The hospital costs of high emergency department pediatric readiness.

Objective: We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS) ≥ 88 (0-100 scale) across EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness. Methods: We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day-to-day ED operations (ie, direct clinical care and routine ED supplies). Results: The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719-100,694) for low volume EDs to $279,134 (95% CI 196,487-362,179) for very high volume EDs; equipment costs accounted for 0.9-5.0% of expenses. The total annual cost-per-patient ranged from $3/child (95% CI 2-4/child) to $222/child (95% CI 156-288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child. Conclusions: Annual hospital costs for HPR are modest, particularly when considered per child.

Increasing Use of Rapid Magnetic Resonance Imaging for Children with Blunt Head Injury.

OBJECTIVE: To increase the percentage of patients who undergo rapid magnetic resonance imaging (rMRI) rather than computed tomography (CT) for evaluation of mild traumatic brain injury (TBI) from 45% in 2020 to 80% by December 2021. STUDY DESIGN: This was a quality improvement initiative targeted to patients presenting to the pediatric emergency department presenting with mild TBI, with baseline data collected from January 2020 to December 2020. From January 2021 to August 2021, we implemented a series of improvement interventions and tracked the percentage of patients undergoing neuroimaging who received rMRI as their initial study. Balancing measures included proportion of all patients with mild TBI who underwent neuroimaging of any kind, proportion of patients requiring sedation, emergency department length of stay, and percentage with clinically important TBI. RESULTS: The utilization of rMRI increased from a baseline of 45% to a mean of 92% in the intervention period. Overall neuroimaging rates did not change significantly after the intervention (19.8 vs 23.2%, P = .24). There was no difference in need for anxiolysis (12 vs 7%, P = .30) though emergency department length of stay was marginally increased (1.4 vs 1.7 hours, P = < 0.01). CONCLUSION: In this quality improvement initiative, transition to rMRI as the primary imaging modality for the evaluation of minor TBI was achieved at a level 1 pediatric trauma center with no significant increase in overall use of neuroimaging.

Impact of social media "challenges" on poison center case volume for intentional ingestions among school-aged children: an observational study.

INTRODUCTION: Mental health problems among youth have escalated over the past decade, with increased rates of self-harm, including suicide attempts by ingestion. Social media use has been linked to youth mental health, including "challenges" urging youth to ingest substances for recreational and other purposes. We hypothesized that social media challenges for particular substances would temporally correspond with increased ingestions of these substances. METHODS: We identified peak Google Trends search times for social media ingestion challenges involving diphenhydramine, laundry pods, nutmeg, and cinnamon, and used data from America's Poison Centers National Poison Data System to plot reported ingestions 3 months before and after peak searches in school-aged children. RESULTS: There were 2,169 individuals in the analysis. Diphenhydramine was the most frequently reported ingestion for misuse/abuse and suicidal purposes (n = 266 and 1,609, respectively). For all ingestions together, 45 percent (n = 979) had a moderate health effect, and 6.35 percent (n = 137) had a major health effect. Time of peak searches corresponded with increased ingestions for each substance. DISCUSSION: We found a temporal relationship between peak Google Trends searches for ingestion challenges and ingestions of that substance reported to United States poison centers. Compared to misuse/abuse ingestions, most suicidal ingestions peaked 1-2 months later, suggesting a public health opportunity for intervention. LIMITATIONS: This retrospective observational study does not establish causal effect. All data are a result of self-reporting of the exposures, which may lead to a reporting bias. Google Trends is not the only search engine and likely underestimates the true incidence of social media posts. CONCLUSIONS: Additional research is needed on the relationship between social media and youth mental health, particularly around "challenges" that place youths' health at risk. There may be opportunities for intervention to decrease medical and mental health sequelae of these challenges.

Timing and causes of death to 1 year among children presenting to emergency departments.

