Clinical Characteristics of Acute Hematogenous Osteomyelitis With and Without Subperiosteal Abscesses in the Acute Care Setting.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a common pediatric disease that can progress to involve nearby structures leading to complications including subperiosteal abscesses (SPAs). Those with SPAs, in particular, often require surgical intervention for complete treatment. Staphylococcus aureus remains one of the most common causes of AHO. With the emergence of community-associated methicillin-resistant Ataphylococcus aureus and its propensity to form abscesses, there has been an observed increased frequency of AHO with SPAs in children. Although magnetic resonance imaging (MRI) remains the gold standard of imaging for AHO, it is not readily available on a 24/7 basis and often necessitates procedural sedation in children. Delay in MRI and surgical intervention in patients with SPAs may lead to increased complications. The goal of this study is to identify, using clinical features easily obtained in the acute care setting, patients at high risk for AHO with SPAs who may benefit from emergent MRI and/or surgical intervention. DESIGN/METHODS: A retrospective chart review of patients aged birth to younger than 18 years diagnosed with AHO, who presented to a tertiary pediatric hospital from June 10, 2012, to November 1, 2017, were evaluated. Demographic, clinical, laboratory, and imaging data were collected. Patients were divided into 2 groups: AHO alone and AHO with SPAs. RESULTS: A final cohort of 110 subjects were included and analyzed. Of these, 73 (66%) were identified as having AHO alone and 37 (33.6%) as having AHO with SPAs. Patients had a higher risk of AHO with SPAs if they had a history of fever, decreased range of motion, edema, or elevated laboratory studies including white blood cell, absolute neutrophil count, erythrocyte sedimentation rate, and C-reactive protein. C-reactive protein was shown to have the highest correlation of AHO with SPAs, with an optimal cut point of 10.3 mg/dL, yielding a sensitivity of 67.7% and specificity of 77.6%. Patients with AHO with SPAs were at higher risk of having a positive blood culture for methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Clinicians in acute care settings should have a high index of suspicion of AHO with SPAs in children with history of fever, decreased range of motion, or elevated laboratory values (white blood cell, absolute neutrophil count, erythrocyte sedimentation rate, and C-reactive protein). In particular, those with a significantly elevated CRP are at a higher risk for having AHO with SPAs in comparison with an uncomplicated AHO. However, with the significant overlap in historical and clinical variables in the initial presentations of children with AHO with and without SPAs, the clinical urgency in obtaining a magnetic resonance imaging must continue to be individualized based on overall clinical suspicion and availability of resources.

Critical Care Interventions for Asthmatic Patients Admitted From the Emergency Department to the Pediatric Intensive Care Unit.

OBJECTIVES: The aim of this study was to assess the frequency and predictors of critical interventions in asthmatic patients admitted to the pediatric intensive care unit (PICU) at a tertiary-care pediatric hospital. METHODS: We conducted a retrospective chart review of patients admitted from our emergency department (ED) to the PICU for treatment of status asthmaticus between January 1, 2008, and March 31, 2013. Patients with concomitant medical conditions and those who received a critical intervention, other than continuously aerosolized albuterol, in the ED before admission were excluded. Data collected included patient demographics, clinical characteristics including clinical asthma scores (CASs), hospital course, and adverse events. RESULTS: A total of 384 patients were included in the analyses (mean age, 8.2 ± 4.5 years). Thirty-four patients (8.9%) received at least 1 critical intervention. No patients were intubated, had central venous catheter placement, and developed circulatory collapse or pneumothoraxes. Independent predictors associated with an increased likelihood of receiving a critical intervention included age above 8 years (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.9-9.4), previous PICU admission (OR, 3.2; 95% CI, 1.5-6.6), altered mental status on ED arrival (OR, 4.5; 95% CI, 1.5-13.4), CAS on ED arrival of 5 or greater (OR, 3.4; 95% CI, 1.3-9.1), and CAS on PICU admission of 5 or greater (OR, 4.3; 95% CI, 1.8-10.2). CONCLUSIONS: Patients admitted to the PICU for status asthmaticus infrequently require critical interventions if they have not been initiated in the ED. Patients with a CAS of less than 5 may be safely managed with continuously aerosolized albuterol on non-critical care units with low risk for clinical deterioration.

