Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations.

BACKGROUND: Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding. METHODS: A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups. RESULTS: Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue. CONCLUSIONS: Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.

Immunization Status and the Management of Febrile Children in the Pediatric Emergency Department: What Are We Doing?

OBJECTIVES: Widespread Haemophilus influenzae and Streptococcus pneumoniae immunization has decreased occult bacteremia and bacterial meningitis rates. Practice has evolved in pediatric emergency departments (PEDs) to favor fewer diagnostic tests for and empiric treatment of invasive bacterial infection. We lack evidence-based guidance on evaluation and treatment of unimmunized (UnI) or underimmunized (UnderI) febrile children. This study aims to determine how parental report of immunization status in febrile PED patients impacts rates of diagnostic testing, interventions, and hospital admissions. METHODS: This is a retrospective cohort study with chart review of encounters of children aged 3 to 36 months presenting to an academic, tertiary care PED in 2019 using International Classification of Diseases-10 code for fever (R50.9). Inclusion criteria were documented fever of 38°C and higher and well appearance. Encounters were excluded if there was a history of chronic illness or documentation of ill appearance or hemodynamic instability. Encounters were grouped by provider-documented immunization status. Fischer exact test and logistic regression compared rates of diagnostic testing (serum, urine or cerebrospinal fluid laboratory studies, and chest radiographs), interventions (intravenous fluid bolus, intravenous antibiotic or steroid administration, respiratory support, or breathing treatment), and hospital admissions between UnderI, UnI, and fully immunized (FI) groups. RESULTS: Of the 1813 encounters reviewed, 1093 (60%) included provider-documented immunization status and 788 (43%) met final inclusion criteria: 23 (2.1%) UnI, 44 (5.8%) UnderI, and 721 (92.1%) FI. The UnderI and UnI children experienced significantly higher rates of laboratory evaluation including complete blood count and blood culture, medical intervention, and antibiotic prescriptions while in the PED. No significant differences were observed for rates of chest radiographs, hospital admissions, or 72-hour PED return visits. CONCLUSIONS: Higher rates of laboratory testing and interventions were observed in UnderI and UnI versus FI febrile patients at a PED, likely demonstrating increased clinical suspicion for invasive bacterial infection in this group despite lacking national guidelines. Given continued vaccine hesitancy, further studies are needed for guiding management of febrile UnI and UnderI children presenting for emergency care.

The Impact of a New On-site Inpatient Psychiatric Unit in an Urban Pediatric Emergency Department.

OBJECTIVE: The objective of this study was to describe the impact of opening an inpatient child psychiatric unit in an urban tertiary care pediatric emergency department (PED). DESIGN/METHODS: A retrospective chart review was performed of pediatric patients seen in the PED at a large tertiary care center who presented for a primary psychiatric concern before opening of the inpatient psychiatric unit within the same hospital and 6 months following, allowing for a 6-month adjustment period. Patients were identified via query of the ED Cube model, an institutional database by a "behavioral health" flag that is documented in triage. Patients were excluded if subsequent chart review did not reveal a psychiatric concern and the patient did not undergo psychiatric evaluation during the PED visit. Charts were reviewed for baseline patient demographics, psychiatric interventions performed, and disposition. Additional flow metrics obtained were PED volume, percentage of psychiatric visits, and length of stay for both psychiatric-related visits compared with the general population. RESULTS: Visits to the PED for psychiatric evaluation increased 135% from 91 to 226 after initiation of an inpatient psychiatric unit. There was no difference in baseline patient demographics or rate of medical/mechanical restraints used. Percentage of behavioral health patients admitted to medical units decreased, although overall admission rate remained stable. Length of stay for behavioral health patients was longer after opening of the unit and remained significantly higher than the general population before opening of the inpatient unit, 363 minutes versus 177 minutes, respectively, and further lengthened after to 418 minutes versus 188 minutes. DISCUSSION: Patients presenting for psychiatric evaluation are a significant burden to PED flow both in volume and time for evaluation and boarding. This is to the detriment of patients seeking appropriate mental health services and to the rest of patients in the PED. Both inpatient and outpatient psychiatric services are overwhelmed creating a downstream affect; limited resources delays disposition and increases boarding in the PED. Further resources are needed to appropriately address psychiatric concerns, such as dedicated psychiatric holding units and brief PED interventions targeted to safety planning and interventions.

Modified Valsalva Maneuver for Pediatric Supraventricular Tachycardia.

Vagal maneuvers can be successful in terminating supraventricular tachycardia in pediatric patients. We present a case of a modified Valsalva maneuver identified in the REVERT trial successfully terminating supraventricular tachycardia in a 9-year-old boy.

A Quality Improvement Initiative to Decrease Time to Analgesia in Patients With Sickle Cell and Vaso-Occlusive Crisis: A Population With Disparities in Treatment.

INTRODUCTION: Vaso-occlusive crises (VOCs) are the leading cause of emergency department (ED) visits and hospitalizations in patients with sickle cell disease (SCD). Timely administration of analgesia, within 60 minutes of patient registration, is the standard of care for SCD patients with VOCs. Patients with VOCs have longer times to initial analgesia compared to similar painful conditions. The primary aim of the project is to have 75% of patients with VOCs receive initial analgesia within 60 minutes of being registered, the current recommended time frame from the National Heart, Lung, and Blood Institute (NHLBI). METHODS: A multi-disciplinary team used quality improvement (QI) methodology to develop a plan involving multiple Plan-Do-Study-Act (PDSA) cycles. A rapid evaluation process was employed which included notification of a patient with a VOC being placed in a room, rapid evaluation by all team members and use of an electronic order set. RESULTS: The aim was met 72% of the time during our intervention period, compared to 17% pre-intervention. Average time to initial analgesia was decreased from 61 minutes to 42 minutes (p-value < 0.001), while time to disposition was also decreased when time goals were achieved. CONCLUSION: Using a rapid evaluation process we were able to decrease time to initial analgesia in a patient population that has previously experienced delays in care and decrease overall time to disposition.