BACKGROUND AND OBJECTIVES: A better characterization of deaths in children following emergency care is needed to inform timely interventions. This study aimed to describe the timing, location, and causes of death to 1 year among a cohort of injured and medically ill children. METHODS: We conducted a retrospective cohort study of children <18 years requiring emergency care in six states from January 1, 2012, through December 31, 2017, with follow-up through December 31, 2018, for patients who were not discharged from the emergency department (ED). In this cohort, 1-year mortality, time to death within 1 year, and causes of death were assessed from ED, inpatient, and vital status records. RESULTS: There were 546,044 children during the 6-year period. The 1-year mortality rate was 2.2% (n = 1356) for injured children and 1.4% (n = 6687) for medically ill children. Matched death certificates were available for 861 (63.5%) of 1356 deaths in the injury cohort and for 4712 (70.5%) of 6687 deaths in the medical cohort. Among deaths in the injury cohort, 1274 (94.0%) occurred in the ED or hospital. The most common causes of death were motor vehicle collisions, firearm injuries, and pedestrian injuries. Among the 6687 deaths in the medical cohort, 5081 (76.0%) children died in the ED or hospital (primarily in the ED) and 1606 (24.0%) occurred after hospital discharge. The most common causes of death were sudden infant death syndrome, suffocation and drowning, and congenital conditions. CONCLUSIONS: The 1-year mortality of children presenting to an ED is 2.2% for injured children and 1.4% for medically ill children with most deaths occurring in the ED. Future interventional trials, quality improvement efforts, and health policy focused in the ED could have the potential to improve outcomes of pediatric patients.

Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity.

Importance: Presentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness. Objective: To evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies. Design, Setting, and Participants: This cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023. Exposure: Hospitalization for acute medical emergency or traumatic injury. Main Outcomes and Measures: The primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality. Results: The cohort included 633 536 children (median [IQR] age 4 [0-12] years]). There were 557 537 children (98 504 Black [17.7%], 167 838 Hispanic [30.1%], 311 157 White [55.8%], and 147 876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75 999 children (12 727 Black [16.7%], 21 604 Hispanic [28.4%], 44 203 White [58.2%]; and 21 609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort. Conclusions and Relevance: In this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.

Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers.

Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results: This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.

Transgender and Gender Nonbinary Patient Experiences in the Emergency Department: A Regional Study.

Purpose: Transgender people experience discrimination in health care, including reports of avoiding or delaying emergency department (ED) care due to prior negative experiences, fear of discrimination, poor accommodations, and inappropriate staff behavior. Emergency physicians receive minimal training on transgender care. This study sought to understand the experience of transgender patients when visiting EDs in the Portland metro area, and the knowledge and training experience of Oregon Health & Science University (OHSU) ED staff. Methods: Two populations were examined via survey: (1) Transgender people who accessed, or felt they should access, ED care in Portland, Oregon, in the past 5 years; and (2) OHSU ED patient-facing staff. Data were analyzed to identify trends in ED experiences, and predictors of positive experiences. Potential relationships between self-reported proficiency in transgender care and formal training experience, professional role, and duration of practice were also assessed. Results: Of the predictors assessed, only the opportunity to provide pronouns at check-in was associated with better perceived experiences (p<0.01). The differences between reported best and worst ED experiences were significant in all domains of perceived experiences but one (p<0.01). ED providers who had formal training were more likely to rate themselves as proficient (p<0.01). There was no relationship found between self-reported proficiency and length of practice. Conclusion: This study demonstrated that there are significant differences between reported best and worst ED experiences by transgender patients, and thus areas for ED improvement. It is our recommendation that EDs provide the opportunity for patients to supply their pronouns, and offer trainings in transgender health care for employees.

Interrater Reliability of Point-of-Care Cardiopulmonary Ultrasound in Patients With Septic Shock: An Analysis of Agreement Between Treating Clinician and Expert Reviewers.

BACKGROUND: Cardiopulmonary ultrasound (CPUS) is commonly used to assess cardiac function and preload status in patients with septic shock. However, the reliability of CPUS findings at the point of care is unknown. OBJECTIVE: To assess interrater reliability (IRR) of CPUS in patients with suspected septic shock between treating emergency physicians (EPs) vs emergency ultrasound (EUS) experts. METHODS: Single-center, prospective, observational cohort enrolling patients (n = 51) with hypotension and suspected infection. Treating EPs performed and interpreted CPUS for cardiac function parameters (left ventricular [LV] function and right ventricular [RV] function and size) and preload volume parameters (inferior vena cava [IVC] diameter and pulmonary B-lines). The primary outcome was IRR (assessed by Kappa values [κ] and intraclass correlation coefficient [ICC]) between EP and EUS-expert consensus. Secondary analyses examined the effects on IRR of operator experience, respiratory rate, and known difficult views on a Cardiology-performed echocardiogram. RESULTS: IRR was fair for LV function, κ = 0.37, 95% confidence interval (CI) 0.1-0.64; poor for RV function, κ = -0.05, 95% CI -0.6-0.5; moderate for RV size, κ = 0.47, 95% CI 0.07-0.88; and substantial for B-lines, κ = 0.73, 95% CI 0.51-0.95 and IVC size, ICC = 0.87, 95% CI 0.2-0.99. Involvement of ultrasound-trained faculty was associated with improved IRR of RV size (p = 0.002), but not other CPUS domains. CONCLUSIONS: Our study demonstrated high IRR for preload volume parameters (IVC size and presence of B-lines), but not for cardiac parameters (LV function and RV function and size) in patients presenting with concern for septic shock. Future research must focus on determining sonographer and patient-specific factors affecting CPUS interpretation in real-time.

