Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Process and Impact of Development of an Adolescent Emergency Psychiatry Unit at a Large Urban Hospital.

OBJECTIVES: Boarding of adolescent patients with mental health concerns requiring ongoing observation and treatment is of increasing concern across US emergency departments. The objective was a proof of concept of developing an adolescent psychiatric emergency unit and assessment of the impact of this unit on lengths of stay (LOS). METHODS: We describe the creation of the unit designed to allow safe assessment and boarding of patients, and appropriate interventions and services, while arranging transfer to inpatient facility or safe discharge home. Using a precreation and postcreation analysis and comparison with a similar facility that did not create such a unit, we utilized linear regression to investigate the primary outcome of total length of stay and secondary outcomes of psychiatric emergency department and pediatric emergency department length of stay for both unit-eligible patients and all patients. RESULTS: The overall length of stay was not associated with a statistically significant change for unit-eligible patients; however, there was a significant decrease in the pediatric emergency department LOS for unit-eligible patients. This was associated with a decrease in beds lost to boarding in the pediatric emergency department of 544 hours per month. CONCLUSIONS: Creation of an adolescent psychiatric emergency unit without allotment of significant additional resources is an option to decrease pediatric emergency department boarding times for adolescent patients requiring ongoing emergent therapy for mental health concerns.

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

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

ACEP SimBox: A Pediatric Simulation-Based Training Innovation.

Thirty million pediatric visits (<18 years old) occur across 5,000 US emergency departments (EDs) each year, with most of these cases presenting to community EDs. Simulation-based training is an effective method to improve and sustain EDs' readiness to triage and stabilize critically ill infants and children, but large simulation centers are mostly concentrated at academic hospitals. The use of pediatric simulation-based training has been limited in the community ED setting due to the high cost of equipment and limited access to content experts in pediatric critical care. We designed an innovative "off-the-shelf" simulation-based training resource, "American College of Emergency Physicians (ACEP) SimBox," that provides a free low-technology manikin along with teaching aids and train-the-trainer materials to community EDs to run a simulation drill in their own workspaces with local educators. The goal was to develop an "off-the-shelf," free, open-access, simulation-based resource to improve the readiness of community EDs to triage, resuscitate, and transfer critically ill infants as measured by presimulation and postsimulation surveys measuring opinions regarding the scenario, session experience, and most valuable aspect of the session. Between January 2018 and December 2019, 179 ACEP SimBoxes were shipped across the United States, reaching 36 of 50 states. Facilitators and participants who completed the postsimulation survey evaluated the session as a valuable use of their time. All facilitator respondents reported that the low-technology manikins, paired with their institution-specific equipment, were sufficient for learning, thus reducing costs. All participant respondents reported an increased commitment to pediatric readiness for their ED after completing the simulation session. This innovation resulted in the implementation of a unique simulation-based training intervention across many community EDs in the United States. The ACEP SimBox innovation demonstrates that an easy to use and unique simulation-based training tool can be developed, distributed, and implemented across many community EDs in the United States to help improve community ED pediatric readiness.

Prevalence of marijuana use among trauma patients before and after legalization of medical marijuana: The Arizona experience.

BACKGROUND: In recent years, marijuana has become legal for use in many states, for either medicinal or recreational purposes. Objective: The primary objective is to determine if legalization of medical marijuana is associated with an increased use among trauma patients. Methods: Prospective observational study included three periods; (pre-legalization; period 1); legal to grow for medicinal purposes but no dispensaries open (period 2); and legal to purchase medicinal marijuana in a dispensary (period 3). The study included all adult trauma patients presenting to an urban level I trauma center in Phoenix, AZ. The prevalence of use (as defined by positive urine drug screen or self-reporting) in each time period was determined and compared using two sample tests of proportion. Confidence intervals for prevalence (self-reporting only) were compared with published age matched data from the same geographical region of the general population. Results: The prevalence of marijuana use increased significantly from pre-legalization (period 1) to post legalization (periods 2 and 3), but there was no significant change between the two post legalization periods. After controlling for age and sex, the odds of being marijuana positive post-legalization vs. pre-legalization was 1.36, p = 0.006 95%CI [1.09-1.7]. Overall, the prevalence of marijuana among trauma patients was nearly four-fold higher than the population as a whole in the same geographic region. Patients who use marijuana are more likely to use cocaine or amphetamine (OR 2.31; 95% CI 1.86-2.89) or had an ethanol level above 80 mg/dL (OR 1.57; 95% CI 1.32-1.87). Conclusion: The legalization of medicinal marijuana is associated with significantly increased prevalence among trauma patients. It appears that legalization, rather than the convenience of dispensaries, is associated with an increase in use.

