Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome.

STUDY OBJECTIVE: To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines. METHODS: A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed. RESULTS: We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in 2021. CONCLUSION: Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.

Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations.

OBJECTIVE: To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED). STUDY DESIGN: Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge. RESULTS: 564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes. CONCLUSIONS: Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Acceptability and feasibility of video-based firearm safety education in a Colorado emergency department for caregivers of adolescents in firearm-owning households.

BACKGROUND: Easy firearm access increases injury risk among adolescents. We evaluated the acceptability and feasibility of improving knowledge of a 3 min safe firearm storage education video in the paediatric emergency department. METHODS: We conducted a single-centre block trial in a large paediatric emergency department (August 2020-2022). Participants were caregivers of adolescents (10-17 years) in firearm-owning households. First block participants (control) completed a baseline survey about child safety behaviours (including firearms). Second block participants (intervention) completed a baseline survey, watched the safe firearm storage video and evaluated acceptability. Participants completed a 3-month follow-up survey about firearm safety behaviours and knowledge recall. Demographic and clinical variables were compared between the intervention and control groups using Fisher's exact and χ2 tests. McNemar's test was used to compare firearm storage behaviours at the initial and 3-month visit within each group. RESULTS: Research staff approached 1264 caregivers; 371 consented to participate (29.4%) and 144 (38.8%) endorsed firearm ownership. There were 95 participants in the control group and 62 in the intervention group. Follow-up was lower in the intervention group (53.7% vs 37.1%, p=0.04). Among participants viewing the video, 80.3% liked the video and 50.0% felt they learnt something new from the video. CONCLUSIONS: Video-based firearm education in a paediatric emergency department is acceptable among a population of caregivers of adolescents with household firearms. This is a higher-risk group that may uniquely benefit from consistent education in the paediatric emergency department. Further study with larger populations is needed to evaluate intervention effectiveness. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov (NCT05168878).

Parental perspective on penicillin allergy delabeling in a pediatric emergency department.

BACKGROUND: Penicillin (PCN) allergy is frequently mislabeled and inaccurately diagnosed in children. Successful implementation of pediatric emergency department (PED) delabeling efforts requires parental understanding and willingness for children to be delabeled as PCN-nonallergic. OBJECTIVE: To describe the parental perspective on allergy delabeling in the PED for children identified as low risk for true PCN allergy. METHODS: This is a cross-sectional survey of parents of children with documented PCN allergy presenting to a single tertiary-care PED. Parents were first approached to complete a PCN allergy identification questionnaire to stratify their child as high- or low-risk for true PCN allergy. Facilitators and barriers to PED-based oral challenge and delabeling were subsequently assessed by parents of low-risk children. RESULTS: A total of 198 participants completed the PCN identification questionnaire. Of 198 children, 49 (25%) screened low risk for true PCN allergy. Of the 49 low-risk children, 29 (59%) parents were uncomfortable with a PED-based PCN oral challenge. Reasons include fear of allergic reaction (72%), availability of adequate alternative antibiotics (45%), and longer PED stay (17%). Reasons for willingness to delabel included PCN's low adverse effect profile (65%) and avoidance of antimicrobial resistance from alternative antibiotics (74%). Participants without a family history (FH) of PCN allergy were more comfortable with PED-based PCN oral challenge (60% vs 11%; P = .001) and delabeling (67% vs 37%; P = .04) compared with those with FH. CONCLUSION: Most parents of children with low-risk PCN allergy are uncomfortable with oral challenge or delabeling in the PED. Before implementing oral challenges in PEDs, efforts should be made to highlight the safety of oral challenging low-risk children, the benefits and risks of alternative antibiotics, and the minimal impact that FH has on PCN allergy.

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial.

STUDY OBJECTIVE: Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED). METHODS: We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI). RESULTS: Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1). CONCLUSIONS: We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Comparison of Two-Bag Versus Three-Bag N-Acetylcysteine Regimens for Pediatric Acetaminophen Toxicity.