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care.

Importance: Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. Design, Setting, and Participants: This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. Exposure: ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. Main Outcomes and Measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. Results: There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. Conclusions and Relevance: These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

A Geospatial Evaluation of 9-1-1 Ambulance Transports for Children and Emergency Department Pediatric Readiness.

OBJECTIVE: Whether ambulance transport patterns are optimized to match children to high-readiness emergency departments (EDs) and the resulting effect on survival are unknown. We quantified the number of children transported by 9-1-1 emergency medical services (EMS) to high-readiness EDs, additional children within 30 minutes of a high-readiness ED, and the estimated effect on survival. METHODS: This was a cross-sectional study using data from the National EMS Information System for 5,461 EMS agencies in 28 states from 1/1/2012 through 12/31/2019, matched to the 2013 National Pediatric Readiness Project assessment of ED pediatric readiness. We performed a geospatial analysis of children 0 to 17 years requiring 9-1-1 EMS transport to acute care hospitals, including day-, time-, and traffic-adjusted estimates for driving times to all EDs within 30 minutes of the scene. We categorized receiving hospitals by quartile of ED pediatric readiness using the weighted Pediatric Readiness Score (wPRS, range 0-100) and defined a high-risk subgroup of children as a proxy for admission. We used published estimates for the survival benefit of high readiness EDs to estimate the number of lives saved. RESULTS: There were 808,536 children transported by EMS, of whom 253,541 (31.4%) were high-risk. Among the 2,261 receiving hospitals, the median wPRS was 70 (IQR 57-85, range 26-100) and the median number of receiving hospitals within 30 minutes was 4 per child (IQR 2-11, range 1 to 53). Among all children, 411,685 (50.9%) were taken to EDs in the highest quartile of pediatric readiness, and 180,547 (22.3%) children transported to lower readiness EDs were within 30 minutes of a high readiness ED. Findings were similar among high-risk children. Based on high-risk children, we estimated that 3,050 pediatric lives were saved by transport to high-readiness EDs and an additional 1,719 lives could have been saved by shifting transports to high readiness EDs within 30 minutes. CONCLUSIONS: Approximately half of children transported by EMS were taken to high-readiness EDs and an additional one quarter could have been transported to such an ED, with measurable effect on survival.

Point-of-Care Noninvasive Technology for Pediatric Dehydration Assessment.

OBJECTIVE: Dehydration is a commonly encountered problem worldwide. Current clinical assessment is limited by subjectivity and limited provider training with children. The objective of this study is to investigate a new noninvasive, point-of-care technology that measures capillary refill combined with patient factors to accurately diagnose dehydration. METHODS: This is a prospective observational study at a tertiary care children's hospital in Buenos Aires, Argentina. Patients were eligible if younger than 10 years who presented to the emergency department with vomiting and/or diarrhea whom the triage nurse deems to be potentially dehydrated. Patients had the digital capillary refill device done on presentation in addition to standard of care vital signs and weight. Patients had serial weights measured on hospital scales throughout their stay. The primary outcome was dehydration, which was calculated as a percent change in weight from admission to discharge. RESULTS: Seventy-six children were enrolled in the study with 56 included in the final analysis. A stepwise forward method selection chose malnutrition, temperature, and systolic blood pressure for the multivariable model. The area under the curve for the final model was fair (0.7431). To further look into the utility of such a device in the home setting where blood pressure is not available often, we reran the model without systolic blood pressure. The area under the curve for the final model was 0.7269. CONCLUSIONS: The digital capillary refill point-of-care device combined with readily available patient-specific factors may improve the ability to detect pediatric dehydration and facilitate earlier treatment or transfer to higher levels of care.

Impact of individual components of emergency department pediatric readiness on pediatric mortality in US trauma centers.

