Treatment of Acute COVID-19 and COVID-19 Exposures in Children and Adolescents.

ABSTRACT: The landscape of acute COVID-19 therapeutics has dramatically evolved since the onset of the pandemic. The treatment of acute COVID-19 in children and adolescents requires knowledge of risk factors and clinical features to appropriately select antiviral and immunomodulatory therapies. This review article provides updated guidance for emergency physicians in the treatment of acute COVID-19 in children and adolescents.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

A Review of the Diagnosis and Management of Acute Flaccid Myelitis in the Emergency Department.

ABSTRACT: Since 2014, biennial rises in acute flaccid myelitis (AFM) have brought attention to this rare but debilitating condition. Children with AFM typically present with acute onset, flaccid weakness accompanied by longitudinally extensive gray matter injury demonstrated on magnetic resonance imaging. A clearer understanding of the epidemiology and suspected pathogenesis of AFM may result in increased recognition. The purpose of this review article is to guide emergency physicians in recognizing key clinical features, initiating diagnostic evaluation and providing appropriate interventions for children with suspected AFM.

Optimizing Critical Care Documentation in a Pediatric Emergency Department.

OBJECTIVE: Emergency department (ED) physicians frequently provide critical care (CC) but document inconsistently. Variability in documentation can result in underbilling and is inconsistent with financial stewardship. We used admissions to the intensive care unit (ICU) as a proxy for CC provision. At baseline, CC notes were correctly documented for 20% of eligible visits, with potential missed charges of $1.8 million per year.Our objective was to increase CC note placement for eligible patients from 20% to 60% over 2 years. Additionally, we measured CC notes and the number of ICU admissions per 1000 ED visits, and change in facility fees. METHODS: We performed this project at a midwestern quaternary children's hospital with 2 EDs (combined volume 120,000 visits/year). We surveyed the ED physicians to inform our interventions. We used maintenance of certification points and financial incentives for quality improvement work to obtain buy-in. We used serial interventions with plan-do-study-act cycles: (1) CC note simplification, (2) education, (3) follow-up surveys, (4) additional location for CC note, and (5) timely reminders. We reviewed sample charts and used χ2 test and control charts for analysis. RESULTS: Critical care note placement for ICU admissions increased from 20% to 60% in 8 months, and further to greater than 75%. The CC notes increased from 4 to 16 per 1000 ED visits. Intensive care unit admissions increased but remained appropriate. The billed facility fee for CC increased by 263%. CONCLUSIONS: This project resulted in significant and sustained improvements in CC note completion. We believe providing education, simplifying the documentation process, automating reminders, and incentivizing optimal documentation were vital to success.

Pediatric Esophageal Foreign Body: Possible Role for Digital Tomosynthesis.

OBJECTIVES: Foreign body (FB) ingestion is a common reason for emergency department visits, affecting more than 80,000 children in the United States annually. Whereas most ingested FBs are coins or other radiopaque objects, some are radiolucent FBs such as food. Digital tomosynthesis (DTS) is a radiographic technique that produces cross-sectional images with in-plane resolution similar to that of traditional radiographs. Our pilot study evaluated the sensitivity and specificity of DTS to detect FB in comparison to esophagram and clinical impression. METHODS: This was a retrospective review on patients aged 0 to 18 years with suspected esophageal FB who received an esophagram with DTS at our institution between January 2014 and June 2016. Digital tomosynthesis images were analyzed by 3 readers for identification of FB impaction and compared with esophagram and discharge diagnosis. This study was approved by our local institutional review board. RESULTS: A total of 17 patients underwent an esophagography with DTS for suspected esophageal FB, of which 9 (53%) were suspected of having an FB on esophagram. Compared with esophagram, DTS had a sensitivity of 44%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 62%. Compared with clinical impression, DTS had a sensitivity of 33%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 38%. CONCLUSIONS: This pilot study showed that chest DTS has a very high positive predictive value, compared with esophagram and clinical impression, in detecting radiolucent esophageal FBs in children. Chest DTS is a promising modality for ruling in the presence of a radiolucent esophageal FB.

