Identifying pediatric patients with multisystem inflammatory syndrome in children presenting to a pediatric emergency department.

OBJECTIVE: To compare clinical and laboratory features of children with Multisystem Inflammatory Syndrome in Children (MIS-C) to those evaluated for MIS-C in the Emergency Department (ED). METHODS: We conducted a retrospective review of the medical record of encounters with testing for inflammatory markers in an urban, tertiary care Pediatric ED from March 1, 2020 to July 31, 2020. We abstracted demographic information, laboratory values, selected medications and diagnoses. We reviewed the record for clinical presentation for the subset of patients admitted to the hospital for suspected MIS-C. We then used receiver operating curves and logistic regression to evaluate the utility of candidate laboratory values to predict MIS-C status. RESULTS: We identified 32 patients with confirmed MIS-C and 15 admitted and evaluated for MIS-C but without confirmation of SARS CoV-2 infection. We compared these patients to 267 encounters with screening laboratories for MIS-C. Confirmed MIS-C patients had an older median age, higher median fever on presentation and were predominantly of Hispanic and non-Hispanic Black race/ethnicity. All children with MIS-C had a C-reactive protein (CRP) >4.5 mg/dL, were more likely to have Brain Natriuretic Peptide >400 pg/mL (OR 10.50, 95%CI 4.40-25.04), D-Dimer >3 µg/mL (7.51, [3.18-17.73]), and absolute lymphocyte count (ALC) <1.5 K/mcL (21.42, [7.19-63.76]). We found CRP >4.5 mg/dL and ALC <1.5 K/mcL to be 86% sensitive and 91% specific to identify MIS-C among patients screened in our population. CONCLUSIONS: We identified that elevated CRP and lymphopenia was 86% sensitive and 91% specific for identification of children with MIS-C.

Long-term Effects of an Evidence-based Guideline for Emergency Management of Pediatric Syncope.

Variability exists in the management of childhood syncope as clinicians balance resource utilization with the need to identify serious diseases. Limited evidence exists regarding the long-term impact of evidence-based guidelines (EBGs) on clinical practices. This study's objective was to measure long-term changes in the management of syncope after implementing a syncope EBG in a single pediatric emergency department following the redistribution of resources to facilitate compliance over time. METHODS: We included healthy patients aged 8-22 years, presenting to the pediatric emergency department with syncope between 2009 and 2017. Interrupted time series analysis compared testing rates and length of stay among the pre-EBG, short-term follow-up, and long-term follow-up periods. RESULTS: The study included 1,294 subjects. From the pre-EBG period to the long-term follow-up period, recommended electrocardiogram and urine pregnancy test rose significantly [level change odds ratio (95% confidence interval) 5.56 (1.73-17.91) and 3.15 (1.07-9.32), respectively]. Testing and management not recommended by the EBG decreased significantly, including complete blood count, electrolytes, point-of-care glucose, chest radiograph, and intravenous fluids [level change odds ratio (95% confidence interval) 0.19 (0.09-0.40), 0.15 (0.07-0.32), 0.38 (0.18-0.81), 0.17 (0.06-0.49), and 0.18 (0.08-0.39), respectively]. Length of stay declined significantly. No delayed diagnoses occurred. CONCLUSIONS: Sustained improvements in syncope management persisted during long-term follow-up of the EBG despite minimal resources. The EBG was associated with increased focused evaluation and decreased low yield testing. EBGs may be useful tools to influence sustained clinical practices to promote safe, cost-effective, and high-quality care.

Implementing a guideline to improve management of syncope in the emergency department.

BACKGROUND AND OBJECTIVES: Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce the rates of low-yield diagnostic testing for children presenting to an emergency department (ED) with syncope or presyncope. METHODS: Children 8 to 22 years old presenting to a tertiary care pediatric ED with syncope or presyncope were included. We excluded children who were ill-appearing, had previously diagnosed cardiac or neurologic disease, ingestion, or trauma. We measured diagnostic testing rates among children presenting from July 2010 through October 2012, during which time we implemented a quality improvement intervention. Patient follow-up was performed 2 months after the ED visit to ascertain subsequent diagnostic testing and medical care. RESULTS: A total of 349 patients were included. We observed a reduction in the rates of low-yield diagnostic testing after our quality improvement intervention: complete blood count testing decreased from 36% (95% confidence interval 29% to 43%) to 16% (12% to 22%) and electrolyte testing from 29% (23% to 36%) to 12% (8% to 17%). Performance of recommended testing increased, such as electrocardiograms and pregnancy testing in postpubertal girls. Despite a reduction in diagnostic testing among children with syncope, patients were not more likely to undergo subsequent diagnostic testing or seek further medical care following their ED visit. CONCLUSIONS: Implementation of a quality improvement intervention for the ED evaluation of pediatric syncope was associated with reduced low-yield diagnostic testing, and was not associated with subsequent testing or medical care.