BACKGROUND: Injured children initially treated at trauma centers with high emergency department (ED) pediatric readiness have improved survival. Centers with limited resources may not be able to address all pediatric readiness deficiencies, and there currently is no evidence-based guidance for prioritizing different components of readiness. The objective of this study was to identify individual components of ED pediatric readiness associated with better-than-expected survival in US trauma centers to aid in the allocation of resources targeted at improving pediatric readiness. METHODS: This cohort study of US trauma centers used the National Trauma Data Bank (2012-2017) matched to the 2013 National Pediatric Readiness Project assessment. Adult and pediatric centers treating at least 50 injured children (younger than 18 years) and recording at least one death during the 6-year study period were included. Using a standardized risk-adjustment model for trauma, we calculated the observed-to-expected mortality ratio for each trauma center. We used bivariate analyses and multivariable linear regression to assess for associations between individual components of ED pediatric readiness and better-than-expected survival. RESULTS: Among 555 trauma centers, the observed-to-expected mortality ratios ranged from 0.07 to 4.17 (interquartile range, 0.93-1.14). Unadjusted analyses of 23 components of ED pediatric readiness showed that trauma centers with better-than-expected survival were more likely to have a validated pediatric triage tool, comprehensive quality improvement processes, a pediatric-specific disaster plan, and critical airway and resuscitation equipment (all p < 0.03). The multivariable analysis demonstrated that trauma centers with both a physician and a nurse pediatric emergency care coordinator had better-than-expected survival, but this association weakened after accounting for trauma center level. Child maltreatment policies were associated with lower-than-expected survival, particularly in Levels III to V trauma centers. CONCLUSION: Specific components of ED pediatric readiness were associated with pediatric survival among US trauma centers. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival.

OBJECTIVE: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND: ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS: This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS: There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS: ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.

Trends in intentional abuse and misuse ingestions in school-aged children and adolescents reported to US poison centers from 2000-2020.

CONTEXT: Childhood and adolescent misuse and abuse exposures remain a serious public health challenge in the United States. This study aimed to describe recent trends and patterns of intentional substance misuse and abuse exposures among school-aged children and adolescents in the United States. METHODS: This study was a retrospective cohort study of intentional misuse and abuse exposures in children 6 through 18 years reported to the National Poison Data System (NPDS) from January 1, 2000, through December 31, 2020. Demographic trends, reported clinical effects, treatments, management sites, and health outcomes were assessed overall and within four age categories: 6-9, 10-12, 13-15, and 16-18. RESULTS: Between 2000 and 2020, there were 338,727 cases regarding intentional misuse and abuse exposures for children ages 6 through 18 years old. Overall, misuse/abuse ingestions fluctuated over time, with a peak in 2011. The majority of intentional misuse/abuse ingestions occurred in males (58.3%), and more than 80% of all reported exposure cases occurred in youth aged 13 to 18. 32.6% of ingestions resulted in worse than minor clinical outcomes. Older age groups had a greater number of severe medical outcomes compared to younger age groups. Major or life-threatening exposures (including those resulting in death) were more common in males. Overall, deaths were rare (n = 450), 0.1%). Male sex, older age, abuse ingestions, exposure site of a public area or other residence, and multiple ingested substances were other factors associated with increased mortality. Marijuana exposure rates had the highest average monthly increase overall, with the most dramatic rise occurring from 2017 to 2020. Edible marijuana preparations accounted for the highest increase in call rates compared with all other forms of marijuana. DISCUSSION AND CONCLUSION: With over 330,000 poison center cases reported during the 20-year study period, intentional substance misuse and abuse exposures substantially impact the pediatric population. The substances most commonly misused/abused are more widely available substances such as over-the-counter medications, household products and pharmaceuticals commonly prescribed to youth. Differences in age and sex were evident, with males and adolescents more likely to abuse and misuse substances. Our study describes an upward trend in marijuana misuse/abuse exposures among youth, especially those involving edible products. These findings highlight an ongoing concern about the impact of rapidly evolving cannabis legalization on this vulnerable population.

The cost of emergency care for children across differing levels of emergency department pediatric readiness.

High emergency department (ED) pediatric readiness is associated with improved survival in children, but the cost is unknown. We evaluated the costs of emergency care for children across quartiles of ED pediatric readiness. This was a retrospective cohort study of children aged 0-17 years receiving emergency services in 747 EDs in 9 states from January 1, 2012, through December 31, 2017. We measured ED pediatric readiness using the weighted Pediatric Readiness Score (range: 0-100). The primary outcome was the total cost of acute care (ED and inpatient) in 2022 dollars, adjusted for ED case mix and hospital characteristics. A total of 15 138 599 children received emergency services, including 27.6% with injuries and 72.4% with acute medical illness. The average adjusted per-patient cost by quartile of ED pediatric readiness ranged from $991 (quartile 1) to $1064 (quartile 4) for injured children and $1104-$1217 for medical children. The resulting cost differences were $72 (95% CI: -$6 to $151) and $113 (95% CI: $20-$206), respectively. Receiving emergency care in high-readiness EDs was not associated with marked increases in the cost of delivering services.

