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OBJECTIVE: In 2016, the American Academy of Pediatrics published the Brief Resolved Unexplained Event (BRUE) Clinical Practice Guideline (CPG). A multicenter quality improvement (QI) collaborative aimed to improve CPG adherence. METHODS: A QI collaborative of 15 hospitals aimed to improve testing adherence, the hospitalization of lower-risk infants, the correct use of diagnostic criteria, and risk classification. Interventions included CPG education, documentation practices, clinical pathways, and electronic medical record integration. By using medical record review, care of emergency department (ED) and inpatient patients meeting BRUE criteria was displayed via control or run charts for 3 time periods: pre-CPG publication (October 2015 to June 2016), post-CPG publication (July 2016 to September 2018), and collaborative (April 2019 to June 2020). Collaborative learning was used to identify and mitigate barriers to iterative improvement. RESULTS: A total of 1756 infants met BRUE criteria. After CPG publication, testing adherence improved from 56% to 64% and hospitalization decreased from 49% to 27% for lower-risk infants, but additional improvements were not demonstrated during the collaborative period. During the collaborative period, correct risk classification for hospitalized infants improved from 26% to 49% (ED) and 15% to 33% (inpatient) and the documentation of BRUE risk factors for hospitalized infants improved from 84% to 91% (ED). CONCLUSIONS: A national BRUE QI collaborative enhanced BRUE-related hospital outcomes and processes. Sites did not improve testing and hospitalization beyond the gains made after CPG publication, but they did shift the BRUE definition and risk classification. The incorporation of caregiver perspectives and the use of shared decision-making tools may further improve care.
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Evento Inexplicable, Breve y Resuelto , Mejoramiento de la Calidad , Lactante , Humanos , Niño , Hospitalización , Factores de Riesgo , HospitalesRESUMEN
BACKGROUND: A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse. OBJECTIVES: To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age. PARTICIPANTS AND SETTING: Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits. METHODS: This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)). RESULTS: Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation. CONCLUSION: There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.
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Síntomas sin Explicación Médica , Abuso Físico , Lactante , Humanos , Estudios Retrospectivos , Técnicas y Procedimientos DiagnósticosRESUMEN
OBJECTIVES: Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence. METHODS: We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model. RESULTS: Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03). CONCLUSIONS: Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).
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Evento Inexplicable, Breve y Resuelto , Niño , Hospitalización , Hospitales Pediátricos , Humanos , Lactante , Estudios Retrospectivos , Factores de RiesgoRESUMEN
The overall prognosis for most pediatric cancers is good. Mortality for all childhood cancers combined is approximately half what it was in 1975, and the survival rates of many malignancies continue to improve. However, the incidence of childhood cancer is significant and the related emergencies that develop acutely carry significant morbidity and mortality. Emergency providers who can identify and manage oncologic emergencies can contribute significantly to an improved prognosis. Effective care of pediatric malignancies requires an age-appropriate approach to patients and compassionate understanding of family dynamics.
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Servicios Médicos de Urgencia/métodos , Neoplasias/diagnóstico , Neoplasias/mortalidad , Neoplasias/terapia , Adolescente , Niño , Preescolar , Supervivencia sin Enfermedad , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Tasa de Supervivencia , Adulto JovenRESUMEN
Pediatric sepsis is distinct from adult sepsis in its definitions, clinical presentations, and management. Recognition of pediatric sepsis is complicated by the various pediatric-specific comorbidities that contribute to its mortality and the age- and development-specific vital sign and clinical parameters that obscure its recognition. This article outlines the clinical presentation and management of sepsis in neonates, infants, and children, and highlights some key populations who require specialized care.
