Pediatric health care use during the COVID-19 pandemic: Lessons learned from the initial 2020 wave.

Objective: During the height of the coronavirus disease-2019 (COVID-19) pandemic, there was a decline and shift in pediatric medical care use. We aimed to assess changes to pediatric medical use and perceptions/barriers that influenced caregivers' decision-making during the New York State mandated lockdown from March 22 to June 8, 2020, in a population that opted to use the pediatric emergency department (PED) during this period. This study was conducted in New York City (NYC), one of the epicenters at the height of the COVID-19 pandemic. Methods: From June 14 to December 28, 2020, a convenience sample of caregivers who brought children 0-17 years to a NYC PED completed a survey. Results: Participants in the survey included 290 caregivers: 76% were Hispanic; 91% reported having accessed medical care when their children were ill during the lockdown. In-person primary care visits decreased from 64% before to 9% during lockdown; 28% missed well-child checkups or vaccinations, and 26% missed specialist appointments. Telemedicine usage increased from 10% to 54%; none reported lack of internet or electronic devices as barriers to using telemedicine. Regarding access to care: 36% perceived increased difficulty during the lockdown, whereas 56% felt no difference. Barriers included fear of contracting COVID-19 and government advice to avoid health care visits for minor problems. Conclusion: During the initial wave of the COVID-19 pandemic, medical care shifted from an in-person to a virtual platform. Identification of factors and barriers surrounding caregivers' decision-making may positively inform strategies toward future public health emergencies.

Acupuncture for Pediatrics: An Educational Initiative.

Objective: With the ongoing opioid crisis, the Centers for Disease Control and Prevention recommends nonpharmacologic therapies (e.g., acupuncture) for treating pain. Multiple agencies, such as the National Institutes of Health and World Health Organization, recognize acupuncture's effectiveness for treating pain, but acupuncture education for providers is scarce. A Workshop to Introduce Acupuncture for Pediatrics (AcuPeds-Workshop) was developed with support from American Academy of Pediatrics to educate providers. Additional funding was given by the Virginia Apgar Academy to evaluate the effects of attending this workshop. Materials and Methods: This prospective study used Immediate and 1-Month Post-Workshop (PWS) surveys. The AcuPeds-Workshop components included: history; a literature review; videos of patients receiving acupuncture; and hands-on experience. The workshop was presented at numerous conferences. Attendee survey completion was voluntary. Results: Of 327 attendees, the majority were female, non-Hispanic, and were physicians. At baseline, attendees had: heard of acupuncture, 96%; used it, 28%; and/or had a prior lecture, 13%. In the Immediate-PWS: 97% reported an increase in their knowledge and understanding of the indications for acupuncture; majority correctly addressed 3 clinical application scenarios and contraindications. With respect to attitude: 85% would use acupuncture for themselves and 88% would use it for patients. More than 80% rated the workshop components as useful or very useful. In the One-Month-PWS: majority addressed the same 3 clinical scenarios and contraindications correctly, and 11% considered referring patients for acupuncture. Conclusions: Attendance at this AcuPeds-Workshop had a positive impact on attendees' knowledge, application of, and attitude about acupuncture. This workshop supports efforts to educate medical providers on this nonpharmacologic pain therapy.

Battlefield acupuncture instead of opioids for abscess drainage in the pediatric emergency department.

Procedural analgesia with opioids is often needed during incision and drainage (I/D) of pilonidal or large abscesses in the pediatric emergency department (PED). In response to the ongoing opioid misuse pandemic, the Joint Commission has mandated that nonpharmacologic therapies be offered to patients for pain first. Battlefield Acupuncture (BFA) is an auricular acupuncture protocol that is drug free, can achieve rapid pain relief, and is used in the United States military. BFA for painful procedures in the PED has not been reported. We describe 4 cases where BFA was utilized in a PED for pain during I/D of abscesses.

Acupuncture as a Nonpharmacologic Treatment for Pain in a Pediatric Emergency Department.

