Using Dry-Erase Boards to Share Information in a Pediatric Emergency Department to Improve Family Experience of Care.

OBJECTIVES: To determine whether the use of dry-erase boards for communicating the plan of care of children evaluated in the pediatric emergency department (PED) improves the family experience of care. METHODS: Dry-erase boards were mounted at eye level in patient examination rooms. The study was conducted during a 4-week period during which physicians were instructed to use the boards on alternating weeks. During the 2 intervention weeks, they were instructed to write their name and plan of care in addition to their standard verbal communication. A questionnaire was administered to a convenience sample of caregivers that measured their perceptions of physician listening skills, time spent with the physician, their understanding of the care plan, their willingness to ask questions, likelihood to recommend the PED, and overall physician care. Differences between intervention and nonintervention weeks were analyzed using adjusted multivariable modeling taking into account clustered observations within physician. RESULTS: Surveys were completed by 672 caregivers. There were no significant differences in reported experience of care between the intervention and nonintervention weeks. During the intervention weeks, 59% of caregivers recalled use of the dry-erase boards, whereas 10% of caregivers recalled use during nonintervention weeks. Caregivers who recalled the use of dry-erase boards were more likely to report better physician listening skills, better understanding of the plan of care, and higher overall physician ratings. CONCLUSIONS: Recommending use of dry-erase boards in pediatric emergency department rooms did not increase overall measures of experience of care, although patients who recalled dry-erase board use did report higher performance. Further study could explore how to effectively and efficiently use these boards.

Clinical Impact of Warmed Intravenous Saline in Sickle Cell Patients With Vasoocclusive Episodes.

OBJECTIVES: In children with sickle cell disease treated for vasoocclusive episodes (VOEs), it is unknown if the temperature of infused fluids impacts clinical outcomes. We compared infusions of warmed and nonwarmed saline for treatment of VOE. We also assessed the tolerability and feasibility of infusing warmed saline in patients with VOEs. METHODS: Patients aged 4 to 21 years with sickle cell disease presenting to the emergency department with VOE were randomized to infusions of warmed (37.5°C, experimental arm) versus nonwarmed (22°C-24°C, controls) saline. Intravenous opioids were administered according to previously established guidelines. We compared hospital admission rates, pain scores, disposition times, dosages of opioid, and comfort. RESULTS: Eighty of 92 visits were eligible (40 per arm). The mean age of enrollees was 14 years, and 53% were female. Hospital admission rates were comparable (63% experimental arm and 55% control arm, P = 0.5). Pain score reduction (-2.9 and -2.6, P = 0.52), median morphine equivalents (0.23 mg/kg and 0.25 mg/kg, P = 0.58), and mean treatment-to-disposition times (158 minutes and 155 minutes, P = 0.85) were also similar. Global comfort was higher in children who received warmed saline (4 vs 3, P = 0.01). There were no adverse events reported in patients who received warmed saline. CONCLUSIONS: It is feasible and tolerable to infuse warmed saline for the treatment of VOE, and it is well tolerated. Patient comfort was higher in those patients who received warmed saline, but there was no improvement in admission rates, disposition times, pain scores, and opioid dosages.

Sensitivity of plain pelvis radiography in children with blunt torso trauma.

