Rochester Criteria and Yale Observation Scale Score to Evaluate Febrile Neonates with Invasive Bacterial Infection.

BACKGROUND: Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis. OBJECTIVE: Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool. METHODS: Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age ≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool. RESULTS: Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis). CONCLUSION: Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study.

COVID-19 Infection and Symptoms Among Emergency Medicine Residents and Fellows in an Urban Academic Hospital Setting: Cross-sectional Questionnaire Study.

Background: COVID-19, an illness caused by the novel coronavirus SARS-CoV-2, affected many aspects of health care worldwide in 2020. From March to May 2020, New York City experienced a large surge of cases. Objective: The aim of this study is to characterize the prevalence of illness and symptoms experienced by residents and fellows in 2 New York City hospitals during the period of March to May 2020. Methods: An institutional review board-exempt survey was distributed to emergency medicine housestaff in May 2020, and submissions were accepted through August 2020. Results: Out of 104 residents and fellows, 64 responded to our survey (a 61.5% response rate). Out of 64 responders, 27 (42%) tested positive for SARS-CoV-2 antibodies. Most residents experienced symptoms that are consistent with COVID-19; however, few received polymerase chain reaction testing. Out of 27 housestaff with SARS-CoV-2 antibodies, 18 (67%) experienced fever and chills, compared with 8 out of 34 housestaff (24%) without SARS-CoV-2 antibodies. Of the 27 housestaff with SARS-CoV-2 antibodies, 19 (70%) experienced loss of taste and smell, compared with 2 out of 34 housestaff (6%) without SARS-CoV-2 antibodies. Both fever and chills and loss of taste and smell were significantly more commonly experienced by antibody-positive compared to antibody-negative housestaff (P=.002 and <.001, respectively). All 13 housestaff who reported no symptoms during the study period tested negative for SARS-CoV-2 antibodies. Conclusions: Our study demonstrated that in our hospitals, the rate of COVID-19 illness among emergency department housestaff was much higher than previously reported. Further studies are needed to characterize illness among medical staff in emergency departments across the nation. The high infection rate among emergency medicine trainees stresses the importance of supplying adequate personal protective equipment for health care professionals.

Pediatric Emergency Medicine Fellowship Education on Adolescent Sexual Health Care.

OBJECTIVES: Many adolescents use the emergency department as their sole resource for primary care and sexual health care. This provides an opportunity to prevent sexually transmitted infections and unintended pregnancy as well as to educate teenagers about their bodies and sexual health. There is no standard curriculum on sexual health as part of pediatric emergency medicine (PEM) fellowship education. Our goal is to evaluate what is taught in PEM fellowship about adolescent sexual health. METHODS: We administered an anonymous questionnaire to both PEM fellows and program directors (PDs). The questionnaire was distributed through the PEM Program Director Survey Committee. The questionnaire was sent to 88 PDs and 305 fellows total. An introductory email explaining the purpose of the study and a link to the online questionnaire was sent. The questionnaire was created using SurveyMonkey (www.surveymonkey.com). Data were analyzed using descriptive statistics. RESULTS: We achieved a 43% survey response rate from PDs (38 of 88) and a 24% survey response rate from fellows (73 of 305). The PD respondents included 61% females, and almost all (86%) are between ages 35 and 54 years. Seventy-three percent of the fellows are female, and they are all between 25 to 44 years old. There was a great deal of variability in the amount of adolescent sexual health education PDs provide their fellows in the form of lectures and bedside teaching cases. A majority of survey respondents (86% of fellows and 66% of the PDs) agreed that there should be a standard PEM curriculum to teach about adolescent sexual health. More than half (53% of PDs and 56% of fellows) are not satisfied with the number of training opportunities for adolescent sexual health. CONCLUSIONS: We found variability in adolescent sexual health training during PEM fellowship, although fellows and PDs agree that there should be a standardized curriculum. We recommend that the American Board of Pediatrics form a committee to decrease variability in the training of PEM fellows on adolescent sexual health.

The impact of COVID-19 on Diabetic Ketoacidosis patients.