BACKGROUND: Acetaminophen overdose is a leading cause of liver failure, and a leading cause of pediatric poisoning requiring hospital admission. The antidote, N-acetylcysteine (NAC), is traditionally administered as a three-bag intravenous infusion. Despite its efficacy, NAC is associated with high incidence of nonallergic anaphylactoid reactions (NAARs). Adult evidence demonstrates that alternative dosing regimens decrease NAARs and medication errors (MEs). OBJECTIVES: To compare NAARs and MEs associated with two- versus three-bag NAC for acetaminophen overdose in a pediatric population. METHODS: This is a retrospective observational cohort study comparing pediatric patients who received three- versus two-bag NAC for acetaminophen toxicity. The primary outcome was incidence of NAARs. Secondary outcomes were rates of MEs and relevant hospital outcomes (length of stay [LOS], intensive care unit (ICU) admission, liver transplant, death). RESULTS: Two hundred forty-three patients met inclusion criteria (median age of 15 years): 150 (62%) three-bag NAC and 93 (38%) two-bag NAC. There was no difference in overall NAARs (p = 0.54). Fewer cutaneous NAARs were observed in the two-bag group, three-bag: 15 (10%), two-bag: 2 (2%), p = 0.02. MEs were significantly decreased with the two-bag regimen, three-bag: 59 (39%), two-bag: 21 (23%), p = 0.01. No statistical differences were observed in LOS, ICU admissions, transplant, or death. CONCLUSION AND RELEVANCE: A significant decrease in cutaneous NAARs and MEs was observed in pediatric patients by combining the first two bags of the traditional three-bag NAC regimen. In pediatric populations, a two-bag NAC regimen for acetaminophen overdose may improve medication tolerance and safety.

Variation in diagnosis and management of allergic reactions among emergency medicine and allergy immunology providers.

Background: Children with anaphylaxis often emergently present for treatment. Providers' adherence to the principles of optimal management according to the most recent national guidelines is unknown. Objective: To assess the variation in management approaches for allergic reactions and anaphylaxis between allergy/immunology (AI) and emergency medicine (EM) providers. Methods: This was a cross-sectional survey study of AI and EM providers in the University of Colorado affiliated hospitals and Colorado Asthma and Allergy Society. The survey consisted of six cases of patients with allergic reactions, with four cases that represented patients with anaphylaxis that resolved by the time of discharge. For each vignette, the participants were asked about preferred initial therapy, adjunctive therapies, monitoring, outpatient prescription medications, and discharge instructions provided. Survey derivation and validation was accomplished by a multidisciplinary team of experts by using a modified Delphi process. Results: A total of 413 clinicians were contacted, of whom 194, (47%) responded, including 69 pediatric EM, 50 general EM, and 49 AI providers, and 26 did not identify a provider type. There were no statistically significant differences in correct recognition of anaphylaxis between the AI and EM providers. For each case, statistically significant differences were noted in the use of corticosteroids during and after resolution of anaphylaxis: AI providers reported giving fewer prescriptions than did the EM providers for corticosteroids in all cases of anaphylaxis (p < 0.001). The AI providers were less likely to prescribe scheduled antihistamines than were the EM providers in half of the cases (p < 0.02). Conclusion: Across the specialties, there were high rates of recognition of epinephrine as first-line treatment for anaphylaxis. The majority of the EM providers prescribed scheduled corticosteroids and antihistamines after resolution of anaphylaxis, whereas most of the AI providers did not prescribe scheduled corticosteroids. Analysis of the current data suggests against the routine use of corticosteroids in the management of anaphylaxis, particularly continued use after resolution of symptoms. AI involvement in the creation of EM and hospital protocols for allergic reactions could improve overall care.

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.

Facilitators and barriers for parental consent to pediatric emergency research.

BACKGROUND: Obtaining informed consent for clinical research in the pediatric emergency department (ED) is challenging. Our objective was to understand the factors that influence parental consent for ED studies. METHODS: This was a cross-sectional survey assessing parents' willingness to enroll their children into an ED research study. Parents reporting a willingness to enroll in ED studies were presented with two hypothetical scenarios, a low-risk and a high-risk study, and then asked about decision influencers affecting consent. Parents expressing a lack of willingness to enroll were asked which decision influencers impacted their consent decision. RESULTS: Among 118 parents, 90 (76%) stated they would be willing to enroll their child into an ED study; of these, 86 (96%) would consent for a low-risk study and 54 (60%) would consent for a high-risk study. Caucasian parents, and those with previous research exposure, were more likely to report willingness to participate. Those who would consent to the high-risk study cited "benefits that research would provide to future children" most strongly influenced their decision to agree. CONCLUSIONS: ED investigators should highlight the benefits for future children and inquire about parents' previous exposure to research to enhance ED research enrollment. Barriers to consent in non-Caucasian families should be further investigated. IMPACT: Obtaining consent for pediatric emergency research is challenging and this study identified factors influencing parental consent for research in EDs. Benefits for future children and parents' previous research experience were two of the most influential factors in parents' willingness to consent to ED research studies. These findings will help to improve enrollment in ED research studies and better our understanding of how to promote the health and well-being of pediatric patients.

Impact of prehospital pediatric asthma management protocol adherence on clinical outcomes.