STUDY OBJECTIVE: Plain anteroposterior pelvic radiographs are commonly used to screen children for pelvic fractures or dislocations after blunt torso trauma. The test sensitivity and utility, however, are unclear. We assessed the sensitivity of anteroposterior pelvic radiographs for identifying children with pelvic fractures or dislocations after blunt torso trauma. We hypothesized that anteroposterior pelvic radiographs fail to identify all children with pelvic fractures or dislocations, including patients undergoing operative intervention and those with hypotension. METHODS: We conducted a prospective multicenter observational study of children (<18 years) with blunt torso trauma in the Pediatric Emergency Care Applied Research Network. We compared plain anteroposterior pelvic radiographs to the final diagnosis of pelvic fractures or dislocations as documented by the orthopedic faculty physician before emergency department (ED)/hospital discharge. We described the data with descriptive statistics, including 95% confidence intervals (CIs). RESULTS: Of 12,044 patients enrolled in the parent study, 451 (3.7%; 95% CI 3.4% to 4.1%) had pelvic fractures or dislocations. Of these patients, 65 (14%; 95% CI 11% to 18%) underwent operative intervention and 21 (4.7%; 95% CI 2.9% to 7.0%) had age-adjusted hypotension on initial presentation. In the ED, 382 of the 451 patients underwent plain anteroposterior pelvic radiographs, with a sensitivity of 297 of 382 (78%; 95% CI 73% to 82%) for patients with pelvic fractures or dislocations, 55 of 60 (92%; 95% CI 82% to 97%) for patients undergoing operative intervention, and 14 of 17 (82%; 95% CI 57% to 96%) for patients with hypotension. CONCLUSION: Plain anteroposterior pelvic radiographs have a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including patients undergoing operative intervention and those with hypotension.

Comparison of polyurethane foam to nylon flocked swabs for collection of secretions from the anterior nares in performance of a rapid influenza virus antigen test in a pediatric emergency department.

Rapid antigen testing of upper respiratory secretions collected with various swab types is often utilized for laboratory diagnoses of influenza virus infection. There are limited data on the effects of swab composition on test performance. This study compared the performance of the Quidel QuickVue Influenza A+B test on secretions from the anterior nares when a polyurethane foam swab was used for collection to that when a nylon flocked swab was used for collection. One hundred subjects who presented to a pediatric emergency department with symptoms suggestive of an influenza virus infection were recruited for the study. Foam and flocked swabs of the anterior nares were obtained from separate nares of each subject before a posterior nasopharyngeal swab was collected and placed into viral transport medium. The QuickVue test was performed directly on each swab type, and the results were compared to the results of reverse transcription-PCR (RT-PCR), direct fluorescent antibody (DFA) test, and viral culture performed on the transport medium. RT-PCR alone and DFA combined with culture were utilized as separate gold standards. There were 56 cases of influenza detected by RT-PCR; the QuickVue test was positive for 40 foam and 30 flocked swabs, for sensitivities of 71% and 54%, respectively (P = 0.01). Similarly, there were 49 influenza cases detected by DFA and/or culture; the QuickVue test was positive for 38 foam and 30 flocked swabs, for sensitivities of 78% and 61%, respectively (P = 0.13). This study suggests that polyurethane foam swabs perform better than nylon flocked swabs for the collection of secretions from anterior nares in the Quidel QuickVue Influenza A+B test.

Multistate model of the patient flow process in the pediatric emergency department.

OBJECTIVES: The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children's Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling. METHODS: In this study, 75,591 patients admitted to the ED from March 1st, 2016 to February 28th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process. RESULTS: Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong. CONCLUSIONS: The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model.

Serious neurologic sequelae in cases of meningitis arising from infection by conjugate vaccine-related and nonvaccine-related serogroups of Streptococcus pneumoniae.

BACKGROUND: Introduction of the heptavalent conjugate vaccine for Streptococcus pneumoniae (PCV7) has led to a dramatic decline in meningitis by PCV7 serotypes, raising the possibility of similar trends by PCV7-related serogroups through cross-protection. A present concern, however, is of serotype replacement by pneumococci not related to PCV7 serogroups. If this occurs, there are currently few data to predict whether clinical outcomes will change substantially. METHODS: To address these questions, we analyzed medical records of 86 cases of pneumococcal meningitis treated at Nationwide Children's Hospital (1993-2004). Adverse neurologic sequelae and death were compared between cases with cerebrospinal fluid isolates characterized as vaccine-related serogroups-serotypes belonging to PCV7 or related to PCV7 serogroups, and those designated nonvaccine serogroups-serotypes neither belonging to PCV7 nor related to PCV7 serogroups. Serotype 19A, because of recent reports of increased incidence, was subanalyzed separately. RESULTS: Thirty-six of 86 (42%) subjects had serious complications, including 6 who died. All 6 deaths occurred in patients with vaccine-related serogroups. Deafness was the most common complication, occurring in 26 (32.5%) survivors. There was no difference in the frequency of total complications between PCV7-related and non-PCV7 groups: 5 of 12 (42%) for non-PCV7 serogroups versus 31 of 74 (42%) for PCV-related serogroups (OR: 1.0; 95% CI: 0.2-4.0). Serious outcomes occurred in 3 of 4 cases due to serogroup 19A. Non-PCV7 serogroups increased slightly at the end of the study period. CONCLUSIONS: In children with pneumococcal meningitis, infections with non-PCV7 serogroups seem less likely to result in death. Among survivors, there is preliminary evidence of parity in neurologic sequelae between PCV7 and non-PCV7 serogroups.