Hospital Employee Willingness to Work during Earthquakes Versus Pandemics.

BACKGROUND: Research indicates that licensed health care workers are less willing to work during a pandemic and that the willingness of nonlicensed staff to work has had limited assessment. OBJECTIVE: We sought to assess and compare the willingness to work in all hospital workers during pandemics and earthquakes. METHODS: An online survey was distributed to Missouri hospital employees. Participants were presented with 2 disaster scenarios (pandemic influenza and earthquake); willingness, ability, and barriers to work were measured. T tests compared willingness to work during a pandemic vs. an earthquake. Multivariate linear regression analyses were conducted to describe factors associated with a higher willingness to work. RESULTS: One thousand eight hundred twenty-two employees participated (15% response rate). More willingness to work was reported for an earthquake than a pandemic (93.3% vs. 84.8%; t = 17.1; p < 0.001). Significantly fewer respondents reported the ability to work during a pandemic (83.5%; t = 17.1; p < 0.001) or an earthquake (89.8%; t = 13.3; p < 0.001) compared to their willingness to work. From multivariate linear regression, factors associated with pandemic willingness to work were as follows: 1) no children ≤3 years of age; 2) older children; 3) working full-time; 4) less concern for family; 5) less fear of job loss; and 6) vaccine availability. Earthquake willingness factors included: 1) not having children with special needs and 2) not working a different role. CONCLUSION: Improving care for dependent family members, worker protection, cross training, and job importance education may increase willingness to work during disasters.

Emergency Childcare for Hospital Workers During Disasters.

OBJECTIVES: The objectives were to determine the impact of emergency childcare (EC) needs on health care workers' ability and likelihood to work during a pandemic versus an earthquake as well as to determine the anticipated need and expected use of an on-site, hospital-provided EC program. METHODS: An online survey was distributed to all employees of an academic, urban pediatric hospital. Two disaster scenarios were presented (pandemic influenza and earthquake). Ability to work based on childcare needs, planned use of proposed hospital-provided EC, and demographics of children being brought in were obtained. RESULTS: A total of 685 employees participated (96.6% female, 79.6% white), with a 40% response rate. Those with children (n = 307) reported that childcare needs would affect their work decisions during a pandemic more than an earthquake (61.1% vs 56.0%; t = 3.7; P < 0.001). Only 28.0% (n = 80) of those who would need childcare (n = 257) report an EC plan. The scenario did not impact EC need or planned use; during scheduled versus unscheduled shifts, 40.7% versus 63.0% reported need for EC, and 50.8% versus 63.2% reported anticipated using EC. CONCLUSIONS: Hospital workers have a high anticipated use of hospital-provided EC. Provisions for EC should be an integral part of hospital disaster planning.

Simulation training for pediatric residents on central venous catheter placement: a pilot study.

OBJECTIVE: To assess the effect of simulation training on pediatric residents' acquisition and retention of central venous catheter insertion skills. A secondary objective was to assess the effect of simulation training on self-confidence to perform the procedure. DESIGN: Prospective observational pilot study. SETTING: Single university clinical simulation center. SUBJECTS: Pediatric residents, postgraduate years 1-3. INTERVENTIONS: Residents participated in a 60- to 90-minute ultrasound-guided central venous catheter simulation training session. Video recordings of residents performing simulated femoral central venous catheter insertions were made before (baseline), after, and at 3-month following training. Three blinded expert raters independently scored the performances using a 24-item checklist and 100-mm global rating scale. At each time point, residents rated their confidence to perform the procedure on a 100-mm scale. MEASUREMENTS AND MAIN RESULTS: Twenty-six residents completed the study. Compared with baseline, immediately following training, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 83.3% [interquartile range, 70.0-91.7%]), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 79.5 mm [interquartile range, 16.3-91.7 mm]), success rate (38.5% vs 80.8%), and self-confidence (8.0 mm [interquartile range, 3.8-19.0 mm] vs 52.0 mm [interquartile range, 43.5-66.5 mm]) all improved (p < 0.05 for all variables). Compared with baseline, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 54.2% [interquartile range, 45.8-80.4%], p = 0.47), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 35.5 mm [interquartile range, 5.3-77.0], p = 0.62), and success rate (38.5% vs 65.4%, p = 0.35) were similar at 3-month follow-up. Self-confidence, however, remained above baseline at 3-month follow-up (8.0 mm [interquartile range, 3.8-19.0 mm] vs 61.0 mm [interquartile range, 31.5-71.8 mm], p < 0.01). CONCLUSIONS: Simulation training improved pediatric residents' central venous catheter insertion procedural skills. Decay in skills was found at 3-month follow-up. This suggests that simulation training for this procedure should occur in close temporal proximity to times when these skills would most likely be used clinically and that frequent refresher training might be beneficial to prevent skills decay.

