Evaluating the Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR) for Clinical Trials of Antibiotics in Pediatric Pneumonia.

Objective outcomes for pediatric community-acquired pneumonia (CAP) are lacking. The desirability of outcome ranking (DOOR) and response adjusted for duration of antibiotic risk (RADAR) outcome encompass clinical benefit and adverse effects, while also accounting for antibiotic exposure. We evaluated DOOR/RADAR through simulations and compared sample size considerations to non-inferiority designs in a hypothetical trial comparing antibiotics to no antibiotics (i.e., placebo) for children with mild CAP. We also evaluated a trial comparing different durations of antibiotics. Three scenarios were considered - one with no difference in DOOR between the two groups, one in which placebo is more efficacious, and another in which amoxicillin is more efficacious than placebo. Power to detect a difference between arms was greater using DOOR/RADAR compared to DOOR. Assuming a sample size of 200, DOOR had 2.5%, 50%, and 65% power to detect a statistical difference between arms for Scenarios 1-3, respectively, significantly less than DOOR/RADAR. Importantly, DOOR/RADAR incorrectly identified placebo as superior in Scenario 3 where amoxicillin was truly efficacious. Sample size requirements for non-inferiority designs were larger to achieve similar levels of power as DOOR and DOOR/RADAR. DOOR/RADAR has the potential to lead to an incorrect conclusion declaring placebo superior when amoxicillin is efficacious.

Pediatric Emergency Medicine Physicians' Perceptions of Colleagues' Clinical Performance Over Career Span.

OBJECTIVE: The US physician workforce is aging, prompting concerns regarding clinical performance of senior physicians. Pediatric emergency medicine (PEM) is a high-acuity, multitasking, diagnostically complex and procedurally demanding specialty. Aging's impact on clinical performance in PEM has not been examined. We aimed to assess PEM physician's' perceptions of peers' clinical performance over career span. METHODS: We surveyed 478 PEM physician members of the American Academy of Pediatrics' Section on Emergency Medicine survey study list-serve in 2020. The survey was designed by the investigators with iterative input from colleagues. Respondents rated, using a 5-point Likert scale, the average performance of 4 age categories of PEM physicians in 9 clinical competencies. Additional items included concerns about colleague's performance and preferences for age of physician managing a critically ill child family member. RESULTS: We received 232 surveys with responses to core initial items (adjusted response rate, 49%). Most respondents were 36 to 49 (34.9%) or 50 to 64 (47.0%) years old. Fifty-three percent reported ever having concern about a colleague's performance. For critical care-related competencies, fewer respondents rated the ≥65-year age group as very good or excellent compared with midcareer physicians (36-49 or 50-64 years old). The ratings for difficult communications with families were better for those 65 years or older than those 35 years or younger. Among 129 of 224 respondents (58%) indicating a preferred age category for a colleague managing a critically ill child relative, most (69%) preferred a 36 to 49-year-old colleague. CONCLUSIONS: Pediatric emergency medicine physicians' perceptions of peers' clinical performance demonstrated differences by peer age group. Physicians 65 years or older were perceived to perform less well than those 36 to 64 years old in procedural and multitasking skills. However, senior physicians were perceived as performing as well if not better than younger peers in communication skills. Further study of age-related PEM clinical performance with objective measures is warranted.

Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia.

OBJECTIVE: To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). METHODS: Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. RESULTS: Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). CONCLUSIONS: In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.

Viral Detection Is Associated With Severe Disease in Children With Suspected Community-Acquired Pneumonia.

