Streptococcal Pharyngitis: Compliance With National Testing Guidelines in a Pediatric Emergency Department.

OBJECTIVES: The Infectious Diseases Society of America (IDSA) guidelines regarding group A streptococcal (GAS) pharyngitis advise against routine testing for patients younger than 3 years, patients without pharyngitis, and patients with symptoms suggesting a viral infection. Group A streptococcal testing may be overused in some clinical settings; thus, we conducted this study to evaluate compliance with the IDSA guidelines in a pediatric emergency department (ED) setting. METHODS: This retrospective cohort study describes patients younger than 18 years presenting to 2 urban pediatric EDs in 2016 who underwent rapid antigen detection testing for GAS pharyngitis. Testing was classified as noncompliant with the IDSA guidelines if the chief complaint was not indicative of GAS infection and/or the patient age was younger than 3 years. Appropriate nonparametric tests compared groups by IDSA testing compliance status. RESULTS: A total of 13,585 patient encounters met inclusion criteria; 5255 (39%) were noncompliant with the IDSA testing guidelines, the majority due to a chief complaint inconsistent with GAS pharyngitis (67%) and secondarily due to the age of younger than 3 years (48%). Among the patients with noncompliant testing, 51% were prescribed an antibiotic, and return encounters were more likely to occur (13% vs 10%, P < 0.001). Return encounters more commonly resulted in respiratory diagnoses in those with noncompliant GAS testing (60% vs 45%, P < 0.001). CONCLUSIONS: Nearly 40% of all pediatric ED encounters with GAS testing were noncompliant with the IDSA guidelines and were associated with greater return encounter rates. Potential negative outcomes from noncompliant GAS testing include misdiagnosis, inappropriate use of antibiotics, allergic reactions, and loss of school days. Informed interventions to reduce unnecessary GAS testing are warranted.

Pediatric lateral patellar dislocation: is there a role for plain radiography in the emergency department?

BACKGROUND: Osteochondral fractures are reported to complicate patellar dislocations in 5-95% of patients. For this reason, post-reduction radiographs are recommended for the routine evaluation of patellar dislocations in all patients. To date, no data have been reported regarding the impact plain radiography has on the Emergency Department (ED) management of pediatric patients with lateral patellar dislocations. STUDY OBJECTIVES: To estimate the incidence of fractures detected by post-reduction plain radiographs in pediatric patients presenting with unreduced lateral patellar dislocations and to examine differences in ED management between patients with and without radiographically apparent fractures. METHODS: Retrospective review of records for pediatric patients who presented to an ED, received a diagnosis of lateral patellar dislocation, and underwent a reduction procedure. RESULTS: Of 80 patients who met criteria for inclusion in the study, 8 patients (10%; 95% CI 3-17) had a fracture identified. All patients, regardless of their radiographic findings, had their dislocation reduced uneventfully and were discharged with knee immobilization and a plan for outpatient follow-up. There were no statistically significant differences between those patients who had a detected fracture as compared to those without in terms of intravenous line placement (p = 1.000), parenteral analgesic administration (p = 0.965), procedural sedation administration (p = 0.922), ED length of stay (p = 0.706), or provision of a prescription for an oral analgesic upon discharge (p = 0.103). CONCLUSION: Osteochondral fractures were detected by plain radiography in 10% of patients presenting with lateral patellar dislocation and did not alter ED management. Pediatric patients with lateral patellar dislocations may be candidates for discharge from the ED after reduction without plain radiography. The modality by which to best determine the presence of a complicating osteochondral fracture (i.e., plain radiography, computed tomography, magnetic resonance imaging, or arthroscopy) may be left to the discretion of the orthopedic surgeon accepting the child in follow-up. Further study is needed to determine if forgoing plain radiographs in the ED decreases length of stay and reduces patient costs.