Improving Pediatric Ovarian Torsion Evaluation in the Pediatric Emergency Department: A Quality Improvement Initiative.

Background: Transabdominal pelvic ultrasound (TPUS) is the diagnostic test of choice for the evaluation of ovarian torsion, a time-sensitive surgical emergency. A full bladder is required to visualize the ovaries. Bladder filling is a time-consuming process leading to delays to TPUS, poor visualization of ovaries requiring repeat studies, and prolonged emergency department length of stay (ED LOS). The primary objective was to decrease the time to TPUS by standardizing the bladder filling process. Methods: This quality improvement initiative occurred at a single, academic, quaternary-care children's hospital ED and utilized the Institute for Healthcare Improvement Model for Improvement with sequential plan-do-study-act cycles. The first set of interventions implemented in August 2021 included a new electronic order set and bladder scan by ED nurses. Subsequent plan-do-study-act cycles aimed to decrease the time to intravenous fluid, decrease fluid requirement, and decrease the need for intravenous fluid. The primary outcome measure was the monthly mean time to TPUS. Secondary outcome measures included monthly mean ED LOS and percentage of repeat TPUS. We performed data analysis with statistical process control charts to assess for system change over time. Results: The preintervention baseline included 292 ED encounters more than 10 months, and postintervention analysis included 526 ED encounters more than 16 months. Time to TPUS decreased (138-120 min), ED LOS decreased (372-335 min), and repeat TPUS decreased (18% to 4%). All changes met the rules for special cause variation. Conclusions: Standardizing the bladder filling process was associated with decreased time to TPUS, ED LOS, and repeat TPUS.

Ultrasound guided peripheral IV placement: An observational study of the learning curve in pediatric patients.

BACKGROUND: Ultrasound guided peripheral intravenous catheter placement (USGPIV) has demonstrated benefits in children including higher success rates and fewer attempts compared to the traditional technique. Little is known about the experience needed to establish competence with USGPIV in children. In adult patients, nurses with four USGPIV attempts had a subsequent 70% probability of success after training. The objective of this study is to measure the competency of nurses with USGPIV in children after training. METHODS: Pediatric nurses completed 2 h of training on USGPIV, after which they used ultrasound at their discretion for children with difficult access. Data was collected prospectively via study forms and retrospectively from medical records. Mixed effects logistic regression models were used to estimate the probability of successful USGPIV placement. RESULTS: Thirty-five nurses underwent training from the pediatric emergency department and intravenous access team. The overall USGPIV success rate was 70%. Participants with less nursing experience made more USGPIV attempts than those with more experience, but had similar success rates. Forty percent of participants performed ten or more attempts during the study period. Mixed effects logistic regression estimated that it took nine USGPIV attempts after training for learners to achieve a 70% probability of success for the subsequent attempt. CONCLUSION: After training, 40% of participants adopted USGPIV into their practice. When developing training programs for USGPIV for children with difficult access, trainers can anticipate the experience needed to acquire this skill and the fact that not everyone trained will use this skill in their daily practice.

A Readily Available, Inexpensive, and Reusable Simulation Model for Teaching Ultrasound-Guided Abscess Identification and Drainage.

BACKGROUND: The use of point-of-care ultrasonography as a noninvasive diagnostic tool for soft tissue infections has been shown to be superior to clinical judgment alone in determining the presence or absence of an occult abscess. As ultrasound-guided procedures become standard of care, there is an increasing demand to develop better and inexpensive simulation models to educate trainees. To date, there are no low-cost models for abscess simulation that can be constructed with minimal preparation time, be reused, and withstand multiple procedural attempts. OBJECTIVE: To create an inexpensive, readily available, and reusable homemade ultrasound phantom that simulates a superficial soft tissue abscess and can be easily constructed. DISCUSSION: We experimented with precooked polenta to create a model that would appear similar to human soft tissue under ultrasound examination. Paintballs were embedded in the polenta and evaluated at different depths until a sonographically satisfactory phantom abscess model was obtained. The use of a precooked commercial polenta phantom and commercial paintballs required minimal preparation and closely replicated a superficial soft tissue abscess on ultrasonographic examination. Various paintball brands and sizes were evaluated to confirm ease of reproducibility. The polenta can be reshaped easily and the model may be punctured or incised multiple times. CONCLUSION: A homemade high-fidelity simulation phantom that simulates an abscess in superficial soft tissue can be made inexpensively in <5 min and reused for numerous trainees. This model allows for training for procedures such as ultrasound-guided abscess drainage.

Homemade ultrasound phantom for teaching identification of superficial soft tissue abscess.

BACKGROUND: Point-of-care ultrasonography (POCUS) is often used to distinguish abscess from cellulitis in superficial soft tissue infections. With the increased use of POCUS in emergency medicine, it is important that training to use POCUS is enhanced by practice using phantom models. OBJECTIVE: To create an easily made, inexpensive, homemade phantom capable of simulating an abscess in superficial soft tissue infection. METHODS: Increasing amounts of Jell-O (Northfield, Illinois, USA) brand gelatin and sugar-free Metamucil (Cincinnati, Ohio, USA) brand psyllium hydrophilic mucilloid fibre were experimented with until a satisfactory model was achieved. Various liquids were injected into it to simulate superficial abscess formation. The desired goal was for the phantom to appear similar to superficial human soft tissue under ultrasound scan and to be firm enough to withstand pressure from an ultrasound probe scan. The goal for the simulated abscess was to appear as a hypoechoic space under ultrasound scan. A Sonosite M-Turbo (Bothell, Washington, USA) bedside ultrasound machine with linear array transducer probe was used for the ultrasound scans. RESULTS: The optimal homemade phantom incorporated 12 tablespoons of Jell-O and four tablespoons of Metamucil in one liter of water. CONCLUSION: An easily made, inexpensive phantom model for instruction on identification of superficial skin abscess was achieved.

