Caregiver Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs: A Qualitative Study.

OBJECTIVES: Almost half of pediatric EMS calls may be for low-acuity problems. Many EMS agencies have implemented alternative disposition programs for low-acuity patients, including transportation to clinics, substituting taxis for ambulances, and treatment in place without transport to an emergency department. Including children in such programs poses specific challenges, with one concern being potential caregiver opposition. Limited published evidence addresses caregiver perspectives on including children in alternative disposition programs. Our objective was to describe caregiver perspectives of alternative EMS disposition systems for low-acuity pediatric patients. METHODS: We conducted six virtual focus groups (one in Spanish) with caregivers. A PhD-trained facilitator moderated all groups using a semi-structured moderator guide. A hybrid inductive and deductive analytical strategy was used. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 38 participants. Participants had diverse race-ethnicity (39% non-Hispanic white, 29% non-Hispanic Black, and 26% Hispanic) and insurance status (42% Medicaid and 58% private health insurance). There was agreement that caregivers often utilize 9-1-1 for low-acuity complaints. Caregivers were generally supportive of alternative disposition programs, with some important caveats. Potential advantages of alternative dispositions included freeing up resources for more emergent cases, quicker access to care, and more cost-effective and patient-centered care. Caregivers had multiple concerns regarding the effects of alternative disposition programs, including timeliness in receiving care, capabilities of receiving sites (including pediatric expertise), and challenges to care coordination. Additional logistical concerns with alternative disposition programs for children included the safety of taxi services, the loss of parental autonomy, and the potential for inequitable implementation. CONCLUSIONS: Caregivers in our study generally supported alternative EMS dispositions for some children and identified multiple potential benefits of such programs for both children and the health care system. Caregivers were concerned about the safety and logistical details of how such programs would be implemented and wanted to retain final decision-making authority. Caregiver perspectives should be considered when designing and implementing alternative EMS disposition programs for children.

Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area.

OBJECTIVES: Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area. METHODS: This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status. RESULTS: A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status. CONCLUSIONS: One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study.

STUDY OBJECTIVE: Many Emergency Medical Services (EMS) agencies have developed alternative disposition processes for patients with nonemergency problems, but there is a lack of evidence demonstrating EMS clinicians can accurately determine acuity in pediatric patients. Our study objective was to determine EMS and other stakeholders' ability to identify low acuity pediatric EMS patients. METHODS: We conducted a prospective, observational study of children transported to a pediatric emergency department (ED) by EMS. Acuity was defined using a composite measure that included data from the patient's vital signs and examination, resources used (laboratory results, radiographs, etc), and disposition. For each patient, an EMS clinician, patient caregiver, ED nurse, and ED provider completed a survey as soon as possible after the patient's arrival at the ED. The survey asked respondents 2 questions: to state their level of agreement that a patient was low acuity and could the patient have been managed by various alternative dispositions. For each respondent group, we calculated the sensitivity, specificity, and positive and negative predictive values for low acuity versus the composite measure. RESULTS: From August 2020 through September 2021, we approached 1,015 caregivers, of whom 996 (99.8%) agreed to participate and completed the survey. Survey completion varied between 78.7% and 84.1% for EMS and ED nurses and providers. The mean patient age was 7 years, 62.6% were non-Hispanic Black, and 60% were enrolled in public insurance programs. Of the 996 patient encounters, 33% were determined to be low acuity by the composite measure. The positive predictive value for EMS clinicians when identifying low acuity children was 0.60 (95% confidence intervals [CI], 0.58 to 0.67). The positive predictive value for ED nurses and providers was 0.67 (95% CI, 0.61 to 0.72) and 0.68 (95% CI, 0.63 to 0.74) respectively. The negative predictive value for EMS clinicians when identifying not low acuity children was 0.62 (95% CI, 0.58 to 0.67). The negative predictive value for ED nurses and providers was 0.72 (95% CI, 0.68 to 0.76) and 0.73 (95% CI, 0.70 to 0.77) respectively. Caregivers had the lowest positive predictive value 0.34 (95% CI, 0.30 to 0.40) but the highest negative predictive value 0.82 (95% CI, 0.79 to 0.85). The EMS clinicians, ED nurses and providers were more likely than caregivers to think that a child with a low acuity complaint could have been safely managed by alternative disposition. CONCLUSION: All 4 groups studied had a limited ability to identify which children transported by EMS would have no emergency resource needs, and support for alternative disposition was limited. For children to be included in alternative disposition processes, novel triage tools, training, and oversight will be required to prevent undertriage.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport.

