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.

Comparative Cost of Virtual Reality Training and Live Exercises for Training Hospital Workers for Evacuation.

Adoption of virtual reality technology may be delayed due to high up-front costs with unknown returns on that investment. In this article, we present a cost analysis of using virtual reality as a training tool. Virtual reality was used to train neonatal intensive care workers in hospital evacuation. A live disaster exercise with mannequins was also conducted that approximated the virtual experience. Comparative costs are presented for the planning, development, and implementation of both interventions. Initially, virtual reality is more expensive, with a cost of $229.79 per participant (total cost $18 617.54 per exercise) for the live drill versus $327.78 (total cost $106 951.14) for virtual reality. When development costs are extrapolated to repeated training over 3 years, however, the virtual exercise becomes less expensive with a cost of $115.43 per participant, while the cost of live exercises remains fixed. The larger initial investment in virtual reality can be spread across a large number of trainees and a longer time period with little additional cost, while each live drill requires additional costs that scale with the number of participants.

Effectiveness of positive pressure ventilation during newborn care unit evacuation.

OBJECTIVE: Assess the utility of high fidelity simulation in understanding effectiveness of bag-valve ventilation in a simulated newborn intensive care unit vertical evacuation. PARTICIPANTS: A total of 70 participants, (13 teams of 4-6 staff) including physicians, nurses, respiratory therapists and other support personnel participated in a 90-min evacuation sessions. METHODS: Two wireless high-fidelity newborn mannequins (Gaumand ScientificR) provided real-time data of ventilation support during a NICU evacuation exercise. Trained evaluators also recorded data related to performance. Following the exercises, the simulator data were downloaded and analyzed for rate and consistency of respirations. RESULTS: Using the data from the simulators and evaluator comments, it was found the infants received proper airway management during the evacuation only 58% of the time. This study highlights the need for ongoing training for NICU staff around safe, effective, coordinated, and timely care of these fragile newborns in the event of an evacuation.

Intravenous migraine therapy in children with posttraumatic headache in the ED.

BACKGROUND: More than 3.8 million children sustain traumatic brain injuries annually. Treatment of posttraumatic headache (PTH) in the emergency department (ED) is variable, and benefits are unclear. OBJECTIVE: The objective of the study is to determine if intravenous migraine therapy reduces pain scores in children with PTH and factors associated with improved response. METHODS: This was a retrospective study of children, 8 to 21 years old, presenting to a tertiary pediatric ED with mild traumatic brain injury (mTBI) and PTH from November 2009 to June 2013. Inclusion criteria were mTBI (defined by diagnosis codes) within 14 days of ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Primary outcome was treatment success defined by greater than or equal to 50% pain score reduction during ED visit. Bivariate analysis and logistic regression were used to determine predictors of treatment success: age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics. RESULTS: A total of 254 patients were included. Mean age was 13.8 years, 51% were female, 80% were white, mean time since injury was 2 days, and 114 patients had negative head CTs. Eighty-six percent of patients had treatment success with 52% experiencing complete resolution of headache. Bivariate analysis showed that patients who had a head CT were less likely to respond (80% vs 91%; P = .008). CONCLUSIONS: Intravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI. Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.

Methicillin-resistant Staphylococcus aureus: decolonization and prevention prescribing practices for children treated with skin abscesses/boils in a pediatric emergency department.

OBJECTIVE: This study aimed to describe methicillin-resistant Staphylococcus aureus (MRSA) eradication/prevention practices of clinicians managing patients with skin and soft tissue infections (SSTIs), specifically, in those patients undergoing abscess incision and drainage (I&D) in a pediatric emergency department (ED). METHODS: A retrospective cohort study was performed for children aged 0 to 18 years old undergoing I&D of cutaneous abscess between January 1, 2011, and December 31, 2011, in the Cincinnati Children's Hospital Medical Center ED. RESULTS: Five hundred seventy-five patients underwent abscess I&D during our study period. Approximately 25% of our population had previous history of MRSA, SSTI, or boil/abscess; in addition, 26% of our population had a household family member with a previous history of MRSA, SSTI, or boil/abscess. Wound cultures were obtained in 399 (69%) of 575 of I&D abscesses, and of these, 57% of the I&D abscesses grew MRSA. Of all patients, only 3.7% (21 patients) had documentation of MRSA eradication/prevention instructions for patient/family. CONCLUSIONS: Methicillin-resistant S aureus eradication/prevention discussions are not commonly included in discharge instructions for patients undergoing abscess I&D. Given the significant proportion with previous MRSA infection, the ED may be a setting to provide instructions to patients/families with recurrent infections.