Procedural sedation for fracture reduction in children with hyperactivity.

OBJECTIVE: Children with attention-deficit/hyperactivity disorder (ADHD) have a higher rate of more severe injuries than the general population. However, their ADHD may cause them to respond differently to procedural sedation required for treatment. The purpose of this article is to compare procedural sedation for children with and without ADHD. METHODS: Retrospectively, 44 patients with ADHD and 41 controls sedated with fentanyl and midazolam for forearm-fracture reduction in the emergency department (ED) at a children's hospital were identified. Drug dosages, vital signs, and sedation scores were compared. RESULTS: Drug dosages, vital signs, and sedation scores did not significantly differ between cases and controls. Mean ED visit duration was significantly longer for patients with ADHD than for controls as was sedation duration. CONCLUSIONS: Children with and without ADHD were equally sedated with the same total drug dosages. The differences in sedation duration and visit duration warrant further investigation.

Leukocyte counts in urine reflect the risk of concomitant sepsis in bacteriuric infants: a retrospective cohort study.

BACKGROUND: When urine infections are missed in febrile young infants with normal urinalysis, clinicians may worry about the risk--hitherto unverified--of concomitant invasion of blood and cerebrospinal fluid by uropathogens. In this study, we determine the extent of this risk. METHODS: In a retrospective cohort study of febrile 0-89 day old infants evaluated for sepsis in an urban academic pediatric emergency department (1993-1999), we estimated rates of bacteriuric sepsis (urinary tract infections complicated by sepsis) after stratifying infants by urine leukocyte counts higher, or lower than 10 cells/hpf. We compared the global accuracy of leukocytes in urine, leukocytes in peripheral blood, body temperature, and age for predicting bacteruric sepsis. The global accuracy of each test was estimated by calculating the area under its receiver operating characteristic curve (AUC). Chi-square and Fisher exact tests compared count data. Medians for data not normally distributed were compared by the Kruskal-Wallis test. RESULTS: Two thousand two hundred forty-nine young infants had a normal screening dipstick. None of these developed bacteremia or meningitis despite positive urine culture in 41 (1.8%). Of 1516 additional urine specimens sent for formal urinalysis, 1279 had 0-9 leukocytes/hpf. Urine pathogens were isolated less commonly (6% vs. 76%) and at lower concentrations in infants with few, compared to many urine leukocytes. Urine leukocytes (AUC: 0.94) were the most accurate predictors of bacteruric sepsis. Infants with urinary leukocytes < 10 cells/hpf were significantly less likely (0%; CI:0-0.3%) than those with higher leukocyte counts (5%; CI:2.6-8.7%) to have urinary tract infections complicated by bacteremia (N = 11) or bacterial meningitis (N = 1)--relative risk, 0 (CI:0-0.06) [RR, 0 (CI: 0-0.02), when including infants with negative dipstick]. Bands in peripheral blood had modest value for detecting bacteriuric sepsis (AUC: 0.78). Cases of sepsis without concomitant bacteriuria were comparatively rare (0.8%) and equally common in febrile young infants with low and high concentrations of urine leukocytes. CONCLUSION: In young infants evaluated for fever, leukocytes in urine reflect the likelihood of bacteriuric sepsis. Infants with urinary tract infections missed because of few leukocytes in urine are at relatively low risk of invasive bacterial sepsis by pathogens isolated from urine.

