Preferred language and diagnostic errors in the pediatric emergency department.

OBJECTIVES: To investigate the relationship between language and diagnostic errors (DxE) in the pediatric emergency department (ED). METHODS: Electronic trigger identified ED encounters resulting in unplanned hospital admission that occurred within 10 days of an index visit from January 2018 through February 2022. Manual screening of each triggered encounter identified cases where the index visit diagnosis and hospitalization discharge diagnosis differed, and these were screened in for review using the Revised Safer Dx instrument to determine if a diagnostic error (DxE) occurred. Non-English primary language (NEPL) and English-proficient (EP) groups were established based on caregiver language. The primary outcome was the proportion of DxE each group. Data were analyzed using univariate analysis and multivariable logistic regression to identify independent predictors of DxE. RESULTS: Electronic trigger identified 3,551 patients, of which 806 (22.7 %) screened in for Safer Dx review. 172 (21.3 %) experienced DxE. The proportion of DxE was similar between EP and NEPL groups (21.5 vs. 21.7 %; p=0.97). Age≥12 years and fewer prior admissions in the preceding 6 months predicted higher odds of DxE. NEPL did not predict higher odds of DxE. CONCLUSIONS: NEPL was not associated with increased odds DxE resulting in unplanned admission.

Anaphylaxis in Children.

ABSTRACT: Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings. Recently published clinical guidelines emphasize early recognition of anaphylaxis and administration of epinephrine as the mainstay of management. Literature regarding adjuvant therapies, biphasic reactions, observation times, and disposition of patients with anaphylaxis remains controversial. In this article, we will review the background and pathophysiology of anaphylaxis, as well as the diagnostic approach, management, and future directions of anaphylaxis in children.

Use of e-triggers to identify diagnostic errors in the paediatric ED.

BACKGROUND: Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting. OBJECTIVES: To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems. DESIGN/METHODS: Retrospective single-centre cohort study of children ages 0-22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems. RESULTS: An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen's κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital's incident reporting system and five to the ED case review team (one reported to both). CONCLUSION: An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.

Ketamine Sedation and Hypoxia: A Quality Improvement Project to Reduce Respiratory Events Receiving Intervention.

BACKGROUND: Ketamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally. OBJECTIVE: A quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from > 10% to < 6% in our network of EDs and UCs. METHODS: Inclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay. RESULTS: REs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation. CONCLUSIONS: Using QI methodology, we reduced and maintained rates of RE to < 6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.

Epidemiologic comparison of ankle injuries presenting to US emergency departments versus high school and collegiate athletic training settings.

BACKGROUND: Ankle sprains account for a large proportion of injuries presenting to both United States (US) emergency departments (EDs) as well as high school (HS) and collegiate school athletic training settings. The epidemiologic differences across these settings by both sport and diagnosis have not been well differentiated. Ankle injury data from 3 national surveillance datasets. Athletic training setting data from the National High School Sports-Related Injury Surveillance System and the National Collegiate Athletic Association Injury Surveillance Program was from academic years 2009/10 through 2013/14 and the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (ED setting) data was from calendar years 2009 through 2013. Data was analyzed for patients 14-22 years old participating in 12 sports (male football, baseball, basketball, lacrosse, soccer, and wrestling, and female softball, basketball, lacrosse, soccer, volleyball, and field hockey). We calculated sport-specific injury rates, proportions, and rate ratios (RRs) with 95% confidence intervals (CI). RESULTS: During the study period, the surveillance systems captured 20,261 ankle injuries presenting to EDs plus 5546 HS and 2725 collegiate injuries presenting to school athletic training settings. Rates were higher in collegiate compared to HS athletes presenting in the athletic training setting. Football accounted for the largest proportion of ankle injuries presenting to HS (31.2%) and college (41.0%) athletic training settings; male basketball accounted for the largest proportion presenting to EDs among both HS (41.0%) and college (65.8%) aged patients. Sprains/strains accounted for over 80% of injuries in all three settings. Fractures accounted for a larger proportion of ankle injuries presenting to EDs (9.5%) compared to HS (3.8%) and college (0.8%) athletic training settings. There was no change in injury rates during the study period across the three settings. CONCLUSIONS: Injury rates and patterns varied by sport and presentation setting, with athletic trainers evaluating more ankle injuries overall in the collegiate setting compared to the high school setting. Ankle injuries presenting to EDs were more commonly fractures, suggesting that more severe injuries present to this setting. Understanding the epidemiology of such patterns will help readers interpret differences in publications reporting data from varied clinical settings.

Intracranial Complications of Pediatric Sinusitis.

"Headache and fever" is a common presentation to the urgent care and emergency department setting and can have many etiologies. We present a case of a 10-year-old girl who presented with headache and fever and was found to have intracranial extension of sinusitis despite lack of typical sinus or chronic upper respiratory tract infection symptoms. This case illustrates the need in the emergency department or urgent care to keep a broad differential diagnosis for pediatric headache, especially when initial interventions are unsuccessful. We also review the epidemiology of pediatric sinusitis, age at sinus development, and associated intracranial complications.