OBJECTIVE: To evaluate the frequency of EMS protocol non-adherence during pediatric asthma encounters and its association with emergency department (ED) length of stay (LOS) and hospital admission. METHODS: This is a retrospective review of asthma encounters aged 2-17 years transported by EMS to a pediatric ED from 2012 to 2017. Our primary outcome was hospital admission based on prehospital protocol adherence defined as: (1) bronchodilator administration, (2) treatment of hypoxia with oxygen, or (3) administration of intramuscular (IM) epinephrine in encounters with high severity of distress. Multivariable logistic regression estimated the association between protocol non-adherence and hospital admission. RESULTS: During the study period, 290 EMS encounters met inclusion criteria. Median age was 9 years (IQR 5-12), 63% were male, 40% had moderate to severe exacerbations, and 24% were admitted. Protocol non-adherence occurred in 32% of encounters with failure to administer bronchodilators in 27% and failure to administer IM epinephrine when indicated in 83%. Prehospital steroids were administered in 8% of encounters. After adjusting for covariates, protocol non-adherence was not statistically associated with likelihood of inpatient admission (OR 1.3; 95% CI: 0.6-2.6). CONCLUSIONS: Among prehospital pediatric asthma encounters, EMS protocol non-adherence is common but not associated with a higher frequency of hospital admission. Hospital admission was associated with acute exacerbation severity suggesting further research is needed to develop a valid prehospital asthma severity assessment scoring tool.Supplemental data for this article can be accessed at publisher's website.

Evaluating Provider Documentation of Suicide Risk Factors Among Youth Screening Positive for Suicide Risk in a Pediatric Emergency Department.

OBJECTIVE: Screening for suicidal ideation in the pediatric emergency department (ED) enhances recognition of suicidality among patients presenting with a nonmental health complaint. Little is known about the assessment of suicide risk factors and disposition among these patients. This study aimed to evaluate pediatric ED providers' documentation of suicide risk factors in this population. METHODS: We performed a retrospective cohort study of patients screening at risk for suicide on the Ask Suicide-Screening Questions tool. Demographic variables and risk factors for youth suicide were extracted from the electronic health record for eligible patients each month from January 1, 2019, to December 31, 2019. We compared risk factors using χ2 or Fisher exact test. RESULTS: In 2019, of the 7484 patients screened for suicide, 524 (7%) had a positive screen. Of 220 patient charts reviewed, no suicide risk factors were documented in 53.6% of encounters, and only 1 risk factor was documented in 18.2% of encounters. Substance use was the most frequently discussed risk factor, documented in 33.6% of encounters. History of nonsuicidal self-injury was documented in 11.8% of visits. Other risk factors were documented in fewer than 10% of at-risk patients. CONCLUSION: Pediatric ED providers do not routinely document risk factors for suicide in medical patients screening at risk. Although the Ask Suicide-Screening Questions is an important initial screen, a standardized secondary risk factor assessment is necessary for a more complete risk stratification for patients with suicidal ideation.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children.

OBJECTIVE: When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. METHODS: Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. RESULTS: There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/µL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. CONCLUSIONS: Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Renewable carbon feedstock for polymers: environmental benefits from synergistic use of biomass and CO2.

Polymer production is a major source of greenhouse gas (GHG) emissions. To reduce GHG emissions, the polymer industry needs to shift towards renewable carbon feedstocks such as biomass and CO2. Both feedstocks have been shown to reduce GHG emissions in polymer production, however often at the expense of increased utilization of the limited resources biomass and renewable electricity. Here, we explore synergetic effects between biomass and CO2 utilization to reduce both GHG emissions and renewable resource use. For this purpose, we use life cycle assessment (LCA) to quantify the environmental benefits of the combined utilization of biomass and CO2 in the polyurethane supply chain. Our results show that the combined utilization reduces GHG emissions by 13% more than the individual utilization of either biomass or CO2. The synergies between bio- and CO2-based production save about 25% of the limited resources biomass and renewable electricity. The synergistic use of biomass and CO2 also reduces burden shifting from climate change to other environmental impacts, e.g., metal depletion or land use. Our results show how the combined utilization of biomass and CO2 in polymer supply chains reduces both GHG emissions and resource use by exploiting synergies between the feedstocks.

Pediatric Sepsis in Community Emergency Care Settings: Guideline Concordance and Outcomes.

OBJECTIVES: Bundled pediatric sepsis care has been associated with improved outcomes in tertiary pediatric emergency departments. Sepsis care at nontertiary sites where most children seek emergency care is not well described. We sought to describe the rate of guideline-concordant care, and we hypothesized that guideline-concordant care in community pediatric emergency care settings would be associated with decreased hospital length of stay (LOS). METHOD: This retrospective cohort study of children with severe sepsis presenting to pediatric community emergency and urgent care sites included children 60 days to 17 years with severe sepsis. The primary predictor was concordance with the American College of Critical Care Medicine 2017 pediatric sepsis resuscitation bundle, including timely recognition, vascular access, intravenous fluids, antibiotics, vasoactive agents as needed. RESULTS: From January 1, 2015, to December 31, 2017, 90 patients with severe sepsis met inclusion criteria; 22 (24%) received guideline-concordant care. Children receiving concordant care had a median hospital LOS of 95.3 hours (50.9-163.8 hours), with nonconcordant care, LOS was 88.3 hours (57.3-193.2 hours). In adjusted analysis, guideline-concordant care was not associated with hospital LOS (incident rate ratio, 0.99 [0.64-1.52]). The elements that drove overall concordance were timely recognition, achieved in only half of cases, vascular access, and timely antibiotics. CONCLUSIONS: Emergency care for pediatric sepsis in the community settings studied was concordant with guidelines in only 24% of the cases. Future study is needed to evaluate additional drivers of outcomes and ways to improve sepsis care in community emergency care settings.