Modeling and detection of respiratory-related outbreak signatures.

BACKGROUND: Time series methods are commonly used to detect disease outbreak signatures (e.g., signals due to influenza outbreaks and anthrax attacks) from varying respiratory-related diagnostic or syndromic data sources. Typically this involves two components: (i) Using time series methods to model the baseline background distribution (the time series process that is assumed to contain no outbreak signatures), (ii) Detecting outbreak signatures using filter-based time series methods. METHODS: We consider time series models for chest radiograph data obtained from Midwest children's emergency departments. These models incorporate available covariate information such as patient visit counts and smoothed ambient temperature series, as well as time series dependencies on daily and weekly seasonal scales. Respiratory-related outbreak signature detection is based on filtering the one-step-ahead prediction errors obtained from the time series models for the respiratory-complaint background. RESULTS: Using simulation experiments based on a stochastic model for an anthrax attack, we illustrate the effect of the choice of filter and the statistical models upon radiograph-attributed outbreak signature detection. CONCLUSION: We demonstrate the importance of using seasonal autoregressive integrated average time series models (SARIMA) with covariates in the modeling of respiratory-related time series data. We find some homogeneity in the time series models for the respiratory-complaint backgrounds across the Midwest emergency departments studied. Our simulations show that the balance between specificity, sensitivity, and timeliness to detect an outbreak signature differs by the emergency department and the choice of filter. The linear and exponential filters provide a good balance.

Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.

CONTEXT: Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/microL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10,000 cells/microL, and a history of seizure before or at the time of presentation. OBJECTIVE: To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination. DESIGN, SETTING, AND PATIENTS: A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture. MAIN OUTCOME MEASURE: The sensitivity and negative predictive value of the Bacterial Meningitis Score. RESULTS: Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized. CONCLUSIONS: This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.

Accuracy of Complete Blood Cell Counts to Identify Febrile Infants 60 Days or Younger With Invasive Bacterial Infections.

Importance: Clinicians often risk stratify young febrile infants for invasive bacterial infections (IBIs), defined as bacteremia and/or bacterial meningitis, using complete blood cell count parameters. Objective: To estimate the accuracy of individual complete blood cell count parameters to identify febrile infants with IBIs. Design, Setting, and Participants: Planned secondary analysis of a prospective observational cohort study comprising 26 emergency departments in the Pediatric Emergency Care Applied Research Network from 2008 to 2013. We included febrile (≥38°C), previously healthy, full-term infants younger than 60 days for whom blood cultures were obtained. All infants had either cerebrospinal fluid cultures or 7-day follow-up. Main Outcomes and Measures: We tested the accuracy of the white blood cell count, absolute neutrophil count, and platelet count at commonly used thresholds for IBIs. We determined optimal thresholds using receiver operating characteristic curves. Results: Of 4313 enrolled infants, 1340 (31%; 95% CI, 30% to 32%) were aged 0 to 28 days, 2412 were boys (56%), and 2471 were white (57%). Ninety-seven (2.2%; 95% CI, 1.8% to 2.7%) had IBIs. Sensitivities were low for common complete blood cell count parameter thresholds: white blood cell count less than 5000/µL, 10% (95% CI, 4% to 16%) (to convert to 109 per liter, multiply by 0.001); white blood cell count ≥15 000/µL, 27% (95% CI, 18% to 36%); absolute neutrophil count ≥10 000/µL, 18% (95% CI, 10% to 25%) (to convert to × 109 per liter, multiply by 0.001); and platelets <100 × 103/µL, 7% (95% CI, 2% to 12%) (to convert to × 109 per liter, multiply by 1). Optimal thresholds for white blood cell count (11 600/µL), absolute neutrophil count (4100/µL), and platelet count (362 × 103/µL) were identified in models that had areas under the receiver operating characteristic curves of 0.57 (95% CI, 0.50-0.63), 0.70 (95% CI, 0.64-0.76), and 0.61 (95% CI, 0.55-0.67), respectively. Conclusions and Relevance: No complete blood cell count parameter at commonly used or optimal thresholds identified febrile infants 60 days or younger with IBIs with high accuracy. Better diagnostic tools are needed to risk stratify young febrile infants for IBIs.

