Detection of Pulmonary Embolism in High-Risk Children.

OBJECTIVE: To evaluate 2 commonly used adult-based pulmonary embolism (PE) algorithms in pediatric patients and to derive a pediatric-specific clinical decision rule to evaluate children at risk for PE, given the paucity of data to guide diagnostic imaging in children for whom PE is suspected. STUDY DESIGN: We performed a single-center retrospective study among 561 children <22 years of age undergoing either D-dimer testing or radiologic evaluation (computed tomography or ventilation-perfusion scan) in the emergency department setting for concern of PE. A diagnosis of PE required radiologic confirmation and anticoagulant treatment. We evaluated the test characteristics of the Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) low-risk rule and used recursive partition analysis to derive a clinical decision rule. RESULTS: Among the 561 patients included in the study, 36 (6.4%) were diagnosed with PE. The Wells criteria demonstrated a sensitivity and specificity of 86% and 60%, respectively. The sensitivity and specificity of the PERC were 100% and 24%, respectively. A clinical decision rule including the presence of oral contraceptive use, tachycardia, and oxygen saturation <95% demonstrated a sensitivity and specificity of 90% and 56%, respectively, a positive and negative likelihood ratio of 2.0 and 0.2, and a positive and negative predictive value of 0.12 and 0.99, respectively. CONCLUSIONS: The risk of PE is low among children not receiving estrogen therapy and without tachycardia and hypoxia in those with an initial suspicion of PE. Application of the PERC rule and Wells criteria should be used cautiously in the pediatric population.

A pediatric hospital-wide asthma severity score: Reliability and effectiveness.

BACKGROUND: Asthma is a leading cause of pediatric hospitalization in the United States. Children hospitalized with asthma are often managed in different care settings during hospitalization, posing challenges to accurate communication among care providers about illness severity. Our objective was to study the feasibility, reliability, and safety of a new pediatric hospital-wide asthma severity score (HASS) across different care units within a single tertiary-care pediatric center. METHODS: 150 patients between the ages of 2 and 18 years hospitalized with a principal diagnosis of status asthmaticus were included in this study. Study patients were followed from the time of initial triage in the emergency department until the time of medical readiness for discharge. Rates of medical errors, early transfers to a higher level of care and medically indicated hospital length of stay (LOS) were compared between 75 patients before and 75 patients after widespread implementation of the HASS using retrospective chart review and anonymous staff reporting. Interrater reliability was determined by collecting independent HASS scores from blinded staff members after tandem or simultaneous patient assessment. RESULTS: Interrater reliability among untrained staff members using the HASS was high. Hospital LOS, rates of adverse events, medical errors, and early transfer to a higher level of care were not significantly different before and after widespread HASS implementation. CONCLUSION: The HASS is a reliable asthma severity tool that can be used throughout hospitalization and among multiple clinical providers to trend clinical progress and optimize communication, particularly during times of care handoffs.

A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis.

BACKGROUND: Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. METHODS: We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. RESULTS: Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes. CONCLUSIONS: In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002 [ClinicalTrials.gov].).

A method to identify pediatric high-risk diagnoses missed in the emergency department.

BACKGROUND: Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review. METHODS: Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance. RESULTS: Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis. CONCLUSIONS: We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.

Imaging studies after a first febrile urinary tract infection in young children.