A Quality Improvement Bundle Including Pay for Performance for the Standardization of Order Set Use in Moderate Asthma.

OBJECTIVE: In order to standardize use of our hospital's computerized asthma order set, which was developed based on an asthma clinical practice guideline, for moderately ill children presenting for care of asthma, we developed a quality improvement bundle, including a time-limited pay-for-performance component, for pediatric emergency department and pediatric urgent care faculty members. METHODS: Following baseline measurement, we used a run-in period for education, feedback, and improvement of the asthma order set. Then, faculty members earned 0.1% of salary during each of 10 successive months (evaluation period) in which the asthma order set was used in managing 90% or more of eligible patients. RESULTS: At baseline, the asthma order set was used in managing 60.5% of eligible patients. Order set use rose sharply during the run-in period. During the 10-month evaluation period, use of the asthma order set was significantly above baseline, with a mean of 91.6%; faculty earned pay-for-performance bonuses during 8 of 10 possible months. Following completion of the evaluation period, asthma order set use remained high. CONCLUSIONS: A quality improvement bundle, including a time-limited pay-for-performance component, was associated with a sustained increase in the use of a computerized asthma order set for managing moderately ill asthmatic children.

System Stresses in 2 Pediatric Emergency Departments and 2 Pediatric Urgent Care Centers During the 2014 Enterovirus-D68 Outbreak.

OBJECTIVE: To describe the association of an unprecedented large-scale Enterovirus-D68 outbreak in 2014 with changes in patient volume and acuity and system stress in 2 pediatric emergency departments and 2 pediatric urgent care centers of a single children's hospital. METHODS: We compared measures of patient volume, acuity, and system stress during the 2014 Enterovirus-D68 outbreak and the corresponding dates of the previous year. RESULTS: Both settings experienced large census increases during the Enterovirus-D68 outbreak; patient census increased significantly more in the pediatric urgent care setting (20.3%) than in the pediatric emergency departments (14.3%). Both settings had significant increases in patient acuity. The proportion of pediatric emergency department patients requiring hospital admission increased; the proportion of patients who left the pediatric urgent care setting without being seen also increased. Although there was no emergency department inpatient boarding during the 2013 comparison period, 4.4% of admitted patients required emergency department boarding during the 2014 outbreak. There was no significant change in the mean length of stay or the probability that patient admission was to the pediatric intensive care unit. CONCLUSIONS: Both the pediatric emergency departments and the pediatric urgent care centers experienced increased patient volumes and acuity and significant system stress in association with the 2014 Enterovirus-D68 outbreak. These data will inform those planning resource allocation for future large-scale viral outbreaks.

Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children.

STUDY OBJECTIVE: Epinephrine autoinjector use for anaphylaxis is increasing. There are reports of digit injections because of incorrect autoinjector use, but no previous reports of lacerations, to our knowledge. We report complications of epinephrine autoinjector use in children and discuss features of these devices, and their instructions for use, and how these may contribute to injuries. METHODS: We queried emergency medicine e-mail discussion lists and social media allergy groups to identify epinephrine autoinjector injuries involving children. RESULTS: Twenty-two cases of epinephrine autoinjector-related injuries are described. Twenty-one occurred during intentional use for the child's allergic reaction. Seventeen children experienced lacerations. In 4 cases, the needle stuck in the child's limb. In 1 case, the device lacerated a nurse's finger. The device associated with the injury was operated by health care providers (6 cases), the patient's parent (12 cases, including 2 nurses), educators (3 cases), and the patient (1 case). Of the 3 epinephrine autoinjectors currently available in North America, none include instructions to immobilize the child's leg. Only 1 has a needle that self-retracts; the others have needles that remain in the thigh during the 10 seconds that the user is instructed to hold the device against the leg. Instructions do not caution against reinjection if the needle is dislodged during these 10 seconds. CONCLUSION: Epinephrine autoinjectors are lifesaving devices in the management of anaphylaxis. However, some have caused lacerations and other injuries in children. Minimizing needle injection time, improving device design, and providing instructions to immobilize the leg before use may decrease the risk of these injuries.

