Use and Cost Analysis of Comprehensive Respiratory Panel Testing in a Pediatric Emergency Department.

OBJECTIVES: Fever and respiratory infections are among the leading causes of pediatric emergency department visits and hospitalizations. Although typically self-resolving, clinicians may perform diagnostic tests to determine microbial etiologies of these illnesses. Although comprehensive respiratory viral panels can quickly identify causative organisms, cost to the hospital and patient may be significant. The objective of this study was to analyze the financial impact of comprehensive respiratory viral panel use in relation to associated clinical outcomes. METHODS: This study was a single-center, retrospective chart review of pediatric emergency department patients who were evaluated between October 1, 2016, and April 30, 2018, with International Classification of Diseases, Tenth Revision (ICD-10) code diagnoses of acute upper respiratory infection, fever unspecified, and/or bronchiolitis. Our primary outcome was the effect of comprehensive respiratory viral panel testing and results on the total health care charge to patients. Secondary outcomes were the effect of comprehensive respiratory viral panel testing and results on emergency department length of stay and antimicrobial use. RESULTS: A total of 5766 visits were included for primary analysis, with 229 (4%) undergoing comprehensive respiratory viral panel testing. Of these, 163 had a positive result (71%) for at least 1 organism. The total cost was significantly higher in the group that underwent comprehensive respiratory viral panel testing ($643.39 [$534.18-$741.15] vs $295.15 [$249.72-$353.92]; P < 0.001). There was no decrease in emergency department length of stay or significant change in antimicrobial use associated with comprehensive respiratory viral panel use. CONCLUSIONS: This study demonstrates that the utilization of comprehensive respiratory viral panels in pediatric emergency department patients with bronchiolitis, unspecified fever, and/or acute upper respiratory infection adds significant cost to patient care without a decrease in their length of stay or antimicrobial use. Further studies are needed to determine the appropriate targeted use of comprehensive respiratory viral panels.

Saving Time Under Pressure: Effectiveness of Standardizing Pediatric Resuscitation Carts.

BACKGROUND: Resuscitation situations are high risk and high stress, and delays in care can have significant influences on outcomes. Standardization of care protocols and equipment is postulated to decrease some of the stress and risk. The objective of this study was to document increased efficiency in finding resuscitation equipment in a standardized resuscitation cart. METHODS: A new standardized resuscitation cart design was created, and a multimedia education program addressing the new design was launched. A goal was set to find required equipment in <15 seconds. Five cohorts of 10 nurses were timed at finding randomly chosen items 1, 12, 49, 152, and 351 days after new cart launch. t tests were used to compare estimated acquisition times of requested items using the new cart system to the old cart system (baseline), and a separate regression analysis was used to model skill degradation. RESULTS: All pairwise comparisons showed significant decreases in mean acquisition time compared with baseline. One day after launch, the mean time to find items was reduced by 46%. Mean time to find requested items was below the goal of 15 seconds 12, 49, and 152 days after launch. This effect was lost by 351 days from launch. Regression analysis predicted the time to find items would exceed 15 seconds 287 days after launch. CONCLUSIONS: Standardizing the resuscitation cart design greatly reduced time to find items and was accomplished with reduced financial cost. Skill degradation did occur over time, and refresher training was required.

Balamuthia mandrillaris meningoencephalitis: survival of a pediatric patient.

Balamuthia mandrillaris infections are rare and almost always fatal. This ameba is a naturally occurring soil inhabitant that can cause disease in immunocompetent hosts, with early diagnosis typically proving difficult. We recently cared for a previously healthy 2-year-old boy who was diagnosed with meningoencephalitis secondary to B mandrillaris relatively early in his presentation, which enabled us to initiate targeted antimicrobial therapy. Since discharge from the hospital the child has shown slow, steady improvement with dramatic improvements seen on follow-up brain imaging. Our observations suggest that early diagnosis and treatment may significantly reduce mortality and morbidity rates from this highly virulent organism.

A guideline for the inpatient care of children with pyelonephritis.

BACKGROUND AND OBJECTIVES: Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care. METHODS: We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis. RESULTS: Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence. CONCLUSION: Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

Benign pneumatosis intestinalis in a child with cavopulmonary shunt and immune thrombocytopenic purpura.

We present the case of a nine-year-old boy with hypoplastic left heart syndrome and immune thrombocytopenic purpura who subsequently developed pneumatosis intestinails with a benign clinical examination. While benign pneumatosis intestinails is a well-known clinical entity, the alarming radiographic findings set off a cascade of clinical angst among many providers. This case reminds physicians to correlate the ancillary study results with the patient's clinical presentation and stability.