Does the Role of A Rapid Triage Provider Improve Pain Control in an Academic Pediatric Emergency Department?

Pediatric pain control in the emergency department (ED) remains problematic. This quantifiable metric may be positively affected by the utilization of a rapid triage provider (RTP). This is a retrospective case control study of pediatric patients requiring either ketorelac intravenous (IV) or morphine IV for painful conditions. Patients in the control group were managed according to standard nursing-driven triage process. Patients in the RTP group were seen by the standard triage team as well as by the RTP.We identified 114 patients who required IV pain medications. The mean time from arrival to pain medication administration for the RTP group as compared with the control group was 47 and 64 minutes (P = 0.02). Similarly, the mean time from arrival to IV pain medication order placement was 15 and 43 minutes (P < 0.01). An RTP improves pain control in the pediatric ED via more efficient order placement and IV pain medication administration.

An unusual cause of an isolated scapula fracture.

This article reviews an isolated scapula fracture in a teenage athlete. Although rarely reported in professional athletes, scapula fracture should be included in the differential diagnosis of shoulder injuries. Proper imaging is key to effective diagnosis and management.

Comparison of Primary Care Provider Office Hours and Pediatric Emergency Department Return Visits.

OBJECTIVE: The aim of this study was to evaluate the influence of primary care office hours of operation on 48-hour return visits (RVs) to a pediatric emergency department (ED). We compared characteristics of patients who return with those who follow up outpatient to determine the feasibility of opening off-hour clinics to decrease the RV rate. METHODS: The study was a retrospective chart review of patients presenting to a pediatric ED for a 3-year period. A subset of patients with a hospital-affiliated primary care provider was evaluated to compare those with 48-hour ED RVs with those with office follow-up. RESULTS: Patients with a hospital-affiliated primary care provider had 30,231 visits, of whom 842 had a 48-hour return (2.79%). A significant number (48.5%) of those who returned had seen their primary care doctor between emergency visits. The percentage of RVs occurring at night (55.7%) was slightly lower than the percentage of all visits occurring off hours (58.1%). Patients with more acute presentation at initial visit (emergency severity index level acuity 2, >20 orders placed) were more likely to follow up with their provider than return to the ED. CONCLUSIONS: The findings from this study show no significant increase in RVs during the evening and overnight hours and many patients with outpatient follow-up before returning to the ED. Opening a clinic at our hospital during nontraditional hours would not likely significantly decrease RV rate.

COVID-19 Screening in the Pediatric Emergency Department.

BACKGROUND: Screening for COVID-19 infection in pediatrics is challenging as its clinical presentation may be asymptomatic or mimic other common childhood infections. We examined the use of a COVID-19 screening protocol (CSP) in the pediatric emergency department (PED) to determine the incidence of positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) tests in patients who are CSP+ and CSP-. METHODS: We conducted a retrospective cohort study of pediatric patients with SARS-CoV-2 testing completed in an urban tertiary care PED from November 1 to December 31, 2020. Demographics, CSP designation, test results, and disposition were compared. Statistical significance was determined using chi-square or a comparison of means. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) with 95% confidence intervals (CI) were calculated. RESULTS: A total of 1,613 patients had SARS-CoV-2 tests completed with 9.1% (N=147) having positive test results. Of 1,014 (62.9%) patients who were CSP+, 12.9% tested positive. Comparatively, 599 (37.1%) patients were CSP- with only 2.7% positive tests, p<0.0001. The sensitivity, specificity, NPV, and PPV of the CSP in all tested patients were 89.1%, 39.8%, 97.3%, and 12.9%, respectively. Of tested patients, 887 (55.0%) were admitted to the hospital and were more likely to be positive if CSP+, p≤0.001. Within the admitted group, 16.8% were admitted to the operating room, of whom 83.9% were CSP- with 4.0% testing positive for SARS-CoV-2. CONCLUSIONS: COVID-19 screening in the pediatric population is a useful modality to risk stratify most patients presenting to the PED for the purpose of selective testing and guiding personal protective equipment use. This may be particularly useful in low-resource settings.

The Emergency Severity Index Version 4: reliability in pediatric patients.