Managing Pediatric Foreign Body Ingestions.

Foreign body ingestion is common among children. A variety of foreign bodies are ingested, most of which are harmless and pass spontaneously through the gastrointestinal (GI) tract. There are a few particularly harmful and life threatening objects that should be identified and removed immediately to avoid serious complications.

Reducing Post-Operative Hospital Length of Stay following Uncomplicated Appendectomy in Pediatric Patients: A Prospective Clinical Study.

An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children's hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3-16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.

Pediatric button battery and small magnet coingestion: two cases with different outcomes.

Ingestion of button batteries and ingestion of 2 or more small magnets have both been increasingly recognized as having high potential for injury. Coingestion of a button battery and a small magnet has only rarely been described but has the potential for both ischemic injury due to the tight magnetic adherence and the electric current injury from the button battery. We report 2 cases of button battery and small magnet coingestion; one required surgical repair of an important bowel injury, while the other had a benign course. We discuss the management and role of radiography in these cases and the potential factors to consider when predicting which patients will have serious injury and which will do well.

Academic Medical Center Visits by Adolescents Preceding Emergency Department Care for Suicidal Ideation or Suicide Attempt.

OBJECTIVE: Suicide is a leading cause of death in children and adolescents, and healthcare encounters relating to suicidal ideation (SI) and suicide attempt (SA) are steadily increasing. Studies examining healthcare utilization by adolescents prior to emergency department (ED) evaluation for SI/SA are lacking and may guide risk assessment. METHODS: We performed a descriptive study of patients 10 to 18 years evaluated for SI/SA in either of our 2 academic, pediatric EDs between January 1 and December 31, 2016. We quantified and characterized healthcare encounters in the year preceding ED evaluation for SI/SA by obtaining data from the electronic health record. RESULTS: We identified 599 patients with an index ED visit for evaluation of SI/SA. Mean age was 14.1 years (SD 2.0 years); 69.8% female, 61.9% White, 55.4% publicly insured. Fifty-six percent (336/599) had at least one previous encounter within our healthcare system in the year preceding their index ED visit (median 3, maximum 40, IQR: 2, 7), most commonly among Black/African American and Hispanic adolescents. Among all patients we identified 1409 previous encounters, and 55.4% (780/1409) occurred within 6 months of the index ED visit. Sixty-two percent (880/1409) of previous encounters were to an outpatient clinic, primarily nonmental health, subspecialty clinics. CONCLUSIONS: Adolescent healthcare encounters in the year preceding ED evaluation for SI/SA occur in a variety of settings. A broad approach to suicide risk screening may improve opportunities for early identification and intervention.

Universal Adolescent Suicide Screening in a Pediatric Urgent Care Center.

The aim of this article is to describe the implementation of a 2-question suicide screening tool in a pediatric urgent care center to identify patients at risk of suicide. Adolescents presenting during a 12-month period completed the screening tool. Positive response to either question triggered further social work evaluation, including a Columbia-Suicide Severity Rating Scale (C-SSRS). Of 4,786 patients screened, 95 (2%) responded positively. Of these, 75 (79%) also had a positive C-SSRS. Only 7 (7%) had chief complaints related to mental health. A group of 78 patients (82%) were discharged with outpatient mental health referral, and 10 (10%) were admitted to a psychiatric facility. Universal adolescent suicide screening in an acute care setting did not significantly affect flow in our pediatric urgent care and was able to detect patients at risk of suicide, especially those with chief complaints unrelated to mental health.

Emergency department drug orders: does drug storage location make a difference?

