes of severe sepsis in this study.

Use of the C-MAC Macintosh 0 Blade for Intubation of Infants in the Emergency Department.

ABSTRACT: First-pass success rates during intubation of infants in the emergency department have been shown to be low. Video laryngoscopy is being increasingly used during advanced airway management in the emergency department, but available data have not supported improved outcomes with use in pediatrics. The newly available Macintosh size 0 (curved) blade for the C-MAC video laryngoscope offers a narrower blade for use in infants. We describe the use of the new C-MAC Macintosh 0 blade for intubation of 2 infants with apnea secondary to respiratory syncytial virus bronchiolitis. The included video recording demonstrates the favorable glottic view and improved maneuverability offered by the narrower blade but also highlights the limitation in use beyond young infants given the short blade length.

Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency Department.

INTRODUCTION: Procedural sedation for fracture reduction in the pediatric emergency department (ED) is a time-consuming process requiring multidisciplinary coordination. We implemented a quality improvement initiative aimed at (1) decreasing mean ED length of stay (LOS) for children with sedated long bone fracture reductions by 15% over 12 months and (2) improving interdisciplinary communication around procedural sedation. METHODS: Pediatric emergency medicine fellows at a children's hospital designed and implemented an initiative targeting the efficiency of the sedation process. Interventions included a centralized sedation tracking board, a team member responsibility checklist, family handouts, early discharge initiatives, and postsedation review forms. We tracked progress via statistical process control charts and interdisciplinary communication by intermittent surveys. RESULTS: Pediatric emergency medicine fellows performed 2,246 sedations during the study period. Mean LOS decreased from 361 to 340 minutes (5.8%) after implementation and demonstrated sustainability over the postintervention period. One hundred eight providers completed the preimplementation communication survey, with 58 and 64 completing surveys at 4 and 9 months postimplementation, respectively. The proportion reporting somewhat or strong satisfaction with communication increased from 68% at baseline to 86% at 4 months (P = 0.02) and 92% at 9 months (P < 0.001 versus baseline). CONCLUSIONS: A quality improvement initiative created a sustainable process to reduce ED LOS for sedated reductions while improving satisfaction with interdisciplinary communication.

Reducing Time to Antibiotics in Children With Intestinal Failure, Central Venous Line, and Fever.

BACKGROUND: Children with intestinal failure (IF) on parenteral nutrition (PN) are at high risk for bacteremia, and delays in antibiotic administration have been associated with increased morbidity and mortality. We designed an emergency department (ED) quality improvement (QI) initiative to reduce time to administration of intravenous antibiotics in febrile children with IF on PN. METHODS: Our aim was to decrease the mean time for febrile children with IF on PN to receive intravenous antibiotics by 50% to <60 minutes over a 12-month period. Secondary outcome measures were ED, hospital, and ICU length of stay (LOS). Our process measure was the rate of ordering recommended antibiotics, and our balancing measure was the rate of hypoglycemia. Interventions included increasing provider knowledge of IF, streamlining order entry, providing individualized feedback, and standardizing the triage process. Results were analyzed by using statistical process control methodology and time series analysis. RESULTS: We identified 149 eligible ED patients, of which 62 (41.6%) had bacteremia. The mean time to antibiotics decreased after the onset of the QI initiative from 112 to 39 minutes, and the ED LOS decreased from 286 to 247 minutes, but the total length of hospital and ICU stays were unchanged. The rate of hypoglycemia was also unchanged. CONCLUSIONS: Our QI intervention for febrile children with IF on PN shortened the time to receive antibiotics. Larger studies are needed to demonstrate the impact on overall LOS and mortality.

Comparison Between Direct and Video-assisted Laryngoscopy for Intubations in a Pediatric Emergency Department.