Sterile cerebrospinal fluid pleocytosis in young febrile infants with urinary tract infections.

OBJECTIVES: To determine the prevalence of and to identify risk factors for sterile cerebrospinal fluid (CSF) pleocytosis in a large sample of febrile young infants with urinary tract infections (UTIs) and to describe the clinical courses of those patients. DESIGN: Secondary analysis of a multicenter retrospective review. SETTING: Emergency departments of 20 North American hospitals. Patients Infants aged 29 to 60 days with temperatures of 38.0°C or higher and culture-proven UTIs who underwent a nontraumatic lumbar puncture from January 1, 1995, through May 31, 2006. MAIN EXPOSURE: Febrile UTI. OUTCOME MEASURES: Presence of sterile CSF pleocytosis defined as CSF white blood cell count of 10/µL or higher in the absence of bacterial meningitis and clinical course and treatment (ie, presence of adverse events, time to defervescence, duration of parenteral antibiotic treatment, and length of hospitalization). RESULTS: A total of 214 of 1190 infants had sterile CSF pleocytosis (18.0%; 95% confidence interval, 15.9%-20.3%). Only the peripheral white blood cell count was independently associated with sterile CSF pleocytosis, and patients with a peripheral white blood cell count of 15/µL or higher had twice the odds of having sterile CSF pleocytosis (odds ratio, 1.97; 95% confidence interval, 1.32-2.94; P = .001). In the subset of patients at very low risk for adverse events (ie, not clinically ill in the emergency department and without a high-risk medical history), patients with and without sterile CSF pleocytosis had similar clinical courses; however, patients with CSF pleocytosis had longer parenteral antibiotics courses (median length, 4 days [interquartile range, 3-6 days] vs 3 days [interquartile range, 3-5 days]) (P = .04). CONCLUSION: Sterile CSF pleocytosis occurs in 18% of young infants with UTIs. Patients with CSF pleocytosis at very low risk for adverse events may not require longer treatment with antibiotics.

Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia.

BACKGROUND: There is limited evidence from which to derive guidelines for the management of febrile infants aged 29 to 60 days with urinary tract infections (UTIs). Most such infants are hospitalized for ≥48 hours. Our objective was to derive clinical prediction models to identify febrile infants with UTIs at very low risk of adverse events and bacteremia in a large sample of patients. METHODS: This study was a 20-center retrospective review of infants aged 29 to 60 days with temperatures of ≥38°C and culture-proven UTIs. We defined UTI by growth of ≥50,000 colony-forming units (CFU)/mL of a single pathogen or ≥10,000 CFU/mL in association with positive urinalyses. We defined adverse events as death, shock, bacterial meningitis, ICU admission need for ventilator support, or other substantial complications. We performed binary recursive partitioning analyses to derive prediction models. RESULTS: We analyzed 1895 patients. Adverse events occurred in 51 of 1842 (2.8% [95% confidence interval (CI): 2.1%-3.6%)] and bacteremia in 123 of 1877 (6.5% [95% CI: 5.5%-7.7%]). Patients were at very low risk for adverse events if not clinically ill on emergency department (ED) examination and did not have a high-risk past medical history (prediction model sensitivity: 98.0% [95% CI: 88.2%-99.9%]). Patients were at lower risk for bacteremia if they were not clinically ill on ED examination, did not have a high-risk past medical history, had a peripheral band count of <1250 cells per µL, and had a peripheral absolute neutrophil count of ≥1500 cells per µL (sensitivity 77.2% [95% CI: 68.6%-84.1%]). CONCLUSION: Brief hospitalization or outpatient management with close follow-up may be considered for infants with UTIs at very low risk of adverse events.

'Postconditioning' the human heart: multiple balloon inflations during primary angioplasty may confer cardioprotection.

Growing evidence from experimental models suggests that relief of myocardial ischemia in a stuttering manner (i.e., 'postconditioning' [PostC] with brief cycles of reperfusion-reocclusion) limits infarct size. However, the potential clinical efficacy of PostC has, to date,been largely unexplored. Using a retrospective study design, our aim was to test the hypothesis that creatine kinase release (CK: clinical surrogate of infarct size) would be attenuated in ST-segment elevation myocardial infarction (STEMI) patients requiring multiple balloon inflations-deflations during primary angioplasty versus STEMI patients who received minimal balloon inflations and/or direct stenting. To investigate this concept, we reviewed the records of all STEMI patients with single vessel occlusion who presented to our institution from November 2004 - April 2006 for primary angioplasty. Exclusion criteria were: previous MI, cardiogenic shock, patients resuscitated from cardiac arrest, or pre-infarct angina. Patients were prospectively divided into two subsets: those receiving 1-3 balloon inflations (considered the minimum range to achieve patency and stent placement) versus those in whom 4 or more inflations were applied. Peak CK release was significantly lower in patients requiring > or =4 versus 1-3 inflations (1655 versus 2272 IU/L; p<0.05), an outcome consistent with the concept that relief of sustained ischemia in a stuttered manner (analogous to postconditioning) may evoke cardioprotection in the clinical setting.