Corrections for leukocytes and percent of neutrophils do not match observations in blood-contaminated cerebrospinal fluid and have no value over uncorrected cells for diagnosis.

BACKGROUND: The utility of published adjustments for leukocytes in blood-contaminated cerebrospinal fluid (CSF) is controversial. In this study, we assess how these adjustments and a novel rule for predicting percent of neutrophils match observations in CSF. We also determine the incremental value of corrected over uncorrected cells in CSF for discriminating between bacterial and viral meningitis. METHODS: We analyzed blood-contaminated CSF specimens collected from 1-month to 18-year-old children presenting to an urban academic pediatric emergency department between 1993 and 2003. Predictions of leukocytes (total) and neutrophils in CSF were derived from a standard rule and from an alternative rule based on a regression between neutrophils in peripheral blood and CSF. The match between observed and predicted cell counts was estimated by the coefficient of determination (R(2)). The value of corrected over uncorrected cells for diagnosing bacterial meningitis was evaluated by comparing the areas under respective receiver operator characteristic curves (AUC). RESULTS: At an R(2) of 0.11, predicted leukocytes matched observed leukocytes poorly for 682 CSF specimens that met study criteria. The percent of neutrophils in CSF predicted by the regression 7% + (0.5 x percent of neutrophils in peripheral blood) also fit observed neutrophils only modestly (R(2) 0.27). For diagnosing bacterial meningitis, there was no difference between AUC values for corrected and uncorrected leukocytes and percent of neutrophils. CONCLUSION: In blood-contaminated CSF, there is poor to modest correlation between observed and predicted counts of leukocytes and of neutrophils. Adjusted blood counts in CSF have no advantage over uncorrected counts for predicting bacterial meningitis.

A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis.

BACKGROUND: Studies in adults, but not in children, have shown a beneficial effect of one dose of steroid on the severity and duration of throat pain in acute pharyngitis. The effectiveness of longer steroid treatment has not been evaluated in children. METHODS: We performed a randomized, double-blind, 3-arm, placebo-controlled trial to estimate the effectiveness of one dose versus 3 daily doses of oral dexamethasone in the treatment of 4- to 21-year-old patients with group A beta-hemolytic streptococcal (GABHS) pharyngitis. Participants used the Wong-Baker FACES scale to rate their symptoms at enrollment and twice daily for 5 days. Patient-completed diaries and telephone interviews provided follow-up data. Primary end points-severity of throat pain, improvement in general condition and improvement in activity level-were evaluated by survival analysis. RESULTS: Ninety patients were enrolled. For each end point, we rejected the null hypothesis of a common survival experience for the 3 study arms. With the exception of 2 days for throat pain in participants receiving one dose of dexamethasone, the median time to improvement for all end points was 1 day for both arms of dexamethasone and 2 days for placebo. There was no difference between study arms in return to a clinical setting for symptoms related to GABHS pharyngitis or absenteeism from work/school. No patient experienced complications related to GABHS pharyngitis in the 30 days after enrollment. CONCLUSIONS: In this pilot study, children with GABHS pharyngitis who receive dexamethasone as add-on therapy have a more rapid improvement in general condition and level of activity and, for those receiving 3 daily doses of dexamethasone, in resolution of throat pain.

Local weather effects on emergency department visits: a time series and regression analysis.