Decline in Pediatric Emergency Department Behavioral Team Activations After Institution of an Agitation Protocol.

OBJECTIVE: Aggressive behavior among pediatric patients with psychiatric complaints in emergency departments is a growing problem. An agitation protocol was instituted in 1 pediatric emergency department to provide scaled recommendations for differing levels of aggression. The study objective was to determine if the frequency of activation of an emergency behavioral response team changed after protocol initiation. METHODS: A protocol for escalating management of agitation in pediatric patients was introduced in February 2016. The electronic medical record was queried for subsequent behavioral response team activations over the next 16 months. Patient demographics and specific features surrounding the activation were retrospectively recorded from the medical record, including length of stay, medications administered, and documented deescalation techniques. Frequency and features of behavioral team activations were compared with activations from a period before the planning and implementation of the protocol (May 2014 to May 2015). RESULTS: Twenty-one patient visits were found to require behavioral response team activation over 16 months, compared with 31 for the 13-month preprotocol period. Attempts at verbal/ environmental redirection were seen in 77% and deescalation by medication administration before the activation occurred in 14% of patients. During the behavioral team activation, 81% of the patients were given psychiatric medications and 81% were placed in physical restraints. CONCLUSIONS: A decrease from a baseline of 2.4 to 1.3 behavioral response team activations per month, or a 46% decline, was noted following the institution of a clinical protocol for pediatric agitation.

Occult Pneumothorax Identification on Extended Focused Assessment with Sonography for Trauma Examination in Children.

OBJECTIVE: Occult pneumothoraces (OPTXs) are defined by air within the pleural space that is not visible on conventional chest radiographs (CXR). The aim of this study was to understand how frequently the Extended Focused Assessment with Sonography for Trauma (eFAST) examination identifies occult PTX in a pediatric blunt trauma population as compared with a criterion standard of chest computed tomography (CCT). METHODS: This study is a secondary analysis of blunt trauma patients younger than 18 years who underwent CCT at Los Angeles County +USC Medical Center Emergency Department from October 2015 to April 2017. The eFAST examination was performed and documented by an emergency medicine resident with attending oversight or by an emergency medicine attending for each trauma. The eFAST results were reviewed for patients diagnosed with small or trace pneumothoraces identified on CCT. RESULTS: Of 168 pediatric trauma patients undergoing CCT, 16 had OPTXs not seen on CXR and 4 patients had a small/trace PTX without a corresponding CXR performed. None were identified on eFAST. CONCLUSIONS: Although the sample size in this data set was small, our eFAST examinations identified none of 16 proven and 4 presumed OPTXs. The standard eFAST examination performed poorly in the detection of OPTXs in this single-center study of pediatric blunt trauma victims.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

BACKGROUND: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. METHODS: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. RESULTS: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001). CONCLUSIONS: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Review of Interventions and Radiation Exposure from Chest Computed Tomography in Children with Blunt Trauma.

OBJECTIVE: To determine the radiation risk to a child undergoing trauma evaluation with chest computed tomography (CCT) for every clinically actionable injury identified. STUDY DESIGN: This observational, cross-sectional study included all blunt trauma patients under 18 years of age undergoing CCT in a single urban emergency department. Via a retrospective chart review, therapeutic interventions done exclusively for chest injuries identified on CCT scan were identified. Effective radiation from each CCT was calculated and averaged and the dose required to diagnose 1 management-changing chest injury was determined. RESULTS: Of 209 children undergoing CCT over a 19-month period, 168 were victims of blunt trauma. Ten required an intervention specifically for a chest injury identified on CCT (suggesting development of 1 malignancy per 37 actionable injures identified). None required an intervention for an injury exclusively noted on CCT, as all 10 actionable injuries were apparent via other modalities (radiograph, ultrasound examination, clinical examination). CONCLUSION: Although 10 uniquely actionable injuries were identified on CCT, none were found only on CCT. Because CCTs rarely modified management, the amount of radiation administered per management change was sufficiently high to recommend reconsideration of current imaging practice in this single-center study.

The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants.

OBJECTIVE: The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels. METHODS: This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports. RESULTS: Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%). CONCLUSIONS: The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.

Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study.

