Workplace Violence in the Pediatric Emergency Department: A National Survey of Physicians in the United States.

OBJECTIVES: Previous work shows that health care workers, and particularly emergency department (ED) staff, are at an above average risk of workplace violence (WPV), defined as verbal threats or physical violence in the workplace. Previous data suggest that staff of a single pediatric ED frequently feel unsafe. The objective of this study was to conduct the first national survey study to assess the prevalence and incidence of WPV in the pediatric ED. METHODS: In this cross-sectional survey study, a representative sample of US pediatric emergency medicine physicians were invited to participate in a national survey adapted from the previously validated Workplace Violence in the Health Sector questionnaire from the World Health Organization. The primary outcome measure was the proportion of physicians who have been exposed to WPV. Rates of exposure to violence, reporting habits, and physician perception of various violence prevention strategies were studied secondarily. RESULTS: Surveys were completed by 207 (45%) invited participants, representing 31 US children's hospitals. The prevalence of WPV exposure was 96%. Physical violence with a weapon was witnessed by 20% of participants. Injuries requiring medical attention or time off work were experienced by 10% of participants. Half of participants never reported violent events. Security guards were welcome by 99%, armed law enforcement officers by 70%, and metal detectors by 81% of physicians. Self-arming was opposed by 85% of respondents. CONCLUSIONS: Exposure to WPV is frequent among pediatric emergency medicine physicians with a prevalence similar to that of general emergency departments. Workplace violence remains underreported. This national survey contributes to the objective evaluation of individual- and systems-level violence prevention interventions.

Retiring From Pediatric Emergency Medicine Too Soon?: A Survey to Discover the Reasons and Start a Conversation About Solutions.

OBJECTIVE: Pediatric emergency medicine is a subspecialty known for high acuity, high stress, and variable scheduling that may be difficult to maintain as one gets older. This survey sought to gain information on the reasons or plans for early retirement in pediatric emergency medicine and offer ways to address these concerns to improve longevity in the field. METHODS: A cross-sectional survey was sent via email to board-certified pediatric emergency medicine physicians who were older than 50 years to assess preretirement and postretirement considerations. Results were collected from October 3, 2019, through March 15, 2020. RESULTS: Pediatric emergency medicine physicians who find it more difficult to perform simple procedures are 3.02 (1.23-7.36) times more likely to retire before the age of 66 years. In addition, women were significantly more likely to report an intention to retire before the age of 66 years versus men (50% vs 31%, P = 0.022). DISCUSSION: The topic of retirement in a field that requires a wide range of procedural skills as well as constantly evolving technology is important. Understanding when and why physicians choose to retire may identify strategies to make it possible for pediatric emergency medicine physicians to prolong their careers. This may involve changes in work hours, a shift in responsibilities to a greater educational or mentor role, and/or providing opportunities to maintain skills. CONCLUSIONS: Perceived basic procedure skills deterioration significantly increased the risk for early retirement. In addition, women were significantly more likely to express intention to retire before the age of 66 years. Further research should be directed toward obtaining more detailed information to develop strategies to retain pediatric emergency medicine physicians in a capacity that benefits the physician, their institution, and their patients.

A novel medical apparatus for the containment and evaluation of a pediatric patient under suspicion for highly communicable infectious disease.

BACKGROUND: Highly communicable infectious diseases (HCIDs) such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Ebola are a containment challenge for the emergency department (ED). Donning and doffing personal protective equipment is necessary to protect healthcare workers but is time consuming and rife with errors. Furthermore, children present an additional containment challenge since they are often unable to follow directions or be separated from family members. To address these challenges, a novel child-friendly medical apparatus was developed for the rapid containment and evaluation of a HCID patient in the ED. OBJECTIVES: The primary objective was to determine if routine emergency triage procedures (vital signs and basic physical examination) can be performed using this medical apparatus. The secondary objective was to determine if invasive procedures (bag-valve-mask ventilation and endotracheal intubation) can be performed. DESIGN: This was a prospective pilot study. A clear acrylic apparatus was built containing arm ports with gloves, simulating a specialized HCID barrier. Emergency physicians attempted routine triage procedures on a healthy volunteer and invasive procedures using a simulation mannequin through this apparatus. RESULTS: Twenty-four physicians were enrolled. All physicians (100 percent) successfully obtained vital signs, auscultated heart/lung sounds, completed bag-valve-mask ventilation, and performed intubation through the apparatus. CONCLUSIONS: This novel apparatus is a feasible tool in the rapid evaluation of a HCID patient in the ED. A future study is needed to assess protection and training using this apparatus.