Chlorpromazine for the treatment of migraine in a pediatric emergency department.

BACKGROUND: Migraine headache is a common presenting condition to the pediatric emergency department (PED). Dopamine receptor antagonists, such as prochlorperazine and metoclopramide, serve as the primary treatment for migraine headache in many emergency departments; however, in 2012, our institution experienced a shortage of these drugs, resulting in the use of alternative medications. Chlorpromazine was included as an option for treatment at our institution during this shortage, although limited data exist on the effectiveness in children. OBJECTIVE: The objectives of this study were: (1) to compare the treatment failure rate of chlorpromazine in the treatment of migraine headache in youth presenting to the PED with those who received prochlorperazine; and (2) to identify the frequency and type of adverse events, and change in pain score. METHODS: We performed a retrospective cohort study of patients 12-21 years of age treated for migraine headache in our emergency department. Our treatment group received intravenous chlorpromazine between February and April 2012, while the comparison group consisted of children treated with intravenous prochlorperazine between February and April 2011. The outcomes of interest were: (1) treatment failure, defined as need for additional therapy, hospitalization or 48-hour return; (2) adverse reactions to drug therapy; and (3) change in pain score. RESULTS: This study yielded 75 patients in the treatment group and 274 in the comparison group. Forty percent (30/75) of the treatment group had treatment failure compared with 15% (41/274) of the comparison group. There was no difference in mean change in pain score between the groups. The most common adverse effects included hypotension in the treatment group (12%) and akathisia in the comparison group (12%). CONCLUSIONS: This is the first study that has examined the use of chlorpromazine as a therapy in pediatric migraines. Abortive therapy for migraine headache in the PED with chlorpromazine is associated with greater need for rescue medication and hospitalization, and higher rates of hypotension.

An atypical presentation of atypical Kawasaki disease.

Kawasaki disease (KD) is a well-known inflammatory disorder that, despite its classic description, can pose a diagnostic challenge. We report a case of a 3-year-old girl who presented to the emergency department with a limp and urinary incontinence who was ultimately diagnosed with KD. She was found to have a large coronary artery aneurysm on echocardiogram. We discuss the challenges in diagnosing incomplete KD.

Maternal use of oxycodone resulting in opioid intoxication in her breastfed neonate.

A 4-day-old breastfed infant presented with opioid intoxication resulting from the maternal use of oxycodone after cesarean delivery. The infant was hypothermic, lethargic, and had pinpoint pupils. A dose of naloxone reversed the symptoms. This report highlights the importance of recognizing the potential effects of maternal oxycodone on the breastfed neonate in the emergency department setting.

A comprehensive view of parental satisfaction with pediatric emergency department visits.

STUDY OBJECTIVE: We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data. METHODS: This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview-style question. RESULTS: Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview-style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their child's diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care. CONCLUSION: Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.

Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children.

Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children.

Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children.

Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Return visit characteristics among patients who leave without being seen from a pediatric ED.

OBJECTIVES: The primary aim of this study was to evaluate for differences in acuity level and rate of admission on return visit between patients who leave without being seen (LWBS) and those who are initially evaluated by a physician. Our secondary aim was as well as to identify predictors of which LWBS patients will return to the ED with high acuity or require admission. METHODS: A cross-sectional study using an administrative database at an academic tertiary-care pediatric hospital in the United States from January 1, 2006, to December 31, 2008 was done. RESULTS: There were 3525 patients who LWBS during the study period (1.2% of total ED visits). Of these, 87% were triaged as nonurgent, and 13% as urgent at their initial visit. Two hundred eighty-nine (8%) of LWBS patients returned to the ED within 48 hours. Compared with the population who returned to the ED after previous evaluation, patients who LWBS from their initial visit and returned had significantly lower odds of urgent acuity at time of return visit (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.15-0.32) and of being admitted (OR, 0.58; 95% CI, 0.40-0.84). Urgent acuity at initial visit (OR, 2.86; 95% CI, 1.35-6.04) and number of ED visits in last 6 months (OR, 1.24; 95% CI, 1.02-1.52) were significant predictors of admission at return visit among the LWBS population. CONCLUSIONS: Generally, patients who LWBS from a pediatric ED were unlikely to return for ED care, and those who did were unlikely to either be triaged as urgent or require hospital admission. This study showed that urgent acuity during the initial visit and number of previous ED visits were significant predictors of admission on return. Identification of these predictors may allow a targeted intervention to ensure follow-up of patients who meet these criteria after they LWBS from the pediatric ED.

Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging.

BACKGROUND: Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED). OBJECTIVES: The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast-enhanced confirmatory imaging on ED length of stay (LOS). METHODS: This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit. RESULTS: A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P < .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement. CONCLUSIONS: For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.

Prevalence and trends of the adult patient population in a pediatric emergency department.

OBJECTIVES: Although pediatric emergency departments (PEDs) generally do not care for adult patients (≥21 years old), adult patients still present to PEDs with short-term complaints. The purpose of this study was to describe trends in the prevalence, the acuity, and the causes of adult patients presenting to a PED. METHODS: Patients consisted of adults (≥21 years old) seen in a large, urban PED from January 1, 2004, to December 31, 2008. Data were obtained retrospectively from the electronic medical record. Data included demographics, triage acuity, primary codes according to the International Classification of Diseases, 9th Revision, insurance status, referred status, and disposition. RESULTS: There were 463,827 patient visits during the study period. Of these visits, 3361 (0.7%) were adult patients, with a mean (SD) age of 27.5 (9) years. During the 5-year study period, overall PED visits increased by 9% (from 85,987 to 93,753), whereas adult patient visits increased 29% (from 605 to 780). Of the adult patients seen, 1898 (55%) were white and 2100 (62%) were female. Moreover, 1465 (44%) were triaged either emergently or to the medical/trauma resuscitation room, 652 (20%) were admitted, and 677 (20%) were transferred to another facility. Of these adult patients, 712 (21%) were referred to our PED by a primary care provider or subspecialist, and 790 (29%) had no insurance. CONCLUSIONS: Adult visits to a large, urban PED have increased significantly during the past 5 years. Often, these patients have little or no insurance and present with a high acuity. Transitioning adult patients with long-term "pediatric" conditions and further training PED staff on how to care for adult patients are essential.

Is spontaneous pneumothorax really a pediatric problem? A national perspective.

OBJECTIVES: Research on spontaneous pneumothorax (SP) has focused on management strategies in adolescents and adults, yet pediatric population-based data are lacking. The objective of this study was to determine the incidence of SP in the pediatric population in different age groups. METHODS: This was a retrospective analysis of patients aged 0 to 17 years hospitalized with a diagnosis of SP from the Healthcare Cost and Utilization Project Kids' Inpatient Database between 1997 and 2006. Trends of overall incidence and demographic information, including age, sex, length of stay, associated procedures, and associated conditions, were obtained and analyzed. RESULTS: The overall incidence of SP in children younger than 18 years increased from 2.68 per 100,000 population in 1997 to 3.41 per 100,000 in 2006. Average age (15.1 years; SE, 0.1 years), age distribution (83% = 15-17 years old), and hospital length of stay (4.7 days; SE, 0.1 days) remained constant. Between 1997 and 2006, males rose from 3.7 times to 4.2 times as likely to develop SP as females. In 2006, 70% of all hospitalized SP patients had therapeutic procedures documented: chest tube (32%), bleb excision (20%), and thoracotomy (8%) were the most common. Emphysematous bleb (21%), asthma (10%), and tobacco use (4%) were the most common associated diagnoses in 2006. CONCLUSIONS: Although uncommon in children, SP appears to be primarily a condition of males and adolescents and appears to be increasing in incidence in this population. According to these data, a large portion of children are being managed without procedural intervention.

Is pediatric emergency department utilization by pregnant adolescents on the rise?