OBJECTIVES: Computed tomography is the criterion standard imaging modality to detect intracranial hemorrhage (ICH) in children and infants after closed head injury, but its use can be limited by patient instability, need for sedation, and risk of ionizing radiation exposure. Cranial ultrasound is used routinely to detect intraventricular hemorrhage in neonates. We sought to determine if point-of-care (POC) cranial ultrasound performed by emergency physicians can detect traumatic ICH in infants. METHODS: Infants with ICH diagnosed by computed tomography were identified. For every infant with an ICH, 2 controls with symptoms and diagnoses unrelated to head trauma were identified. Point-of-care cranial ultrasound was performed by an emergency physician on all patients, and video clips were recorded. Two ultrasound fellowship-trained emergency physicians, blinded to the patients' diagnosis and clinical status, independently reviewed the ultrasound clips and determined the presence or absence of ICH. RESULTS: Twelve patients were included in the study, 4 with ICH and 8 controls. Observer 1 identified ICH with 100% sensitivity (95% confidence interval [CI], 40%-100%) and 100% specificity (95% CI, 60%-100%). Observer 2 identified ICH with 50% sensitivity (95% CI, 9%-98%) and 87.5% specificity (95% CI, 47%-99%). Agreement between observers was 75%, κ = 0.4 (P = 0.079; 95% CI, 0-0.95). CONCLUSIONS: Traumatic ICH can be identified with POC cranial ultrasound by ultrasound fellowship-trained emergency physicians. Although variations between observers and wide confidence intervals preclude drawing meaningful conclusions about sensitivity and specificity from this sample, these results support the need for further investigation into the role of POC cranial ultrasound.

Reasons for Energy Drink Use and Reported Adverse Effects Among Adolescent Emergency Department Patients.

OBJECTIVES: There is concern of energy drink use by adolescents. The objective of this study was to evaluate the energy drink consumption use, frequency, age of first use, reasons for use, influences of choice of brand, and adverse events recorded in a predominant Latino adolescent population. METHODS: Subjects between the ages of 13 and 19 years utilizing emergency department services for any reason at a large county hospital answered a questionnaire about energy drink usage. RESULTS: There were 192 subjects, of which 49% were male and 51% were female. Latino adolescents were 85% of the participants, although other ethnic groups participated including African American, white, and Asian. Reasons for use include 61% to increase energy, 32% as study aide, 29% to improve sports performance, and 9% to lose weight. Twenty-four percent reported using energy drinks with ethanol or illicit drugs including marijuana, cocaine, and methamphetamine. Adverse reactions were reported in 40% of the subjects including insomnia (19%), feeling "jittery" (19%), palpitations (16%), gastrointestinal upset (11%), headache (8%), chest pain (5%), shortness of breath (4%), and seizures (1%). CONCLUSIONS: Both brand name and packaging influenced the choice of energy drink in most subjects. Forty percent reported at least 1 adverse effect. While most adverse effects were not severe, a small number are serious. In addition, we showed intentional ingestion with ethanol and illicit drugs. Of additional concern is that both brand and packaging seem to directly affect choice of energy drink consumed.

Brief resolved unexplained event: New diagnosis in infants.

QUESTION: For many years, the term apparent life-threatening event (ALTE) was associated with sudden infant death syndrome, and parents who described an acute event in their infants were sent to the hospital for admission. I understand that for infants new terminology is recommended. What is the current approach to a near-death experience of an infant? ANSWER: A recent clinical practice guideline revised the name and definition of an ALTE to a brief resolved unexplained event (BRUE). The diagnosis of BRUE in infants younger than 1 year of age is made when infants experience 1 of the following BRUE symptoms: a brief episode (ie, less than 1 minute and usually less than 20 to 30 seconds) that is entirely resolved (infant is at baseline), which remains unexplained after the history and physical examination are completed, and includes an event characterized by cyanosis or pallor; absent, decreased, or irregular breathing; hypertonia or hypotonia; or altered responsiveness. Low-risk infants should not be admitted to the hospital and overtesting is discouraged.

Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool.