OBJECTIVES: The Emergency Severity Index version 4 (ESI v.4) is a triage system, which demonstrates reliability in adult populations, however, it has not been extensively studied in pediatrics. The goal of this study was to measure interrater reliability and agreement rates within and between a group of pediatric emergency medicine physicians and pediatric triage (PT) nurses using ESI v.4 in a pediatric population. METHODS: Pediatric emergency medicine physicians and PT nurses completed ESI v.4 training and a survey of 20 pediatric case scenarios, requiring them to assign a triage category to each case. Cases and standardized responses were adapted from the ESI v.4 training materials. Unweighted and weighted J was measured, and agreement rates for each group were compared with the standard response. RESULTS: Sixteen physicians and 17 nurses completed the study. The group had a mean of 10.2 (T7.7) years experience in pediatrics. Nurses had a mean of 7.6 (T8.7) years experience in triage. Unweighted J for physicians and nurses was 0.68 and 0.67, respectively. Weighted J for physicians and nurses was 0.92 and 0.93, respectively. The agreement rate among physicians and nurses with the standardized responses to case scenarios was 83%. CONCLUSIONS: ESI v.4 is a reliable tool for triage assessments in pediatric patients when used by experienced pediatric emergency medicine physicians and PT nurses. It is a triage system with high agreement between physicians and nurses.

The Emergency Severity Index Version 4: reliability in pediatric patients.

OBJECTIVES: The Emergency Severity Index version 4 (ESI v.4) is a triage system, which demonstrates reliability in adult populations, however, it has not been extensively studied in pediatrics. The goal of this study was to measure interrater reliability and agreement rates within and between a group of pediatric emergency medicine physicians and pediatric triage (PT) nurses using ESI v.4 in a pediatric population. METHODS: Pediatric emergency medicine physicians and PT nurses completed ESI v.4 training and a survey of 20 pediatric case scenarios, requiring them to assign a triage category to each case. Cases and standardized responses were adapted from the ESI v.4 training materials. Unweighted and weighted kappa was measured, and agreement rates for each group were compared with the standard response. RESULTS: Sixteen physicians and 17 nurses completed the study. The group had a mean of 10.2 (+/-7.7) years experience in pediatrics. Nurses had a mean of 7.6 (+/-8.7) years experience in triage. Unweighted kappa for physicians and nurses was 0.68 and 0.67, respectively. Weighted kappa for physicians and nurses was 0.92 and 0.93, respectively. The agreement rate among physicians and nurses with the standardized responses to case scenarios was 83%. CONCLUSIONS: ESI v.4 is a reliable tool for triage assessments in pediatric patients when used by experienced pediatric emergency medicine physicians and PT nurses. It is a triage system with high agreement between physicians and nurses.

Clinical predictors of respiratory syncytial virus infection in children.

AIM: The aim of this study was to develop a clinical prediction model that identifies respiratory syncytial virus (RSV) infection in infants and young children. METHODS: Children < or = 36 months of age with respiratory illness, who were suspected of having RSV infection, were enrolled in this prospective cohort study during the study period between January and February 2002. RSV testing was performed on all patients. RESULTS: Of the 197 patients enrolled in the study, 126 (64%) were positive for RSV and 71 (36%) patients were either negative for RSV or had a positive culture for viruses other than RSV. The mean age of patients was 5 months and 57% were male. Backwards stepwise logistic regression analysis identified cough (p = 0.000), wheezing (p = 0.002), and retractions (p = 0.008) as independent variables predictive of RSV infection. The prediction model had a sensitivity of 80% (95% CI, 71-87%), specificity of 68% (95% CI, 54-79%), positive predictive value 82% (95% CI, 74-89%), negative predictive value 66% (95% CI, 52-77), positive likelihood ratio 2.5 (95% CI, 1.8-3.7) and post-test probability of 82%. CONCLUSION: The combination of cough, wheezing and retractions predicts RSV infection in infants and young children.

Predicting pertussis in infants.