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Sepsis/diagnóstico , Adolescente , Adulto , Factores de Edad , Niño , Preescolar , Diagnóstico Diferencial , Servicio de Urgencia en Hospital , Humanos , Lactante , Recién Nacido , Enfermedades del Recién Nacido/diagnóstico , Enfermedades del Recién Nacido/terapia , Sepsis/terapiaRESUMEN
INTRODUCTION: Linking educational objectives and clinical learning during clerkships can be difficult. Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences, some of which may not be relevant to recommended educational objectives. Students can be directed to standardize their clinical experiences, and this improves performance on examinations. We hypothesized that applying a "flipped classroom" model to the clinical clerkship would improve performance on multiple-choice testing when compared to standard learning. METHODS: Students at two institutions were randomized to complete two of four selected EM clerkship topics in a "flipped fashion," and two others in a standard fashion. For flipped topics, students were directed to complete chief complaint-based asynchronous modules prior to a shift, during which they were directed to focus on the chief complaint. For the other two topics, modules were to be performed at the students' discretion, and shifts would not have a theme. At the end of the four-week clerkship, a 40-question multiple-choice examination was administered with 10 questions per topic. We compared performance on flipped topics with those performed in standard fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and willingness of preceptors to allow a chief-complaint focus. RESULTS: Sixty-nine students participated; examination scores for 56 were available for analysis. For the primary outcome, no difference was seen between the flipped method and standard (p=0.494.) A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly (3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol. CONCLUSION: Preparation for a clinical shift with pre-assigned, web-based learning modules followed by an attempt at chief-complaint-focused learning during a shift did not result in improvements in performance on a multiple-choice assessment of knowledge; however, one third of participants did not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned learning as well as clinical experiences, and consider alternate measures of knowledge.
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Prácticas Clínicas/métodos , Curriculum , Medicina de Emergencia/educación , Modelos Educacionales , Competencia Clínica , Instrucción por Computador , Humanos , Maryland , VirginiaRESUMEN
BACKGROUND: Abscess is a distinct skin and soft tissue infection (SSTI) requiring incision and drainage (I&D). Previous national surveys combined all SSTIs to estimate abscess and evaluate management. We hypothesized that antibiotic rates are declining in response to evidence that antibiotics are unnecessary for most SSTIs requiring I&D. METHODS: Emergency department (ED) patients included in the National Hospital Ambulatory Medical Care Survey from 2007-2010 with diagnosis codes for cutaneous abscess or SSTI were filtered using a procedure code for I&D available since 2007. The number of patients with SSTI, the percentage of patients receiving I&D, and the percentage of patients receiving antibiotics were determined. Antibiotics were characterized based on efficacy to methicillin-resistant Staphylococcus aureus (MRSA). RESULTS: ED visits for SSTI increased from 3.55 million (95% confidence interval [CI], 3.24 million-3.86 million) in 2007 to 4.21 million (95% CI, 3.89 million-4.55 million) in 2010. Incidences of I&D rose from 736,000 (95% CI, 602,000-869,000) to 1.48 million (95% CI, 1.30 million-1.65 million) and comprised 32.2% of SSTI visits over the 4 years. In 2007, 85.1% (95% CI, 82.6%-87.7%) of patients received antibiotics after I&D with no change over 4 years. In 2010, 15.5% (95% CI, 12.1%-18.7%) received ≥2 antibiotics. Commonly prescribed antibiotics were trimethoprim-sulfamethoxazole (mean, 50.4%) followed by cephalexin (mean, 17.2%) and clindamycin (mean, 16.3%). CONCLUSION: ED visits for SSTIs continue to rise. Despite mounting evidence, antibiotic use in SSTIs requiring I&D is high, and many patients receive multiple antibiotics, including drugs with no efficacy on MRSA.
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Absceso/tratamiento farmacológico , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/tendencias , Enfermedades Cutáneas Infecciosas/tratamiento farmacológico , Absceso/diagnóstico , Antibacterianos/uso terapéutico , Clindamicina/uso terapéutico , Codificación Clínica , Bases de Datos Factuales , Manejo de la Enfermedad , Encuestas de Atención de la Salud , Humanos , Staphylococcus aureus Resistente a Meticilina , Enfermedades Cutáneas Infecciosas/diagnóstico , Infecciones de los Tejidos Blandos/diagnóstico , Infecciones de los Tejidos Blandos/tratamiento farmacológicoRESUMEN
The overall prognosis for most pediatric cancers is good. Mortality for all childhood cancers combined is approximately half what it was in 1975, and the survival rates of many malignancies continue to improve. However, the incidence of childhood cancer is significant and the related emergencies that develop acutely carry significant morbidity and mortality. Emergency providers who can identify and manage oncologic emergencies can contribute significantly to an improved prognosis. Effective care of pediatric malignancies requires an age-appropriate approach to patients and compassionate understanding of family dynamics.
