Optimizing the Yield of In-and-Out Urinary Catheter Cultures by Applying a "Midstream-Like" Approach in Pediatric Patients.

Despite appropriate disinfection, sample contamination during in-and-out urinary catheterization is not uncommon, yielding false-positive and "mixed-culture" interpretations. We implemented a "midstream-like" catheterization technique, and cultured both first- and second-voided urine fractions. Second-fraction cultures exhibited less contaminants and "mixed-culture" interpretations and were better aligned with pyuria, thereby enhancing diagnostic accuracy and minimizing the risk of clinical misdiagnosis and unwarranted antibiotic use.

Safety of pediatric sedation and analgesia during burn dressing changes by pediatric residents.

BACKGROUND: Acute pain and anxiety management during pediatric burn dressing change is very challenging. There are limited data regarding feasibility and safety of sedation administration by nonanesthesiologists. We sought to describe the implementation of a sedation protocol for pediatric residents during burn dressing changes in the pediatric ward. METHODS: An analgesia and sedation protocol was designed and implemented in the pediatric wards in 2015. Retrospective data were collected on all children who were sedated by pediatric residents for burns in the pediatric wards over a 4-year period in our hospital. Demographics, burn characteristics, and data regarding adverse events were collected from patients' electronic medical records. The main outcomes were successful procedure completion and safety. RESULTS: During the study period, 1130 sedations were performed in 272 patients by pediatric residents. The median age was 2.5 years (IQR 1.3-9.1). Sixty-two percent (695/1130) of the patients were male. The majority of the burns (84%, 955/1130) were <20%, and the majority of the patients (91%, 1030/1130) had an ASA (American Society of Anesthesiologists) score of 1. The incidence rate of adverse events was 4.3% (49/1130) and 1.3% (15/1130) for serious adverse events . There were no statistically significant differences in gender, age, ASA, or burn degree between patients with or without adverse events. CONCLUSIONS: We designed and implemented an analgesia and sedation protocol for pediatric residents to be applied in patients during burn dressing change. The implemented protocol in the pediatric wards was found to be feasible and with a low incidence of adverse events.

Pediatric Hospitalizations After School Reopening During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Alpha (B.1.1.7) Variant Spread: A Multicenter Cross-sectional Study in Israel.

This multicenter, cross-sectional study provides evidence on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated emergency department visits and hospitalizations in pediatric wards and intensive care units after school reopening during the SARS-CoV-2 Alpha (B.1.1.7) variant spread in Israel. Study findings suggest that school reopening was not followed by an increase in SARS-CoV-2-related pediatric morbidity.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.

Comparison of three intraosseous access devices for resuscitation of term neonates: a randomised simulation study.

OBJECTIVES: To compare the success rates and ease of use of three intraosseous (IO) access devices used in term neonates. DESIGN: A three-arm randomised controlled simulation study was conducted. SETTING: A simulation laboratory. PARTICIPANTS: Seventy-two paediatric residents completing their emergency department rotation as part of their residency training, and 20 paediatric specialists. INTERVENTION: Using an animal bone model, the one-attempt success rate of the EZ-IO drill, the NIO-I needle and the Jamshidi needle was compared. Uncooked Cornish Hen bones were used because of their similarity in length and diameter to the bones of neonates. Participants were asked to record the perceived ease of use of their assigned device using a 5-point Likert Scale. MAIN OUTCOME MEASURE: The main outcome was the visualisation of flow emerging from the distal end of the bone, and perceived ease of use of the three IO devices. RESULTS: The EZ-IO, NIO-I and Jamshidi groups included 30, 31 and 31 participants, respectively, with median (IQR) years of experience of 3 (2-5), 3 (2-6) and 4 (3-5) years. Participants had significantly lower one-attempt success rates with the EZ-IO drill than with the NIO-I and the Jamshidi needles (14 of 30 (46.7%) vs 24 of 31 (77.4%); p=0.016, and 14 of 30 (46.7%) vs 25 of 31 (80.7%); p=0.007, respectively). The median (IQR) ease-of-use score of the EZ-IO drill was higher than that of the NIO-I and Jamshidi needles (5 (4-5) vs 4 (4-5); p=0.008, and 5 (4-5) vs 4 (3-4); p=0.0004, respectively). CONCLUSIONS: Although easier to use, the EZ-IO drill demonstrated lower success rates than the IO needles in establishing IO access on a neonatal bone model.

Endotracheal intubation of COVID-19 patients by paramedics using a box barrier: A randomized crossover manikin study.