BACKGROUND: The incidence of reported cases of pertussis is increasing, despite high rates of vaccination among infants and children. The burden of disease, and rates of complication and death are highest among infants. The limited availability of a timely reliable confirmatory test for pertussis hinders early identification of infected infants. OBJECTIVE: Our objective is to identify clinical and laboratory predictors for pertussis among infants. METHODS: Demographic, clinical, and laboratory data were collected from the medical records of all infants aged 12 months or younger who underwent confirmatory testing (culture, direct fluorescent assay, or polymerase chain reaction) for Bordetella pertussis from January 1, 2001, to July 31, 2005. The association of 15 variables with a positive pertussis test was analyzed using univariate and multivariate analysis, and when appropriate, using receiver operating characteristics. RESULTS: We reviewed the medical records of 141 infants who were tested for pertussis. The mean age was 88 days, and the most common chief complaints were cough and breathing difficulty. Eighteen patients (13%) had a positive pertussis test, and 123 (87%) had a negative test. Bronchiolitis and upper respiratory tract infection were the most common discharge diagnoses among infants with a negative test. The 2 groups were similar with respect to sex, history of cough, vomiting, fever, symptoms of apparent life-threatening event, presence of fever, or hypoxia, and heart rate. Infants who were younger (55 days vs 93 days, P = 0.02), evaluated between July and October (23% vs 9%, P = 0.02), less tachypneic (39 breaths/min vs 47 breaths/min, P = 0.02), had higher white blood cell counts (20,000/microL vs 15,000/microL, P = 0.02), higher percentage of lymphocytes (72 vs 55, P = 0.00), and higher absolute lymphocyte counts ([ALC] 14,536/microL vs 8357/microL, P = 0.00) were more likely to have a positive test. Receiver operating characteristics for ALC demonstrated an area under the curve of 0.81, with a 95% confidence interval of 0.72 to 0.90. An ALC cutoff point of 9400 was determined to maximize sensitivity (89%) and specificity (75%). The negative predictive value of this cutoff point was 97%, and the positive likelihood ratio was 3.6, with a 95% confidence interval of 2.3 to 5.4. CONCLUSIONS: Among infants who underwent confirmatory testing for pertussis, those who are younger, evaluated between July and October, less tachypneic, have higher white blood cell counts, higher percentage of lymphocytes, and higher ALCs are more likely to have a positive test. The ALC was the best predictor of pertussis, and an ALC of less than 9400/microL excluded almost all infants without pertussis.

Patterns of injury associated with routine childhood falls.

OBJECTIVE: To identify the pattern of injuries associated with routine childhood falls. METHODS: Retrospective chart review of patients at most 12 years presenting to a children's hospital emergency department with complaint of a fall. Patients were classified into 3 age groups (<2, 2-4, and 5-12 years) and analyzed for the type of fall and diagnosis. RESULTS: Seven hundred eighty-seven patients were enrolled. Mean age was 5.7 years. Fifty-six percent were boys. The types of falls reported were categorized as a fall down steps, from patient's own height, from an object, and other. In all 3 groups, the most common fall was fall from an object (50%, 50%, and 48%, respectively). There were 91 (12%) patients in the younger-than-2-year-old age group and 235 (30%) in the 2- to 4-year-old age group. Both groups commonly fell from a bed/chair (35% and 25%, respectively). In the youngest group, the most frequent diagnosis was head injury (41%; odds ratio [OR], 5.0; 95% confidence interval [CI], 3.0-8.1). Children ages 5 to 12 years numbered 461 (58%) and most commonly fell from playground equipment (26%) sustaining a fracture (65%; OR, 3.1; 95% CI, 2.3-4.3). Of these, 77% were in the upper extremity (arm fracture; OR, 41; 95% CI, 22-79). CONCLUSIONS: In children who presented to a children's hospital emergency department with a fall, fall from an object was the most common type. Those younger than 2 years, most commonly fell from a bed/chair and sustained head injury. Children 5 to 12 years old were likely to fall from playground equipment and fracture their arm. These findings may be helpful to clinicians who evaluate routine childhood falls.

An unusual case of knee pain.

Osteomyelitis of the patella is a rare disease, which primarily affects the pediatric population. We present a case of hematogenous osteomyelitis of the patella with secondary development of septic arthritis of the knee. There is often a delay in diagnosis, as illustrated by our case report, due to the rarity of the condition and nonspecific presentation. There is usually no history of trauma. Focal tenderness over the patella is the most helpful clinical sign. A small joint effusion may be present which is usually sterile and reactionary due to inflammation of the patella. Treatment of osteomyelitis of the patella is similar to treatment of osteomyelitis in other areas. Function and range of motion of the knee usually returns to normal after completion of treatment. A delay in diagnosis may lead to progression of disease and complications such as septic arthritis of the knee.