BACKGROUND: Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as over-triage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality. At this time, there is no validation tool specifically developed for the pediatric population to test an MCI algorithm's inherent capabilities to correctly triage children. OBJECTIVE: To develop a set of criteria for outcomes and interventions to be used as a validation tool for testing an MCI algorithm's ability to correctly triage patients from a cohort of pediatric trauma patients. METHODS: Expert opinion and literature review was used to formulate an initial Criteria Outcomes Tool (COT) that retrospectively categorizes pediatric (≤14 years of age) MCI victims based on resource utilization and clinical outcomes using the classic Red to Black MCI triage designations: Red - cardiopulmonary or mental status compromise needing intervention, Yellow - stable cardiopulmonary status but may require life or limb therapy, Green - minimally injured, and Black - deceased or likely to die given the circumstances. Using an anatomic approach, a list of criteria were defined and a modified-Delphi approach was used to create a summative COT that was reviewed by the American Academy of Pediatrics Disaster Preparedness Advisory Council. The resulting COT was independently applied to a weighted retrospective cohort of 25 pediatric victims from a single Level I trauma center by two reviewers to determine reproducibility. RESULTS: We created a Criteria Outcomes Tool (COT) with 47 outcomes and interventions to validate an MCI algorithm's triage designation. When the COT was applied to a cohort of 25 weighted pediatric charts, we identified the following resource utilization and outcome based triage designations: six Red, six Yellow, six Green, and seven Black triage outcomes. The 100% agreement was obtained between the two reviewers in each of the four categories. CONCLUSIONS: We designed an outcomes and resource utilization tool, the COT, to evaluate the ability of an MCI algorithm to correctly triage pediatric patients. Our tool has good reproducibility on initial study. KEY WORDS: pediatric; disaster; validation tools; triage algorithms; emergency.

The Flipped Classroom in Emergency Medicine Using Online Videos with Interpolated Questions.

BACKGROUND: Utilizing the flipped classroom is an opportunity for a more engaged classroom session. This educational approach is theorized to improve learner engagement and retention and allows for more complex learning during class. No studies to date have been conducted in the postgraduate medical education setting investigating the effects of interactive, interpolated questions in preclassroom online video material. OBJECTIVES: We created a flipped classroom for core pediatric emergency medicine (PEM) topics using recorded online video lectures for preclassroom material and interactive simulations for the in-classroom session. METHODS: Lectures were filmed and edited to include integrated questions on an online platform called Zaption. One-half of the residents viewed the lectures uninterrupted (Group A) and the remainder (Group B) viewed with integrated questions (2-6 per 5-15-min segment). Residents were expected to view the lectures prior to in-class time (total viewing time of approximately 2½ h). The 2½-h in-class session included four simulation and three procedure stations, with six PEM faculty available for higher-level management discussion throughout the stations. Total educational time of home preparation and in-class time was approximately 5 h. RESULTS: Residents performed better on the posttest as compared to the pretest, and their satisfaction was high with this educational innovation. In 2014, performance on the posttest between the two groups was similar. However, in 2015, the group with integrated questions performed better on the posttest. CONCLUSION: An online format combined with face-to-face interaction is an effective educational model for teaching core PEM topics.

Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis?

BACKGROUND: Acute appendicitis is the most common cause of acute abdomen in pediatric emergency department (ED) visits, and right lower quadrant abdominal ultrasound (RLQUS) is a valuable diagnostic tool in the clinical approach. The utility of ultrasound in predicting perforation has not been well-defined. OBJECTIVES: We sought to determine the sensitivity of RLQUS to identify perforation in pediatric patients with appendicitis. METHODS: A chart review of all patients 3 to 21 years of age who received a radiographic work-up and who were ultimately diagnosed with perforated appendicitis between 2010 and 2013 at a pediatric ED was conducted. The final read for ultrasonography was compared to either the operative diagnosis, surgical pathology diagnosis, or further imaging results (if the patient was managed nonoperatively). Test characteristics were calculated for the identification of appendicitis and identification of perforation. RESULTS: Of the 539 patients evaluated for appendicitis, 144 (26.7%) patients had appendicitis, and 40 of these (27.8%) were perforated. Thirty-nine had RLQUS performed as part of their evaluation. Of these, 28 had positive findings for appendicitis, and 9 were read as definite or possible perforated appendicitis. The sensitivity of RLQUS for the diagnosis of appendicitis in the group with perforation was 77.1% (95% confidence interval [CI], 59.4-89%) and the sensitivity for diagnosing a perforation was 23.1% (95% CI, 11.1-39.3%). CONCLUSION: There was a low rate of detection of perforation by RLQUS in our pediatric population. If larger studies confirm this, additional imaging should be recommended in patients with a high suspicion of perforation and in whom a diagnosis of perforation would change management.

Do emergency pediatric psychiatric visits for danger to self or others correspond to times of school attendance?

