Variability in the management of infants under 3 months with minor head injury in paediatric emergency departments.

INTRODUCTION: In the assessment of infants younger than 3 months with minor traumatic head injury (MHI), it is essential to adapt the indication of imaging tests. The Pediatric Head Injury/Trauma Algorithm (PECARN) clinical prediction rule is the most widely used to guide clinical decision making. OBJECTIVES: To analyse the variability in the performance of imaging tests in infants under 3 months with MHI in paediatric emergency departments (PEDs) and the adherence of each hospital to the recommendations of the PECARN rule. POPULATION AND METHODS: We conducted a prospective multicentre observational study in 13 paediatric emergency departments in Spain between May 2017 and November 2020. RESULTS: Of 21 981 children with MHI, 366 (1.7%) were aged less than 3 months; 195 (53.3%) underwent neuroimaging, with performance of CT scans in 37 (10.1%; interhospital range, 0%-40.0%), skull X-rays in 162 (44.3 %; range, 0%-100%) and transfontanellar ultrasound scans in 22 (6.0%; range, 0%-24.0%). The established recommendations were followed in 25.6% (10/39) of infants classified as high-risk based on PECARN criteria (range, 0%-100%); 37.1% (36/97) classified as intermediate-risk (range, 0%-100%) and 57.4% (132/230) classified as low-risk (range, 0%-100%). CONCLUSION: We found substantial variability and low adherence to the PECARN recommendations in the performance of imaging tests in infants aged less than 3 months with MHI in Spanish PEDs, mainly due to an excessive use of skull X-rays.

Improving emergency department care of infants with acute bronchiolitis by reducing the use of unrecommended drugs: a quality-of-care initiative in a Spanish autonomous community. / Iniciativa de mejora para reducir el uso de fármacos no recomendados en el manejo de lactantes con bronquiolitis aguda en los servicios de urgencias de una comunidad autónoma.

OBJECTIVES: To evaluate the impact of a quality-of-care improvement program implemented in emergency departments (EDs) in a Spanish autonomous community with the aim of reducing the use of unrecommended drugs when treating infants for acute bronchiolitis. MATERIAL AND METHODS: Before-after quasi-experimental intervention study. We retrospectively included infants aged 12 months or less who were treated for acute bronchiolitis in 24 Spanish national health system hospital EDs in December during 2 epidemic periods: in 2018, before implementing the program, and in 2019, after implementation. Data collected included epidemiologic information, clinical and care details, and clinical course. The program consisted of providing informative material and training sessions before the epidemic period started. RESULTS: A total of 7717 episodes (4007 in 2018 and 2710 in 2019) were identified. Epidemiologic and clinical characteristics did not differ between the 2 periods. ED use of the following treatments decreased between the 2 periods: salbutamol, from 29.4% (95% CI, 28.8%-30.8%) in 2018 to 10.6% (95% CI, 9.6%-11.6%) in 2019; epinephrine from 6.0% (95% CI, 5.3%-6.8%) to 0.9% (95% CI, 0.7%-1.3%); and hypertonic saline solution fell from 8.2% (95% CI, 7.3%-9.1%) to 2.1% (95% CI, 1.7%-2.6%) (P.001, all comparisons). Prescriptions for salbutamol on discharge fell from 38.7% (95% CI, 36.9%-40.4%) to 10.6% (95% CI, 9.6%-11.6%) (P.001). Admissions and readmissions did not change, and the median time (interquartile range) spent in the ED fell from 81 (44-138) minutes to 66 (37-127) minutes (P.001). CONCLUSION: The quality-of-care improvement initiative was able to decrease the number of unrecommended therapeutic interventions for acute bronchiolitis. However, we identified great variations between EDs, suggesting that training and assessment of impact should continue.

