Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs.

BACKGROUND: Vital signs (VS) are used to triage and identify children at risk for severe illness. Few studies have examined the association of pediatric VS at emergency department (ED) discharge with patient outcomes. OBJECTIVE: To determine if children discharged from the ED with abnormal VS have high rates of return visits, admission or adverse outcomes. METHODS: We conducted a retrospective cohort study of children discharged from 2 pediatric EDs with abnormal VS between July 2018-June 2019. We queried electronic health records (EHR) for children ages 0-18 years discharged from the ED with abnormal last recorded VS. VS were considered erroneously entered and thus excluded from analysis if heart rate was <30 or ≥ 300, respiratory rate was 0 or ≥ 100 or oxygen saturation was <50. Patients who were declared deceased at index visit were excluded. Demographic, clinical, and outcome data including return visits within 48 h and adverse outcomes after the initial ED discharge were obtained. RESULTS: Of the 97,824 children evaluated in the EDs during the study period, 17,661 (18.1%) were discharged with abnormal VS. 404 (2.28%) returned to the ED, of which 95 (23.5%) were admitted for the same chief complaint within 48 h. In comparison, the 48-h return rate for children discharged with normal VS was 2.45% (p = 0.219). Children discharged with abnormal VS were more likely to return if they had 2 or more abnormal VS (OR 1.6; 95% CI 1.23-2.07), were less than 3 years old (OR 1.69, 95% CI 1.39-2.06) or their initial acuity level was high (OR 1.34; 95% CI 1.1-1.63). Higher initial acuity level and age less than 3 years were also associated with admission at revisit (OR 2.58; 95% CI 1.59-4.2; OR 2.20, 95% CI 1.36-3.55). Four of the children who returned required PICU admission, but none died, required CPR or endotracheal intubation. CONCLUSION: Although many children were discharged from the ED with abnormal VS, few returned and required admission. Having 2 or more abnormal VS, age less than 3 years and higher acuity increased odds of revisit. Few children suffered serious adverse outcomes.

Pediatric Malpractice Claims in the Emergency Department and Urgent Care Settings From 2001 to 2015.

OBJECTIVES: This study aimed to provide an assessment of medical malpractice claims involving pediatric patients cared for in emergency department and urgent care settings. METHODS: We performed a retrospective review of all closed malpractice claims involving children (0-17 years old) originating from emergency department or urgent care centers from the Physician Insurers Association of America's Data Sharing Project database for a 15-year period (2001-2015). Reported data collected include medical specialty involved, medical diagnoses, chief medical factors, severity of resulting injury, claim disposition, average indemnity, and average defense costs. RESULTS: A total of 728 closed claims in pediatric emergency care settings were reviewed. Money was paid to the claimant in 30% of cases (220/728), with a total of US $70.3 million (average $319,513) paid to patients or families during the 15-year period. The most common resulting medical conditions were cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs. Error in diagnosis was the most common chief medical factor (41%), whereas those that involved failure or delay in admission to the hospital, which was the eighth most common chief medical factor, resulted in the highest average indemnity. Of the 728 closed claims, 220 involved a patient death (30%), but claims involving major permanent injury more often resulted in a payment. Of the 57 cases that went to trial, verdicts favored the physician in 47 cases (82%). CONCLUSIONS: Cardiac conditions, appendicitis, and disorder of the male genital organs are the most common medical conditions, and error in diagnosis is the most common chief medical factor in pediatric emergency care malpractice suits. It is important for providers practicing in these settings to be familiar with the common diagnoses and chief medical factors involved in these claims.

Pediatric Heatstroke Fatalities Caused by Being Left in Motor Vehicles.

OBJECTIVES: Fatalities due to being left in motor vehicles is an important cause of pediatric mortality. Few studies in the medical literature focus on this topic. This study aims to describe the circumstances surrounding these deaths, to determine their geographic distribution, and to evaluate the legal consequences for those responsible. METHODS: This is a retrospective cohort study of individuals ≤14 years old who died of heatstroke after being left in motor vehicles from 1990 through 2016 using a database provided by KidsAndCars.org. Descriptive data and specified outcomes regarding victims and responsible individuals were recorded. RESULTS: Of the 541 cases included for analysis, 528 fatalities involved a single victim and 26 fatalities involved 2 or more victims left in a vehicle. Of all fatalities, 54.4% were male and the mean age was 16.4 (±13.7) months. The responsible individual(s) unknowingly left the victim(s) in the vehicle in 78.2% of cases and knowingly left the victim(s) in 16.6% of cases. A single individual was responsible for leaving the victim(s) in 88.9% of cases. The cases were noted in 45 of 50 states and most commonly occurred in Texas (15%), Florida (12%), and California (7%). Criminal charges against the responsible individual(s) occurred in 58.2% of cases. CONCLUSIONS: Pediatric fatalities due to being left in motor vehicles most commonly occur when a caregiver leaves a child unknowingly in a home parking area. These fatalities occur most often in Texas, Florida, and California. Responsible individuals are frequently charged with a crime.

Medical Errors and Malpractice Lawsuits: Impact on Providers- Part 2 of 6.

Every pediatric emergency medicine provider will be involved in medical errors during their career and many will face the prospect of at least one malpractice lawsuit. These events can cause significant stress, including detrimental effects on providers' mental and physical health. This stress may also impact the provider's ability to care for future patients. In this installment of our series, "A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress," we examine how medical errors and malpractice lawsuits may affect providers and how individuals and organizations can address these events.

A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress-Part 1 of 6.