OBJECTIVES: With epidemic opioid deaths and abuse in the United States, government agencies recommend nonpharmacological treatments for pain. However nonopioid treatment options for moderate to severe pain in the pediatric emergency department (PED) are limited. Acupuncture has been shown to be effective for pain. The objective of this study was to evaluate the feasibility of using traditional acupuncture (TA) and battlefield acupuncture (BFA) in the treatment of pain in the PED. METHODS: A pediatric cohort treated with acupuncture for pain in an urban PED was assessed. All subjects received TA or BFA as treatment, and pre/postacupuncture pain scores, feedback, and adverse events were assessed. The primary outcome was a change in pain score. RESULTS: Twelve patients received BFA, and 13 received TA for these pain conditions: headaches, sciatica, paraphimosis, torticollis, joint pains (knee, shoulder, jaw), sprains (foot, wrist, thumb), dysmenorrhea, otitis externa, sickle cell, and muscle knot. The mean ± SD pain score change, 5.8 ± 2.5 (P < 0.05; 95% confidence interval, 4.9-7.0), was clinically and statistically significant. Over 90% of subjects reported significant improvement or resolution of pain; 96% were satisfied with pain relief and would receive acupuncture again. Two adverse events were noted: one patient reported dizziness, and another, a tinge of blood at 1 of 90 needled points. CONCLUSIONS: This study suggests that acupuncture is a potential nonpharmacologic therapeutic option for acute pain management in the PED.

2017 AAAEM Benchmarking Survey: Comparing Pediatric and Adult Academic Emergency Departments.

OBJECTIVES: The Academy of Administrators in Academic Emergency Medicine Benchmark Survey of academic emergency departments (EDs) was conducted in 2017. We compared operational measures between pediatric and adult (defined as fewer than 5% pediatric visits) EDs based on survey data. Emergency departments in dedicated pediatric hospitals were not represented. METHODS: Measures included: (1) patient volumes, length of stay, and acuity; and 2) faculty staffing, productivity, and percent effort in academics. t Tests were used to compare continuous measures and inferences for categorical variables were made using Pearson χ2 test. RESULTS: The analysis included 17 pediatric and 52 adult EDs. We found a difference in the number of annual visits between adult (median, 66,275; interquartile range [IQR], 56,184-77,702) and pediatric EDs (median, 25,416; IQR, 19,840-29,349) (P < 0.0001). Mean "arrivals per faculty clinical hour" and "total arrivals per treatment space" showed no differences. The proportion of visits (1) arriving by emergency medical services and (2) for behavioral health were significantly higher in adult EDs (both P < 0.0001). The mean length of stay in hours for "all" patients was significantly longer in adult (5.4; IQR, 5.0-6.6) than in pediatric EDs (3.5; IQR, 2.9-4.3; P = 0.017). A similar difference was found for "discharged" patients (P = 0.004). Emergency severity indices, professional evaluation and management codes, and hospitalization rates all suggest higher acuity in adult EDs (all P < 0.0001). There were no differences in mean work relative value units per patient or in the distribution of full time equivalent effort dedicated to academics. CONCLUSIONS: In this cohort, significant differences in operational measures exist between academic adult and pediatric EDs. No differences were found when considering per unit measures, such as arrivals per faculty clinical hour or per treatment space.

Emergency Department Well-being Initiatives During the COVID-19 Pandemic: An After-action Review.

The COVID-19 pandemic has significantly impacted the well-being of our health care professionals, particularly frontline providers in the emergency department (ED). Our ED, located in New York City, was severely affected, exposing the staff to a combination of unique stressors. Our ED Wellness Committee responded by implementing various initiatives focusing on the physical, mental, and social needs of our providers to support them through this difficult time. The initiatives we describe offer a framework that may help other departments understand the importance of provider well-being during a pandemic.

Acupuncture for pediatric sickle cell pain management: A promising non-opioid therapy.

OBJECTIVE: To describe the use of acupuncture for pain management in children with sickle cell disease. DESIGN: A retrospective chart review of a single-institution experience on the use of acupuncture in pediatric patients with sickle cell disease was evaluated between 2012-2019. Demographic characteristics, presenting pain location, pain scores pre- and post-acupuncture, and adverse events were collected. SETTING: Columbia University Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital Pediatric Hematology outpatient and inpatient units. INTERVENTIONS: Acupuncture was performed by six licensed acupuncturists. Point prescriptions were based on pain location, philosophies of Traditional Chinese Medicine and Japanese Style of Kiiko Matsumoto acupuncture. MAIN OUTCOME MEASURES: Pain reduction as measured by two Verbal Pain Scales. RESULTS: Ninety acupuncture treatments were administered to twenty-four patients with sickle cell disease: median age 17.5 years, 62 % female, 37.5 % African American, 50 % Hispanic. The mean treatment duration was 18.5 ±â€¯4.8 min. Fifty-five treatments had documented pre/post-acupuncture pain scores. Pain reduction was achieved in 65.5 % of these treatments. A 0-10 pain scale used in 13 treatments reported a mean pre-acupuncture score of 7.31 ±â€¯1.75, post-acupuncture score of 6.08 ±â€¯1.85, and a mean pain score change of 1.23 ±â€¯1.09 (p = 0.11); A 0-4 pain scale used in 42 treatments reported a mean pre-acupuncture pain score of 3.31 ±â€¯0.72, post-acupuncture score of 2.33 ±â€¯0.98, and a mean pain score change of 0.98 ±â€¯0.99 (p < 0.0001). No adverse events were noted. CONCLUSION: Acupuncture therapy decreased pain for our patients with sickle cell disease, providing a safe non-opioid therapeutic option.