OBJECTIVES: The objective was to compare video-assisted laryngoscopy (VAL) to direct laryngoscopy (DL) on success rate and complication rate of intubations performed in a pediatric emergency department (ED). METHODS: This is a retrospective cohort study of attempted intubations of children aged 0-18 years in a pediatric ED between 2004 and 2014 with first attempt by an ED provider. In VAL, the laryngoscopist attempts direct visualization of the glottis with a C-MAC video laryngoscope while the video monitor is used for real-time guidance by a supervisor, back-up visualization for the laryngoscopist should the direct view be inadequate, and confirmation of endotracheal tube passage through the vocal cords. We performed univariate comparisons of intubations using DL to intubations using VAL on rates of first-pass success, complications, and whether the patient was successfully intubated by an ED provider. We then created a logistic regression model to adjust for provider experience level, difficult airway characteristics, and indications for intubation to compare intubations using DL to intubations using VAL for each outcome. RESULTS: We identified 452 endotracheal intubations of 422 unique patients, of which 445 intubations had a first attempt by an ED provider. Six intubations were excluded due to insufficient information available in the record. Of the included intubations, 240 (55%) were attempted with DL and 199 (45%) with VAL. The overall first-pass success rate was 71% in the DL group and 72% in the VAL group. After adjustment for covariates, the first-pass success rate was similar between laryngoscopy approaches (adjusted odds ratio = 1.23, 95% confidence interval = 0.78 to 1.94). CONCLUSIONS: We found no difference between DL and VAL with regard to first-pass intubation success rate, complication rate, or rate of successful intubation by ED providers for children undergoing intubation in a pediatric ED.

Duration and course of post-concussive symptoms.

OBJECTIVES: To examine the incidence, duration, and clinical course of individual post-concussive symptoms in patients presenting to a pediatric emergency department (ED) with a concussion. METHODS: We conducted secondary analysis of a prospective cohort study of patients 11 to 22 years old presenting to the ED of a children's hospital with an acute concussion. The main outcome measure was duration of symptoms, assessed by the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ). Patients initially completed a questionnaire describing mechanism of injury, associated symptoms, past medical history, and the RPSQ, then were serially administered the RPSQ for 3 months after the concussion or until all symptoms resolved. RESULTS: Headache, fatigue, dizziness, and taking longer to think were the most common symptoms encountered at presentation, whereas sleep disturbance, frustration, forgetfulness, and fatigue were the symptoms most likely to develop during the follow-up period that had not initially been present. Median duration of symptoms was the longest for irritability (16 days), sleep disturbance (16 days), frustration (14 days), and poor concentration (14 days), whereas nausea, depression, dizziness, and double-vision abated most quickly. One month after injury, nearly a quarter of children still complained of headache, >20% suffered from fatigue, and nearly 20% reported taking longer to think. CONCLUSIONS: Among patients presenting to a pediatric ED after a concussion, physical symptoms such as headache predominate immediately after the injury, emotional symptoms tend to develop later in the recovery period, and cognitive symptoms may be present throughout.

Time interval between concussions and symptom duration.

OBJECTIVE: To test the hypothesis that children with a previous history of concussion have a longer duration of symptoms after a repeat concussion than those without such a history. METHODS: Prospective cohort study of consecutive patients 11 to 22 years old presenting to the emergency department of a children's hospital with an acute concussion. The main outcome measure was time to symptom resolution, assessed by the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ). Patients and providers completed a questionnaire describing mechanism of injury, associated symptoms, past medical history, examination findings, diagnostic studies, and the RPSQ. Patients were then serially administered the RPSQ for 3 months after the concussion or until all symptoms resolved. RESULTS: A total of 280 patients were enrolled over 12 months. Patients with a history of previous concussion had a longer duration of symptoms than those without previous concussion (24 vs 12 days, P = .02). Median symptom duration was even longer for patients with multiple previous concussions (28 days, P = .03) and for those who had sustained a concussion within the previous year (35 days, P = .007) compared with patients without those risk factors. In a multivariate model, previous concussion, absence of loss of consciousness, age ≥13, and initial RPSQ score >18 were significant predictors of prolonged recovery. CONCLUSIONS: Children with a history of a previous concussion, particularly recent or multiple concussions, are at increased risk for prolonged symptoms after concussion. These findings have direct implications on the management of patients with concussion who are at high risk for repeat injuries.