OBJECTIVES: Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol. METHODS: We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight. CONCLUSIONS: EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

National Characteristics of Non-Transported Children by Emergency Medical Services in the United States.

Study Objective: Most 911 calls result in ambulance transport to an emergency department. In some cases, transport is refused or deemed unnecessary. The frequency of pediatric non-transport is unknown. Our primary objective was to describe the proportion of pediatric EMS activations resulting in non-transport. Our secondary objective was to identify patient, community, and EMS agency factors associated with pediatric non-transport.Methods: We conducted a cross-sectional study using 2019 data from the National EMS Information System registry. We compared non-transport rates for children (<18 y/o), adults (18 - 60 y/o) and elderly (>60 y/o) patients. We then used generalized estimating equations to identify factors associated with pediatric non-transport while accounting for geographical clustering.Results: There were 21,931,490 EMS activations, including 1,403,454 pediatric 911 responses. 30% of pediatric 911 responses resulted in non-transport. Non-transport was less likely for adults (19%, OR 0.54 [0.54, 0.55]) and elderly patients (13%, OR 0.35 [0.35, 0.36]). The most common pediatric non-transport dispositions were: refused evaluation/care, and treated/released. Non-transport was associated with: pulmonary (aOR 3.84 [3.30, 4.48]) and musculoskeletal chief complaints (aOR 3.75 [3.22, 4.36]). Non-transport was more likely for: rural EMS calls (aOR 1.28 [1.24, 1.32]); calls classified by EMS as Lower Acuity (aOR 7.88 [5.98, 10.38]); and Tribal EMS agencies (aOR 3.49 [3.09, 3.94]).Conclusion: Almost one-third of pediatric 911 activations result in non-transport. Although very few children have been included in pilots of alternate transport processes to date, non-transport is actually more common in children than adults. More work is needed to understand better the patient safety and economic implications of this practice.

Coronavirus Disease 2019 in the Emergency Department: Establishing an Interprofessional Incident Command System.

Coronavirus disease 2019 was declared a national emergency in the United States on March 13, 2020, at which time the Children's National Hospital Emergency Department in Washington, DC, mobilized to develop and implement a unit-based Incident Command System. Anticipating that the unique and challenging nature of this pandemic might require a large interprofessional team, emergency nurses, emergency physicians, and emergency physician assistants were placed in traditional Incident Command System roles to provide an organizational framework for the ED response. This framework served multiple purposes but most importantly it helped to efficiently streamline and coordinate communications within the emergency department, with hospital leadership and with other hospital departments. The focus on intentionally taking an interprofessional approach to assigning Incident Command System roles was key to optimize staff safety, patient care, and clinical efficiency. This paper highlights a unique concept of applying the Incident Command System model to a single hospital department in a disaster scenario, using existing ED staff to function in various roles not typically held during regular operations. Given that policies and procedures can be ever-changing during a pandemic, emergency departments can implement an interprofessional incident command structure to provide a framework for communications and operational planning that allows for agility based on evolving priorities. The Children's National Hospital ED Incident Command System model established during the coronavirus disease 2019 pandemic can serve as a guide for other emergency departments during a disaster response.

Results of Testing Children for Severe Acute Respiratory Syndrome Coronavirus-2 Through a Community-based Testing Site.

OBJECTIVE: To describe the demographics, clinical features, and test results of children referred from their primary provider for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the community setting. STUDY DESIGN: Retrospective cross-sectional study of children ≤22 years of age who were tested for SARS-CoV-2 at a community-based specimen collection site in Washington, DC, affiliated with a large children's hospital between March 21 and May 16, 2020. RESULTS: Of the 1445 patients tested at the specimen collection site for SARS-CoV-2 virus, 408 (28.2%) had a positive polymerase chain reaction test. The daily positivity rate increased over the study period, from 5.4% during the first week to a peak of 47.4% (Ptrend < .001). Patients with fever (aOR, 1.7; 95% CI, 1.3-2.3) or cough (aOR, 1.4; 95% CI, 1.1-1.9) and those with known contact with someone with confirmed SARS-CoV-2 infection (aOR, 1.6; 95% CI, 1.0-2.4.) were more likely have a positive test, but these features were not highly discriminating. CONCLUSIONS: In this cohort of mildly symptomatic or well children and adolescents referred to a community drive-through/walk-up SARS-CoV-2 testing site because of risk of exposure or clinical illness, 1 in 4 patients had a positive test. Children and young adults represent a considerable burden of SARS-CoV-2 infection. Assessment of their role in transmission is essential to implementing appropriate control measures.