Rapid bedside triage does not affect the delivery of pain medication for extremity pain in the pediatric emergency department.

OBJECTIVE: Rapid bedside triage (RBT), rather than traditional waiting room triage (WRT), is becoming a "best practice" in managing emergency department (ED) patient flow, yet little is known about the impact of this process on other aspects of patient care. This study was designed to compare overall adherence to an existing nurse-driven ED pain protocol after changing from a WRT to an RBT process. METHODS: On November 1, 2011, the triage process at our institution changed from a traditional WRT system to an in-department RBT allowing for comparison of the 2 groups. A retrospective chart review assessing compliance with the department's pain protocol was performed on all patients presenting to the ED during October and November 2011, representing the immediate time periods before and after the implementation of the change in triage process. Patients younger than 19 years, with complaint of isolated extremity pain or injury, were included in this analysis. Compliance was defined as patients having a pain score assessed and pain medication given for scores of 4 or more within 30 minutes of arrival. RESULTS: In total, 546 patients were identified for inclusion in the study; 306 received traditional WRT, and 240 received RBT. Compliance with the pain protocol was seen in 54.6% of patients receiving WRT versus 57.5% receiving RBT (P = 0.50). CONCLUSIONS: Changing from a traditional WRT process to an in-department RBT process resulted in no change in the compliance with the existing pain protocol.

Evaluation of a high-dose continuous albuterol protocol for treatment of pediatric asthma in the emergency department.

OBJECTIVES: This study aimed to assess the safety and efficacy of a high-dose continuous nebulized albuterol (CNA) protocol for treatment of asthma in the pediatric emergency department (ED). A secondary objective included a cost-benefit analysis of protocol use. METHODS: In this retrospective chart review, we compared cohorts of patients treated in our ED for acute asthma exacerbation before and after implementation of a CNA protocol. Patients between the ages of 2 and 21 years seen between March 1 and May 31, 2008 (preprotocol, n = 393), and March 1 to May 31, 2009 (postprotocol, n = 373), were included. Safety data included medication-related adverse effects as well as serum potassium and glucose levels. Efficacy data included ED length of stay, disposition, return visits, time to first albuterol treatment, and corticosteroid administration. Cost analysis included the cost of medications and respiratory therapy time. RESULTS: Postprotocol patients more often received CNA (57.9% vs 25.2%, P < 0.01). No significant adverse effects, including tachyarrhythmia and symptomatic hypokalemia, were found in either group. Serum potassium levels were higher in the postprotocol group (3.9 mEq/L [n = 34] vs 3.5 mEq/L [n = 28], P < 0.01). Emergency department stay was longer in the postprotocol group (217.8 minutes vs 187.2 minutes, P < 0.01). Emergency department disposition was similar in both groups. The mean cost per patient was higher in the postprotocol group ($327.21 vs $277.95, P < 0.01). CONCLUSIONS: We found the CNA protocol to be safe. Superior efficacy to a traditional treatment approach was not demonstrated. The mean cost of treatment was higher in the postprotocol group. Further prospective studies should be conducted to confirm the findings of this retrospective, observational study.

Pandemic influenza extension areas in an urban pediatric hospital.