BACKGROUND: Guidelines from the American Academy of Pediatrics recommend obtaining a voiding cystourethrogram and a renal ultrasonogram for young children after a first urinary tract infection; renal scanning with technetium-99m-labeled dimercaptosuccinic acid has also been endorsed by other authorities. We investigated whether imaging studies altered management or improved outcomes in young children with a first febrile urinary tract infection. METHODS: In a prospective trial involving 309 children (1 to 24 months old), an ultrasonogram and an initial renal scan were obtained within 72 hours after diagnosis, contrast voiding cystourethrography was performed one month later, and renal scanning was repeated six months later. RESULTS: The ultrasonographic results were normal in 88 percent of the children (272 of 309); the identified abnormalities did not modify management. Acute pyelonephritis was diagnosed in 61 percent of the children (190 of 309). Thirty-nine percent of the children who underwent cystourethrography (117 of 302) had vesicoureteral reflux; 96 percent of these children (112 of 117) had grade I, II, or III vesicoureteral reflux. Repeated scans were obtained for 89 percent of the children (275 of 309); renal scarring was noted in 9.5 percent of these children (26 of 275). CONCLUSIONS: An ultrasonogram performed at the time of acute illness is of limited value. A voiding cystourethrogram for the identification of reflux is useful only if antimicrobial prophylaxis is effective in reducing reinfections and renal scarring. Renal scans obtained at presentation identify children with acute pyelonephritis, and scans obtained six months later identify those with renal scarring. The routine performance of urinalysis, urine culture, or both during subsequent febrile illnesses in all children with a previous febrile urinary tract infection will probably obviate the need to obtain either early or late scans.

Impact of a bronchiolitis guideline on ED resource use and cost: a segmented time-series analysis.

OBJECTIVE: Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED). METHODS: We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS). RESULTS: There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge. CONCLUSIONS: A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.

Bacteremia risk and outpatient management of febrile patients with sickle cell disease.

BACKGROUND AND OBJECTIVES: Previous studies have indicated that febrile children with sickle cell disease (SCD) had a 3% to 5% risk of being bacteremic due to compromised immune function. The introduction of routine penicillin prophylaxis and conjugate vaccines may have lowered the risk of bacteremia. Our goals were to determine the rate of bacteremia among children with SCD per febrile episode and to estimate the safety of outpatient management among these febrile SCD patients. METHODS: This 18-year retrospective cohort study included febrile SCD patients who presented to Boston Children's Hospital between 1993 and 2010. RESULTS: A total of 1118 febrile episodes were evaluated. Nine blood specimens had growth of a pathogen in culture (0.8%; 95% confidence interval: 0.3%-1.3%). Of the 466 febrile patients initially managed as outpatients, 3 were bacteremic (0.6%). All 3 received intravenous ceftriaxone at the initial outpatient visit and returned when contacted after growth of bacteria was detected in the blood culture. Upon return to the hospital, none were "ill appearing," required supportive care, or were admitted to an ICU. CONCLUSIONS: Our rate of bacteremia among febrile children with SCD is much lower than previous estimates, and there was no associated morbidity or mortality among the patients managed as outpatients. A well-appearing febrile child with SCD may be managed as an outpatient after blood is obtained for bacterial culture and parenteral antibiotics are administered, provided there are no other reasons for admission and the patient is able to return promptly for worsening condition or for growth of a pathogen from their blood culture.

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.

Acute pediatric rhabdomyolysis: causes and rates of renal failure.

OBJECTIVES: The goals were to (1) compare the causes, clinical presentation, and prevalence of acute renal failure in pediatric rhabdomyolysis with the published data for adults; (2) determine predictors of acute renal failure in pediatric patients with rhabdomyolysis; and (3) explore the relationship of acute renal failure with treatment modalities such as fluid and bicarbonate administration. METHODS: We performed a retrospective chart review to identify patients with creatinine kinase levels of > 1000 IU/L who were treated in the emergency department of a tertiary pediatric hospital between 1993 and 2003, and we constructed regression models. RESULTS: Two hundred ten patients were studied. One hundred ninety-one patients met study eligibility (128 male and 63 female), with a median age of 11 years. The most common documented symptoms were muscle pain (45%), fever (40%), and symptoms of viral infection (39%). The most common causes of pediatric rhabdomyolysis were viral myositis (38%), trauma (26%), and connective tissue disease (5%). Six of 37 patients with creatinine kinase levels of > or = 6000 IU/L had previously undiagnosed dermatomyositis or hereditary metabolic disease, compared with 10 of 154 patients with creatinine kinase levels of 1000 to 5999 IU/L. Nine of 191 patients developed acute renal failure. None of 99 patients with initial urinary heme dipstick results of < 2+ developed acute renal failure, compared with 9 of 44 patients with urinary heme dipstick results of > or = 2+. Higher initial creatinine kinase levels and higher fluid administration rates were associated with higher maximal creatinine levels. CONCLUSIONS: The cause of acute pediatric rhabdomyolysis is different from that of adult rhabdomyolysis. The risk of acute renal failure in children is much less than the risk reported for adults.