Few practicing emergency physicians will avoid life-changing stressors such as a medical error, personal illness, malpractice litigation, or death of a patient. Many will be unprepared for the toll they will take on their lives. Some may ultimately experience burnout, post-traumatic stress disorder, and suicidal ideation. Medical education, continuing education, and maintenance of certification programs do not teach physicians to recognize helplessness, moral distress, or maladaptive coping mechanisms in themselves. Academic physicians receive little instruction on how to teach trainees and medical students the art of thriving through life-changing stressors in their career paths. Most importantly, handling a life-changing stressor is that much more overwhelming today, as physicians struggle to meet the daily challenge of providing the best patient care in a business-modeled health care environment where profit-driven performance measures (eg, productivity tracking, patient reviews) can conflict with the quality of medical care they wish to provide.Using personal vignettes and with a focus on the emergency department setting, this 6-article series examines the impact life-changing stressors have on physicians, trainees, and medical students. The authors identify internal constraints that inhibit healthy coping and tools for individuals, training programs, and health care organizations to consider adopting, as they seek to increase physician satisfaction and retention. The reader will learn to recognize physician distress and acquire strategies for self-care and peer support. The series will highlight the concept that professional fulfillment requires ongoing attention and is a work in progress.

Meaningful Work, Career Fit, and Professional Well-Being of Pediatric Academicians in the United States.

OBJECTIVE: Examine associations between time spent in academic activities perceived as meaningful and professional well-being among academic pediatrics faculty. METHODS: The sample comprised 248 full-time pediatric faculty (76% female, 81% white, non-Hispanic, 41% instructor or assistant professor) across the United States who completed an online survey in November 2019. Survey items included sociodemographic and professional characteristics, professional well-being measures (Stanford Professional Fulfillment Index; Maslach Burnout Inventory; Intention to Leave Academic Medicine), perceived meaningfulness of academic activities and assigned time to those activities. We defined global career fit as total percentage time assigned to professional activities considered meaningful by individuals, and activity-specific career fit as percentage time assigned to each meaningful professional activity. RESULTS: As global career fit scores increased, professional fulfillment increased (r = 0.45, P < .001), whereas burnout (r = -0.29, P < .001) and intention to leave (r = -0.22, P < .001) decreased. Regarding activity-specific career fit, for individuals who considered patient care meaningful, as assigned time to patient care increased, professional fulfillment decreased (r = -0.14, P = .048) and burnout (r = 0.16, P = .02) and intention to leave (r = 0.26, P < .001) increased. There was no significant correlation between assigned time for teaching, research, or advocacy and professional well-being. Faculty were less likely to intend to leave academic medicine as assigned time increased for administrative or leadership activities if considered meaningful (r = -0.24, P = .01). CONCLUSIONS: Time assigned to meaningful work activities may relate to professional well-being of academic pediatrics faculty. More time assigned to patient care, despite being meaningful, was associated with poor self-reported professional well-being. Effort allocation among diverse academic activities needs to be optimized to improve faculty well-being.

Adequacy of informed consent for lumbar puncture in a pediatric emergency department.

OBJECTIVE: To determine whether informed consent is adequately obtained by documentation of appropriate risks, benefits, alternatives, and procedure explanation for children who had a lumbar puncture (LP) in a pediatric emergency department (PED). METHODS: Authors agreed on the criteria for appropriate informed consent for LP, including risks and benefits of the procedure, alternatives to doing the procedure, explanation of the procedure including the purpose of the LP, and a signature of a witness. A retrospective chart review was done for all children who had LP during a 1-year period in a PED. Information documented on a general procedure consent form was analyzed. RESULTS: There were 336 patients who had LP in the PED during a 1-year period. Mean (SD) age of patients was 37.8 (61.9) months (median age, 1.6 months), and 56.5% were boys. Consent was obtained by attending physicians (18.9%), pediatric emergency medicine fellows (7.1%), residents (73.6%), and medical students (0.3%). Documented risks of the LP included back pain (19.3%), infection (88.2%), bleeding (86.5%), apnea for infants 1 year or younger (9.5%), and post-LP headache for children 10 years and older (44.9%). Benefits of the procedure were documented for 36.1%, alternatives for 12.5%, explanation of the procedure for 45.9%, purpose for 94.3%. There was no statistically significant difference for training level of person obtaining consent and risks documented. However, pediatric emergency medicine fellows documented benefits more frequently (P = 0.005), residents documented alternatives more frequently (P = 0.006), and attending physicians documented explanation of the procedure more frequently (P = 0.005). CONCLUSIONS: Risks, benefits, alternatives, and explanation of the LP procedure are not adequately documented on consent forms in the PED. Although the actual discussion with guardians is unknown, these data imply that informed consent may not have been properly obtained before the LP was performed. In the event of a complication and subsequent malpractice lawsuit, clinicians may be unable to demonstrate they adequately informed a guardian about the LP.

Chest pain and chest wall deformity.

Chest pain and chest wall deformities are common in children. Although most children with chest pain have a benign diagnosis, some have a serious etiology for pain, so the complaint must be addressed carefully. Unfortunately, there are few prospective studies to evaluate this complaint in children. Serious causes for chest pain are rare, making it difficult to develop clear guidelines for evaluation and management. The child who appears well, has a normal physical examination, and lacks worrisome history deserves reassurance and careful follow-up rather than extensive studies. Multicenter studies are needed to better define this important symptom.

Pediatric myocarditis: presenting clinical characteristics.

OBJECTIVE: The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis. METHODS: A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes. RESULTS: A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results. CONCLUSIONS: These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.