INTRODUCTION: The 2009 H1N1 influenza pandemic created a surge of patients with low-acuity influenza-like-illness (ILI) to hospital Emergency Departments (EDs). The development and results of a tiered surge plan to care for these patients at a Pediatric Emergency Department (PED) were studied. HYPOTHESIS/PROBLEM: By providing standard assessment and treatment algorithms within physically separate ILI Extension Areas, it was hypothesized that patient care could be streamlined and the quality of care maintained. METHODS: Hospital administrators created the tiered H1N1 surge plan within the framework of the existing emergency operations plan (EOP). After the initial expansion of space and staff utilization within the existing PED footprint, ILI Extension Areas were opened and staffed by non-ED physicians and nursing to provide care rapidly for ILI patients after Registered Nurse (RN) screening. Volumes, length of stay (LOS), left without being seen (LWBS) rates, patient satisfaction, and costs were tracked and measured. RESULTS: Significantly elevated volumes of patients were seen in the months of September and October of 2009 (42.0% and 32.7% increase over 2008). During this time, 612 patients were triaged to the ILI Extension Areas. The LOS was similar to that experienced in prior years. The LWBS rates in September (4.8%) and October (3.4%) were slightly elevated over the 2009 yearly average (3.2%), but remained lower than during a prior, high-volume month. Satisfaction, measured as patients' "likelihood to recommend," remained within the range observed during other parts of the year. Cost estimates indicate favorable financial performance for the institution. CONCLUSION: The tiered surge response plan represented a success in managing large volumes of low-acuity patients during an extended period of time. This design can be utilized effectively in the future during times of patient surge.

Greater saphenous vein location in a pediatric population.

The purpose of this study was to assess the accuracy of a landmark technique for cannulation of the greater saphenous vein (GSV) near the medial malleolus. We performed bedside ultrasound in a convenience sample of 100 children, ages 3 to 16 years, to evaluate the anatomy of the GSV at the ankle. Despite the proposed constancy of the landmark technique regardless of patient age, the GSV location varied significantly with increasing patient age and weight. In children less than 10 years old or weighing less than 40 kg, the traditional landmark rarely predicted the precise location of the GSV.

Impact of disaster drills on caregiver perception and satisfaction in the pediatric emergency department.

OBJECTIVE: The objective of this study was to assess caregiver perception and satisfaction of a regional disaster drill in a pediatric emergency department (ED). METHODS: Caregivers of children receiving care during a 2-hour disaster drill were given a survey regarding perceived importance of the drill, waiting time to see a physician, service timeliness, impact on comfort, and overall recommendation of the ED. As a control, the survey was also given to caregivers a week before and after the drill. RESULTS: Caregivers on the drill date were more likely to consider drill conduction to be highly important (100% vs 82.9%, P < 0.045). Compared with the drill date, there were no significant differences in the perceived duration of waiting, impact on care, or likelihood to recommend the ED to others. CONCLUSIONS: In a single regional disaster drill, we found that caregivers feel that disaster drills are important and unlikely to impact care of children negatively. These findings can help support decision making by hospital administrators to commit personnel and resources to conduct necessary disaster drills involving children.

The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children.