Characteristics and Clinical Outcomes of Children and Adolescents Aged <18 Years Hospitalized with COVID-19 - Six Hospitals, United States, July-August 2021.

During June 2021, the highly transmissible† B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, became the predominant circulating strain in the United States. U.S. pediatric COVID-19-related hospitalizations increased during July-August 2021 following emergence of the Delta variant and peaked in September 2021.§ As of May 12, 2021, CDC recommended COVID-19 vaccinations for persons aged ≥12 years,¶ and on November 2, 2021, COVID-19 vaccinations were recommended for persons aged 5-11 years.** To date, clinical signs and symptoms, illness course, and factors contributing to hospitalizations during the period of Delta predominance have not been well described in pediatric patients. CDC partnered with six children's hospitals to review medical record data for patients aged <18 years with COVID-19-related hospitalizations during July-August 2021.†† Among 915 patients identified, 713 (77.9%) were hospitalized for COVID-19 (acute COVID-19 as the primary or contributing reason for hospitalization), 177 (19.3%) had incidental positive SARS-CoV-2 test results (asymptomatic or mild infection unrelated to the reason for hospitalization), and 25 (2.7%) had multisystem inflammatory syndrome in children (MIS-C), a rare but serious inflammatory condition associated with COVID-19.§§ Among the 713 patients hospitalized for COVID-19, 24.7% were aged <1 year, 17.1% were aged 1-4 years, 20.1% were aged 5-11 years, and 38.1% were aged 12-17 years. Approximately two thirds of patients (67.5%) had one or more underlying medical conditions, with obesity being the most common (32.4%); among patients aged 12-17 years, 61.4% had obesity. Among patients hospitalized for COVID-19, 15.8% had a viral coinfection¶¶ (66.4% of whom had respiratory syncytial virus [RSV] infection). Approximately one third (33.9%) of patients aged <5 years hospitalized for COVID-19 had a viral coinfection. Among 272 vaccine-eligible (aged 12-17 years) patients hospitalized for COVID-19, one (0.4%) was fully vaccinated.*** Approximately one half (54.0%) of patients hospitalized for COVID-19 received oxygen support, 29.5% were admitted to the intensive care unit (ICU), and 1.5% died; of those requiring respiratory support, 14.5% required invasive mechanical ventilation (IMV). Among pediatric patients with COVID-19-related hospitalizations, many had severe illness and viral coinfections, and few vaccine-eligible patients hospitalized for COVID-19 were vaccinated, highlighting the importance of vaccination for those aged ≥5 years and other prevention strategies to protect children and adolescents from COVID-19, particularly those with underlying medical conditions.

Implementing Paper Documentation During an Influenza Surge in a Pediatric Emergency Department.

OBJECTIVE: We hypothesized that a paper documentation and discharge bundle can expedite patient care during an influenza-related surge. METHODS: Retrospective cohort study of low-acuity patients younger than 21 years surging into a pediatric emergency department between January and March 2018 with influenza-like illness. Patient visits documented using a paper bundle were compared with those documented in the electronic medical record on the same date of visit. The primary outcome of interest was time from physician evaluation to discharge for patient visits documented using the paper bundle compared with those documented in the electronic medical record. Secondary outcome was difference in return visits within 72 hours. We identified patient and visit level factors associated with emergency department length of stay. RESULTS: A total of 1591 patient visits were included, 1187 documented in the electronic health record and 404 documented using the paper bundle. Patient visits documented using the paper bundle had a 21% shortened median time from physician evaluation to discharge (41 minutes; interquartile range, 27-62.8 minutes) as compared with patient visits documented in the electronic health record (52 minutes; interquartile range, 35-61 minutes; P < 0.001). There was no difference in return visits (odds ratio, 0.7; 95% confidence interval, 0.2, 2.2). CONCLUSIONS: Implementation of paper charting during an influenza-related surge was associated with shorter physician to discharge times when compared with patient visits documented in the electronic health record. A paper bundle may improve patient throughput and decrease emergency department overcrowding during influenza or coronavirus disease-related surge.

Pediatric disaster preparedness: identifying challenges and opportunities for emergency department planning.