BACKGROUND: In the prehospital setting, endotracheal intubation (ETI) may be required to secure the coronavirus disease 2019 (COVID-19) patient airway. It has been suggested that the use of a protective barrier can reduce possible aerosol delivery from patients to clinicians during ETI. We sought to assess the performance of ETI by paramedics wearing personal protective equipment with and without the use of a box barrier. METHODS: A randomized, crossover simulation study was performed in a simulation laboratory. Study participants were 18 paramedics actively working in the clinical environment. Participants' performance of ETI via direct laryngoscopy (DL) with and without the use of a box barrier was assessed. The sequence of intubation was randomized to either BoxDL-first or DL-first. The primary outcome was the success rate of ETI on first-attempt. The secondary and tertiary outcomes were ETI success rates on three attempts and total intubation time, respectively. RESULTS: There were no differences between the DL group and the BoxDL group in one-attempt success rates (14/18 vs 12/18; P = 0.754), and in overall success rates (16/18 vs 14/18; P = 0.682). The mean (standard deviation) of the total intubation times for the DL group and the BoxDL group were 27.3 (19.7) seconds and 36.8 (26.2) seconds, respectively (P < 0.015). CONCLUSIONS: The findings of this pilot study suggest that paramedics wearing personal protective equipment can successfully perform ETI using a barrier box, but the intubation time may be prolonged. The applicability of these findings to the care of COVID-19 patients remain to be investigated.

Pediatric Intraosseous Access Performed by Emergency Department Nurses Using Semiautomatic Devices: A Randomized Crossover Simulation Study.

BACKGROUND: No study has examined the performance of emergency department (ED) nurses in establishing intraosseous access (IO) access. This study aimed to evaluate ED nurses' success rate in establishing pediatric IO access using semiautomatic devices. METHODS: A randomized crossover simulation study was conducted. The success rates of ED nurses were compared with those of paramedics with similar years of experience. The study instruments were the new spring-loaded injector (NIO) and the battery power drill (EZ-IO). Uncooked piglets' bones were used as the study model. All attempts were filmed by a video camera. Successful placement was defined as the visualization of flow from the marrow cavity. Participants recorded their ranking of the "ease of use" of each device. RESULTS: No differences in 1-attempt success rate was found between nurses and paramedics (27/34 [79.4%] vs 25/30 [83.3%], P = 0.68). Nurses and paramedics had similar success rates with the 2 semiautomatic IO devices (12/17 vs 12/15 with the spring-loaded injector, P = 0.69, and 15/17 vs 13/15 with the battery power drill, P = 0.9). The number of failed attempts and the causes for failure were equally distributed between nurses and paramedics. Median ease-of-use Likert-scale scores of the spring-loaded injector and the battery power drill were 4 (interquartile range [IQR] = 3-4) and 5 (IQR = 5-5) (P < 0.04) for the nurses and 5 (IQR = 4-5) and 5 (IQR = 4-5) (P = 0.44) for the paramedics, respectively. CONCLUSIONS: Emergency department nurses and paramedics had a similarly high insertion success rates on a pediatric bone model. This pilot study suggests that ED nurses can successfully perform this procedure.

Assessment of Alternative Personal Protective Equipment by Emergency Department Personnel During the SARS-CoV-2 Pandemic: A Simulation-Based Pilot Study.

STATEMENT: Shortage of personal protective equipment (PPE) for frontline healthcare workers managing the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a major, global challenge. In this pilot study, we describe a simulation-based method for evaluating the suitability and acceptability of an alternative biological isolation garment (BIG, a gown or a suit) for clinical use by emergency department (ED) personnel. Using a high-fidelity simulator, participants provided airway management according to the SARS-CoV-2 protocol. A nonvisible fluorescent marker was used as a surrogate marker of contamination. We assessed ultraviolet light visualization of the fluorescent marker after doffing and satisfaction with donning, use during simulation, and doffing. We found that after doffing, markers were not visualized on any of the participants and that the median satisfaction scores of the alternative and standard BIG (sBIG) were 4 [interquartile range (IQR) = 1-5] and 4 (IQR = 2-4), respectively. The results suggest the suitability and acceptability of the alternative BIG (aBIG) for use by ED personnel.

Keeping up with the information explosion: a surge in consumption of data on pediatric SARS-CoV-2 infection by pediatric emergency physicians.