OBJETIVO: Evaluar el impacto de una iniciativa de mejora realizada en los servicios de urgencias (SU) de una comunidad autónoma para reducir el uso de fármacos no recomendados en lactantes con bronquiolitis aguda (BA). METODO: Estudio cuasi-experimental analítico del tipo "antes y después de una intervención". Se incluyeron de forma retrospectiva todas las BA en niños # 12 meses atendidas en los SU de 24 hospitales públicos durante el mes de diciembre de dos periodos epidémicos: 2018 (preintervención) y 2019 (postintervención). Se recogieron variables epidemiológicas, clínicas, asistenciales y evolutivas. La intervención consistió en difundir material informativo y realizar actividades formativas previas al periodo epidémico. RESULTADOS: Se incluyeron 7.717 episodios (2018: 4.007 y 2019: 3.710). No existieron diferencias en las características epidemiológicas y clínicas. El empleo de salbutamol en los SU descendió del 29,4% [intervalo de confianza del 95% (IC 95%): 28,8-30,8] en 2018 al 10,6% (IC 95%: 9,6-11,6) en 2019 (p 0,001), el de adrenalina del 6,0% (IC 95%: 5,3-6,8) al 0,9% (IC 95%: 0,7-1,3) y el de suero salino hipertónico del 8,2% (IC 95%: 7,3-9,1) al 2,1% (IC 95%: 1,7-2,6) (p 0,001). La prescripción al alta de salbutamol se redujo del 38,7% (IC 95%: 36,9-40,4) al 10,6% (IC 95%: 9,6-11,6) (p 0,001). La tasa de ingreso y la tasa de readmisión no cambiaron y la mediana de tiempo de estancia en los SU se redujo 81 minutos [rango intercuartil (RIC) 44-138] a 66 (RIQ: 37-127) (p 0,001). CONCLUSIONES: La iniciativa de mejora ha conseguido disminuir la tasa de intervenciones terapéuticas no indicadas en BA. Sin embargo, existe una gran variabilidad entre los diferentes SU por lo que la estrategia y la medición de su impacto deben mantenerse en el tiempo.

Variabilidad en la atención en urgencias al lactante menor de 3 meses con un traumatismo craneoencefálico leve / Variability in the management of infants under 3 months with minor head injury in paediatric emergency departments

Introducción: En la valoración de los lactantes menores de 3 meses con un traumatismo craneoencefálico (TCE) leve es imprescindible adecuar la indicación de pruebas radiológicas. La regla de predicción clínica PECARN es la más utilizada para ayudar en la toma de decisiones clínicas. Objetivos: Evaluar la variabilidad en la realización de pruebas radiológicas en los menores de 3 meses con un TCE leve en los servicios de urgencias pediátricos y la adherencia de cada hospital a las recomendaciones de la regla de predicción clínica PECARN. Población y métodos: Estudio de cohortes prospectivo en<3 meses con un TCE leve que consultaron en 13 servicios de urgencias pediátricos españoles entre mayo de 2017 y noviembre de 2020. Resultados: Se atendieron 21.981 pacientes con un TCE leve, de los que 366 (1,7%) eran menores de 3 meses. Se realizaron pruebas de imagen al 53,3% (195): TC craneal a 37 (10,1% [rango entre hospitales 0-40%]), radiografía de cráneo a 162 (44,3% [rango 0-100%]) y ecografía transfontanelar a 22 (6,0% [rango 0-24%]). Se siguieron las recomendaciones PECARN en el 25,6% (10/39) de los lactantes con criterios de alto riesgo (rango 0-100%); el 37,1% (36/97) de los de riesgo intermedio (rango 0-100%) y el 57,4% (132/230) de los de bajo riesgo (rango 0-100%). Conclusiones: Existe gran variabilidad, con un bajo cumplimiento de las recomendaciones PECARN, en la realización de pruebas radiológicas en los menores de 3 meses que consultan por un TCE leve en los servicios de urgencias pediátricos españoles, a expensas fundamentalmente de un exceso en el empleo de radiografías de cráneo. (AU)

Introduction: In the assessment of infants younger than 3 months with minor traumatic head injury (MHI), it is essential to adapt the indication of imaging tests. The Pediatric Head Injury/Trauma Algorithm (PECARN) clinical prediction rule is the most widely used to guide clinical decision making. Objectives: To analyse the variability in the performance of imaging tests in infants under 3 months with MHI in paediatric emergency departments and the adherence of each hospital to the recommendations of the PECARN rule. Population and methods: We conducted a prospective multicentre observational study in 13 paediatric emergency departments in Spain between May 2017 and November 2020. Results: Of 21,981 children with MHI, 366 (1.7%) were aged less than 3 months; 195 (53.3%) underwent neuroimaging, with performance of CT scans in 37 (10.1%; interhospital range, 0%–40.0%), skull X-rays in 162 (44.3%; range, 0%–100%) and transfontanellar ultrasound scans in 22 (6.0%; range, 0%–24.0%). The established recommendations were followed in 25.6% (10/39) of infants classified as high-risk based on PECARN criteria (range, 0%–100%); 37.1% (36/97) classified as intermediate-risk (range, 0%–100%) and 57.4% (132/230) classified as low-risk (range, 0%–100%). Conclusion: We found substantial variability and low adherence to the PECARN recommendations in the performance of imaging tests in infants aged less than 3 months with MHI in Spanish paediatric emergency departments s, mainly due to an excessive use of skull X-rays. (AU)