OBJECTIVE: To evaluate the role of virus detection on disease severity among children presenting to the emergency department (ED) with suspected community-acquired pneumonia (CAP). METHODS: We performed a single-center prospective study of children presenting to a pediatric ED with signs and symptoms of a lower respiratory tract infection and who had a chest radiograph performed for suspected CAP. We included patients who had virus testing, with results classified as negative for virus, human rhinovirus, respiratory syncytial virus (RSV), influenza, and other viruses. We evaluated the association between virus detection and disease severity using a 4-tiered measure of disease severity based on clinical outcomes, ranging from mild ( discharged from the ED) to severe (receipt of positive-pressure ventilation, vasopressors, thoracostomy tube placement, or extracorporeal membrane oxygenation, intensive care unit admission, diagnosis of severe sepsis or septic shock, or death) in models adjusted for age, procalcitonin, C-reactive protein, radiologist interpretation of the chest radiograph, presence of wheeze, fever, and provision of antibiotics. RESULTS: Five hundred seventy-three patients were enrolled in the parent study, of whom viruses were detected in 344 (60%), including 159 (28%) human rhinovirus, 114 (20%) RSV, and 34 (6%) with influenza. In multivariable models, viral infections were associated with increasing disease severity, with the greatest effect noted with RSV (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.30-4.81) followed by rhinovirus (aOR, 2.18; 95% CI, 1.27-3.76). Viral detection was not associated with increased severity among patients with radiographic pneumonia (n = 223; OR, 1.82; 95% CI, 0.87-3.87) but was associated with severity among patients without radiographic pneumonia (n = 141; OR, 2.51; 95% CI, 1.40-4.59). CONCLUSIONS: The detection of a virus in the nasopharynx was associated with more severe disease compared with no virus; this finding persisted after adjustment for age, biomarkers, and radiographic findings. Viral testing may assist with risk stratification of patients with lower respiratory tract infections.

Development and Internal Validation of a Prediction Model to Risk Stratify Children With Suspected Community-Acquired Pneumonia.

BACKGROUND: Although community-acquired pneumonia (CAP) is one of the most common infections in children, no tools exist to risk stratify children with suspected CAP. We developed and validated a prediction model to risk stratify and inform hospitalization decisions in children with suspected CAP. METHODS: We performed a prospective cohort study of children aged 3 months to 18 years with suspected CAP in a pediatric emergency department. Primary outcome was disease severity, defined as mild (discharge home or hospitalization for <24 hours with no oxygen or intravenous [IV] fluids), moderate (hospitalization <24 hours with oxygen or IV fluids, or hospitalization >24 hours), or severe (intensive care unit stay for >24 hours, septic shock, vasoactive agents, positive-pressure ventilation, chest drainage, extracorporeal membrane oxygenation, or death). Ordinal logistic regression and bootstrapped backwards selection were used to derive and internally validate our model. RESULTS: Of 1128 children, 371 (32.9%) developed moderate disease and 48 (4.3%) severe disease. Severity models demonstrated excellent discrimination (optimism-corrected c-indices of 0.81) and outstanding calibration. Severity predictors in the final model included respiratory rate, systolic blood pressure, oxygenation, retractions, capillary refill, atelectasis or pneumonia on chest radiograph, and pleural effusion. CONCLUSIONS: We derived and internally validated a score that accurately predicts disease severity in children with suspected CAP. Once externally validated, this score has potential to facilitate management decisions by providing individualized risk estimates that can be used in conjunction with clinical judgment to improve the care of children with suspected CAP.

Proadrenomedullin Predicts Severe Disease in Children With Suspected Community-acquired Pneumonia.

