Emergency Provider Use of Plain Radiographs in the Evaluation of Pediatric Constipation.

BACKGROUND: More than half of children evaluated as outpatients for abdominal pain are diagnosed with constipation. X-ray use in this scenario is variable: less than 5% in clinic settings, greater than 70% in emergency departments. X-rays increase misdiagnosis rate, remain costly, and involve radiation exposure. OBJECTIVES: The aim of this study was to assess the use of plain radiographs by pediatric emergency medicine (PEM) providers in the diagnostic evaluation and management of pediatric constipation. METHODS: A cross-sectional survey of PEM providers was performed. Survey participants were subscribers to the American Academy of Pediatrics Section on Emergency Medicine Listserv. To assess diagnostic and therapeutic approaches, participants were presented a case of pediatric constipation meeting Rome III clinical criteria. Participants also categorized frequency of x-ray use, reasons for obtaining, estimated diagnostic utility, and elements of institutional standard approach. Descriptive statistical analyses were performed. RESULTS: Three hundred five of 1272 Listserv members (24%) responded. Ninety-nine percent elected to treat for constipation in a case meeting Rome III clinical criteria; one third (31%) would obtain plain radiographs for this same scenario. Plain radiographs were viewed as somewhat (59%) or minimally (29%) value-added in the evaluation of suspected pediatric constipation. Obtaining family buy-in (44%) was the most common reason for utilizing plain radiographs. Frequency of use varied across geographic regions and with participant and hospital characteristics. CONCLUSIONS: This survey suggests that many PEM providers obtain radiographs to convince families of the diagnosis of constipation. This is not a viable management plan given the risks of radiation as well as costs. There remains room for improvement as we attempt to reduce use of radiation in the evaluation of common pediatric illnesses.

Digital nerve blocks: A systematic review and meta-analysis.

Study objective: Digital nerve blocks (DNBs) provide local anesthesia for minor procedures of the digits. Several DNB techniques have been described, but it is unclear which technique provides adequate anesthesia with the least pain. DNB techniques can be grouped into a dorsal approach, which requires 2 injections, versus 3 different types of volar approaches, which require a single injection. We performed a meta-analysis to compare DNB techniques with respect to time to anesthesia (TTA), duration of anesthesia (DOA), and pain of injection. We also reviewed data on degree and distribution of anesthesia and discuss the techniques preferred by study participants and clinicians performing injections. Data Sources: We searched MEDLINE, EMBASE, and CENTRAL databases with terms "digital block," "digital nerve block," "local anesthetic," "local anesthesia," "lidocaine," and/or "bupivacaine." Study Selection: Randomized controlled trials (RCTs) were prioritized, though high-quality prospective cohort studies were also eligible. All included studies evaluated DNB techniques or anesthetics. There were 23 papers (21 RCTs, 2 prospective descriptive studies) included. Data Extraction: DNBs studied included dorsal ring block, traditional dorsal block, transthecal block, modified transthecal block, and volar subcutaneous digital blocks. Outcomes measured included TTA, DOA, pain of injection scores, and degree of anesthesia. Results: Overall, mean TTA was 4.5 minutes (95% confidence interval [CI] 3.5, 5.6), mean DOA was 187 minutes (95% CI 104.3, 269.7), and mean pain score was 2.1 out of 10 (95% CI 1.3, 2.8) without significant differences between studies or techniques. Conclusions: There were no significant differences in the outcomes of TTA, DOA, and pain of injection between different DNB techniques. Single-injection volar approaches may be preferred by participants and clinicians over dorsal approaches that require 2 injections, particularly with respect to pain. However, 2-injection dorsal approaches may have better coverage of the proximal dorsal surface based on degree and distribution of anesthesia.

Improving Care for Children with Bloody Diarrhea at Risk for Hemolytic Uremic Syndrome.

INTRODUCTION: Children with infectious bloody diarrhea are at an increased risk for developing hemolytic uremic syndrome (HUS). Early intervention may improve outcomes. This study evaluated the impact of a clinical pathway designed to identify those at risk for HUS, guide initial management, and provide decision support regarding patient disposition. METHODS: We performed a retrospective cohort study of children 4 months to 19 years of age who presented with the acute onset of bloody diarrhea or other HUS risk factors to the pediatric emergency department (ED) from September 2015 through July 2020. A rapid stool polymerase chain reaction (PCR) test became available in May 2017. The clinical pathway was implemented in January 2018. We used Fisher's exact tests and statistical process control charts to analyze patient- and system-level changes following pathway implementation. RESULTS: Three hundred five patients were included. Postimplementation, stool PCR use increased (78%-91%), hospitalization decreased (49%-30%), and mean total charges decreased ($7715-$6797). There were increases in length of stay (226-288 minutes) and charges ($2651-$3524) for patients discharged from the ED. All changes met rules for special cause variation. There was no change in early IV fluid administration, inpatient length of stay, ED return visits, hospital readmissions, or patients with Shiga toxin-producing Escherichia coli (STEC), acute kidney injury (AKI) or HUS. CONCLUSIONS: For children presenting to the ED with bloody diarrhea, introduction of a rapid stool PCR test and clinical pathway correlated with decreased hospitalizations and overall costs without adverse clinical outcomes.

Evaluation of a Modified Objective Structured Assessment of Technical Skills Tool for the Assessment of Pediatric Laceration Repair Performance.

Introduction The Accreditation Council for Graduate Medical Education (ACGME) has developed milestones including procedural skills under the core competency of patient care. Progress in training is expected to be monitored by residency programs. To our knowledge, there exists no tool to evaluate pediatric resident laceration repair performance. Methods The Objective Structured Assessment of Technical Skills was adapted to evaluate resident laceration repair performance using two components: a global rating scale (GRS) and a checklist. Pediatric and family medicine residents at a tertiary care children's hospital were filmed performing a simulated laceration repair. Videos were evaluated by at least five physicians trained in laceration repair. Concordance correlation coefficients (CCC) were calculated for the GRS and checklist scores. Scores for each resident were compared across levels of training and procedural experience. Spearman's rank order correlations were calculated to compare the checklist and GRS. Results Thirty residents were filmed performing laceration repair procedures. The CCC showed fair concordance across reviewers for the checklist (0.55, 95% CI: 0.38-0.69) and the GRS (0.53, 95% CI: 0.36-0.67). There was no significant difference in scores by self-reported experience or training level. There was correlation between the median GRS and checklist scores (Spearman ρ = 0.730, p < .001). Conclusions A novel tool to evaluate resident laceration repair performance in a pediatric emergency department showed fair agreement across reviewers. The study tool is not precise enough for summative evaluation; however, it can be used to distinguish between trainees who have and have not attained competence in laceration repair for formative feedback.