Iniciativa de mejora para reducir el uso de fármacos no recomendados en el manejo de lactantes con bronquiolitis aguda en los servicios de urgencias de una comunidad autónoma / Improving emergency department care of infants with acute bronchiolitis by reducing the use of unrecommended drugs: a quality-of-care initiative in a Spanish autonomous community

Objetivo. Evaluar el impacto de una iniciativa de mejora realizada en los servicios de urgencias (SU) de una comunidad autónoma para reducir el uso de fármacos no recomendados en lactantes con bronquiolitis aguda (BA).Método. Estudio cuasi-experimental analítico del tipo “antes y después de una intervención”. Se incluyeron de forma retrospectiva todas las BA en niños # 12 meses atendidas en los SU de 24 hospitales públicos durante el mes de diciembre de dos periodos epidémicos: 2018 (preintervención) y 2019 (postintervención). Se recogieron variables epidemiológicas, clínicas, asistenciales y evolutivas. La intervención consistió en difundir material informativo y realizar actividades formativas previas al periodo epidémico.Resultados. Se incluyeron 7.717 episodios (2018: 4.007 y 2019: 3.710). No existieron diferencias en las características epidemiológicas y clínicas. El empleo de salbutamol en los SU descendió del 29,4% [intervalo de confianza de 95% (IC 95%): 28,8-30,8] en 2018 al 10,6% (IC 95%: 9,6-11,6) en 2019 (p < 0,001), el de adrenalina del 6,0% (IC 95%: 5,3-6,8) al 0,9% (IC 95%: 0,7-1,3) y el de suero salino hipertónico del 8,2% (IC 95%: 7,3-9,1) al 2,1% (IC 95%: 1,7-2,6) (p < 0,001). La prescripción al alta de salbutamol se redujo del 38,7% (IC 95%: 36,9-40,4) al 10,6% (IC 95%: 9,6-11,6) (p < 0,001). La tasa de ingreso y la tasa de readmisión no cambiaron y la mediana de tiempo de estancia en los SU se redujo 81 minutos [rango intercuartil (RIC) 44-138] a 66 (RIQ: 37-127) (p < 0,001).Conclusiones. La iniciativa de mejora ha conseguido disminuir la tasa de intervenciones terapéuticas no indicadas en BA. Sin embargo, existe una gran variabilidad entre los diferentes SU por lo que la estrategia y la medición de su impacto deben mantenerse en el tiempo. (AU)

Objective. To evaluate the impact of a quality-of-care improvement program implemented in emergency departments (EDs) in a Spanish autonomous community with the aim of reducing the use of unrecommended drugs when treating infants for acute bronchiolitis. Methods. Before-after quasi-experimental intervention study. We retrospectively included infants aged 12 months or less who were treated for acute bronchiolitis in 24 Spanish national health system hospital EDs in December during 2 epidemic periods: in 2018, before implementing the program, and in 2019, after implementation. Data collected included epidemiologic information, clinical and care details, and clinical course. The program consisted of providing informative material and training sessions before the epidemic period started. Results. A total of 7717 episodes (4007 in 2018 and 2710 in 2019) were identified. Epidemiologic and clinical characteristics did not differ between the 2 periods. ED use of the following treatments decreased between the 2 periods: salbutamol, from 29.4% (95% CI, 28.8%-30.8%) in 2018 to 10.6% (95% CI, 9.6%-11.6%) in 2019; epinephrine from 6.0% (95% CI, 5.3%-6.8%) to 0.9% (95% CI, 0.7%-1.3%); and hypertonic saline solution fell from 8.2% (95% CI, 7.3%-9.1%) to 2.1% (95% CI, 1.7%-2.6%) (P<.001, all comparisons). Prescriptions for salbutamol on discharge fell from 38.7% (95% CI, 36.9%-40.4%) to 10.6% (95% CI, 9.6%-11.6%) (P<.001). Admissions and readmissions did not change, and the median time (interquartile range) spent in the ED fell from 81 (44-138) minutes to 66 (37-127) minutes (P<.001). Conclusions. The quality-of-care improvement initiative was able to decrease the number of unrecommended therapeutic interventions for acute bronchiolitis. However, we identified great variations between EDs, suggesting that training and assessment of impact should continue. (AU)

Evaluation of the PECARN rule for traumatic brain injury applied to infants younger than 3 months and creation of a modified, age-specific rule.

