Population Pharmacokinetics of Single Bolus Dose Fentanyl in Obese Children.

BACKGROUND: Childhood obesity is a significant problem. Obesity may alter the pharmacokinetics (PKs) of medications. Fentanyl is commonly used for procedural sedation, but there is a paucity of bolus dose fentanyl PK data in obese children. Better understanding of fentanyl PK in obese children would facilitate dosing recommendations. We conducted a study involving children with and without obesity to assess the potential differences in bolus dose fentanyl PK between the 2 groups. METHODS: We enrolled children 2 to 12 years of age with and without obesity, defined as >95th percentile body mass index (BMI) for age and sex, undergoing elective tonsillectomy ± adenoidectomy. After induction, subjects had 2 intravenous (IV) lines placed in 2 different extremities: 1 for medications and IV fluids and 1 for obtaining blood aliquots for fentanyl concentration analysis. After administration of 1 mcg/kg of fentanyl based on total body weight (TBW), blood sample collections for fentanyl concentration analysis were attempted at 5, 15, 30, 60, 90, and 120 minutes. Five-minute fentanyl concentrations were compared between obese and nonobese cohorts. Population PK analysis to examine the differences between obese and nonobese children was performed and included various body size descriptors, such as TBW, BMI, and fat-free mass (FFM), to examine their influence on model parameters. RESULTS: Half of the 30 subjects were obese. Mean fentanyl concentrations at 5 minutes were 0.53 ng/mL for the nonobese group and 0.88 ng/mL for the obese group, difference 0.35 ng/mL (95% CI, 0.08-0.61 ng/mL; P = .01). Population PK analysis showed that FFM was a significant covariate for the central volume of distribution. The potential clinical effect of an IV bolus dose of fentanyl based on TBW versus FFM in an obese child was assessed in a simulation using our model. 1 mcg/kg fentanyl dose based on TBW resulted in an approximately 60% higher peak fentanyl effect site concentration than dosing based on FFM. CONCLUSIONS: Our data demonstrated higher peak plasma fentanyl concentrations in obese compared to nonobese subjects. Population PK analysis found that FFM was a significant covariate for the central volume of distribution. Model simulation showed dosing of fentanyl in obese children based on TBW resulted in significantly higher peak concentrations than dosing based on FFM. Based on this modeling and the known concentration-effect relationship between fentanyl and adverse effects, our results suggest that bolus dosing of fentanyl in obese children should be based on FFM rather than TBW, particularly for procedures of short duration.

Medication Errors in Pediatric Patients after Implementation of a Field Guide with Volume-Based Dosing.

BACKGROUND: Several studies have demonstrated the high frequency of medication errors in pediatric patients by prehospital providers during both patient care and simulation. In 2015, our hospital-based urban EMS system introduced the HandtevyTM Field Guide that provides precalculated pediatric doses in milliliters (mL) by patient age. We hypothesized that implementation of the Field Guide would increase the percentage of correct pediatric medication doses to greater than 85%. METHODS: We performed a single center retrospective cohort study of medications administered to patients < 13 years of age from August 2017 to July 2019 compared to 2014 baseline data through electronic medical record review. We excluded nebulized medications and online medication direction cases. Our primary outcome was the percentage of correct doses defined as a dose within 80-120% of the Field Guide dose recommendation. Each dosing error was reviewed by two investigators. RESULTS: We analyzed 483 drug administrations in 375 patients for the Field Guide study period. Doses were correct in 89.4% of medication administrations with 68.5% reportedly administered exactly as dictated by the Field Guide compared to 51.1% in the baseline period (p < 0.001). During the Field Guide study period, the following medications had 100% appropriate dosing: adenosine, dextrose 10%, diphenhydramine, epinephrine 1:10,000, glucagon, naloxone and oral ondansetron. Overdoses accounted for 4.4% of medication errors and underdoses accounted for 6.2% of medications errors. The most overdosed medications were intranasal (IN) midazolam (11.8%) and intravenous fentanyl (9.4%). The most underdosed medications were IN midazolam (23.5%) and intramuscular epinephrine 1:1000 (12.5%). The highest percentage of errors (20%) were seen in the zero to one-year-old age group. CONCLUSION: After implementation of a precalculated mL dose system by patient age for EMS providers, most pediatric medications were reportedly administered within the appropriate dose range. A field guide with precalculated doses (in mL) may be an effective tool for reducing pediatric medication dosing errors by EMS providers.