Harnessing the Electronic Health Record and Computerized Provider Order Entry Data for Resource Management During the COVID-19 Pandemic: Development of a Decision Tree.

BACKGROUND: The COVID-19 pandemic has resulted in shortages of diagnostic tests, personal protective equipment, hospital beds, and other critical resources. OBJECTIVE: We sought to improve the management of scarce resources by leveraging electronic health record (EHR) functionality, computerized provider order entry, clinical decision support (CDS), and data analytics. METHODS: Due to the complex eligibility criteria for COVID-19 tests and the EHR implementation-related challenges of ordering these tests, care providers have faced obstacles in selecting the appropriate test modality. As test choice is dependent upon specific patient criteria, we built a decision tree within the EHR to automate the test selection process by using a branching series of questions that linked clinical criteria to the appropriate SARS-CoV-2 test and triggered an EHR flag for patients who met our institutional persons under investigation criteria. RESULTS: The percentage of tests that had to be canceled and reordered due to errors in selecting the correct testing modality was 3.8% (23/608) before CDS implementation and 1% (262/26,643) after CDS implementation (P<.001). Patients for whom multiple tests were ordered during a 24-hour period accounted for 0.8% (5/608) and 0.3% (76/26,643) of pre- and post-CDS implementation orders, respectively (P=.03). Nasopharyngeal molecular assay results were positive in 3.4% (826/24,170) of patients who were classified as asymptomatic and 10.9% (1421/13,074) of symptomatic patients (P<.001). Positive tests were more frequent among asymptomatic patients with a history of exposure to COVID-19 (36/283, 12.7%) than among asymptomatic patients without such a history (790/23,887, 3.3%; P<.001). CONCLUSIONS: The leveraging of EHRs and our CDS algorithm resulted in a decreased incidence of order entry errors and the appropriate flagging of persons under investigation. These interventions optimized reagent and personal protective equipment usage. Data regarding symptoms and COVID-19 exposure status that were collected by using the decision tree correlated with the likelihood of positive test results, suggesting that clinicians appropriately used the questions in the decision tree algorithm.

Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.

BACKGROUND: The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. OBJECTIVE: The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. METHODS: This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. RESULTS: A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). CONCLUSIONS: Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

Application of Frequent, Spaced Multiple-choice Questions as an Educational Tool in the Pediatric Emergency Department.

OBJECTIVES: The objective was to assess the feasibility of using spaced multiple-choice questions (MCQs) to teach residents during their pediatric emergency department (PED) rotation and determine whether this teaching improves knowledge retention about pediatric rashes. METHODS: Residents rotating in the PED from four sites were randomized to four groups: pretest and intervention, pretest and no intervention, no pretest and intervention, and no pretest and no intervention. Residents in intervention groups were automatically e-mailed quizlets with two MCQs every other day over 4 weeks (20 questions total) via an automated e-mail service with answers e-mailed 2 days later. Retention of knowledge was assessed 70 days after enrollment with a posttest of 20 unique, content-matched questions. RESULTS: Between August 2015 and November 2016, a total 234 residents were enrolled. The completion rate of individual quizlets ranged from 93% on the first and 76% on the 10th quizlet. Sixty-six residents (55%) completed all 10 quizlets. One-hundred seventy-three residents (74%) completed the posttest. There was no difference in posttest scores between residents who received a pretest (61.0% ± 14.5%) and those who did not (64.6% ± 14.0%; mean difference = -3.7, 95% confidence interval [CI] = -8.0 to 0. 6) nor between residents who received the intervention (64.5% ± 13.3%) and those who did not receive the intervention (61.2% ± 15.2%; mean difference = 3.2, 95% CI = -1.1 to 7.5). For those who received a pretest, scores improved from the pretest to the posttest (46.4% vs. 60.1%, respectively; 95% CI = 9.7 to 19.5). CONCLUSION: Providing spaced MCQs every other day to residents rotating through the PED is a feasible teaching tool with a high participation rate. There was no difference in posttest scores regardless of pretest or intervention. Repeated exposure to the same MCQs and an increase in the number of questions sent to residents may increase the impact of this educational strategy.