Infants < 3 months with minor head trauma (MHT) are a particularly vulnerable group, though few studies have focused specifically on these patients. We aimed to evaluate the application of the PECARN prediction rule, designed for clinically important traumatic brain injury (ciTBI) in children < 2 years in infants < 3 months, and create a specific prediction rule for this population. We conducted a prospective multicenter observational study in 13 pediatric emergency departments (PEDs) in Spain. The PECARN rule was applied to all patients. A new specific prediction rule for infants < 3 months of age was created. The main outcome measures were (1) ciTBI, (2) TBI evidenced on computed tomography (CT) scan, and (3) isolated skull fracture (ISF). Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 21,981 children with MHT, 366 (1.7%) were < 3 months old and 195 (53.3%) underwent neuroimaging, including 37 (10.1%) with CT scan. The sensitivity and negative predictive value (NPV) of the PECARN prediction rule for ciTBI were 100% (95% CI, 20.7-100) and 99.7% (95% CI, 98.4-100%), respectively. Of the 230 infants (62.8%) who met the PECARN low-risk criteria, none had ciTBI, 1 (0.4% overall, 95% CI, 0-2.4) had TBI on CT, and 2 (0.9% overall; 95% CI, 0.1-3.1) had an ISF. Among the 136 infants (37.2%) who did not meet the PECARN low-risk criteria, 1 (0.3% overall; 95% CI, 0-1.5) had ciTBI, 11 (8.1% overall; 95% CI, 4.1-14.0) had TBI on CT, and 18 (13.2% overall; 95% CI, 8-20.1) had an ISF. The sensitivity and NPV of the Spanish prediction rule for ciTBI were 100% (95% CI, 20.7-100) and 100% (95% CI, 98.4-100%), respectively. No infants in the registry developed complications during follow-up. CONCLUSION: The PECARN rule for infants < 2 years old accurately identified infants < 3 months old at low risk for ciTBI in our population, although the adapted Spanish rule presented here could be even more accurate. WHAT IS KNOWN: • Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination. • A low threshold for CT scan is recommended in this population. WHAT IS NEW: • PECARN rule for infants < 2 years old is an adequate tool with which to identify infants < 3 months old at low risk for clinically important traumatic brain injury. • Spanish rule could identify even more low-risk infants without overlooking important outcomes but it should be validated to confirm its predictive capacity.

Epidemiology of minor blunt head trauma in infants younger than 3 months.

Specific knowledge of the features of minor head trauma in infants is necessary to develop appropriate preventive strategies and adjust clinical management in pediatric emergency departments (PEDs). The aim of this study is to describe the epidemiology of minor blunt head trauma in infants < 3 months who present to PEDs. We performed a prospective study of infants evaluated in any of 13 Spanish PEDs within 24 h of a minor head trauma (Glasgow Coma Scale scores of 14-15) between May 2017 and November 2020. Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 1,150,255 visits recorded, 21,981 children (1.9%) sustained a head injury, 386 of whom (0.03%) were under 3 months old. Among the 369 patients who met the inclusion criteria (0.03%), 206 (56.3%) were male. The main causes of trauma were fall-related (298; 80.8%), either from furniture (138/298; 46.3%), strollers (92/298; 30.9%), or a caregiver's arms (61/298; 20.5%). Most infants were asymptomatic (317; 85.9%) and showed no signs of injury on physical exam (210; 56.9%). Imaging studies were performed in 195 patients (52.8%): 37 (10.0%) underwent computed tomography (CT) scan, 162 (43.9%) X-ray, and 22 (6.0%) ultrasound. A clinically important traumatic brain injury (ciTBI) occurred in 1 infant (0.3% overall; 95% CI, 0-1.5), TBI was evidenced on CT scan in 12 (3.3% overall; 95% CI, 1.7-5.7), and 20 infants had an isolated skull fracture (5.5% overall; 95% CI, 3.4-8.3). All outcomes were caused by falls onto hard surfaces. CONCLUSION:  Most head injuries in infants younger than 3 months are benign, and the rate of ciTBI is low. Prevention strategies should focus on falls onto hard surfaces from furniture, strollers, and caregivers' arms. Optimizing imaging studies should be a priority in this population. WHAT IS KNOWN: • Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination. • A low threshold for CT scan is recommended in this population. WHAT IS NEW: • Most cases of blunt head trauma in infants younger than 3 months have good outcomes, and the rate of clinically important traumatic brain injury is low. • Optimizing imaging studies should be a priority in this population, avoiding X-ray examinations and reducing unnecessary CT scans.