BACKGROUND: Proadrenomedullin (proADM), a vasodilatory peptide with antimicrobial and anti-inflammatory properties, predicts severe outcomes in adults with community-acquired pneumonia (CAP) to a greater degree than C-reactive protein and procalcitonin. We evaluated the ability of proADM to predict disease severity across a range of clinical outcomes in children with suspected CAP. METHODS: We performed a prospective cohort study of children 3 months to 18 years with CAP in the emergency department. Disease severity was defined as mild (discharged home), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with supplemental oxygen, broadening of antibiotics, complicated pneumonia), and severe (eg, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined using proportional odds logistic regression within the cohort with suspected CAP and in a subset with radiographic CAP. RESULTS: Among 369 children, median proADM increased with disease severity (mild: median [IQR], 0.53 [0.43-0.73]; mild-moderate: 0.56 [0.45-0.71]; moderate-severe: 0.61 [0.47-0.77]; severe: 0.70 [0.55-1.04] nmol/L) (P = .002). ProADM was significantly associated with increased odds of developing severe outcomes (suspected CAP: OR, 1.68; 95% CI, 1.2-2.36; radiographic CAP: OR, 2.11; 95% CI, 1.36-3.38) adjusted for age, fever duration, antibiotic use, and pathogen. ProADM had an AUC of 0.64 (95% CI, .56-.72) in those with suspected CAP and an AUC of 0.77 (95% CI, .68-.87) in radiographic CAP. CONCLUSIONS: ProADM was associated with severe disease and discriminated moderately well children who developed severe disease from those who did not, particularly in radiographic CAP.

Recognition, Evaluation, and Management of Pediatric Hereditary Angioedema.

ABSTRACT: Hereditary angioedema (HAE) is a rare, often underrecognized genetic disorder caused by either a C1 esterase inhibitor deficiency (type 1) or mutation (type 2). This leads to overproduction of bradykinin resulting in vasodilation, vascular leakage, and transient nonpitting angioedema occurring most frequently in the face, neck, upper airway, abdomen, and/or extremities. Involvement of the tongue and laryngopharynx has been associated with asphyxiation and death. Hereditary angioedema is an autosomal-dominant condition; therefore, there is a 50% chance an offspring will inherit this disorder. Any patient presenting with isolated angioedema should be screened with a C4 measurement, as 25% of cases have no family history of HAE. All patients with HAE will have a functional deficiency of C1 esterase inhibitor. Contributors that delay the diagnosis of HAE include recognition delay by clinicians who confuse this condition with histaminergic angioedema, the disease's varied presentations, and limitations to timely testing. Pediatric emergency clinicians should be knowledgeable about how to distinguish between bradykinin- and histamine-mediated angioedema, as there are significant differences in the diagnostic testing, treatment, and clinical response between these 2 different conditions. Evidence indicates that early diagnosis and treatment of HAE reduces morbidity and mortality. Clinician recognition of the mechanistically different problems will ensure patients are appropriately referred to an expert for outpatient management.

Factors Associated With Antibiotic Prescribing and Outcomes for Pediatric Pneumonia in the Emergency Department.

OBJECTIVES: Chest radiographs (CXRs) are often performed in children with respiratory illness to inform the decision to prescribe antibiotics. Our objective was to determine the factors associated with clinicians' plans to treat with antibiotics prior to knowledge of CXR results and the associations between preradiograph plans with antibiotic prescription and return to medical care. METHODS: Previously healthy children aged 3 months to 18 years with a CXR for suspected pneumonia were enrolled in a prospective cohort study in the emergency department. Our primary outcomes were antibiotic prescription or administration in the emergency department and medical care sought within 7 to 15 days after discharge. Inverse probability treatment weighting was used to limit bias due to treatment selection. Inverse probability treatment weighting was included in a logistic regression model estimating the association between the intention to give antibiotics and outcomes. RESULTS: Providers planned to prescribe antibiotics prior to CXR in 68 children (34.9%). There was no difference in the presence of radiographic pneumonia between those with and without a plan for antibiotics. Children who had a plan for antibiotics were more likely to receive antibiotics than those without (odds ratio [OR], 6.39; 95% confidence interval [CI], 3.7-11.0). This association was stronger than the association between radiographic pneumonia and antibiotic receipt (OR, 3.49; 95% CI, 1.98-6.14). Children prescribed antibiotics were more likely to seek care after discharge than children who were not (OR, 1.85; 95% CI, 1.13-3.05). CONCLUSIONS: Intention to prescribe antibiotics based on clinical impression was the strongest predictor of antibiotic prescription in our study. Prescribing antibiotics may lead to subsequent medical care after controlling for radiographic pneumonia.

Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age.

BACKGROUND: Febrile infants commonly present to emergency departments for evaluation. OBJECTIVE: We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network. METHODS: We enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28 days of age) and older (29-60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance. RESULTS: Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%. CONCLUSIONS: The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29-60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

Validation of the Pediatric Infectious Diseases Society-Infectious Diseases Society of America Severity Criteria in Children With Community-Acquired Pneumonia.

Background: The Pediatric Infectious Diseases Society (PIDS)-Infectious Diseases Society of America (IDSA) guideline for community-acquired pneumonia (CAP) recommends intensive care unit (ICU) admission or continuous monitoring for children meeting severity criteria. Our objective was to validate these criteria. Methods: This was a retrospective cohort study of children aged 3 months-18 years diagnosed with CAP in a pediatric emergency department (ED) from September 2014 through August 2015. Children with chronic conditions and recent ED visits were excluded. The primary predictor was the PIDS-IDSA severity criteria. Outcomes included disposition, and interventions and diagnoses that necessitated hospitalization (ie, need for hospitalization [NFH]). Results: Of 518 children, 56.6% were discharged; 54.3% of discharged patients and 80.8% of those hospitalized for less than 24 hours were classified as severe. Of those admitted, 10.7% did not meet severity criteria; 69.5% met PIDS-IDSA severity criteria. Of those children, 73.1% did not demonstrate NFH. The areas under the receiver operator characteristic curves (AUC) for PIDS-IDSA major criteria were 0.63 and 0.51 for predicting disposition and NFH, respectively. For PIDS-IDSA minor criteria, the AUC was 0.81 and 0.56 for predicting disposition and NFH, respectively. The sensitivity, specificity, and likelihood ratios (LR)+ and LR- of the PIDS-IDSA criteria were 89%, 46%, 1.65, and 0.23 for disposition and 95%, 16%, 1.13, and 0.31 for NFH. Conclusions: More than half of children classified as severe by PIDS-IDSA criteria were not hospitalized. The PIDS-IDSA CAP severity criteria have only fair ability to predict the need for hospitalization. New predictive tools specifically for children are required to improve clinical decision making.

Incident Reporting to Improve Patient Safety: The Effects of Process Variance on Pediatric Patient Safety in the Emergency Department.

OBJECTIVE: Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care. SETTING/PARTICIPANTS: We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics. OUTCOME MEASURES: The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008. RESULTS: Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels. CONCLUSIONS: Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.

Radiologic Safety Events Within a Pediatric Emergency Medicine Network.

OBJECTIVES: The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network. METHODS: This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based. RESULTS: Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization. CONCLUSIONS: We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

Laboratory Errors in a Pediatric Emergency Department Network: An Analysis of Incident Reports.

OBJECTIVES: To describe the types and severity of reported laboratory errors in pediatric emergency departments. METHODS: Retrospective review of incident reports classified as laboratory errors from July 2007 to June 2008 within the Pediatric Emergency Care Applied Research Network. Laboratory testing errors recorded included: delayed results or lost specimen, unlabeled specimens, wrong patient, failure to label specimen correctly, and other. The severity of laboratory-related incidents was characterized using the National Coordinating Council for Medication Error Reporting and Prevention severity classification system. Contributing factors were classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems-based. RESULTS: A total of 335 (42.2%) laboratory reports were related to events in the preanalytic phase. Involved staff personnel were identified in 345 of the reports (43.5%). Nurses were identified in 179 (22.6%) and physicians in 38 (4.8%). The majority of laboratory errors [408 (51.5%)] were not associated with harm; 138 (17.4%) patients were harmed by the error; 136 (98.6%) patients were temporarily harmed and required treatment, and 1 (0.7%) patient was hospitalized or had their hospitalization prolonged with the event. Human factors 657 (82.8%) were the most common contributing factor. CONCLUSIONS: Laboratory errors are a common cause of safety events in the pediatric ED. Most events are preanalytic and involve problems with specimens that are improperly collected, mislabeled, or lost. Although most events were not associated with harm, there is potential for significant injury.