A descriptive study of screening and navigation on health-related social needs in a safety-net hospital emergency department.

BACKGROUND: Health-related social needs (HRSN) have been associated with worse clinical outcomes, increased Emergency Department (ED) utilization and higher healthcare costs. The ED is uniquely positioned to bring HRSN screening to the bedside and develop effective interventions. We evaluated whether navigation services for high-risk patients led to the resolution of HRSN. METHODS: Navigators screened a convenience sample of patients for HRSN with the Accountable Health Communities Screening Tool from October 2019 to January 2022. Patients with HRSN were considered high-risk if they had at least two ED visits in the previous 12 months. Patients who were high-risk were eligible for navigation including community referrals and one-on-one close follow-up. The HRSN status (resolved, in-progress, unable to resolve) was queried from the Centers for Medicare and Medicaid database. The state hospital association provided data on ED visits and inpatient hospitalizations within 6 months of the screening visit. RESULTS: Of 185,470 ED visits, HRSN screening occurred in 4050 (2%). HRSN were self-reported in 48% (1944) of patient visits, with 71% of these (1379) considered high-risk. 15% of high-risk patients with HRSN opted out of navigation. Food insecurity was the most identified HRSN (35%) followed by housing instability (26%), transportation needs (24%) and utility assistance (15%). Food insecurity was the most resolved HRSN (39%, in-progress 32%) followed by utility assistance (37%, in-progress 26%), transportation needs (35%, in-progress 35%) and housing instability (28%, in-progress 36%). High-risk visits in which the patient or guardian accepted navigation were less likely to be associated with an ED visit within 6 months of the screening visit (51%) compared to high-risk patients in which the patient or guardian opted out of navigation (61%, p < 0.001), but there was no difference in inpatient hospitalizations (p = 0.427). CONCLUSIONS: During the study period, one-third of HRSN were successfully resolved with another one-third in-progress. Navigation in high-risk patients was associated with fewer subsequent ED visits.

Screening for health-related social needs in the emergency department: Adaptability and fidelity during the COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: We sought to evaluate a screening and referral program for health-related social needs (HRSN) in our ED. Our goals were to (1) quantify successful screenings prior to and during the initial peak of the pandemic, and (2) describe the HRSNs identified. METHODS: We performed an observational analysis of ED-based screening for HRSN in Medicare and Medicaid patients at our large urban safety-net hospital. Screening was performed by patient navigators utilizing the ten question, validated Accountable Health Communities (AHC) Screening Tool, which screens for food insecurity, housing instability, transportation needs and utility assistance and interpersonal safety. Patients who screened positive for HRSN were provided with handouts listing community resources. For patients with two or more self-reported ED visits in the last 12 months and any identified HRSN, ongoing navigation after discharge was provided utilizing community resource referrals. During the pre-pandemic period from November 1, 2019 - January 31, 2020, screening occurred in-person. Screening during the pandemic from March 1, 2020 - May 31, 2020 occurred remotely via telephone. Descriptive statistics including frequency rates and percentages were calculated. Successful screening was defined as completing the screening survey with a navigator and being triaged to either no assistance, resource handouts, or navigation services. RESULTS: Among the adult and pediatric patients screened for HRSN, 158 (16%) qualified for community resource handouts and 440 (44.4%) qualified for patient navigator services. The proportion of patients receiving both resources and care navigation remained similar in the pre- and post-periods of the study, at 227 (45%) and 213 (43.9%) respectively. However, the proportion of ED patients with a HRSN need doubled from 56 (11.1%) in the pre-period to 102 (21%) in the post-period. Food insecurity was the most identified HRSN in both the pre-pandemic period (27.3%) and during the pandemic (35.8%). CONCLUSION: We found that remote HRSN screening for ED patients during the COVID-19 pandemic resulted in similar proportions of successfully completed screenings compared to pre-pandemic efforts. This demonstrates the feasibility of utilizing alternative methods of screening and referral to community resources from the ED, which could facilitate this type of intervention in other EDs. During the pandemic HRSN increased, likely reflecting the economic impact of the pandemic.