Infecciones durante oxigenación de membrana extracorpórea / Experience with infections in the use of extracorporeal membrane oxygenation

OBJETIVO: Identificar factores de riesgo asociados con el desarrollo de infecciones nosocomiales en pacientes pediátricos asistidos con oxigenación por membrana extracorpórea (ECMO). PACIENTES Y MÉTODOS: Se han revisado de forma retrospectiva los pacientes que han recibido asistencia en ECMO de enero de 2011 a diciembre de 2014. Se han recogido datos demográficos, sobre la asistencia y sobre las infecciones que aparecen durante dicha asistencia. RESULTADOS: En este periodo hubo 50 asistencias en ECMO. Veinte pacientes tuvieron 23 episodios de infección, de los que 16 fueron bacteriemias, siendo el microorganismo más frecuente el estafilococo coagulasa negativo (habiendo 2 casos de candidemia). En cuanto a los grupos de edad, el lugar y el tipo de canulación, la presencia de coagulopatía grave y la realización de intervenciones quirúrgicas durante la asistencia, ninguno de estos factores resultó un factor de riesgo de infección estadísticamente significativo. La duración media de soporte en ECMO fue significativamente mayor en los pacientes que tuvieron alguna infección (8,91 vs. 5,96 días; p = 0,039). No hubo diferencias significativas en cuanto a la estancia en la Unidad de Cuidados Intensivos Pediátricos ni en cuanto a la supervivencia. CONCLUSIONES: La incidencia de infección durante ECMO es muy alta y los pacientes que tienen una infección están asistidos un tiempo significativamente mayor, por lo que se deben instaurar medidas para prevenir la aparición de estas infecciones e intentar minimizar el tiempo de asistencia en ECMO

OBJECTIVE: To identify risk factors associated with infectious complications acquired by paediatric patients during extracorporeal life support (ECLS). PATIENTS AND METHODS: Patients under ECLS from January 2011 to December 2014 have been retrospectively reviewed and data on demographics, care and infectious complications were collected. RESULTS: There were 50 ECLS assistances in the study period, of which 20 patients had 23 infectious complications: 16 were bloodstream infections, with coagulase negative staphylococci being the predominant isolate (there were 2 cases of candidaemia). Age, site of cannulation procedure, cannulation site, severe coagulopathy, and surgical interventions during assistance were analysed as risk factors for infectious complications, but no significant differences were found. ECLS duration was significantly longer in patients with infectious complications (8.91 vs 5.91 days; P=.039). There were no significant differences as regards Paediatric Intensive Care Unit (PICU) stay, or in survival. CONCLUSIONS: Infectious complications during ECLS are very common, and ECLS duration is significantly longer in patients with infections. Measures should be put in place to prevent infectious complications and reduce time on ECLS

[Experience with infections in the use of extracorporeal membrane oxygenation]. / Infecciones durante oxigenación de membrana extracorpórea.

OBJECTIVE: To identify risk factors associated with infectious complications acquired by paediatric patients during extracorporeal life support (ECLS). PATIENTS AND METHODS: Patients under ECLS from January 2011 to December 2014 have been retrospectively reviewed and data on demographics, care and infectious complications were collected. RESULTS: There were 50 ECLS assistances in the study period, of which 20 patients had 23 infectious complications: 16 were bloodstream infections, with coagulase negative staphylococci being the predominant isolate (there were 2 cases of candidaemia). Age, site of cannulation procedure, cannulation site, severe coagulopathy, and surgical interventions during assistance were analysed as risk factors for infectious complications, but no significant differences were found. ECLS duration was significantly longer in patients with infectious complications (8.91 vs 5.91 days; P=.039). There were no significant differences as regards Paediatric Intensive Care Unit (PICU) stay, or in survival. CONCLUSIONS: Infectious complications during ECLS are very common, and ECLS duration is significantly longer in patients with infections. Measures should be put in place to prevent infectious complications and reduce time on ECLS.