Cardiac troponin T as a screening test for myocarditis in children.

OBJECTIVE: The objective of this study was to define the test characteristics of cardiac troponin T (cTnT) in pediatric patients who presented with suspected myocarditis. METHODS: We performed a retrospective cohort study of all patients at a large urban children's hospital 21 years or younger who had a cTnT test sent for evaluation for myocarditis over a 13-month period. Patients were excluded if they had any history of heart disease or cardiac arrest before presentation, or the cTnT was sent for reasons other than concern for myocarditis. Positive cases of myocarditis were defined by characteristic pathology findings, magnetic resonance imaging results, or diagnosis of the attending cardiologist at time of discharge. RESULTS: Six hundred fifty-two patients had cTnT sent during the study period. Two hundred sixty were excluded because of prior history of heart disease, and 171 had the test sent for reasons other than concern for myocarditis. Of the 221 patients included in the study, 49 had an initial positive cTnT (≥0.01 ng/mL), whereas 172 had a negative test result. Eighteen cases of myocarditis were identified. All patients with myocarditis had an elevated cTnT at presentation. Using a cutoff value of 0.01 ng/mL or greater as a positive test, cTnT had a sensitivity of 100% (95% confidence interval [CI], 78%-100%), with a negative predictive value of 100% (CI, 97%-100%), and a specificity of 85% (CI, 79%-89%), with positive predictive value of 37% (CI, 24%-52%), in the diagnosis of myocarditis. CONCLUSIONS: In children without preexisting heart disease, a cTnT level of less than 0.01 ng/mL can be used to exclude myocarditis.

Development and order set utilization in ambulatory pediatric specialty care.

One of the keys to any successful CPOE implementation is the development, deployment, and maintenance of well designed order sets that promote evidence based best practice. At Seattle Children's we implemented ambulatory CPOE in multiple subspecialty pediatric clinics. Using our previous experience with inpatient CPOE, we translated our order set process to the ambulatory setting, making sure to understand the unique features of ambulatory subspecialty practice.

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

OBJECTIVE: Our goal was to determine if there were any changes in risk-adjusted mortality after the implementation of a computerized provider order entry system in our PICU. METHODS: Study was undertaken in a tertiary care PICU with 20 beds and 1100 annual admissions. Demographic, admission source, primary diagnosis, crude mortality, and Pediatric Risk of Mortality III risk-adjusted mortality were abstracted retrospectively on all admissions from the PICUEs database for the period October 1, 2002, to December 31, 2004. This time period reflects the 13 months before and 13 months after computerized provider order entry implementation. Pediatric Risk of Mortality III mortality risk adjustment was used to determine standardized mortality ratios. RESULTS: During the study period, 2533 patients were admitted to the PICU, of which 284 were transported from another facility. The 13-month preimplementation mortality rate was 4.22%, and the 13-month postimplementation mortality rate was 3.46%, representing a nonsignificant reduction in the risk of mortality in the postimplementation period. The standardized mortality ratio was 0.98 vs 0.77, respectively, and the mortality rate for the transported patients was 9.6% vs 6.29%. This yields a nonsignificant mortality risk reduction in the postimplementation period. The standardized mortality ratio was 1.10 preimplementation versus 0.70 postimplementation. Analysis of the 13-month preimplementation versus 5-month postimplementation periods showed a non-statistically significant trend in reduction of mortality for all PICU patients and for transported patients. CONCLUSIONS: Implementation of a computerized provider order entry system, even in the early months after implementation, was not associated with an increase in mortality. Our experience suggests that careful design, build, implementation, and support can mitigate the risk of implementing new technology even in an ICU setting.