OBJECTIVES: This study evaluates trends of pregnant adolescents' utilization of pediatric emergency departments (PEDs), describes patient demographics, and reviews common pregnancy-related conditions seen in the PED. METHODS: This was a retrospective cross-sectional study of a large pediatric emergency medicine research network database including 11 freestanding PEDs, 3 separate PEDs from a site with a general ED, and 8 general EDs that see pediatric patients. Pediatric patients (<19 years old) were identified from January 1, 2003, to December 31, 2007, by any International Classification of Diseases, Ninth Revision pregnancy or pregnancy-related condition diagnosis code. Demographic information (age, race, payer type) and disposition (admit, discharge home, transfer) were recorded. RESULTS: There were 15,190 unique pregnancy-related visits with an overall annual growth rate of 2.8% (P = 0.03). There was a statistically significant increase in visits to freestanding PEDs (P = 0.02) and separate PED from a site with a general ED (P = 0.03), but there was not in the general EDs (P = 0.16). The 3 most common pregnancy-related conditions were abdominal pain, genitourinary infection, and hemorrhage in early pregnancy. CONCLUSIONS: Pregnant adolescents make up a small (<1%) but growing proportion of overall visits to PEDs. Future direction should include an evaluation of the educational opportunities provided during pediatric residency and pediatric emergency medicine fellowship training and, if inadequacies exist, work to develop an innovative curriculum for this particular patient population.

Pediatric-Specific Hazard Vulnerability Analysis: The Missing Component of Regional and Hospital-Based Preparedness.

Though children comprise a large percentage of the population and are uniquely vulnerable to disasters, pediatric considerations are often omitted from regional and hospital-based emergency preparedness. Children's absence is particularly notable in hazard vulnerability analyses (HVAs), a commonly used tool that allows emergency managers to identify a hazard's impact, probability of occurrence, and previous mitigation efforts. This paper introduces a new pediatric-specific HVA that provides emergency managers with a quantifiable means to determine how a hazard might affect children within a given region, taking into account existing preparedness most relevant to children's safety. Impact and preparedness categories within the pediatric-specific HVA incorporate age-based equipment and care needs, long-term developmental and mental health consequences, and the hospital and community functions most necessary for supporting children during disasters. The HVA allows emergency managers to create a more comprehensive assessment of their pediatric populations and preparatory requirements.

A "rare" case of melena in a 3-year-old.

Melena is a potential sign of life-threatening upper gastrointestinal bleeding; however, there are numerous substances ingested resulting in a stool appearance similar to melena. Examples of such substances include black licorice, bismuth subsalicylate, and iron supplements. We report a case of a well-appearing 3-year-old Vietnamese girl presenting to our emergency department after 2 episodes of "black, sticky" stool. The cause of her "melena" was determined after father revealed that she had ingested 2 bowls of pork blood soup during the preceding 12 hours. This case highlights the need for a careful dietary history and cultural considerations in children presenting with what may appear to be melena.

Evaluation and management of sexually transmitted infections in adolescent males presenting to a pediatric emergency department: is the chief complaint diagnostic?

OBJECTIVES: The objectives of the study were to (1) describe evaluation and treatment patterns for adolescent males presenting with a concern for sexually transmitted infection (STI) in a pediatric emergency department, (2) assess the rates of STIs in symptomatic males, and (3) determine the utility of urinalysis alone in predicting STIs in adolescent males. METHODS: A retrospective cohort study was conducted of all patients presenting to our pediatric emergency department from January 1, 2007, to December 31, 2007. Inclusion criteria included males, aged 15 to 21 years, with an STI or urinary chief complaint. Exclusion criteria were referrals from pediatricians, a previous history of urinary tract infection or preexisting urologic condition, or primary complaint of scrotal and/or testicular pain. RESULTS: A total of 270 patients were identified. Testing included urinalysis with microscopy (UA) (64%), urine culture (53%), Neisseria gonorrhoeae (GC), and Chlamydia trachomatis (CT) (93%), and Trichomonas vaginalis (5%). Sixty-four percent of males tested positive for either GC or CT, or both. Overall, 91% of patients were treated for CT and GC, 18% for T. vaginalis, and 5% for urinary tract infection. The sensitivity and specificity of a positive UA for presence of GC and/or CT were 86% and 82%, respectively, whereas the positive and negative predictive values were 89% and 77%, respectively. There were no positive urine cultures in the cohort. CONCLUSIONS: Sixty-four percent of patients were diagnosed with either GC or CT. Although UA is helpful in predicting STI, limited use is warranted, given the high prevalence of disease in this selected population. The urine culture does not appear to be a necessary adjunct in the management of these patients.