Evaluation of an Integrated Psychology Service in a Pediatric Emergency Department and Urgent Care.

OBJECTIVES: Children visiting emergency departments (EDs) are disproportionately affected by mental health disorders. Integrated behavioral health models hold promise for improving care among ED patients. We implemented and evaluated a novel behavioral health service integrated psychology trainees in a safety net hospital's pediatric ED and urgent care. METHODS: Consultations and interventions provided were identified from the service's patient registry. Patients treated by the service were matched based on age, sex, day, and month of presentation to control patients who received a brief assessment by a specialized psychiatric nurse or patients receiving comprehensive management in a psychiatric emergency service. Rates of ED return visits were obtained from local hospital records, and insurance claims were used to identify rates of psychiatric hospitalization and outpatient follow-up care. RESULTS: The most commonly provided interventions among 71 intervention patients were assistance with connection to follow-up behavioral health treatment (65%), relaxation training (41%), and motivational interviewing (31%). These patients were matched with 142 comparison patients. There was no difference among groups in return rates within 90 days among intervention versus nurse assessment or psychiatric emergency service patients (25% vs 23% vs 13%, P = 0.14). Insurance claims data were available for 115 patients (54%): within 90 days, integrated care patients were less likely to have at least 1 outpatient claim (52% vs 78% vs 84%, P < 0.01), and there was no difference in rates of psychiatric hospital admission (18% vs 20% vs 24%, P = 0.83). CONCLUSIONS: Although this psychology-led integrated behavioral health service delivered a range of brief psychotherapeutic interventions, its impact on outpatient, inpatient, and emergency care was mixed. This lower follow-up rate among intervention patients may reflect the success of active psychological treatment in the ED, lower acuity among intervention patients, or implications of the study's safety net setting. The authors discuss this model's potential for enhancing mental health care in pediatric EDs.

Evaluation of a Novel Point-of-Care Ultrasound Curriculum for First-Year Pediatric Residents.

OBJECTIVE: The aim of the study is to evaluate a novel point-of-care ultrasound (POCUS) educational curriculum for pediatric residents. METHODS: The cohort study in graduate medical education was completed from January 2017 to March 2019. Postgraduate year 1 (PGY1) pediatric residents attended the educational curriculum that consisted of 3 half-day sessions over a 3-month period. Each session consisted of a lecture (introduction, extended focused assessment with sonography for trauma, soft tissue/musculoskeletal, cardiac, and resuscitative applications) followed by supervised hands-on scanning sessions. Group ratio was 3 learners to 1 machine/expert instructor. Main outcome measures included pre- and post-written test scores, as well as objective structured clinical examination (OSCE) scores. RESULTS: Forty-nine PGY1 residents (78% women) completed the curriculum. The mean (SD) pretest score was 68% (8.5), and the mean posttest score was 83% (8.3) with a difference of 15 (95% confidence interval, 12.5-17.6; P < 0.001). Mean (SD) focused assessment with sonography for trauma OSCE score after the curriculum was 88.7% (11.9). The number of PGY1 pediatric residents that were comfortable performing POCUS examinations increased from pretraining to posttraining for soft tissue/musculoskeletal (14%-61%, P < 0.001), extended focused assessment with sonography for trauma (24%-90%, P < 0.001), and cardiac (18%-86%, P < 0.001). All participants found the curriculum useful, and 42 of 49 (86%) stated the curriculum increased their ability to acquire and interpret images. CONCLUSIONS: Postgraduate year 1 pediatric residents learned the basics of POCUS through 3 brief educational sessions. The increase in posttest scores demonstrated improved POCUS knowledge, and the high OSCE score demonstrated their ability to acquire ultrasound images. Point-of-care ultrasound guidelines are needed for pediatric residency programs.

Critically Ill Pediatric Case Exposure During Emergency Medicine Residency.