PURPOSE OF REVIEW: To review the current literature on best practices for pediatric disaster preparedness in an emergency department (ED). RECENT FINDINGS: Children have unique anatomical, physiologic, immunologic, and psychosocial needs that impact their vulnerability to and resilience in a disaster, yet they have been historically underrepresented in disaster planning at local and national levels. Lessons learned from recent disaster events, disaster research, and disaster experts provide guidance on pediatric disaster preparedness for ED. SUMMARY: All EDs should include children in their disaster plans and exercises. ED staff should be knowledgeable about their role in institutional disaster operations and familiar with standard disaster management principles.

Evaluation of a Selective Prehospital Pediatric Spinal Protection Protocol.

Background: Recent studies demonstrate an association between spinal immobilization and neck pain, increased use of radiographs, and increased admission rates for pediatric trauma patients. There is an increasing trend toward spinal protection protocols that limit the use of backboards in trauma patients. However, many of these protocols do not address the youngest patients. Objectives: The objective was to analyze whether implementation of a selective prehospital pediatric spinal protection protocol was associated with a reduction in spinal imaging, hospital admission rates, and Emergency Department (ED) length of stay (LOS). Methods: We conducted a single center retrospective chart review to assess the effect of implementing a new selective pediatric spinal immobilization protocol in an EMS system. Patients transported to the same center from a neighboring EMS jurisdiction without a protocol change were analyzed for comparison. We extracted data for all pediatric patients with trauma-related discharge diagnoses transported by EMS to a pediatric trauma center for one year before and after the implementation of the protocol. Results: There were 878 eligible trauma patients transported under the new protocol, compared to 782 transported prior to implementation. We did not find a significant difference in the percentage of trauma patients who received spinal imaging pre- and post-protocol change (20% vs. 18%, OR 0.84 [95% CI 0.66, 1.07]), but did observe a significant reduction in the proportion of trauma patients who were admitted to the hospital (25% vs. 18%, OR 0.66 [95% CI 0.52, 0.83]). This reduced admission rate was not observed in the neighboring jurisdiction. Conclusions: Implementation of a selective spinal immobilization protocol was associated with reduced admission rates, but did not significantly reduce rates of plain radiographs.

Decontamination of the pediatric patient.

PURPOSE OF REVIEW: This article will review current guidelines for decontamination procedures for chemical, biological, and radiologic exposures with a focus on pediatric specific considerations. RECENT FINDINGS: There has been a global increase in terrorist incidents that expose large populations to toxic agents associated with significant morbidity and mortality. The pathophysiology, treatment, and management of these toxic exposures may be unfamiliar to the healthcare provider. Additionally, children are particularly vulnerable to terrorist threats as they have unique anatomical, physiological, psychological, and developmental characteristics distinct from the adult population. SUMMARY: Because pediatric patients are at greater risk than the general population, providers should be prepared to deliver age-appropriate care. Additionally, the ideal decontamination protocol is designed to maintain family units to maximize efficiency and minimize psychological trauma.

Pandemic Planning, Response, and Recovery for Pediatricians: A Focus on Health Equity and Social Determinants of Health.

This article summarizes how pediatricians may be uniquely positioned to mitigate the long-term trajectory of COVID-19 on the health and wellness of pediatric patients especially with regard to screening for social determinants of health that are recognized drivers of disparate health outcomes. Health inequities, that is, disproportionately deleterious health outcomes that affect marginalized populations, have been a major source of vulnerability in past public health emergencies and natural disasters. Recommendations are provided for pediatricians to collaborate with disaster planning networks and lead strategies for public health communication and community engagement in pediatric pandemic and disaster planning, response, and recovery efforts.

Pediatric Primary Care Provider Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs.

INTRODUCTION: Many emergency medical services (EMS) agencies have implemented alternative disposition programs for low-acuity complaints, including transportation to clinics. Our objectives were to describe pediatric primary care providers' views on alternative EMS disposition programs. METHOD: We conducted virtual focus groups with pediatric primary care providers. A hybrid inductive and deductive analytical strategy was used. Codes were grouped into themes by consensus. RESULTS: Participants identified the benefits of alternative dispositions, including continuity of care, higher quality care, and freeing up emergency resources. Participants' concerns included undertriage, difficulty managing patients not previously known to a clinic, and inequitable implementation. Commonly identified logistical barriers included inadequate equipment, scheduling capacity, and coordinating triage. DISCUSSION: Participants agreed there could be significant benefits from including clinics in EMS disposition programs. Participants identified several logistical constraints and raised concerns about patient safety and equitable implementation. These perspectives should be considered when designing pediatric alternative EMS disposition programs.

Rapid Development and Testing of a COVID-19 Vaccine Curriculum for Pediatricians.