A randomized clinical trial of the management of esophageal coins in children.

CONTEXT: Children frequently ingest coins. When lodged in the esophagus, the coin may cause complications and must either be removed or observed to pass spontaneously. OBJECTIVES: (1) To compare relatively immediate endoscopic removal to a period of observation followed by removal when necessary and (2) to evaluate the relationship between select clinical features and spontaneous passage. DESIGN/SETTING: Randomized, prospective study of children <21 years old who presented to an emergency department with esophageal coins in the esophagus. Exclusion criteria were (1) history of tracheal or esophageal surgery, (2) showing symptoms, or (3) swallowing the coin >24 hours earlier. Children were randomized to either endoscopic removal (surgery) or admission for observation, with repeat radiographs approximately 16 hours after the initial image. OUTCOME MEASURES: Proportion of patients requiring endoscopic removal, length of hospital stay, and the number of complications observed. RESULTS: Among 168 children who presented with esophageal coins lodged in the esophagus, 81 were eligible. Of those eligible, 60 enrolled, 20 refused consent, and 1 was not approached. In the observation group, 23 of 30 (77%) children required endoscopy compared with 21 of 30 (70%) in the surgical group. Total hospital length of stay was longer in the randomized-to-observation group compared with the randomized-to-surgery group (mean: 19.4 [SD: +/-8.0] hours vs 10.7 [SD: +/-7.1] hours, respectively). There were no complications in either group. Spontaneous passage occurred at similar rates in both groups (23% vs 30%). Spontaneous passage was more likely in older patients (66 vs 46 months) and male patients (odds ratio: 3.7; 95% confidence interval: 0.98-13.99) and more likely to occur when the coin was in the distal one third of the esophagus (56% vs 27% [95% confidence interval: 1.07-5.57]). CONCLUSIONS: Because 25% to 30% of esophageal coins in children will pass spontaneously without complications, treatment of these patients may reasonably include a period of observation, in the range of 8 to 16 hours, particularly among older children and those with distally located coins.

The role of emergent neuroimaging in children with new-onset afebrile seizures.

OBJECTIVES: The objectives of this study were 1) to determine the frequency of clinically significant abnormal neuroimaging in children coming to the emergency department (ED) with new-onset afebrile seizures (ASZ), and 2) to identify children at high or low risk for clinically significant abnormal neuroimaging. DESIGN/METHODS: Five hundred consecutive cases of new-onset ASZ seen in the ED of a tertiary care children's hospital were reviewed. Neuroimaging reports were categorized as normal, clinically insignificant abnormal, or clinically significant abnormal. Recursive partition analysis was used to identify clinical variables that separated children into high- and low-risk groups for clinically significant abnormal neuroimaging. RESULTS: Ninety-five percent of patients (475/500) with new-onset ASZ had neuroimaging. Clinically significant abnormal neuroimaging was noted in 8% (95% confidence interval [CI]: 6, 11; 38/475) of patients. Recursive partition analysis identified 2 criteria associated with high risk for clinically significant abnormal neuroimaging: 1) the presence of a predisposing condition, and 2) focal seizure if <33 months old. Of the high-risk patients, 26% (95% CI: 17, 35; 32/121) had clinically significant abnormal neuroimaging compared with 2% (95% CI: 0.6, 3.7; 6/354) in the low-risk group. CONCLUSIONS: In this large, retrospective review of children with new-onset ASZ, clinically significant abnormal neuroimaging occurred with relatively low frequency. Emergent neuroimaging should be considered, however, for children who meet high-risk criteria. Well-appearing children who meet low-risk criteria can be safely discharged from the ED (if follow-up can be assured) without emergent neuroimaging, because their risk for clinically significant abnormal neuroimaging is appreciably lower.