STUDY OBJECTIVE: We hypothesize that adding drugs previously only available from the hospital central pharmacy to an existing emergency department (ED) automated medication management system would alter the frequency with which they were ordered. METHODS: A pharmacy database of a large, urban, academic teaching hospital was used to retrospectively calculate changes in drug-ordering frequencies before and after study drugs were added to an ED automated medication management system. Study drugs had been recently added to our ED automated medication management system but were still available from the hospital central pharmacy and were not the subject of changes in hospital prescribing protocols. RESULTS: Four drug preparations met study criteria: moxifloxacin injection, moxifloxacin tablets, azithromycin injection, and pantoprazole injection. All had large increases (4.0-, 7.2-, 6.5-, and 25.0-fold, respectively) in ordering frequency after addition to the ED automated medication management system. Changes in order frequency strongly correlated with how often orders were filled from the ED automated medication management system rather than the hospital central pharmacy. CONCLUSION: Adding drug preparations to an existing ED automated medication management system increased the frequency with which they were ordered, especially when they were most reliably obtained from the system rather than the central hospital pharmacy. Adding drugs to an ED automated medication management system influences physician drug ordering.

Nonemergency Acute Care: When It's Not the Medical Home.

The American Academy of Pediatrics (AAP) affirms that the optimal location for children to receive care for acute, nonemergency health concerns is the medical home. The medical home is characterized by the AAP as a care model that "must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective." However, some children and families use acute care services outside the medical home because there is a perceived or real benefit related to accessibility, convenience, or cost of care. Examples of such acute care entities include urgent care facilities, retail-based clinics, and commercial telemedicine services. Children deserve high-quality, appropriate, and safe acute care services wherever they access the health care system, with timely and complete communication with the medical home, to ensure coordinated and continuous care. Treatment of children under established, new, and evolving practice arrangements in acute care entities should adhere to the core principles of continuity of care and communication, best practices within a defined scope of services, pediatric-trained staff, safe transitions of care, and continuous improvement. In support of the medical home, the AAP urges stakeholders, including payers, to avoid any incentives (eg, reduced copays) that encourage visits to external entities for acute issues as a preference over the medical home.

Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness.

OBJECTIVE: We designed a telemedicine model for diagnosis of common, acute illness to compare telemedicine and in-person evaluations on reproducibility of diagnosis and treatment. METHODS: Subjects were seen by usual physicians in ambulatory settings. Subjects were also evaluated separately by experienced general pediatricians (study physicians), either in person or via telemedicine, based on random assignment. The primary measure of reproducibility was study physician agreement with usual physician on primary diagnosis. Analysis compared reproducibility for telemedicine versus in-person evaluations. Relevance of agreement on primary diagnosis was measured by comparing agreement on prescribed medications. RESULTS: Agreement on diagnosis of study physicians with usual physicians for the 492 visits studied was 89%. The difference in the proportion of visits with disagreements between telemedicine study and in-person study evaluations (13.8% vs 8.3%, respectively) bordered on significance (P = .051). Disagreement proportions for prescriptions were similar (32.2% vs 27.4%), however. Telemedicine evaluation for children with upper respiratory tract (URI)-ear symptoms involved unique technical requirements and clinical judgments. For this largest subgroup of 202 visits, disagreement on diagnosis for telemedicine occurred more often than for in-person evaluation (17.6 vs 6.3%, P < .02). For the remaining 290 visits, telemedicine and in-person study physicians disagreed on diagnosis about equally (11.5 vs 9.9%). CONCLUSIONS: Excluding the URI-ear group, reproducibility of telemedicine diagnosis did not differ from that of in-person diagnosis. For the URI-ear group, reproducibility of diagnosis by telemedicine and in-person evaluation varied significantly.

Does public education reduce ice storm-related carbon monoxide exposure?

Public education to prevent carbon monoxide exposure during ice storms has been recommended; its effects remain unexamined. We compared patients seen for carbon monoxide inhalation at the area's only academic Emergency Department during 1991 and 2003 ice storms; educational efforts were more intense in 2003. There were fewer patients during the second storm (45 vs. 55); all recovered fully. The percentage of Caucasian patients rose (from 57% to 89%) whereas that of African-American patients fell (from 39% to 7%). Indoor grill use, associated with 11% of 1991 cases, was eliminated in 2003. Indoor gas generators remain the most common source. Carboxyhemoglobin levels correlate poorly with ambient carbon monoxide levels. Enhanced public education had a modest effect, especially in reducing the proportion of African-American patients and those from indoor grill use. Research on more effective public health education targeted at gas generator users and combined with physical interventions should be considered.