Prenatal marijuana exposure and neonatal outcomes: a retrospective cohort study.

OBJECTIVES: Previous literature on the effects of marijuana exposure on neonatal outcomes has been limited by the reliance on maternal self-report. The objective of this study was to examine the relationship of prenatal marijuana exposure on neonatal outcomes in infants with marijuana exposure confirmed with meconium drug testing. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Meconium drug screens obtained on infants born in a hospital system in the Pacific Northwest in the USA over a 2.5-year period. 1804 meconium drug screens were initially obtained, with 1540 drug screens included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: Neonates with meconium drug screens positive for delta-9-tetrahydrocannabinol (THC) only were compared with neonates with negative drug screens. The following neonatal outcomes were examined: gestational age, preterm birth (<37 weeks), birth weight, low birth weight (defined as birth weight <2.5 kg), length, head circumference, Apgar scores and admission to the neonatal intensive care unit (NICU). Using multivariable logistical and linear regression, we controlled for confounding variables. RESULTS: 1540 meconium drug screens were included in the analysis, with 483 positive for delta-9-THC only. Neonates exposed to delta-9-THC had significantly lower birth weight, head circumference and length (p<0.001). Neonates with THC exposure had 1.9 times the odds (95% CI 1.3 to 2.7, p=0.001) of being defined as low birth weight. Birth weight was on average 0.16 kg lower (95% CI 0.10 to 0.22, p<0.001) in those exposed to THC. CONCLUSIONS: Prenatal marijuana exposure was significantly associated with decreases in birth weight, length and head circumference, and an increased risk of being defined as low birth weight. These findings add to the previous literature demonstrating possible negative effects of prenatal marijuana use on neonatal outcomes.

Evaluating fomite risk of brown paper bags storing personal protective equipment exposed to SARS-CoV-2: A quasi-experimental study.

INTRODUCTION: Literature is lacking on the safety of storing contaminated PPE in paper bags for reuse, potentially increasing exposure to frontline healthcare workers (HCW) and patients. The aim of this study is to evaluate the effectiveness of paper bags as a barrier for fomite transmission of SARS-CoV-2 by storing face masks, respirators, and face shields. METHODS: This quasi-experimental study evaluated the presence of SARS-CoV-2 on the interior and exterior surfaces of paper bags containing PPE that had aerosolized exposures in clinical and simulated settings. Between May and October 2020, 30 unique PPE items were collected from COVID-19 units at two urban hospitals. Exposed PPE, worn by either an infected patient or HCW during a SARS-CoV-2 aerosolizing event, were placed into an unused paper bag. Samples were tested at 30-minute and 12-hour intervals. RESULTS: A total of 177 swabs were processed from 30 PPE samples. We found a 6.8% positivity rate among all samples across both collection sites. Highest positivity rates were associated with ventilator disconnection and exposure to respiratory droplets from coughing. Positivity rates differed between hospital units. Total positivity rates were similar between 30-minute (6.7%) and 12-hour (6.9%) sample testing time intervals. Control samples exposed to inactivated SARS-CoV-2 droplets had higher total viral counts than samples exposed to nebulized aerosols. CONCLUSIONS: Data suggests paper bags are not a significant fomite risk for SARS-CoV-2 transmission. However, controls demonstrated a risk with droplet exposure. Data can inform guidelines for storing and re-using PPE in situations of limited supplies during future pandemics.

Outcomes of the National Heart, Lung, and Blood Institute K12 program in emergency care research: 7-year follow-up.