BACKGROUND: Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described. OBJECTIVE: The objective was to characterize the critically ill pediatric EM case exposure among EM residents. METHODS: This is a secondary analysis of a multicenter retrospective review of pediatric patients (aged < 18 years) seen by the 2015 graduating resident physicians at four U.S. EM training programs. The per-resident exposure to Emergency Severity Index (ESI) Level 1 pediatric patients was measured. Resident-level counts of pediatric patients were measured; specific counts were classified by age and Pediatric Emergency Care Applied Network diagnostic categories. RESULTS: There were 31,552 children seen by 51 residents across all programs; 434 children (1.3%) had an ESI of 1. The median patient age was 8 years (interquartile range [IQR] 3-12 years). The median overall pediatric critical case exposure per resident was 6 (IQR 3-12 cases). The median trauma and medical exposure was 2 (IQR 0-3) and 3 (IQR 2-10), respectively. For 13 out of 20 diagnostic categories, at least 50% of residents did not see any critical care case in that category. Sixty-eight percent of residents saw 10 or fewer critically ill cases by the end of training. CONCLUSION: Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area.

Teaching Point-of-Care Lung Ultrasound to Novice Pediatric Learners: Web-Based E-Learning Versus Traditional Classroom Didactic.

OBJECTIVE: To assess whether Web-based teaching is at least as effective as traditional classroom didactic in improving the proficiency of pediatric novice learners in the image acquisition and interpretation of pneumothorax and pleural effusion using point-of-care ultrasound (POCUS). METHODS: We conducted a randomized controlled noninferiority study comparing the effectiveness of Web-based teaching to traditional classroom didactic. The participants were randomized to either group A (live classroom lecture) or group B (Web-based lecture) and completed a survey and knowledge test. They also received hands-on training and completed an objective structured clinical examination. The participants were invited to return 2 months later to test for retention of knowledge and skills. RESULTS: There were no significant differences in the mean written test scores between the classroom group and Web group for the precourse test (absolute difference, -2.5; 95% confidence interval [CI], -12 to 6.9), postcourse test (absolute difference, 2.0; 95% CI, -1.4, 5.3), and postcourse 2-month retention test (absolute difference, -0.8; 95% CI, -9.6 to 8.1). Similarly, no significant differences were noted in the mean objective structured clinical examination scores for both intervention groups in postcourse (absolute difference, 1.9; 95% CI, -4.7 to 8.5) and 2-month retention (absolute difference, -0.6; 95% CI, -10.7 to 9.5). CONCLUSIONS: Web-based teaching is at least as effective as traditional classroom didactic in improving the proficiency of novice learners in POCUS. The usage of Web-based tutorials allows a more efficient use of time and a wider dissemination of knowledge.

Brief report: Characterization of marijuana use in us college students by state marijuana legalization status as reported to an online survey.

BACKGROUND AND OBJECTIVE: US college student marijuana use is the highest since 1980. The objective was to investigate use characteristics among college students. METHODS: The RADARS® System College Survey Program surveyed individuals in a university, technical or online school. This was a secondary analysis of existing data. RESULTS: Seven thousand one hundred five students were enrolled, <30% of students' perceived marijuana use a health risk. Students in medical states were more likely to use marijuana compared to non-legal states. (p < .001) Smoking and edibles were common methods of use. CONCLUSIONS: Higher reports of college student use were observed in medical states without differences in risk perception. SCIENTIFIC SIGNIFICANCE: This study further demonstrates the public health impact of marijuana legalization by comparing college study use of marijuana by state legalization status, and demonstrating high rates of use of concentrated products. These findings should be factored when determining regulations and preventative measures when legalizing marijuana. (Am J Addict 2019;28:266-269).

Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age.

BACKGROUND: Febrile infants commonly present to emergency departments for evaluation. OBJECTIVE: We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network. METHODS: We enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28 days of age) and older (29-60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance. RESULTS: Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%. CONCLUSIONS: The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29-60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger.

STUDY OBJECTIVE: To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). METHODS: We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. RESULTS: Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. CONCLUSION: The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.

BACKGROUND: The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. OBJECTIVE: Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). METHODS: This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. RESULTS: Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. CONCLUSIONS: We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger.

IMPORTANCE: Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach. OBJECTIVE: To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. EXPOSURE: RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. MAIN OUTCOMES AND MEASURES: Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. RESULTS: Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). CONCLUSIONS AND RELEVANCE: In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Association of unintentional pediatric exposures with decriminalization of marijuana in the United States.