BACKGROUND: Differentiating bacterial from nonbacterial community-acquired pneumonia in children is difficult. Although several studies have evaluated serum concentrations of C-reactive protein (CRP) as a predictor of bacterial pneumonia in this patient population, the utility of this test remains unclear. OBJECTIVE: The purpose of this meta-analysis was to quantitatively define the utility of serum CRP as a predictor of bacterial pneumonia in acutely ill children. METHODS: Multiple databases were searched, bibliographies reviewed, and 2 authorities in the field were queried. Studies were included if: (1) the patient population was between 1 month and 18 years of age; (2) CRP was quantified in all subjects as part of the initial evaluation of a suspected, infectious, pulmonary process; (3) a cutoff serum CRP concentration between 30 and 60 mg/dL was used to distinguish nonbacterial from bacterial pneumonia; (4) some criteria were applied to differentiate bacterial from nonbacterial or viral pneumonia; (5) all patients were acutely ill; and (6) a chest radiograph was obtained as part of the initial evaluation. The quality of each included study was determined across 4 metrics: diagnostic criteria; study design; exclusion of chronically ill or human immunodeficiency virus infected subjects; and exclusion of patients who recently received antibiotics. Data was extracted from each article; the primary outcome measure was the odds ratio of patients with bacterial or mixed etiology pneumonia and serum CRP concentrations exceeding 30-60 mg/L. Heterogeneity among the studies was determined by Cochran's Q statistic; the methods of both Mantel and Haenszel, and DerSimonian and Laird were used to combine the study results. RESULTS: Eight studies fulfilled inclusion criteria. Combining all of the studies demonstrated a pooled study population of 1230 patients with the incidence of bacterial infection of 41%. Children with bacterial pneumonia were significantly more likely to have serum CRP concentrations exceeding 35-60 mg/L than children with nonbacterial infections (odds ratio = 2.58, 95% confidence interval = 1.20-5.55). Sensitivity analysis demonstrated that this difference was robust. There was significant heterogeneity among the 8 studies (Q = 37.7, P < 0.001, I2 = 81.4) that remained throughout the sensitivity analysis. CONCLUSIONS: In children with pneumonia, serum CRP concentrations exceeding 40-60 mg/L weakly predict a bacterial etiology.

Procedural sedation and analgesia for children in the emergency department.

PSA for children continues to be an integral part of the practice of emergency medicine. The advancement of knowledge for all health care professionals must continue so that pain and anxiety in children may be minimized during their visits to EDs.

Working after a tornado: a survey of hospital personnel in Joplin, Missouri.

In 2011, an EF5 tornado hit Joplin, MO, requiring complete evacuation of 1 hospital and a patient surge to another. We sought to assess the resilience of healthcare workers in these hospitals as measured by number reporting to work, willingness to work, personal disaster preparedness, and childcare responsibilities following the disaster. In May 2013, a survey was distributed to healthcare workers at both Joplin hospitals that asked them to report their willingness to work and personal disaster preparedness following various disaster scenarios. For those with childcare responsibilities, scheduling, costs, and impact of hypothetical alternative childcare programs were considered in the analyses. A total of 1,234 healthcare workers completed the survey (response rate: 23.4%). Most (87.8%) worked the week following the Joplin tornado. Healthcare workers report more willingness to work during a future earthquake or tornado compared to their pre-Joplin tornado attitudes (86.2 vs 88.4%, t=-4.3, p<.001; 88.4 vs 90%, t=-3.1, p<.01, respectively), with no change during other scenarios. They expressed significantly higher post-tornado personal disaster preparedness, but only preevent preparedness was a significant predictor of postevent preparedness. Nearly half (48.5%, n=598) had childcare responsibilities; 61% (n=366) had childcare needs the week of the tornado, and 54% (n=198) required the use of alternative childcare. If their hospital had provided alternative childcare, 51% would have used it and 42% felt they would have been more willing to report to work. Most healthcare workers reported to work following this disaster, demonstrating true resilience. Disaster planners should be aware of these perceptions as they formulate their own emergency operation plans.

A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures.

OBJECTIVES: The primary objective was to compare the cosmetic outcomes of traumatic trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures. The secondary objective was to compare complication rates between the two groups. METHODS: This was a randomized controlled trial comparing wounds repaired with Vicryl Rapide and Prolene sutures. Pediatric and adult patients with lacerations were enrolled in the study. At a 10-day follow-up, the wounds were evaluated for infection and dehiscence. After 3 months, patients returned to have the wounds photographed. Two plastic surgeons blinded to the method of closure rated the cosmetic outcome of each wound using a 100-mm visual analog scale (VAS). Using a noninferiority design, a VAS score of 13 mm or greater was considered to be a clinically significant difference. We used a Student's t-test to compare differences between mean VAS scores and odds ratios (ORs) to compare differences in complication rates between the two groups. RESULTS: Of the 115 patients enrolled, 73 completed the study including 35 in the Vicryl Rapide group and 38 in the Prolene group. The mean (±SD) age of patients who completed the study was 22.1 (±15.5) years, and 39 were male. We found no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. The observer's mean VAS for the Vicryl Rapide group was 54.1 mm (95% confidence interval [CI] = 44.5 to 67.0 mm) and for the Prolene group was 54.5 mm (95% CI = 45.7 to 66.3 mm). The resulting mean difference was 0.5 mm (95% CI = -12.1 to 17.2 mm; p = 0.9); thus noninferiority was established. Statistical testing showed no differences in the rates of complications between the two groups, but a higher percentage of the Vicryl Rapide wounds developed complications. CONCLUSIONS: The use of absorbable sutures for the repair of simple lacerations on the trunk and extremities should be considered as an alternative to nonabsorbable suture repair.