BACKGROUND AND AIM: Describe the prevalence/outcomes of Diabetic Ketoacidosis (DKA) patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods. METHODS: Retrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients that takes place in Eleven hospitals of New York City Health & Hospitals. Our included participants during the pandemic period were admitted COVID-19+ patients (>18 years) and during the pre-pandemic period were admissions (>18 years) selected through the medical record. We excluded transfers during both periods. The intervention was COVID-19+ by PCR testing. The main outcome measured was mortality during the index hospitalization and secondary outcomes were demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (>0.4 mmol/L) and bicarbonate (<15 mmol/L) or pH (<7.3). RESULTS: Demographics and past medical histories were similar during the pre-pandemic (n = 6938) vs. pandemic (n = 7962) periods. DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p > 0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p < 0.001). Surviving vs. non-surviving DKA/COVID-19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0-4.5) (p < 0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2-3.1) (p < 0.001). CONCLUSIONS: COVID-19 increased the prevalence of DKA with higher mortality rates secondary to COVID-19 severity, not DKA. We suggest DKA screening all COVID-19+ patients and prioritizing ICU DKA/COVID-19+ with low oxygen saturation, blood pressures, or renal insufficiency.

The Impact of Personal Protection Equipment on Intubation Times.

INTRODUCTION: Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE. STUDY OBJECTIVE: The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE. METHODS: This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed. RESULTS: All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s). CONCLUSION: There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

Computed tomography angiography for aerodigestive injuries in penetrating neck trauma: A systematic review.

OBJECTIVES: Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? METHODS: Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2. RESULTS: Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. CONCLUSION: CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.

Iatrogenic Pulmonary Air Embolism with Rapid Resolution: A Case Report.

BACKGROUND: Iatrogenic pulmonary air embolism is a fairly common and sometimes deadly complication of i.v. contrast injection. CASE REPORT: We present the case of a 33-year-old man with a symptomatic iatrogenic injection air embolism and resolution within 5 h. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the importance of computed tomography imaging in emergency medicine, clinicians should be aware of the risk for injection air embolism from i.v. contrast injection.

The prevalence of serious bacterial infections in neutropenic immunocompetent febrile children.

CONTEXT: Febrile neutropenic immunocompromised children are at a high risk of Serious Bacterial Infections (SBI). OBJECTIVE: This systematic review and meta-analysis report the prevalence of SBI in healthy children with febrile neutropenia. DATA SOURCE: PubMed, EMBASE, and Web of Science from their inception to August 2020. STUDY SELECTION: Patients with an Absolute Neutrophil Count (ANC) <1000 cells/mm3 up to 18 years of age presenting to the ED with a chief complaint of fever (temperature > 38°C) and who had a workup for SBI as defined by each study. DATA ABSTRACTION: Data from individual studies was abstracted by a subset of the authors and checked independently by the senior author. Any discrepancies were adjudicated by the joint agreement of all the authors. We calculated the prevalence of SBI by using the number of SBI's as the numerator and the total number of febrile events in patients as the denominator. Bias in our studies was quantified by the Newcastle Ottawa Scale. RESULTS: We identified 2066 citations of which five studies (1693 patients) our inclusion criteria. None of our reviewed studies consistently tested every included patient for SBI. Spectrum bias in every study resulted in a wide range of the SBI prevalence of 1.9% (<0.01% - 11%) similar to non-neutropenic children. LIMITATIONS: All of our studies were retrospective and many did not consistently screen all subjects for SBI. CONCLUSION: If the clinical suspicion is low, the risk for SBI is similar between febrile healthy neutropenic and non-neutropenic children.

Predicting Urinary Tract Infections With Interval Likelihood Ratios.

BACKGROUND: Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children. METHODS: Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated. RESULTS: The UTI prevalence was 9.2%, with the most common pathogen being Escherichia coli (75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria. CONCLUSIONS: The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.

The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma. METHODS: We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed. RESULTS: Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model. CONCLUSIONS: In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.

Prevalence of Bacteremia in Febrile Patients With Sickle Cell Disease: Meta-Analysis of Observational Studies.