BACKGROUND AND OBJECTIVES: As the coronavirus disease 2019 (COVID-19) pandemic evolves and vaccines become available to children, pediatricians must navigate vaccination discussions in the setting of rapidly changing vaccine recommendations and approvals. We developed and evaluated an educational curriculum for pediatricians to improve their knowledge about COVID-19 vaccines and confidence in communicating with patients and families about COVID-19 vaccines. METHODS: Five institutions collaborated to develop an online educational curriculum. Utilizing the collaboration's multidisciplinary expertise, we developed a 3-module curriculum focused on the SARS-CoV-2 virus and vaccine basics, logistics and administration of COVID-19 vaccine, and COVID-19 vaccine communication principles. Surveys administered to clinician participants before and after completion of the curriculum assessed knowledge and confidence; a follow-up survey 1 month after the post-survey assessed persistence of initial findings. RESULTS: A total of 152 pediatric providers participated; 72 completed both pre- and post-surveys. The median knowledge score improved from the pre-survey to the post-survey (79%-93%, P < .001). There was an increase in providers' confidence after completing the curriculum, which persisted in the follow-up survey. In the post-survey, 98% of participants had had the opportunity to discuss the COVID-19 vaccine with patients, and most clinicians reported that the modules decreased apprehension some or significantly. CONCLUSIONS: This project demonstrates rapid and feasible deployment of a curriculum providing up-to-date information to front-line clinicians responsible for having complex conversations about COVID-19 vaccine decision-making. Clinicians who completed this curriculum had sustained increased confidence and decreased levels of apprehension when discussing the COVID-19 vaccine.

COVID-19 Result Follow-Up Process in the Pediatric Emergency Department Setting.

The novel coronavirus disease 2019 (COVID-19) pandemic upended the world. As emergency departments and hospitals across the nation and world braced themselves for the surge of this new disease, the emergency department (ED) at Children's National Hospital (CNH) quickly created a process to address surges in patient visits and follow-ups for coronavirus testing. Within 2 wk of the first reported pediatric patient diagnosed with COVID-19 in the Washington, DC, metropolitan area, CNH ED implemented a new comprehensive follow-up process. This article describes the novel process that ensured timely notification of testing results, enabled patients to speak remotely with ED providers, increased patient and staff safety by reducing unnecessary exposures, and suggested a good patient experience. With over 1900 patients discharged pending their COVID-19 results, the program is successful. We anticipate expansion into antibody testing and notification as the pandemic progresses.

Caregiver Perceptions Regarding Alternative Emergency Medical Services Dispositions for Children: A Cross-Sectional Survey Analysis.

INTRODUCTION: Emergency medical services (EMS) systems have developed alternative disposition processes for patients (including leaving the patient at the scene, using taxis, and transporting to clinics) vs taking patients directly to an emergency department (ED). Studies show that patients favorably support these alternative options but have not included the perspectives of caregivers of children. Our objective was to describe caregivers' views about these alternative disposition processes and analyze whether caregiver support is associated with sociodemographic factors. METHODS: We surveyed a convenience sample of caregivers in a pediatric ED. We asked caregivers 15 questions based on a previously validated survey. We then conducted logistic regressions to determine whether sociodemographic factors were associated with levels of support. RESULTS: We enrolled 241 caregivers. The median age of their children was five years. The majority of respondents were non-Hispanic Black (57%) and had public insurance (65%). We found that a majority of respondents supported all alternative EMS disposition options. The overall level of agreement for survey questions ranged from 51-93%. We grouped questions by theme: non-transport; alternative destinations; communication with EMS physician; communication with primary care physician and sharing records; restricted EMS role; and shared decision-making. Regression analyses for each theme found that race/ethnicity, public insurance, and patient age were not significantly associated with the level of support. CONCLUSION: Most caregivers were supportive of alternative EMS disposition options for children with low-acuity complaints. Support did not vary significantly by respondent race/ethnicity, public insurance status, or patient age.

Factors Associated With Severe Illness in Patients Aged <21 Years Hospitalized for COVID-19.