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Neoplasias/complicaciones , Neoplasias/diagnóstico , Síndromes Paraneoplásicos/diagnóstico , Pediatría/métodos , Niño , Urgencias Médicas , Humanos , Neoplasias/terapia , Síndromes Paraneoplásicos/terapiaRESUMEN
Motherhood offers factors that may contribute to or confound attempts to quit smoking, including social cues around pregnancy, post partum depression, financial and other pressures of child rearing, being a role model and concern that secondhand smoke might affect their child's health. We sought to characterize a population of tobacco-using mothers in order to identify barriers to quitting that both mirror the general population and are unique to motherhood. A cross-sectional survey collected information in two urban emergency departments from women who smoked and were mothers of small children. The survey asked about tobacco use, including levels of addiction, attempts to quit, readiness and self efficacy for quitting, and other psychosocial risks. We hypothesized that mothers reporting psychosocial stressors and depression would be less motivated to quit and less likely to have attempted quitting. One hundred ninety-two smoking mothers enrolled, representing 433 children exposed to secondhand smoke. Nicotine addiction was moderate. Women reporting at least one form of stress (relationship, financial, work, emotional, family-related) had similar levels of addiction (Fagerstrom score 2.8 vs. 2.9, p = 0.63) and motivation to quit (Ladder of Contemplation 6.4 vs. 6.1, p = 0.26), but reported feeling less confident in their ability to quit than non-stressed counterparts (6.6 vs. 7.6, p = 0.04). Over half (51.3%) of smoking mothers reported symptoms of depression for more than 2 weeks in a row in the last year. Depressed mothers had similar levels of addiction (Fagerstrom score 2.9 vs. 2.8, p = 0.63), and readiness to quit (6.6 vs. 6.5, p = 0.89), and had attempted to quit at similar rates (78% vs. 82%, p = 0.58). However, depressed mothers were less confident in their ability to quit (6.4 vs. 7.4, p = 0.02) and were more than twice as likely to report they are "not at all confident" (22% vs. 9%, p = 0.03). Providers who encourage mothers to quit smoking must identify and be prepared to address psychosocial stressors and co-morbid depression.
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Depresión/psicología , Bienestar Materno , Madres/psicología , Autoeficacia , Cese del Hábito de Fumar/psicología , Estrés Psicológico , Adaptación Psicológica , Adulto , Distribución de Chi-Cuadrado , Estudios Transversales , Femenino , Encuestas Epidemiológicas , Humanos , Bienestar del Lactante , Recién Nacido , Embarazo , Psicometría , Asunción de Riesgos , Fumar/psicología , Estadística como Asunto , Contaminación por Humo de Tabaco/efectos adversos , Tabaquismo/complicaciones , Tabaquismo/prevención & controlRESUMEN
OBJECTIVE: We hypothesized adult parenting smokers in the emergency department (ED) have a higher interest in quitting and may be more amenable to tobacco cessation counseling than smokers without children. STUDY DESIGN: Cross-sectional survey study of adult smokers in 8 US academic EDs. RESULTS: One thousand one hundred sixty-eight smokers enrolled, 441 (37.8%) with household children (total of 973 exposed children). Compared to smokers without household children, smokers with children were younger (mean age, 37.4 vs 42.8 years), more female (60.3% vs 40.3%), and nonwhite (57.5% vs 44.5%) (all P < .006). Groups did not differ in nicotine addiction (median Fagerstrom score, 4 vs 4; P = .31). Parenting smokers were more interested in quitting (mean Ladder of Contemplation score, 4.8 vs 5.1 [P = .02]), felt it more important to quit (median score, 9 vs 8 [P = .01]), and more confident to quit (7 vs 6 [P = .004]) than nonparenting smokers. Smoking inside the home was banned by 45% of smokers with children vs 30% without household children (P < .001). CONCLUSIONS: Adult ED parenting smokers are interested in quitting and taking steps to limit their children's secondhand smoke exposure. Asking adult ED smokers about household children may enhance motivation to quit.