OBJECTIVE: Pneumococcal vaccination has decreased the bacteremia rate in both the general pediatric and sickle cell disease (SCD) populations. Despite this decrease, and an increasing concern for antibiotic resistance, it remains standard practice to obtain blood cultures and administer antibiotics in all febrile (>38.5°C) patients with SCD. We conducted a systematic review and meta-analysis of the available studies of the prevalence of bacteremia in febrile patients with SCD. METHODS: We searched the medical literature up to November 2018 in PUBMED, EMBASE, and Web of Science with terms epidemiology, prevalence, bacteremia, and sickle cell anemia. We only included studies with patients after 2000, when the pneumococcal 7-valent conjugate (PCV7) vaccine became widely available. The prevalence of bacteremia [95% confidence interval (CI)] was calculated by dividing the number of positive blood cultures by the number of febrile episodes. The I2 statistic measured heterogeneity between prevalence estimates. Bias in our studies was quantified by the Newcastle-Ottawa Quality Assessment Scale. RESULTS: Our search identified 228 citations with 10 studies meeting our inclusion/exclusion criteria. The weighted prevalence of bacteremia across all studies was 1.9% (95% CI, 1.22%-2.73%), and for Streptococcus pneumoniae bacteremia, it was 0.31% (95% CI, 0.16%-0.50%). Risks for bacteremia except central lines could not be determined because of the low prevalence of the outcome. CONCLUSIONS: There appears to be a need to develop a risk stratification strategy to guide physicians to manage febrile patients with SCD based on factors including, but not limited to, history and clinical examination, vaccination status, use of prophylactic antibiotics, laboratory values, likely source of infection, and accessibility to health care.

Flank pain and hematuria is not always a kidney stone.

BACKGROUND: Patients with flank pain and hematuria are common emergency department presentations of nephrolithiasis. We may anchor on this etiology and potentially miss other less common differentials. We present a case of a patient with hematuria and flank pain typical of nephrolithiasis who was diagnosed with a Page kidney causing secondary hypertension. A 50 year-old male with no significant past medical history presented to the Emergency Department with severe left-sided flank pain, vomiting, and blood-tinged urine. We pursued a diagnosis of nephrolithiasis and found a left renal subcapsular hematoma on non-contrast CT. A CTA was done with no active hemorrhage found. The patient had no history of recent trauma and was found to be hypertensive on evaluation. Urology was consulted and management for the patient's hypertension was initiated. He was diagnosed with Page Kidney and admitted to medicine for observation and hypertension management with an angiotensin-converting enzyme inhibitor. Page Kidney is a diagnosis that describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension through the activation of the renin-angiotensin-aldosterone system. Causes may include traumatic subcapsular hematoma, renal cyst rupture, tumor, hemorrhage, arteriovenous malformation, among others. Treatment may involve conservative measures including hypertension management, or more invasive measures like evacuation or nephrectomy. We describe the case of a patient presumed to have nephrolithiasis presenting with typical left-sided flank pain, diagnosed with Page kidney, and treated conservatively.

The Utility of Ultrasound in Detecting Skull Fractures After Pediatric Blunt Head Trauma: Systematic Review and Meta-Analysis.

BACKGROUND: Head trauma is a common reason for evaluation in the emergency department. The evaluation for traumatic brain injury involves computed tomography, exposing children to ionizing radiation. Skull fractures are associated with intracranial bleed. Point-of-care ultrasound (POCUS) can diagnose skull fractures. OBJECTIVES: We performed a systematic review/meta-analysis to determine operating characteristics of POCUS skull studies in the diagnosis of fractures in pediatric head trauma patients. METHODS: We searched PubMed, EMBASE, and Web of Science for studies of emergency department pediatric head trauma patients. Quality Assessment Tool for Diagnostic Accuracy Studies 2 was used to evaluate risk of bias. Point-of-care ultrasound skull study operating characteristics were calculated and pooled using Meta-DiSc. RESULTS: Six studies of 393 patients were selected with a weighted prevalence of 30.84%. Most studies were at low risk of bias. The pooled sensitivity (91%) and specificity (96%) resulted in pooled positive likelihood ratio (14.4) and negative likelihood ratio (0.14). Using the weighted prevalence of skull fractures across the studies as a pretest probability (31%), a positive skull ultrasound would increase the probability to 87%, whereas a negative test would decrease the probability of a skull fracture to 6%. To achieve a posttest probability of a skull fracture of ~2% would require a negative skull ultrasound in a patient with only a pretest probability of ~15%. CONCLUSIONS: A POCUS skull study significantly increases the probability of skull fracture, whereas a negative study markedly decreases the probability if the pretest probability is very low.