The Elephant in the Room: The Need for Increased Integrative Therapies in Conventional Medical Settings.

Pediatric integrative therapy programs are essential to the treatment and well-being of patients. Identifying an effective integrative therapy model within conventional pediatric medical settings, however, often proves difficult. Our goal in this article is to explore varied solutions to increase access and inclusion of integrative therapies in an effort to promote best practice and holistic care. The main methods applied in this article are vignettes that illustrate how the integrative therapies in a metropolitan academic hospital successfully treat the patient by complementing conventional medicine. This leads to comprehensive care. The central finding of the article proposes viable solutions to increase interdisciplinary collaboration both internally within the institution and externally. Integrative therapists detail how they were able to increase visibility and yield best practice through increased educational initiatives and interdisciplinary collaboration.

Legal, Social, Ethical, and Medical Perspectives on the Care of the Statutory Rape Adolescent in the Emergency Department.

Rapes involving adolescents who present to the emergency department (ED) are fraught with ethical and legal complexities and are often emotionally turbulent for patients, their families, and medical providers. Management requires a thoughtful approach from multiple standpoints, including legal, psychosocial, ethical, and medical ones. However, there is no standardized sexual assault education for emergency medicine residents, and management practices vary widely.1,2 We present a hypothetical statutory rape case based on real cases that occurred in New York City and bring together the perspectives of an attorney on the legal parameters, two social workers on the psychosocial issues, an ethicist on the moral considerations, and a pediatric emergency physician-who is also a sexual assault forensic examiner-on the medical treatments. We aim to provide a framework for physicians to navigate issues of patient-physician privilege involving minors, privacy rules, and mandatory reporting laws.

Auricular Acupuncture in Emergency Department Treatment of Acute Pain.

The National Institutes of Health and the World Health Organization note that acupuncture is a safe and effective treatment for pain. Nonopioid treatment options for moderate to severe acute pain in the emergency department (ED) are limited. Additional strategies for managing acute pain in the ED are needed. Auricular Battlefield Acupuncture has been described as a simple, safe, rapid, and effective analgesic option to opioid medications in managing acute pain. We describe 4 cases in which emergency physicians with brief training performed this auricular acupuncture protocol to treat patients with acute pain in EDs when opioid analgesia was not an acceptable option.

What can we learn from chest radiographs in hypoxemic asthmatics?

BACKGROUND: Chest radiographs (X-rays) are frequently obtained on children with asthma exacerbations who remain hypoxemic after therapy even though their utility has not been evaluated. OBJECTIVE: To compare X-rays in hypoxemic and non-hypoxemic asthmatic children. METHODS: Over 21 months, X-rays were obtained on all persistently hypoxemic asthmatics (1-17 years, oxygen saturation <93% in room air), and some non-hypoxemic asthmatics. A pediatric radiologist blinded to the patients' symptoms evaluated each X-ray for lung size, extravascular lung fluid, and atelectasis. Clinical outcomes including duration of hypoxemia, length of hospital stay, and admission to the PICU were assessed through chart audit after hospital discharge. RESULTS: A total of 445 patients were enrolled and stratified into four groups based on initial and post-treatment pulse oximetry measurements. Hypoxemic groups I and II were more likely to have large or small lungs ( P<0.05), severe interstitial fluid ( P<0.01), and atelectasis ( P<0.01) compared to non-hypoxemic group IV. Group I was more likely to have fluid in the alveolar space compared to all other groups ( P<0.01). Within hypoxemic group I, there was no association between any radiographic findings and our clinical outcomes. CONCLUSION: Large or small lung sizes, extravascular fluid, and atelectasis were more common in the X-rays of hypoxemic asthmatics.