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger.

IMPORTANCE: Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach. OBJECTIVE: To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. EXPOSURE: RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. MAIN OUTCOMES AND MEASURES: Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. RESULTS: Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). CONCLUSIONS AND RELEVANCE: In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Utilization of nebulized 3% saline in infants hospitalized with bronchiolitis.

OBJECTIVES: To describe utilization of 3% hypertonic saline (HTS) in hospitalized infants and to evaluate the association between HTS use and length of stay (LOS) in a real-world setting. STUDY DESIGN: This multicenter retrospective cohort study included infants≤12 months hospitalized with bronchiolitis between October 2008 and September 2011 using the Pediatric Health Information System. HTS use was categorized as trial, rescue, daily, or sporadic. Differences in LOS were compared after matching daily HTS recipients and nonrecipients on propensity score. RESULTS: There were 63,337 hospitalizations for bronchiolitis. HTS was used in 24 of 42 hospitals and 2.9% of all hospitalizations. HTS use increased from 0.4% of visits in 2008 to 9.2% of visits in 2011. There was substantial variation in HTS use across hospitals (range 0.1%-32.6%). When used, HTS was given daily during 60.6% of hospitalizations, sporadically in 10.4%, as a trial in 11.3%, and as a rescue in 17.7%. The propensity score-matched analysis of daily HTS recipients (n=953) vs nonrecipients (n=953) showed no difference in mean LOS (HTS 2.3 days vs nonrecipients 2.5 days; ß-coefficient -0.04; 95% CI -0.15, 0.07; P=.5) or odds of staying longer than 1, 2, or 3 days. Daily HTS recipients had a 33% decreased odds of staying in the hospital>4 days compared with nonrecipients (OR 0.67; 95% CI 0.47, 0.97; P=.03). CONCLUSIONS: Variation in HTS use and the lack of association between HTS and mean LOS demonstrates the need for further research to standardize HTS use and better define the infants for whom HTS will be most beneficial.

Traumatic brain injuries and computed tomography use in pediatric sports participants.

BACKGROUND: Childhood sports-related head trauma is common, frequently leading to emergency department (ED) visits. We describe the spectrum of these injuries and trends in computed tomography (CT) use in the Pediatric Emergency Care Applied Research Network. METHODS: This was a secondary analysis of a large prospective cohort of children with head trauma in 25 Pediatric Emergency Care Applied Research Network EDs between 2004 and 2006. We described and compared children 5 to 18 years old by CT rate, traumatic brain injury (TBI) on CT, and clinically important TBI (ciTBI). We used multi-variable logistic regression to compare CT rates, adjusting for clinical severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by [a] death, [b] neurosurgery, [c] intubation>24 hours, or [d] hospitalization for ≥2 nights). FINDINGS: A total of 3289 (14%) of 23082 children had sports-related head trauma. Two percent had Glasgow Coma Scale scores less than 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had ciTBIs. Equestrians had increased adjusted odds (1.8; 95% confidence interval [CI], 1.0-3.0]) of CTs; the rate of TBI on CT was 4% (95% CI, 3%-5%). Compared with team sports, snow (adjusted odds ratio, 4.1; 95% CI 1.5-11.4) and nonmotorized wheeled (adjusted odds ratio, 12.8; 95% CI, 5.5-32.4) sports had increased adjusted odds of ciTBIs. CONCLUSIONS: Children with sports-related head trauma commonly undergo CT. Only 4% of those imaged had TBIs on CT. Clinically important TBIs occurred in 1%, with significant variation by sport. There is an opportunity for injury prevention efforts in high-risk sports and opportunities to reduce CT use in general by use of evidence-based prediction rules. What is known about this subject: Pediatric sports-related head injuries are a common and increasingly frequent ED presentation, as is the use of CT in their evaluation. Little is known about TBIs resulting from different types of sports activities in children. What this study adds to existing knowledge: This study broadens the understanding of the epidemiology of Pediatric TBIs resulting from different sports activities through a prospective assessment of frequency and severity of ciTBIs and ED CT use in a large cohort of head-injured children in a network of pediatric EDs.

Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines.

OBJECTIVE: To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes. STUDY DESIGN: We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission. RESULTS: In total, 64,994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission. CONCLUSIONS: Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.

Bias between capnometry and venous carbon dioxide during initial assessment of pediatric emergency department patients: A video-based study.

Objective: The bias of capnometry (ETCO2) and venous carbon dioxide (vpCO2) among pediatric emergency department (PED) patients triaged to critical care areas is unknown. We aimed to explore correlations and bias between ETCO2 and vpCO2¸and identify predictors of bias. Methods: This was an observational, video-based, retrospective study comparing ETCO2 and vpCO2. Pediatric patients with simultaneous ETCO2 and vpCO2 data were included. Our primary aim utilized linear regressions to determine correlations and Bland-Altman analysis to assess bias. Our secondary aim utilized multiple regression to identify clinical covariates contributing to bias. Covariates included age, respiratory rate, heart rate, mean arterial blood pressure, capnometry interface, PED diagnosis, and PED disposition. Results: A total of 200 PED patients with ETCO2 and vpCO2 data were included. The median (interquartile range [IQR]) ETCO2, vpCO2, and ΔCO2 in mmHg were 38 (32, 46), 49 (41, 61), and 11 (4, 20), respectively. ETCO2 (r = 0.76) and ΔCO2 (r = 0.71) were highly correlated with vpCO2. The mean bias between ETCO2 and vpCO2 was -14.1 mmHg (95% confidence interval [CI], -41.9 -13.7). The bias between ETCO2 and vpCO2 increased at higher values of each measure. ETCO2 sampling interface was the only independent predictor of vpCO2 in our multivariate analysis. Patients requiring bag-valve mask (BVM) ventilation had the highest median bias between ETCO2 and vpCO2 (29 mmHg, IQR 15, 37). Conclusion: ETCO2 and vpCO2 were highly correlated. However, bias increased at higher levels of both ETCO2 and vpCO2. Among PED patients, ETCO2's ability to approximate vpCO2 diminishes with worsening hypercarbic respiratory failure.

Time to Clinical Stability in Children With Community-Acquired Pneumonia.

BACKGROUND AND OBJECTIVES: Time to clinical stability (TCS) is a commonly used outcome in adults with community-acquired pneumonia (CAP), yet few studies have evaluated TCS in children. Our objective was to determine the association between TCS and disease severity in children with suspected CAP, as well as factors associated with reaching early stability. METHODS: This is a prospective cohort study of children (aged 3 months to 18 years) hospitalized with suspected CAP. TCS parameters included temperature, heart rate, respiratory rate, and hypoxemia with the use of supplemental oxygen. TCS was defined as time from admission to parameter normalization. The association of TCS with severity and clinical factors associated with earlier TCS were evaluated. RESULTS: Of 571 children, 187 (32.7%) had at least 1 abnormal parameter at discharge, and none had ≥3 abnormal discharge parameters. A greater proportion of infants (90 [93%]) had all 4 parameters stable at discharge compared with 12- to 18-year-old youths (21 [49%]). The median TCS for each parameter was <24 hours. Younger age, absence of vomiting, diffusely decreased breath sounds, and normal capillary refill were associated with earlier TCS. Children who did not reach stability were not more likely to revisit after discharge. CONCLUSIONS: A TCS outcome consisting of physiologic variables may be useful for objectively assessing disease recovery and clinical readiness for discharge among children hospitalized with CAP. TCS may decrease length of stay if implemented to guide discharge decisions. Clinicians can consider factors associated with earlier TCS for management decisions.