Mpox.

ABSTRACT: Human mpox (formerly known as monkeypox) is a zoonotic disease that causes a smallpox-like infection in humans. The mpox virus, the causative agent of mpox, was first reported to cause human disease in a 9-month-old infant in the Democratic Republic of the Congo in 1970. Since that time, periodic outbreaks in primarily endemic regions have occurred, typically secondary to transmission from wildlife reservoirs. However, in May 2022, after a rapid rise in worldwide cases in largely nonendemic countries, the World Health Organization declared mpox a Public Health Emergency of International Concern. As of January 2022, more than 80,000 cases of mpox in nonendemic countries have occurred, and more than 25,000 cases in the United States alone. Most of these cases occurred in adults, with the highest frequency among men who had sex with men. Children and adolescents represented only 0.3% of US cases as of September 2022, with most infections in young children the result of direct contact with an infected household member. Although infection remains uncommon in US children and teens, pediatric emergency and urgent care providers should be aware of the clinical features, treatment, and prophylaxis of this important emerging infectious disease.

Fever and Knee Effusion in the Pediatric Patient.

ABSTRACT: The pediatric patient with fever and knee effusion is always a cause for clinical concern. A thorough history and physical examination is required to guide appropriate diagnostic evaluation and management. Although pediatric knee effusions are common in the setting of trauma, the presence of fever should prompt consideration of infectious, rheumatologic, vasculitic, and malignant etiologies. This review covers the key components of the history, physical examination, diagnostic strategies, common etiologies, and initial management of the pediatric patient with fever and knee effusion.

Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children.

Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.

Waterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department.

STUDY OBJECTIVE: Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs. METHODS: A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping "waterfall" shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change. RESULTS: A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction. CONCLUSION: This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.

Transient Erythroblastopenia of Childhood: A Review for the Pediatric Emergency Medicine Physician.

Transient erythroblastopenia of childhood is a form of pure red cell aplasia that is self-limited and occurs in children 4 years old and younger. It is characterized by an absence or a significantly reduced quantity of erythroblasts in the bone marrow without underlying congenital red blood cell abnormalities. Transient erythroblastopenia of childhood should be considered in previously healthy children who present with normocytic anemia and lack of reticulocytosis without evidence of blood loss, hemolysis, or other causes of bone marrow suppression. Evaluation should be targeted at ruling out other causes of anemia. Management is mainly supportive, although some children may require blood transfusions for symptomatic anemia. Most patients demonstrate a return of hematopoiesis within two weeks of diagnosis and normalization of blood counts within two months.

Serum Vitamin D and Magnesium levels in a psychiatric cohort.

BACKGROUND: Both Vitamin D deficiency and magnesium deficiency have an increased prevalence and have been associated with an increased risk of and increased severity of symptoms in both depression and schizophrenia (Boerman 2016, Tarleton & Littenberg 2015). This effect appears more pronounced in younger populations and is often apparent from the time of initial diagnosis and is present with adjustment for confounding factors. Thus, the evidence suggests that Vitamin D and magnesium deficiency reflects not only dietary or somatic aspects of health but also may have a role in the pathophysiology of depression and schizophrenia. SUBJECTS AND METHODS: A single site audit of serum Vitamin D and magnesium levels in patients at an Acute Day Treatment Unit was carried out. Blood tests were performed on admission and analysed in house. Data were collected between April - June 2019 and was analysed subsequently, as described below (n=73). RESULTS: Our data show that our psychiatric day treatment unit cohort (n=73) had a higher proportion of vitamin D deficiency (52%) than the general population (40%), although due to the limited sample size this was not significant (p=0.22, Chi-squared test). The percentage of patients who were magnesium deficient was 78.6% (n=22/28). However, the F60 subgroup of patients with personality disorders showed a high prevalence of vit D deficiency (p=0.07), highlighting a trend towards significance despite the limited size of this subgroup. CONCLUSIONS: We carried out a single-site audit of serum vitamin D and magnesium levels in a psychiatric day unit population in order to assess the extent of vitamin deficiency in such patients. These data indicate that that the proportion of patients with vitamin D deficiency is higher than in the general population. Further larger analysis is needed to establish the statistical significance of these data and whether treatment with vitamin D supplementation improves outcomes.

Rapid Electronic Provider Documentation Design and Implementation in an Academic Pediatric Emergency Department.