Identification of Bias in Ordering Further Imaging in Ethnic Groups With Indeterminate Ultrasound for Appendicitis.

Background Recent studies have shown a higher incidence of complications from acute appendicitis in Hispanic populations. Hispanic ethnicity alone has been shown to be a risk factor. In contrast, one study found little evidence of racial disparities in complication rates. The objective of this study was to identify physician bias regarding whether ethnicity drives further testing after initial radiologic imaging has been obtained in the evaluation of appendicitis in our pediatric emergency department (PED). The use of computed tomography (CT) scan in the diagnosis of appendicitis was compared between Hispanic versus non-Hispanic populations when ultrasound (US) was indeterminate. Methodology This is a retrospective cohort study of Hispanic and non-Hispanic patients aged 2-18 who presented to the PED with right lower quadrant abdominal pain over a one-year period (January 1, 2017 to December 29, 2017). Both groups were subdivided into positive, negative, or indeterminate US findings for appendicitis. Each subgroup was analyzed based on those who had CT imaging done. Results A total of 471 ultrasounds were performed, 162 Hispanic and 309 non-Hispanic patients. Indeterminate US scans were documented in 90/162 (56%) Hispanic versus 155/309 (50%) non-Hispanic patients. Of those with indeterminate US scans, 30% Hispanic versus 32% non-Hispanic patients received CT scans. Negative US scans were documented in 54/162 (33%) Hispanic versus 102/309 (33%) non-Hispanic patients. Of those with negative US scans, 7% Hispanic versus 5% non-Hispanic patients received CT scans. Chi-square analysis comparing both the proportion of CT scans received for indeterminate US scans (p=0.71) and negative US scans (p=0.52) showed no statistical significance. Conclusions There was no significant difference in the number of CT scans ordered for indeterminate US scans between Hispanic and non-Hispanic patients. One can infer that there is no inherent bias toward ordering advanced imaging in Hispanic children based on ethnicity alone.

Prevalence of male adolescent dating violence in the pediatric emergency department.

BACKGROUND: Adolescent dating violence (DV) is a growing problem in the United States. Identifying the most optimal venue for screening and determining risk factors for DV is important for treatment and prevention programs. The purposes of this study were to determine the prevalence of DV among male teens presenting to a Midwestern pediatric emergency department (PED) and to determine risk factors, types of injuries sustained, and interest in social service assistance. METHODS: Males (13-21 year old) presenting to a PED were prospectively enrolled. Exclusions included never dated, non-English speaking, critically ill, active psychosis, or caregiver nonwillingness to leave during study participation. The computerized survey consisted of demographics, a validated DV screen, risk factor assessment, and injuries from DV. At completion, all participants received DV educational materials and were offered social service referral. RESULTS: Of the 262 eligible approached participants, 198 (75.6%) were enrolled. The mean ± SE age of participants was 16.2 ± 0.13 years, with 106 white (53%) and 77 African American (39%). A total of 99 (50%) had DV education in the past; 39 (19.7%) screened positive for DV. Risk factors for those who screened positive include the following: 9 (29%) endorse riding in a car with a dating partner who was driving intoxicated, 27 (87%) admitted to drinking alcohol, and 11 (35%) have been treated for an sexually transmitted infection. Almost all injuries sustained as a result of DV (83%) were minor (scratches or scrapes). Only 2 (5%) accepted social service intervention and none for their DV exposure. CONCLUSION: One in five teen males who present to a PED in our population screened positive for DV. Using specific risk factors could aid practitioners in identifying those children more likely to screen positive. Injuries sustained were mild, and most did not accept social services consultation.

Bacterial expression, purification, and characterization of rat kidney-type mitochondrial glutaminase.

The human gene that encodes the kidney-type glutaminase (KGA) spans 84-kb, contains 19 exons, and encodes two alternatively spliced mRNAs. Various segments of the rat KGA cDNA were PCR amplified and cloned into a bacterial expression vector to determine whether the N- and C- terminal ends of the glutaminase protein were essential for activity. A recombinant glutaminase, lacking the coding sequence contained in exon 1, was found to be fully active. In contrast, proteins that lacked sequences from exons 1 and 2 and exons 1-3 were inactive. An additional construct that corresponded to the sequence encoded by exons 2-14 also retained full activity. Both of the fully active, truncated proteins were purified to apparent homogeneity using an incorporated N-terminal His(6)-tag and Ni(2+)-affinity chromatography. The K(M) values for glutamine of the native and recombinant forms of glutaminase were nearly identical. However, the two truncated forms of the glutaminase exhibit the characteristic phosphate activation profile only when dialyzed into a buffer lacking phosphate. Dialysis versus 10mM Tris-phosphate was sufficient to form an active tetramer. Thus, the deleted N-terminal sequence may contribute to the phosphate-dependent oligomerization and activation of the native glutaminase.