STUDY OBJECTIVE: We compare state trends in unintentional pediatric marijuana exposures, as measured by call volume to US poison centers, by state marijuana legislation status. METHODS: A retrospective review of the American Association of Poison Control Centers National Poison Data System was performed from January 1, 2005, to December 31, 2011. States were classified as nonlegal if they have not passed legislation, transitional if they enacted legislation between 2005 and 2011, and decriminalized if laws passed before 2005. Our hypotheses were that decriminalized and transitional states would experience a significant increase in call volume, with more symptomatic exposures and more health care admissions than nonlegal states. RESULTS: There were 985 unintentional marijuana exposures reported from 2005 through 2011 in children aged 9 years and younger: 496 in nonlegal states, 93 in transitional states, and 396 in decriminalized states. There was a slight male predominance, and the median age ranged from 1.5 to 2.0 years. Clinical effects varied, with neurologic effects the most frequent. More exposures in decriminalized states required health care evaluation and had moderate to major clinical effects and critical care admissions compared with exposures from nonlegal states. The call rate in nonlegal states to poison centers did not change from 2005 to 2011. The call rate in decriminalized states increased by 30.3% calls per year, and transitional states had a trend toward an increase of 11.5% per year. CONCLUSION: Although the number of pediatric exposures to marijuana reported to the National Poison Data System was low, the rate of exposure increased from 2005 to 2011 in states that had passed marijuana legislation.

The 2012 PEMpix photograph competition award winner: making a case for pringles-flavored carrots.

This is a case report of a 14-year-old boy with autism who presented with photophobia. Physical examination was significant for bilateral corneal ulcers. Differential diagnosis of this chief complaint and the management of the suspected condition are discussed. This case was presented at the Section of Emergency Medicine Meeting at the National Conference and Exhibition of the American Academy of Pediatrics in 2012 and was awarded first place in the PEMpix photograph competition.

Consensus-Derived Recommended Skills for Transition to Residency Courses.

PURPOSE: Transition to residency (TTR) courses facilitate the medical student-residency transition and are an integral part of senior medical student training. The authors established a common set of skills for TTR courses, and an expected level of entrustment students should demonstrate in each skill on TTR course completion. METHOD: A modified Delphi approach was used with 3 survey iterations between 2020 and 2022 to establish skills to be included in a TTR course. Nine TTR experts suggested general candidate skills and conducted a literature search to ensure no vital skills were missed. A stakeholder panel was solicited from email lists of TTR educators, residency program directors, and residents at the panelists' institutions. Consensus was defined as more than 75% of participants selecting a positive inclusion response. An entrustment questionnaire asked panelists to assign a level of expected entrustment to each skill, with 1 indicating observation only and 6 indicating perform independently. RESULTS: The stakeholder panel initially consisted of 118 respondents with representation across educational contexts and clinical specialties. Response rates were 54% in iteration 2, 42% in iteration 3, and 33% on the entrustment questionnaire. After 3 iterations, 54 skills met consensus and were consolidated into 37 final skills categorized into 18 clinical skills (e.g., assessment and management of inpatient concerns), 14 communication skills (e.g., delivering serious news or having difficult conversations), 4 personal and professional skills (e.g., prioritization of clinical tasks), and 1 procedural skill (mask ventilation). Median entrustment levels were reported for all skills, with 19 skills having a level of expected entrustment of 4 (perform independently and have all findings double-checked). CONCLUSIONS: These consensus skills can serve as the foundation of a standardized national TTR curriculum framework. Entrustment guidance may help educational leaders optimize training and allocation of resources for TTR curriculum development and implementation.

The limited utility of screening laboratory tests and electrocardiograms in the management of unintentional asymptomatic pediatric ingestions.