PEM-Database.org is an unaffiliated, not-for-profit website, dedicated to the field's advancement of pediatric emergency medicine. PEM-Database published the first early access pediatric-related SARS-CoV-2 articles on March 13th, two days following the World Health Organization's declaration of a global pandemic. Over the following 2 weeks, the number of PEM-Database entries increased dramatically. This surge expresses interest by pediatric emergency medicine physicians in data on pediatric SARS-CoV-2 infection.

Variables Associated With Administration of Nurse-initiated Analgesia in Pediatric Triage.

OBJECTIVES: Triage nurse-initiated analgesia (TNIA) has been shown to be associated with decreased time to the provision of analgesia and improved patient satisfaction. We examined variables that influence the provision of analgesia in a pediatric emergency department that uses TNIA. METHODS: A 4-year retrospective cohort study of all children with triage pain scores ≥1 was conducted. Data on demographics and patients' and nurses' characteristics were collected. Logistic regression analyses were used to examine the effect of multiple variables on the provision of any analgesia and opioid analgesia. RESULTS: Overall, 28,746 children had triage pain scores ≥1; 14,443 (50.2%) patients received analgesia of any type and 1888 (6.6%) received opioid analgesia. Mean time to any analgesia was 8.0±3.7 minutes. Of the 9415 patients with severe pain, 1857 (19.7%) received opioid analgesia. Age, sex, hourly number of patients waiting to be triaged, and nurse experience were not associated with the provision of any analgesia or opioid analgesia. Severe pain had the highest odds ratios (ORs) for the provision of any analgesia and opioid analgesia (7.7; 95% confidence interval [CI]: 7.1-8.2 and 22.8; 95% CI: 18.1-28.8, respectively). Traumatic injury and time-to-triage <8 minutes were associated with the provision of opioid analgesia (OR: 4.7; 95% CI: 4.2-5.2 and OR: 1.6; 95% CI: 1.5-1.8, respectively). DISCUSSION: TNIA yielded a short time to analgesia, but rates of any analgesia and opioid analgesia were low. Several variables associated with the provision of any analgesia and opioid analgesia were identified. Our findings provide evidence to guide future educational programs in this area.

Emergency Physician-Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series.

BACKGROUND: Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation. OBJECTIVE: The aim of this study was to report the course of the first patients who were sedated by emergency physicians for pneumatic reduction of intussusception (PRI). METHODS: We conducted a case series analysis of prospectively collected data on patients undergoing PRI, using a sedation recording tool. This tool uses standardized definitions from the Quebec guidelines for terminology and reporting adverse events in emergency medicine. Recording of time interval measurements and adverse events was performed by the emergency physician and nurse. RESULTS: Between February 2016 and March 2018, 11 males and 3 females, with a median age of 11 months (interquartile range [IQR] 6-20 months), underwent sedation for PRI by five attending pediatric emergency physicians. All of the reductions were successful and without complications. Eight patients received ketamine and propofol, 5 received ketamine, and 1 received ketamine and midazolam. Median times for the presedation phase, procedure, sedation, physiologic recovery and emergency department recovery were: 131 min (IQR 79-104 min), 10.5 min (IQR, 9-12 min), 21 min (IQR, 20-30 min), 25 min (IQR, 23-30 min), and 108 min (IQR, 82-161 min), respectively. Four respiratory adverse events that required intervention were recorded. All were effectively treated with airway repositioning, suctioning, oxygen administration, or bag-mask ventilation. CONCLUSIONS: The first series of patients sedated for PRI by emergency physicians is reported. Our initial findings suggest the feasibility of emergency physician-administered sedation for PRI.

Emergency Department Waiting Times in an Israeli Children's Hospital During Times of Military Conflict.

Introduction: During military conflicts in southern Israel, many families moved north, and hospitals and primary care clinics under threat of missile attacks referred their patients to hospitals outside the combat zone, causing overcrowding of the emergency departments (ED). The study objective is to examine the effect of military conflicts on ED waiting time in a children's hospital outside the combat zone. Materials and Methods: A retrospective cohort study of patients admitted between January 2011 and December 2015 was conducted. Multivariable regression was used to examine the effect of age, gender, triage category, arrival time, weekday, and period of admission (peacetime and time of military conflict) on waiting time. Results: Totally, 79,825 children were admitted in peacetimes and 3,058 in times of military conflict. Factors that most influenced shorter waiting times were triage category 1 (change in waiting time: -25.5%; 95% confidence interval: -29.3 to -21.7) or triage category 2 (change in wait time: -21.8%; 95% confidence interval: -23.7 to -20.05). Arriving during times of military conflict did not influence ED waiting time (p=0.18). ED waiting times during times of peace and times of military conflict were 38 min of interquartile range (21-65) and 38 min of interquartile range (22-65), respectively. Conclusions: In this report of a large cohort of patients, waiting times were similar during periods of peace and periods of military conflict. The findings suggest that the 2012 and the 2014 military conflicts did not influence ED waiting times in a hospital outside the combat zone, despite the population shift that occurred during these conflicts. This study is the first to examine the association between periods of military conflict and ED waiting time in children.