Clinical predictors of influenza in children.

BACKGROUND: It is difficult to diagnose influenza infection on clinical grounds alone. Available rapid diagnostic tests have limited sensitivities. OBJECTIVE: To develop a prediction model that identifies children likely to have influenza infection. DESIGN: Prospective study. SETTING: Emergency department of a children's hospital. Patients All patients with a febrile respiratory illness during the influenza season of winter 2002 were eligible. A prospective sample of 128 children who were suspected of having influenza infection based on predetermined criteria was enrolled. Each patient received a nasal wash for viral culture. MAIN OUTCOME MEASURE: Clinical features that are most predictive of influenza infection in children. RESULTS: The mean +/- SD age of patients was 6.2 +/- 5.2 years; 50% were boys. Viral isolates included the following: influenza A, 45 patients (35%); influenza B, 13 (10%); other viruses, 10 (8%); negative results, 60 (47%). Demographic and clinical findings were not significantly different between the influenza A and influenza B groups. Cough (P =.003), headache (P =.04), and pharyngitis (P =.04) were independently associated with influenza infection. This triad used as a prediction model for influenza infection had a sensitivity of 80% (95% confidence interval [CI], 69%-91%); specificity, 78% (95% CI, 67%-89%); and likelihood ratio for a positive viral culture for influenza, 3.7 (95% CI, 2.3-6.3). The posttest probability of this clinical definition is 77% (95% CI, 63%-91%). CONCLUSION: The triad of cough, headache, and pharyngitis is a predictor of influenza infection in children.

Influenza a in young children with suspected respiratory syncytial virus infection.

OBJECTIVES: To determine the prevalence of influenza A in young children suspected of having respiratory syncytial virus (RSV) infection and to compare the clinical presentation of these patients with those who have proven RSV infection. METHODS: Children younger than or at 36 months of age who presented to a pediatric emergency department (ED) with suspected RSV infection during the influenza A season of 2001-2002 were eligible. Eligible children had an RSV antigen test ordered as part of their initial clinical management. A consecutive sample of children was enrolled for prospective observational analysis. The main outcome measure was the prevalence of influenza A in young children with suspected RSV infection. The secondary outcome measure was a comparison of the clinical presentations, of the two groups. RESULTS: During the study period, 420 patients presented for evaluation of respiratory illness. RSV tests were ordered on 251 patients. Of 197 eligible patients, 124 (63%) tested positive for RSV and 33 (17%) for influenza A. Influenza A patients were more likely to have temperatures at or above 39 degrees C than RSV patients (36% vs. 15%; p = 0.01). RSV patients were more tachypneic (54 vs. 43 breaths/minute; p < 0.0001) and more often had wheezing (90% vs. 8%; p < 0.0001). Twenty influenza patients (61%) were hospitalized. CONCLUSIONS: This study found a high prevalence of influenza A in young children suspected of having RSV infection. Clinicians should consider influenza A in young febrile children presenting with respiratory illnesses.

Pulmonary function tests in emergency department pediatric patients with acute wheezing/asthma exacerbation.

Background. Pulmonary function tests (PFT) have been developed to analyze tidal breathing in patients who are minimally cooperative due to age and respiratory status. This study used tidal breathing tests in the ED to measure asthma severity. Design/Method. A prospective pilot study in pediatric patients (3 to 18 yrs) with asthma/wheezing was conducted in an ED setting using respiratory inductance plethysmography and pneumotachography. The main outcome measures were testing feasibility, compliance, and predictive value for admission versus discharge. Results. Forty patients were studied, of which, 14 (35%) were admitted. Fifty-five percent of the patients were classified as a mild-intermittent asthmatic, 30% were mild-persistent asthmatics, 12.5% were moderate-persistent asthmatics, and 2.5% were severe-persistent. Heart rate was higher in admitted patients as was labored breathing index, phase angle, and asthma score. Conclusions. Tidal breathing tests provide feasible, objective assessment of patient status in the enrolled age group and may assist in the evaluation of acute asthma exacerbation in the ED. Our results demonstrate that PFT measurements, in addition to asthma scores, may be useful in indicating the severity of wheezing/asthma and the need for admission.