Diagnostic modalities to determine ventriculoperitoneal shunt malfunction: A systematic review and meta-analysis.

BACKGROUND: Ventriculoperitoneal (VP) shunt malfunction is an emergency. Timely diagnosis can be challenging because shunt malfunction often presents with symptoms mimicking other common pediatric conditions. METHODS: We performed a systematic review and meta-analysis to determine which commonly used imaging modalities; Magnetic resonance imaging (MRI), Computed Tomography (CT), X-ray Shunt series or Optic Nerve Sheath Diameter (ONSD) ultrasound, are superior in evaluating shunt malfunction. INCLUSION CRITERIA: patients less than 21 years old with symptoms of shunt malfunction. We calculated the pooled sensitivity, specificity, Likelihood Ratios (LR+, LR-) using a random-effects model. RESULTS: Eight studies were included encompassing 1906 patients with a prevalence of VP shunt malfunction of (29.3%). Shunt series: sensitivity (14%-53%), specificity (99%), LR+ (23.2), and LR- (0.47-0.87). CT scan: sensitivity (53%-100%), specificity (27%-98%), LR+ (1.34-22.87), LR- (0.37). MRI: sensitivity (57%), specificity (93%), LR+ (7.66), and LR- (0.49). ONSD: sensitivity (64%), specificity (22%-68%), LR+ (4.4-8.7), LR- (0.93). A positive shunt series, CT scan, MRI, or ONSD has a post-test probability of (23%-84%). A normal shunt series, CT scan, MRI, or ONSD results in a post-test probability of (7%-31%). A positive shunt series results in a post-test probability of 80%, which is equivalent to the post-test probability of CT scan (23-84%) and MRI (83%). CONCLUSION: Despite the low sensitivity, a positive shunt series obviates the need for further imaging studies. Prompt referral for neurosurgical intervention is recommended. A negative shunt series or any result (positive or negative) from CT, MRI, or ONSD will still require an emergent neurosurgical referral.

Impact of Provider-In-Triage in a Safety-Net Hospital.

BACKGROUND: Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. OBJECTIVES: We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. METHODS: This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3). RESULTS: There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min). CONCLUSIONS: We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.

Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis.

INTRODUCTION: Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research. STUDY OBJECTIVES: The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput. METHODS: We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI). RESULTS: Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity. CONCLUSION: Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.

Toxic shock-like syndrome and COVID-19: Multisystem inflammatory syndrome in children (MIS-C).

Early reports of COVID-19 in pediatric populations emphasized a mild course of disease with severe cases disproportionately affecting infant and comorbid pediatric patients. After the peak of the epidemic in New York City, in late April to early May, cases of severe illness associated with COVID-19 were reported among mostly previously healthy children ages 5-19. Many of these cases feature a toxic shock-like syndrome or Kawasaki-like syndrome in the setting of SARS-CoV-2 positive diagnostic testing and the CDC has termed this presentation Multisystem Inflammatory Syndrome (MIS-C). It is essential to disseminate information among the medical community regarding severe and atypical presentations of COVID-19 as prior knowledge can help communities with increasing caseloads prepare to quickly identify and treat these patients as they present in the emergency department. We describe a case of MIS-C in a child who presented to our Emergency Department (ED) twice and on the second visit was found to have signs of distributive shock, multi-organ injury and systemic inflammation associated with COVID-19. The case describes two ED visits by an 11- year-old SARS-CoV-2-positive female who initially presented with fever, rash and pharyngitis and returned within 48 hours with evidence of cardiac and renal dysfunction and fluid-refractory hypotension requiring vasopressors and PICU admission.