The effect of in situ simulation training on the performance of tasks related to patient safety during sedation.

In many countries, procedural sedation outside of the operating room is performed by pediatricians. We examined if in situ sedation simulation training (SST) of pediatricians improves the performance of tasks related to patient safety during sedation in the Emergency Department (ED). We performed a single-center, quasi-experimental, study evaluating the performance of sedation, before-and-after SST. Sixteen pediatricians were evaluated during sedation as part of their usual practice, using the previously validated Sedation-Performance-Score (SPS). This tool evaluates physician behaviors during sedation that are conducive to safe patient outcomes. Following the sedation, providers completed SST, followed by a structured debriefing. They were then re-evaluated with the SPS during a subsequent patient sedation in the ED. Using multivariate regression, odds ratios were calculated for each SPS component, and were compared before and after the SST. Thirty-two sedations were performed, 16 before and 16 after SST. SPS scores improved from a median of 4 (IQR 2-5) to 6 (IQR 4-7) following SST (p < 0.0009, median difference 2, 95% CI 1-3). SST was associated with improved performance in four SPS components. The findings of this pilot study suggest that sedation simulation training of pediatricians improves several tasks related to patient safety during sedation.

Validity of the Pediatric Canadian Triage Acuity Scale in a tertiary children's hospital in Israel.

OBJECTIVE: In 2015, the Israeli Ministry of Health issued national guidelines demanding the use of a five-level triage system in pediatric emergency departments (EDs). The present study aimed to evaluate the validity of the Pediatric Canadian Triage Acuity Scale (PedCTAS) in the ED of a tertiary children's hospital in Israel. METHODS: A retrospective cohort study of all patients admitted between January 2011 and December 2015 was carried out. The proportion of hospitalization was the primary outcome measure. The secondary outcomes were proportion of admissions to the ICU, proportions of patients who left without being seen (LWBS), and length of stay (LOS) in the ED. RESULTS: A total of 83 609 patients were included in our analysis. Triage levels 1-5 included 533 (0.6%), 4428 (5.3%), 46 461 (55.6%), 28 510 (34.1%), and 3677 (4.4%) patients, respectively. Hospitalization proportions were 70, 51, 28, 15, and 12% for triage levels 1, 2, 3, 4, and 5, respectively. Admission proportions to ICU were 24.2, 3.05, 0.24, 0.05, and 0.05% for PedCTAS levels 1, 2, 3, 4, and 5, respectively. The proportions of LWBS were 0.001, 0.002, and 0.005% for triage levels 3, 4, and 5, respectively. LOS was shorter as the triage level increased from 2 to 5. CONCLUSION: Triage level was predictive of hospitalization, admission to the ICU, and proportions of LWBS and LOS in the ED. The findings suggest validity of the PedCTAS in this cohort. This is the first report of the performance of a triage tool in an Israeli ED.

Emergency Department waiting times in a tertiary children's hospital in Israel: a retrospective cohort study.

BACKGROUND: The purpose of this study was to assess ethnic differences in Emergency Department (ED) waiting times between Jewish and Arab children in a tertiary childrens' hospital in Israel. METHODS: This was a retrospective cohort study of all children who were admitted to the pediatric ED of the largest hospital in northern Israel, between January 2011 and December 2015. Univariate and multivariate analyses were used to assess the strength of association between ethnicity category and waiting time. The following were tested as possible confounders: triage category, age, gender, time of arrival category. The effect of nurse-patient ethnic concordance was assessed. RESULTS: Full data were available in 82,883 patients, 55,497 (67.0%) Jews and 27,386 (33.0%) Arabs. Jews and Arabs had a similar median waiting time of 38 min (interquartile range [IQR] 22-63 and IQR 21-61, respectively). Ethnicity was not associated with a change in waiting time (p = 0.36). Factors that most influenced shorter waiting time were triage category 1 (change in waiting time: -25.5%; 95% confidence interval [CI]: -29.3 to -21.7), or triage category 2 (change in waiting-time: -21.8%; 95% CI: -23.7 to -20.05). Factors that most influenced longer waiting time were patient arrival during the morning shift period (change in waiting time: 5.45%; 95% CI: 4.59 to 6.31), or during the evening shift period (change in waiting time: 4.46%; 95% CI: 3.62 to 5.29). Ethnic discordance between triage nurses and patients did not yield longer waiting times. CONCLUSION: In this large pediatric cohort, ethnic differences in ED waiting time were not found.