OBJECTIVES: To describe coronavirus disease 2019 (COVID-19)-related pediatric hospitalizations during a period of B.1.617.2 (Δ) variant predominance and to determine age-specific factors associated with severe illness. METHODS: We abstracted data from medical charts to conduct a cross-sectional study of patients aged <21 years hospitalized at 6 United States children's hospitals from July to August 2021 for COVID-19 or with an incidental positive severe acute respiratory syndrome coronavirus 2 test. Among patients with COVID-19, we assessed factors associated with severe illness by calculating age-stratified prevalence ratios (PR). We defined severe illness as receiving high-flow nasal cannula, positive airway pressure, or invasive mechanical ventilation. RESULTS: Of 947 hospitalized patients, 759 (80.1%) had COVID-19, of whom 287 (37.8%) had severe illness. Factors associated with severe illness included coinfection with respiratory syncytial virus (RSV) (PR 3.64) and bacteria (PR 1.88) in infants; RSV coinfection in patients aged 1 to 4 years (PR 1.96); and obesity in patients aged 5 to 11 (PR 2.20) and 12 to 17 years (PR 2.48). Having ≥2 underlying medical conditions was associated with severe illness in patients aged <1 (PR 1.82), 5 to 11 (PR 3.72), and 12 to 17 years (PR 3.19). CONCLUSIONS: Among patients hospitalized for COVID-19, factors associated with severe illness included RSV coinfection in those aged <5 years, obesity in those aged 5 to 17 years, and other underlying conditions for all age groups <18 years. These findings can inform pediatric practice, risk communication, and prevention strategies, including vaccination against COVID-19.

Pediatric rapid fluid resuscitation.

PURPOSE OF REVIEW: Intravenous and enteral fluid resuscitation are frequently used therapies in the management of pediatric patients in emergency departments and critical care settings. Any state of intravascular fluid deficit, ranging from mild dehydration due to gastroenteritis to fulminant septic shock, requires careful assessment and early restoration of hemodynamic stability. Rapid fluid resuscitation has gained increased recognition since the most recent pediatric shock management guidelines. We sought to review the evidence for rapid fluid resuscitation and to outline its clinical indications, implementation, and potential associated risks. RECENT FINDINGS: Rapid fluid resuscitation benefits pediatric patients with severe dehydration or signs of shock. Studies have proven the modality to be safe and efficacious and to reduce morbidity and mortality. Initial and frequent clinical assessments are key in reducing potential complications of overhydration or clinically significant electrolyte disturbances. Rapid enteral rehydration may be used in the uncomplicated, mildly to moderately dehydrated patient. Antiemetics may facilitate rehydration efforts by limiting further fluid losses. SUMMARY: Rapid fluid resuscitation is most commonly used for children with moderate-to-severe dehydration, or for patients in shock to restore circulation. Concerns regarding potential for fluid overload and electrolyte disturbances and regarding the method of rehydration (i.e., enteral versus parenteral) raise some debate about the safety and efficacy of rapid fluid resuscitation in the pediatric patient. Recent studies show that early, aggressive fluid resuscitation of up to 60 ml/kg within 1-2 h may be necessary to replenish circulating intravascular fluid volume. Complications of severe electrolyte disturbances, cerebral edema, or uncontrolled hemorrhage are uncommon and can often be avoided with early clinical assessment and reassessments throughout the resuscitation. In the mildly to moderately dehydrated child, enteral fluid resuscitation with the aid of an antiemetic such as ondansetron can be as effective and efficient as intravenous fluid resuscitation.

An Assessment of Pediatric Resident Disaster Preparedness for the Neonatal Intensive Care Unit.

OBJECTIVE: To assess the level of neonatal intensive care unit (NICU) disaster preparedness among pediatric residents. METHODS: A mixed-methods study including qualitative interviews and quantitative surveys was used. Interviews guided survey development. Surveys were distributed to residents who rotated through Children's National NICU. Questions assessed residents' background in disaster preparedness, disaster protocol knowledge, NICU preparedness, roles during surge and evacuation, and views on training and education. RESULTS: Survey response was 62.5% (n = 80) with 51.3% of invited residents completing it. Pediatric residents (PGY-2 and PGY-3) (n = 41) had low levels of individual disaster preparedness, particularly evacuations (86%). None were aware of specific NICU disaster protocols. Patient acuity, role ambiguity, knowledge, and training deficits were major contributors to unpreparedness. Residents viewed their role as system facilitators (eg, performing duties assigned, recruiting other residents, and clerical work like documentation). Resident training requests included disaster preparedness training every NICU rotation (48%) using multidisciplinary simulations (66%), role definition (56%), and written protocols (50%). Despite their unpreparedness, residents (84%) were willing to respond. CONCLUSION: Pediatric residents lacked knowledge of NICU disaster response but were willing to respond to disasters. Training should include multi-disciplinary simulations that can be refined iteratively to clarify roles, and residents should be involved in planning and execution.