BACKGROUND: Suspected ingestions are a common chief complaint to the emergency department although the majority of ingestions by children are insignificant. OBJECTIVE: Assess the utility of screening laboratory tests and Electrocardiograms (ECGs) in unintentional asymptomatic pediatric poisonings. METHODS: Retrospective chart review at a tertiary care children's hospital and a regional poison center of patients less than 12 years of age using ICD-9 codes from January 2005 through December 2008. Laboratory or ECG results requiring intervention and/or direct treatment, a non-RPC subspecialty consultation, and/or prolonged Emergency Department stay was considered changed management. RESULTS: Five hundred ninety five suspected ingestions met our criteria. The median age was 2.6 years (IQR 1.6, 3.0 years) and 56% were male. One laboratory test or ECG was obtained in 233 patients (39%). Of 24 screening ECGs, 32 complete blood counts and 34 blood gases, none were clinically significant. Fifty-two patients received screening metabolic panels, 3 were abnormal and 2 changed management (anion gap metabolic acidosis with unsuspected salicylate ingestions). None of the 127 (21%) screening acetaminophen levels changed management. Two of sixty-five (13%) screening salicylate levels changed management. Three screening urine toxicology tests on patients with altered mental status were positive without ingestion history. No patient under the age of 12 years with normal vital signs and normal mental status had positive screening tests. CONCLUSIONS: Screening laboratory tests and ECGs were of limited utility and rarely changed management despite being ordered in a significant number of patients. Screening tests are rarely indicated in unintentional overdoses in children who are asymptomatic.

Improving Management of Suspected Chlamydia and Gonorrhea in Adolescents with a Rapid Diagnostic Test.

We aimed to determined the impact of an intervention using rapid chlamydia (CT)/gonorrhea (GC) testing on reducing unnecessary antibiotic use, undertreatment of CT and/or GC, and length of stay (LOS) in an urban safety-net pediatric emergency department. Methods: Before 2020, we tested for CT/GC using a batched nucleic acid amplification test, with results available the following day. Starting in January 2020, we implemented rapid nucleic acid amplification test. Our primary outcome variables were undertreatment and overtreatment. We defined undertreatment as GC and/or CT-positive patients who did not receive appropriate treatment. We defined overtreatment as GC or CT-negative patients who received antibiotics. The balancing measure was the LOS. Results: There were 758 patients evaluated in the preimplementation period (2019), 612 in the implementation period (2020), and 626 in the postimplementation period (2021). Postimplementation, overtreatment decreased from 18.4% to 8.1%. Undertreatment did not differ by period but was less common among those tested with rapid versus standard testing (12.7% versus 9.9%, P = 0.05). Median LOS increased from 166 minutes (preimplementation) to 187 minutes (implementation) and 202 minutes (postimplementation; P < 0.001). Conclusions: Rapid CT/GC testing reduced unnecessary antibiotic use but increased LOS due to patients waiting for the test results before being discharged. Given the rapid increases in CT/GC rates and antimicrobial resistance, health systems should consider implementing rapid testing to appropriately direct antimicrobials to patients most likely to benefit.

Decreasing Percentage of Infants With Very Low 5-Minute Apgar Scores at a Safety-Net Level III NICU.

OBJECTIVES: Low 5-minute Apgar scores predict mortality and may be associated with poor neurologic outcomes. Our percentage of infants with low 5-minute Apgar scores was higher than the national average (2.4%). Therefore, we aimed to decrease the percentage of infants with Apgar scores <4 at 5 minutes from a mean of 5.12% to <2.4% and decrease the percentage of infants receiving chest compressions (CCs) before intubation from 21% to <5%. METHODS: We completed 4 plan-do-study-act (PDSA) cycles from April 2015 through November 2018, including providing 24-hour advanced practice provider coverage (PDSA 1), initiating advanced practice provider-led delivery room scenarios for residents and education to secure the airway before CCs (PDSA 2), developing "Go Bags" with supplies (PDSA 3), and performing multidisciplinary mock codes (PDSA 4). We used a statistical process control p-chart to evaluate our primary outcome measure of the percentage of infants with 5-minute Apgar scores <4 from January 2012 through September 2021. RESULTS: The percent of infants with Apgar scores <4 at 5 minutes decreased from 5.12% in the baseline and intervention period to 2.16% in the sustainment period. We detected special cause with 8 points below the centerline. Infants born in the baseline period were 7.9 times more likely to receive CCs before intubation than in the intervention and sustainment periods (P = .002). CONCLUSIONS: We decreased the percentage of infants with 5-minute Apgar scores <4 and the percentage of infants receiving chest compressions before intubation. Ultimately, rigorous education and team collaboration through frequent multidisciplinary team mock codes were critical to our success.