BACKGROUND: Pediatric and adolescent mental health complaints are growing problems for emergency departments and inpatient facilities. We sought to investigate the relationship between weeks when school is in session (vs vacation) and presentation with concern for danger to self or others. METHODS: We retrospectively studied the risk of presenting with these complaints while school is in attendance compared to the risk while on vacation over a 4-year period (2009-2012) at an academic pediatric emergency department. The week of presentation was recorded for all children making psychiatric visits related to suicidality or homicidality, and these were correlated with the public school calendar for the local school district. The incidence rate ratio (IRR) was calculated for psychiatric visits while in school status vs vacation. Similar data were collected for a diagnosis of urinary tract infection to serve as a control. RESULTS: Of 3223 eligible patients (mean age, 13.8 years), 82.7% presented while in school, although the students only spent 68.6% of their time in school, yielding an IRR of 2.18. By comparison, the IRR for the diagnosis of urinary tract infection was 1.25. CONCLUSIONS: Children and adolescents are more likely to present with concerns for danger to self or others while attending school compared with while on vacations. Causation and opportunities for intervention require further study.

Does Combined Use of the J-tip® and Buzzy® Device Decrease the Pain of Venipuncture in a Pediatric Population?

BACKGROUND: Both the J-tip® (a needle-free device for subcutaneous delivery of lidocaine) and the Buzzy® (a cooled, vibrating device to employ gate control to minimize procedural pain) have shown some efficacy in diminishing the pain of venipuncture. PURPOSE: To develop an optimal protocol for pre-venipuncture/IV start pain management by investigating the impact of adding the use of Buzzy® prior to the use of the J-tip®. PROCEDURES: Pediatric emergency department patients aged 1 month to 21 years were prospectively enrolled in Phase 1 (J-tip® only) then Phase 2 (Buzzy®+J-tip®) for analgesia prior to venipuncture or IV start. Age-appropriate pain scale scores were collected for the subsequent procedure, as well the administration of lidocaine via J-tip®. MAIN FINDINGS: With the combined intervention (phase 2), 14.2% of patients had a pain scale score >3 with venipuncture and 16.1% had a pain scale score >3 with application of the J-tip® itself. With no intervention for pain relief, 71% of patients experienced a pain scale score >3 for venipuncture. With the J-tip® alone (phase 1), 21% had a pain scale score >3 with venipuncture and 22.3% had a pain scale score >3 with application of the J-tip® itself. CONCLUSIONS: Patients receiving either intervention reported lower scores on pain scales during venipuncture or IV start than the no analgesia group. The combined intervention did not yield a significant decrease in scores on pain scale scores over the J-tip® alone.

Should infants presenting with an apparent life-threatening event undergo evaluation for serious bacterial infections and respiratory pathogens?

We sought to identify which patients with an apparent life-threatening event require infectious evaluation through an analysis of infants aged ≤12 months brought to an emergency department with an apparent life-threatening event. Among the 533 children evaluated, there were no cases of meningitis, 1 case of bacteremia, 17 cases of urinary tract infection, 22 cases of bacterial pneumonia, 22 cases of respiratory syncytial virus, and 2 cases of influenza virus identified in respiratory specimens.

Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance.

STUDY OBJECTIVE: We assess whether screening laboratory tests obtained to medically clear pediatric psychiatric patients altered management or disposition. METHODS: This was a retrospective chart review of consecutive patients younger than 18 years and presenting to an academic pediatric emergency department for medical clearance of an acute psychiatric emergency potentially requiring an involuntary hold (danger to self, danger to others, grave disability) from July 2009 to December 2010. Patients were identified by discharge diagnosis codes. History and physical examination and screening laboratory tests were reviewed for changes in management or disposition. Further analysis compared length of stay according to type of laboratory test performed. To avoid missing patients presenting with or for evaluation of an involuntary hold for whom an organic cause was diagnosed, charts with psychiatric chief complaints were reviewed for the same period. RESULTS: One thousand eighty-two visits resulting in 13,725 individual laboratory tests were analyzed. Of 871 visits with laboratory tests performed, abnormal laboratory tests were associated with 7 disposition changes (0.8%) and 50 management changes (5.7%) not associated with a disposition change. Twenty-five patients with noncontributory history and physical examination results had management changes, all non-urgent. One patient with a noncontributory history and physical examination result had a disposition-changing laboratory result, a positive urine pregnancy test. Patients who had any screening test performed had a longer length of stay than patients without testing (117 minutes longer; 95% confidence interval 109.7 to 124.4 minutes). In charts reviewed according to chief complaint, no patient was found to have an organic cause of their symptoms according to only screening tests. CONCLUSION: Screening laboratory tests resulted in few management and disposition changes in patients with noncontributory history and physical examination results but were associated with increased length of stay.