OBJECTIVE: The ability to forecast atypical emergency department (ED) volumes may aid staff/resource allocation. We determine whether deviations from short-term predictions of weather can be used to forecast deviations from short-term predictions of ED volumes. METHODS: In this retrospective study, we attempted to predict the volume of patient visits to an academic pediatric ED based on short-interval local weather patterns (2000). Local temperature and precipitation data in 1- and 3-hour increments were obtained. Precipitation was coded to be present if it exceeded 0.04 in and subclassified as cold rain/snow if the ambient temperature was lower than 40 degrees F. ED visits were categorized as injuries, emergent, or nonemergent visits. For each category of visit, Box-Jenkins Auto-Regressive Integrated Moving Average time-series models were created of natural trends and cycles in temperature and patient volumes. From these models, differences (residuals) between predicted and observed values of these variables were estimated. The correlation between residuals for temperature and ED volumes was derived for various kinds of ED visit, after controlling for type/volume of precipitation. RESULTS: Residuals for ambient temperature controlled for precipitation correlated poorly with residuals for patient volumes, accounting for 1% to 6% of the variability in the volume of injuries, emergent, and nonemergent visits (R2 = 1%, 1%, and 6%, respectively). CONCLUSIONS: Deviations from short-term predictions of temperature correlate poorly with deviations from predictions of patient volume after adjusting for natural trends and cycles in these variables and controlling for precipitation. These weather variables are of little practical benefit for predicting fluctuations in the rates of ED utilization.

Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma.

OBJECTIVES: The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. METHODS: We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. RESULTS: Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). CONCLUSIONS: After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.

Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries After Blunt Torso Trauma.

OBJECTIVES: Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma. METHODS: This was a planned subanalysis of a prospective, multicenter observational study of children (<18 years old) with blunt torso trauma conducted in 20 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Clinicians documented their suspicion for the presence of intra-abdominal injuries needing acute intervention as <1, 1 to 5, 6 to 10, 11 to 50, or >50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention. RESULTS: Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled in the parent study. Intra-abdominal injuries undergoing acute intervention were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI = 32% to 34%) patients with clinician suspicion < 1%. Sensitivity of the prediction rule for intra-abdominal injuries undergoing acute intervention (197 of 203; 97.0%, 95% CI = 93.7% to 98.9%) was higher than that of clinician suspicion ≥1% (168 of 203; 82.8%, 95% CI = 76.9% to 87.7%; difference = 14.2%, 95% CI = 8.6% to 20.0%). Specificity of the prediction rule (4,979 of the 11,716; 42.5%, 95% CI = 41.6% to 43.4%), however, was lower than that of clinician suspicion (9,217 of the 11,716, 78.7%, 95% CI = 77.9% to 79.4%; difference = -36.2%, 95% CI = -37.3% to -35.0%). Thirty-five (0.4%, 95% CI = 0.3% to 0.5%) patients with clinician suspicion < 1% had intra-abdominal injuries that underwent acute intervention. CONCLUSIONS: The derived clinical prediction rule had a significantly higher sensitivity, but lower specificity, than clinician suspicion for identifying children with intra-abdominal injuries undergoing acute intervention. The higher specificity of clinician suspicion, however, did not translate into clinical practice, as clinicians frequently obtained abdominal CT scans in patients they considered very low risk. If validated, this prediction rule can assist in clinical decision-making around abdominal CT use in children with blunt torso trauma.

Differentiating acute bacterial meningitis from acute viral meningitis among children with cerebrospinal fluid pleocytosis: a multivariable regression model.