BACKGROUND: Long-term follow-up for clinician-scientist training programs is sparse. We describe the outcomes of clinician-scientist scholars in the National Heart Lung and Blood Institute (NHLBI) K12 program in emergency care research up to 8.7 years after matriculation in the program. METHODS: This was a cohort study of faculty clinician-scientist scholars enrolled in a NHLBI K12 research training program at 6 sites across the US, with median follow-up 7.7 years (range 5.7-8.7 years) from the date of matriculation. Scholars completed electronic surveys in 2017 and 2019, with the 2019 survey collecting information for their current work setting, percent time for research, and grant funding from all sources. We used NIH RePorter and online resources to verify federal grants through March 2021. The primary outcome was a funded career development award (CDA) or research project grant (RPG) where the scholar was principal investigator. We included funding from all federal sources and national foundations. RESULTS: There were 43 scholars, including 16 (37%) women. Over the follow-up period, 32 (74%) received an individual CDA or RPG, with a median of 36 months (range 9-83 months) after entering the program. Of the 43 scholars, 23 (54%) received a CDA and 22 (51%) received an RPG, 7 (16%) of which were R01s. Of the 23 scholars who received a CDA, 13 (56%) subsequently had an RPG funded. Time to CDA or RPG did not differ by sex (women vs. men log-rank test p = 0.27) or specialty training (emergency medicine versus other specialties, p = 0.59). CONCLUSIONS: After 7 years of follow-up for this NHLBI K12 emergency care research training program, three quarters of clinician-scientist scholars had obtained CDA or RPG funding, with no notable differences by sex or clinical training.

Falls in Older Adults Requiring Emergency Services: Mortality, Use of Healthcare Resources, and Prognostication to One Year.

INTRODUCTION: Older adults who fall commonly require emergency services, but research on long-term outcomes and prognostication is sparse. We evaluated older adults transported by ambulance after a fall in the Northwestern United States (US) and longitudinally tracked subsequent healthcare use, transitions to skilled nursing, hospice, mortality, and prognostication to one year. METHODS: This was a planned secondary analysis of a cohort study of community-dwelling older adults enrolled from January 1-December 31, 2011, with follow-up through December 31, 2012. We included all adults ≥ 65 years transported by 44 emergency medical services agencies in seven Northwest counties to 51 hospitals after a fall. We matched Medicare claims, state inpatient data, state trauma registry data, and death records. Outcomes included mortality, healthcare use, and new claims for skilled nursing and hospice to one year. RESULTS: There were 3,159 older adults, with 147 (4.7%) deaths within 30 days and 665 (21.1%) deaths within one year. There was an initial spike in inpatient days, followed by increases in skilled nursing and hospice. We identified four predictors of mortality: respiratory diagnosis; serious brain injury; baseline disability; and Charlson Comorbidity Index ≥ 2. Having any of these predictors was 96.6% sensitive (95% confidence interval [CI]: 95.7, 97.5%) and 21.4% specific (95% CI: 19.9, 22.9%) for 30-day mortality, and 91.6% sensitive (95% CI: 89.5, 93.8%). and 23.8% specific (95% CI: 22.1, 25.5%) for one-year mortality. CONCLUSION: Community-dwelling older adults requiring ambulance transport after a fall have marked increases in healthcare use, institutionalized living, and mortality over the subsequent year. Most deaths occur following the acute care period and can be identified with high sensitivity at the time of the index visit, yet with low specificity.

Trends Over 2 Decades in Adolescent Suicidal and Recreational Ingestions of Over-the-Counter Coricidin Preparations.

OBJECTIVE: The aim of this study was to assess national trends in recreational and suicidal ingestions of over-the-counter cough preparations that contain Coricidin. METHODS: Using the American Association of Poison Control Center's National Poison Data System, we obtained data from 2004 to 2017 on patients aged 13 to 19 years with an ingestion of "Coricidin." We examined trends over time overall and ingestion intent (recreational vs suicidal) using linear regression. We compared patient characteristics, substances ingested, clinical effects and therapies, and outcomes by suicidal versus misuse or recreational intention. RESULTS: An initial search with the inclusion criteria found 19,213 calls that matched study inclusion criteria. On average, there was a yearly linear increase of 180.0 (95% confidence interval [CI], 136.6-223.3; P < 0.01) ingestions per year. Within suicide ingestions, there was an average yearly increase of 97.9 (95% CI, 66.9-128.9; P < 0.01) ingestions, and within misuse/recreational ingestions, there was an average yearly increase of 82.1 (95% CI, 60.3-103.9; P < 0.01) ingestions. The most common clinical effect was tachycardia, which occurred in 42.4% of ingestions. Altered mental status, mydriasis, and ataxia were all more common in misuse/recreational ingestions. Suicidal ingestions resulted in more hospital admissions and need for medical treatment. Recreational-use coded calls peaked in 2013, whereas calls coded for suicide attempts have continued to rise dramatically, with a 50% increase in the 14-year study period. CONCLUSION: Combination Coricidin products are a major source of morbidity in adolescents. Targeted preventive measures in primary care offices or larger-scale policy/legislative efforts may be helpful to address this.