BACKGROUND: Many emergency departments are transitioning from paper charting to full electronic health records, which include both computerized provider order entry and provider documentation. Implementation of electronic provider documentation (EPD), in particular, has been challenging. Known benefits include legibility, medicolegal and compliance safeguards, and improved access to patient charts. Offsetting these benefits may be reductions in efficiency, patient throughput, and less provider-patient interaction. METHODS: We used a rapid design process coupled with Lean principles, simulation, aggressive training, and continuous process improvement to design and implement a novel EPD system with real-time voice recognition dictation in the pediatric emergency department (PED). We used statistical process control methodologies to compare mean PED lengths of stay (LOSs) for admitted and discharged patients before and after EPD GoLive. RESULTS: We were able to design, test, train, and implement a novel EPD to the PED within 7 months. There was special cause variation, with a 2.7% (5-minute) increase in overall LOS after EPD implementation. There was a temporary 9.3% (15-minute) increase in discharge LOS for 6 weeks after GoLive, with a subsequent return to a new baseline of 4.3% (7-minute) increase. There were no significant changes in admission LOS. There was overall consistent use of the voice recognition system several months after EPD rollout. There have been improving rates of compliance with chart completion over time, as a result of easier tracking and electronic reminders to complete. CONCLUSION: Despite the inherent challenges involved in transitioning from paper charting to EPD, our study showed that an academic ED, EPD, can be rapidly designed and implemented while not significantly negatively impacting ED metrics such as LOS. We had consistent use of the voice dictation system after implementation. Time spent documenting after clinical shift was not reliably captured and is an important area of future research for successful EPD implementation.

Creating a leaner pediatric emergency department: how rapid design and testing of a front-end model led to decreased wait time.

OBJECTIVE: To use Lean methodologies and the Model for Improvement to rapidly redesign and pilot test a new pediatric emergency department (ED) front-end model that reduces time to a licensed independent provider to 30 minutes or less. METHODS: Lean improvement methodologies were applied during a 5-day multidisciplinary model of care redesign event. The new ED front-end model of care included: (1) placement of a registered nurse in the lobby; (2) direct patient rooming with elimination of traditional triage; 3) early documentation of home medications; 4) Team-based immediate assessment; 5) "early Initiation" providers to place orders when a team was not available. An observational, cohort controlled before-and-after study design was used. The new model was tested over 2 pilot periods and compared to a similar period of control days, defined as the "current state." RESULTS: The ED census and patient acuity were similar during both pilot periods. Eighteen patients were included in pilot 1, and 80 patients were included in the expanded second pilot. Patients seen within 30 minutes improved from a baseline of 33% to 93% in pilot 2. Time to a licensed independent provider, to a room, and to visual assessment by a nurse all decreased. The largest decrease was in median time to provider, from 43 minutes in the current state to 7 minutes during pilot 2. CONCLUSIONS: Rapid process improvement methodology was used to design and test a front-end model that reduced patient waiting time. Our experience demonstrates the feasibility of employing Lean principles and the Model for Improvement in actual practice environments to rapidly improve care delivery processes in pediatric emergency departments.

A longitudinal view of resident education in pediatric emergency interhospital transport.

OBJECTIVES: : The focus was to examine the educational structure and curricular planning involved in current pediatric emergency interhospital transport teams that use resident physicians as members of the team and to compare these current results with the findings from 2 previous, similar surveys complete during the past 2 decades. METHODS: : A 33-item questionnaire, assessing curricular components of the transport experience, was sent to a chief resident at all the officially listed nonmilitary pediatric residency program in contiguous United States. Comparisons were done for each similar item on all 3 questionnaires. RESULTS: : After 3 rounds of mailing and telephone follow-up to nonresponders, the overall response rates for the 2006 and 1998 surveys were 81% (n = 156) and 89% (n = 173), respectively. A similar survey on a smaller sample, published in 1990, used for comparison, had a response rate of 99% (n = 75). When asked about training provided to residents before going on transport, respondents varied in the specific experiences and skills required of the residents. In addition, programs reported variation in team backup during the pediatric emergency transport. The most common method of evaluation for the resident on completion of the transport was "no specific method" as reported by 62% of respondents in 2006 compared with 50% in 1998 and 55% in 1990 (P = not significant). The percentage of programs providing informal verbal feedback was reduced significantly in 2006 as compared with that in 1998 (P = 0.011). CONCLUSIONS: : The educational structure for residents serving in pediatric emergency interhospital transport teams remains variable, and the full educational value of pediatric transports continues to be somewhat unrealized particularly in the area of posttransport performance feedback and evaluation. Having medical command available has consistently been a strong point of the residents' experience on the transport team.