BACKGROUND: Although accurate models for predicting acute bacterial meningitis exist, most have narrow application because of the specific variables selected for them. In this study, we estimate the accuracy of a simple new model with potentially broader applicability. METHODS: On the basis of previous reports, we created a reduced multivariable logistic regression model for predicting bacterial meningitis that relies on age (years) (AGE), cerebrospinal fluid (CSF), total protein (TP) and total neutrophil count (TNC) alone. Data were from children ages 1 month-18 years diagnosed with acute enteroviral or bacterial meningitis whose initial CSF revealed >7 white blood cells/mm. A fractional polynomial model was specified and validated internally by the bootstrap procedure. The area under the receiver operating characteristic curve (discrimination: criterion standard, >0.7), the Hosmer-Lemeshow deciles-of-risk statistic (calibration: criterion standard, P > 0.05) and sensitivity-specificity pairs at prespecified probability thresholds of the model were computed. RESULTS: We identified 60 children with bacterial meningitis and 82 with enteroviral meningitis. At an area under the receiver operating characteristic curve of 0.97, our model represented by the equation: log odds of bacterial meningitis = 0.343 - 0.003 TNC - 34.802 TP + 21.991 TP - 0.345 AGE, was highly accurate when differentiating between bacterial and enteroviral meningitis. The model fit the data well (Hosmer-Lemeshow statistic; P =[r] 0.53). At probability cutoffs between 0.1 and 0.4, the model had sensitivity values between 98 and 92% and specificity values between 62 and 94%. CONCLUSIONS: Among children with CSF pleocytosis, a prediction model based exclusively on age, CSF total protein and CSF neutrophils differentiates accurately between acute bacterial and viral meningitis.

A low peripheral blood white blood cell count in infants younger than 90 days increases the odds of acute bacterial meningitis relative to bacteremia.

UNLABELLED: In relying on the peripheral blood white blood cell (WBC) count to identify infants at high risk for acute bacterial meningitis and bacteremia, to the best of the authors' knowledge, it has not been reported previously whether high and low values of the test have similar implications for predicting these separate infections. OBJECTIVE: To analyze the relationship between the peripheral WBC count and the odds of acute bacterial meningitis relative to bacteremia among sick infants aged 3 to 89 days. METHODS: Areas under the receiver operating characteristic curve (AUCs) and likelihood ratios at various intervals of the total peripheral blood WBC count were computed. RESULTS: A pathogen was isolated from blood or cerebrospinal fluid (CSF) from 72 infants aged 3 to 89 days. Fifty-two infants had growth of a pathogen from the blood only, and 20 had growth from the CSF. The most common bacteria isolated were Escherichia coli (32) and group B streptococci (32). The AUC for the peripheral WBC count when differentiating between acute bacterial meningitis and bacteremia was 0.75 (95% CI = 0.63 to 0.88). The odds of acute bacterial meningitis relative to bacteremia were sevenfold higher for a peripheral WBC cutoff below 5,000 cells/mm(3) and threefold lower for a peripheral WBC cutoff at or above 15,000 cells/mm(3). CONCLUSIONS: In young infants, the peripheral blood WBC count is useful for estimating the odds of acute bacterial meningitis relative to isolated bacteremia. A low peripheral blood WBC count should be considered a much more worrisome laboratory finding because it is associated with a relatively high risk for acute bacterial meningitis relative to the potential for bacteremia.

US estimates of hospitalized children with severe traumatic brain injury: implications for clinical trials.

OBJECTIVES: To estimate sample sizes available for clinical trials of severe traumatic brain injury (TBI) in children, we described the patient demographics and hospital characteristics associated with children hospitalized with severe TBI in the United States. METHODS: We analyzed the 2006 Kids' Inpatient Database. Severe TBI hospitalizations were defined as children discharged with TBI who required mechanical ventilation or intubation. Types of high-volume severe TBI hospitals were categorized based on the numbers of discharged patients with severe TBI in 2006. National estimates of demographics and hospital characteristics were calculated for pediatric severe TBI. Simulation analyses were performed to assess the potential number of severe TBI cases from randomly selected hospitals for inclusion in future clinical trials. RESULTS: The majority of children with severe TBI were discharged from either a children's unit in general hospitals (41%) or a nonchildren's hospital (34%). Less than 5% of all hospitals were high-volume TBI hospitals, which discharged >78% of severe TBI cases and were more likely to be a children's unit in a general hospital or a children's hospital. Simulation analyses indicate that there is a saturation point after which the benefit of adding additional recruitment sites decreases significantly. CONCLUSIONS: Children with severe TBI are infrequent at any one hospital in the United States, and few hospitals treat large numbers of children with severe TBI. To effectively plan trials of therapies for severe TBI, much attention has to be paid to selecting the right types of centers to maximize enrollment efficiency.