Success rate of pneumatic reduction of intussusception with and without sedation.

BACKGROUND: Pneumatic reduction of ileocolic intussusception is often performed without sedation. The aim of this study was to evaluate the success rate of pneumatic reduction of intussusception with and without sedation. METHODS: We conducted a retrospective cohort study in Israel in two tertiary care centers using a similar protocol for pneumatic reduction of intussusception. In one center, patients had pneumatic reduction of intussusception under propofol-based sedation, while in the other, patients had pneumatic reduction of intussusception without any sedation. Children aged 3 months to 8 years who were diagnosed with ileocolic intussusception between January 1, 2008 and July 31, 2015 were included in the study. Multivariable regression was used to adjust for the possible confounders of age, gender, number of cases of intussusception prior to the study period, time period from the beginning of symptoms to emergency department admission (<12 h, >12 h), and time period from emergency department admission to the beginning of pneumatic reduction of intussusception. Secondary outcomes of the study included the proportion of bowel perforations during the procedure, and the proportion of early (within 48 h) recurrence of intussusception. RESULTS: The sedation and nonsedation cohorts included 124 and 90 patients, respectively. The cohorts were comparable with regard to demographic characteristics, hemodynamic vital signs on admission to the emergency department, blood gases tests during emergency department stay, and time variables prior to reduction of intussusception. Multivariable regression revealed reduction of intussusception success rates of 89.5% and 83.3% for the sedation group and nonsedation group, respectively, with an adjusted odds ratio of 1.2, 95% CI 1.1-5.3. Three sedated patients and 0 nonsedated patients developed bowel perforations during the procedure. Rates of early recurrence of intussusception of sedated patients and nonsedated patients were 5.1% (6/117) and 1.3% (1/79), respectively (P = 0.15, RR = 3.9, 95% CI: 0.47 to 31.81). CONCLUSION: The findings suggest that the pneumatic reduction of intussusception under propofol-based sedation had a slightly higher success rate than the pneumatic reduction of intussusception without sedation; however, the safety of this practice is yet to be determined.

[Sea urchin spine injury--a case report of chronic synovitis of the foot].

Sea urchin spine injuries can range from minimal local trauma to chronic synovitis and arthritis, with long term morbidity. The abundance of these marine creatures in shallow sea water exposes the potential for injury of the extremities, especially the foot, knees, and hands. Early treatment is crucial to avoid future consequences of these injuries. We report a case of chronic synovitis of the foot in an adolescent, treated surgically two years after the initial insult, with complete resolution of symptoms.

Modelling the long QT syndrome with induced pluripotent stem cells.

The ability to generate patient-specific human induced pluripotent stem cells (iPSCs) offers a new paradigm for modelling human disease and for individualizing drug testing. Congenital long QT syndrome (LQTS) is a familial arrhythmogenic syndrome characterized by abnormal ion channel function and sudden cardiac death. Here we report the development of a patient/disease-specific human iPSC line from a patient with type-2 LQTS (which is due to the A614V missense mutation in the KCNH2 gene). The generated iPSCs were coaxed to differentiate into the cardiac lineage. Detailed whole-cell patch-clamp and extracellular multielectrode recordings revealed significant prolongation of the action-potential duration in LQTS human iPSC-derived cardiomyocytes (the characteristic LQTS phenotype) when compared to healthy control cells. Voltage-clamp studies confirmed that this action-potential-duration prolongation stems from a significant reduction of the cardiac potassium current I(Kr). Importantly, LQTS-derived cells also showed marked arrhythmogenicity, characterized by early-after depolarizations and triggered arrhythmias. We then used the LQTS human iPSC-derived cardiac-tissue model to evaluate the potency of existing and novel pharmacological agents that may either aggravate (potassium-channel blockers) or ameliorate (calcium-channel blockers, K(ATP)-channel openers and late sodium-channel blockers) the disease phenotype. Our study illustrates the ability of human iPSC technology to model the abnormal functional phenotype of an inherited cardiac disorder and to identify potential new therapeutic agents. As such, it represents a promising paradigm to study disease mechanisms, optimize patient care (personalized medicine), and aid in the development of new therapies.