Prescribing Patterns of Oral Opioid Analgesic for Acute Pain at a Tertiary Care Children's Hospital Emergency Departments and Urgent Cares.

OBJECTIVES: Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days. METHODS: A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded. RESULTS: Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4-3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for >7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received >3 days of opioids were younger (P < 0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications. CONCLUSIONS: Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.

Prescribing Patterns of Oral Opioid Analgesic for Long Bone Fracture at Tertiary Care Children's Hospital Emergency Departments and Urgent Cares.

OBJECTIVES: Disparities in opioid prescribing in children can lead to underprescribing and poorly controlled pain. On the contrary, unnecessary overprescribing can increase the risk for misuse, abuse, and diversion. The primary objective of this study was to compare the demographics and clinical characteristics of children with an extremity fracture who did and did not receive an opioid prescription from a tertiary care children's hospital. METHODS: This was a retrospective cohort study of children younger than 22 years with extremity fracture evaluated at a tertiary care children's hospital emergency department (ED) and surrounding satellite locations (3 EDs and 4 urgent cares), from January 1, 2017, to December 31, 2017. RESULTS: There were 3325 patients younger than 22 years who were seen for evaluation of an extremity fracture. The overall median age of patients was 8 years (interquartile range [IQR], 4-11), and 1976 (59.4%) were male. Patients with extremity fractures who received opioid analgesics were older than those who did not receive opioids (median age of 10 years [IQR, 6-13 years] vs 7 years [IQR, 4-11 years], P < 0.001). There was a significant difference found between insurance types, specifically those patients receiving Medicaid and private insurance. Patients who received opioid analgesics had a higher initial pain score (7 [IQR, 4-9] vs 5 [IQR, 2-7], P < 0.001), were more likely to have an physician (MD/DO) provider (P < 0.001), and were more likely to present to the ED (P < 0.001). CONCLUSIONS: Younger patients, patients with Medicaid insurance, patients treated by an advanced care provider, and patients who presented to an urgent care were less likely to receive opioid analgesics upon discharge. These findings demonstrate that more standardization and guidance on opioid prescribing are needed in pediatrics, to both adequately treat pain and reduce harms from overprescribing of opioid analgesics.

Illicit Drug Exposures in Young Pediatric Patients Reported to the National Poison Data System, 2006-2016.

This retrospective review of poison center calls found that there were 9122 illicit drug exposures reported in children <10 years of age between 2006 and 2016. Marijuana and methamphetamine were reported most frequently, with significant increases over the study period; methamphetamine was associated with the most deaths.

Ketamine Sedation and Hypoxia: A Quality Improvement Project to Reduce Respiratory Events Receiving Intervention.

BACKGROUND: Ketamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally. OBJECTIVE: A quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from > 10% to < 6% in our network of EDs and UCs. METHODS: Inclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay. RESULTS: REs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation. CONCLUSIONS: Using QI methodology, we reduced and maintained rates of RE to < 6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.

Using the Trauma Quality Improvement Program Metrics Data to Enhance Clinical Practice.

The American College of Surgeons Trauma Quality Improvement Program (TQIP) provides trauma centers with hospital-specific performance data and the ability to compare their performance data with that of similar hospitals nationwide. Utilizing the TQIP data and drill down feature can lead to changes in clinical practice and improved care. The purpose of this article is to provide a guide that demonstrates how using the TQIP hospital-specific data can improve outcomes. We recommend 4 separate categories by which data and reports should be evaluated: processes of care, quality of care, data coding, and data mapping. We discuss these categories using 4 targeted examples. Utilizing our guidelines, trauma programs participating in the TQIP should be able to (1) identify trends and focus on outliers in their institutional data, (2) create processes and implement practice improvements, and (3) evaluate the results of their corrective action plan. This topic may be of special interest to those involved in the management of programs or systems-level policies as reduction in costs and improving quality are program drivers.

New Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma.

OBJECTIVE: The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury. METHODS: This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12-6/30/14) and after (7/1/14-12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses. RESULTS: Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p < 0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p < 0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24-1.30, p = 0.18) was similar post-protocol implementation after adjusting for injury severity. CONCLUSIONS: There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.