Quality Improvement Methodologies: Principles and Applications in the Pediatric Emergency Department.

The origins of quality improvement in health care trace back to industry. Lessons learned from the "flow production" system of the Ford Model-T assembly line in Michigan and the Toyota Production System led to direct applications of Lean and Six Sigma to improve health care systems. Emergency medicine is well suited as a testing and proving ground for quality improvement methodologies because of high patient volume and rapid turnover. This article reviews the history of quality improvement in health care, describes Lean principles in detail, and provides illustrative examples of applications of Lean and quality improvement methodologies in the pediatric emergency department.

Miscellaneous causes of pediatric chest pain.

This article describes some of the miscellaneous etiologies of pediatric chest pain that are important to recognize early and diagnose. Up to 45% of pediatric chest pain cases may elude definitive diagnosis. Serious morbidity or mortality is infrequent. Accurate diagnosis of more obscure causes may help to avoid unnecessary emergency department evaluation and cardiology referral, while also alleviating the concern and stress families and patients experience when dealing with chest pain.

Radiologic procedures, policies and protocols for pediatric emergency medicine.

Protocol development between radiology and pediatric emergency medicine requires a multidisciplinary approach to manage straightforward as well as complex and time-sensitive needs for emergency department patients. Imaging evaluation requires coordination of radiologic technologists, radiologists, transporters, nurses and coordinators, among others, and might require accelerated routines or occur at sub-optimal times. Standardized protocol development enables providers to design a best practice in all of these situations and should be predicated on evidence, mission, and service expectations. As in any new process, constructive feedback channels are imperative for evaluation and modification.

Pediatric critical care transport--the safety of the journey: a five-year review of vehicular collisions involving pediatric and neonatal transport teams.

OBJECTIVE: To determine the frequency and consequences of vehicular crashes among dedicated pediatric and neonatal transport teams. METHODS: A three-page questionnaire was sent to the transport teams of National Association of Children's Hospitals and Related Institutions (NACHRI) member hospitals. The survey instrument consisted of three sections. The first section requested demographic information about the team and asked the team to report any vehicular collisions or incidents in the previous five years. The second section was directed at teams that did not report collisions or incidents and asked the team to identify potential reasons for their safety record. The third section was directed to those teams reporting collisions or incidents and asked about the causes and consequences of these events. RESULTS: Ninety of 153 (59%) surveys were returned. Thirty-eight of the 90 teams (42%) reported at least one collision in the previous five years. A total of 66 collisions were reported (nine aircraft crashes and 57 ambulance collisions). The number of collisions was not related to the total number of transports performed by the team. Most teams attributed the collisions to errors on the part of a team member or to the actions of a third party. Collisions resulted in eight deaths, ten cases of moderate to severe injury, and 28 minor injuries to patients, health care workers, and/or the ambulance crew. All deaths resulted from aircraft crashes. Additionally, there were operational impacts upon the teams. These included missed workdays and disability on the part of team members and changes in team practices. Collision-free teams attributed their safety record to specific policies of the team and/or the vehicle owner or vendor and to luck. CONCLUSIONS: Collisions/crashes among pediatric transport teams are unusual. However, they have resulted in deaths, injuries, and disability. Collisions/crashes appear to be caused by the actions of a team member and/or those of third parties. Specific safety policies on the part of the team and/or vehicle owner or provider may prevent or decrease collisions/crashes.

The state of pediatric interfacility transport: consensus of the second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference.

Interfacility transport of pediatric and neonatal patients for advanced or specialty medical care is an integral part of our medical delivery system. Assessment of current services and planning for the future are imperative. As part of this process, the American Academy of Pediatrics and the Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in Chicago in June 2000. Ninety-nine total participants, representing 25 states and 5 international locations, debated and discussed issues relevant to the developing specialty of pediatric transport medicine. These topics included: 1) the role of the medical director, 2) benchmarking of neonatal and pediatric transport programs, 3) clinical research, 4) accreditation, 5) team configuration, 6) economics of transport medicine in health care delivery, 7) justification of transport teams in institutions, and 8) international transport/extracurricular transport opportunities. Insights and conclusions from this meeting of transport leaders are presented in the consensus statement.