Prospective multicenter study of the viral etiology of bronchiolitis in the emergency department.

OBJECTIVES: To determine the viral etiology of bronchiolitis and clinical characteristics of children age < 2 years presenting to the emergency department (ED) with bronchiolitis. METHODS: The authors conducted a 14-center prospective cohort study during 2005-2006 of ED patients age < 2 years with bronchiolitis. The study was conducted in 10 states as part of the Emergency Medicine Network. Researchers collected nasopharyngeal aspirates and conducted structured interviews, medical record reviews, and 2-week follow-up telephone calls. Samples were tested using reverse transcription polymerase chain reaction for respiratory syncytial virus (RSV), rhinovirus (RV), human metapneumovirus (hMPV), and influenza viruses (Flu). RESULTS: Testing of 277 samples revealed 176 (64%) positive for RSV, 44 (16%) for RV, 26 (9%) for hMPV, 17 (6%) for Flu A, and none for Flu B. When children were categorized as RSV only, RV only, RV and RSV, and all others (hMPV, Flu, no identified virus), children with RV only were more likely to be African American (19, 62, 14, and 40%, respectively; p < 0.001) and have a history of wheezing (23, 52, 21, and 15%, respectively; p = 0.01). In multivariate models, children with RV were more likely to receive corticosteroids (odds ratio [OR] 3.5; 95% confidence interval [CI] = 1.5 to 8.15). The duration of illness may be shorter for children with RV (Days 8, 3, 6, and 8; p = 0.07). CONCLUSIONS: In this multicenter study, RSV was the most frequent cause of bronchiolitis (64%). RV was present in 16%, and these children have a distinct profile in terms of demographics, medical history, and ED treatment.

Rate and prediction of traumatic injuries detected by abdominal computed tomography scan in intubated children.

BACKGROUND: Recent concerns about the lifetime cancer risk associated computed tomography (CT) caused us to reevaluate the utility of this test in traumatized children. In addition, little is known regarding the utility of abdominal CT in children who have been emergently intubated. We sought to describe the injuries identified by abdominal CTs in intubated pediatric trauma patients and create a derivation set of predictors of intra-abdominal injury in this patient population. METHODS: A review was conducted of patients cared for at a Level I pediatric trauma center. Patients were included if they were emergently intubated after blunt trauma and had an emergent abdominal CT performed. Outcome measures included the presence of an intra-abdominal injury on CT, the need for exploratory laparotomy (ELAP), the findings of the ELAP, and death. Logistic regression was used to determine which variables were associated with an abnormal abdominal CT scan. RESULTS: In all, 118 met inclusion criteria; the median age was 7.2 years. Thirty- two patients (27.1%) were found to have at least one abdominal injury on CT scan. One ELAP was performed and 12 patients died. Of the variables analyzed, abdominal examination abnormalities and elevated liver function tests (LFTs) were significantly associated with injuries. When both were abnormal, 75% of patients (12/16) had abnormal scans (sensitivity = 71%, specificity = 92%, positive predictive value = 75%, negative predictive value = 91%). CONCLUSIONS: In this series, a significant number of intubated pediatric trauma victims had intra-abdominal injuries identified by CT scan. The presence of abnormal abdominal examination findings and elevated LFTs appear to predict an abnormal CT scan.