LA phonospirometry technique compared to pediatric respiratory assessment measure and peak expiratory flow measurement as a novel technique to assess the severity of an asthma exacerbation.

Objective: Asthma is a common chronic disease treated in emergency departments. The measurements of Peak Expiratory Flow (PEF) and Pediatric Respiratory Assessment Measure (PRAM) scores have been recommended as objective techniques in the assessment of acute asthma exacerbations, but have multiple barriers limiting their use. The Los Angeles phonospirometry technique is an easier, trans-cultural technique. The technique assesses dyspnea by measuring how many seconds a child is able to chant "LA LA LA" in a single breath. The objective of this study is to determine the correlation of this technique with PEF measurements and PRAM scores in children with acute asthma exacerbations, both before and after nebulized bronchodilator treatment. Methods: A convenient sample of children aged 5-17 years being treated for asthma in the ED was enrolled. Phonospirometry, PRAM, and PEF measurements were obtained through pre and post inhaled bronchodilator treatments. The highest values from each measurement were correlated using Spearman's correlation coefficient. Results: A total of 91 children were enrolled. The correlations at pre-treatment, after first, second, and third treatments between phonospirometry and PEF were 0.38 (p < 0.001), 0.60 (p < 0.001), 0.54 (p < 0.001), 0.52 (p < 0.01), respectively; between phonospirometry and PRAM were -0.37 (p < 0.001), -0.42 (p < 0.001), -0.26 (p < 0.05), and -0.06 (p > 0.05), respectively; and between PEF and PRAM were -0.6 (p < 0.01), -0.54 (p < 0.001), -0.38 (p < 0.01), and -0.36 (p - 0.05), respectively. Conclusions: This novel technique correlates mild to moderately with PEF, and shows promising aide in the assessment of children with acute asthma exacerbations.

Predictors of prior asthma specialist care among pediatric patients seen in the emergency department for asthma.

Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist care among an ED population seeking pediatric asthma care are unknown. Objective: To examine, in an ED population, factors associated with prior asthma specialist use based on parental reports of prior asthma morbidity and asthma care. Methods: Parents of children ages 0 to 17 years seeking ED asthma care were surveyed regarding socio-demographics, asthma morbidity, asthma management and current asthma specialist care status. We compared prior asthma care and morbidity between those currently cared for by an asthma specialist versus not. Multivariable logistic regression models to predict factors associated with asthma specialist use were adjusted for parent education and insurance type. Results: Of 150 children (62% boys, mean age 4.7 years, 69% Hispanic), 22% reported asthma specialist care, 75% did not see a specialist and for 3% specialist status was unknown. Care was worse for those not seeing a specialist, including under-use of controller medications (24% vs. 64%, p < 0.001) and asthma action plans (20% vs. 62%, p < 0.001). Multivariable logistic regression revealed that lack of recommendation by the primary care physician reduced the odds of specialist care (OR 0.01, 95% CI <0.01, 0.05, p < 0.001). Conclusions: Asthma specialist care was infrequent among this pediatric ED population, consistent with the sub-optimal chronic asthma care we observed. Prospective trials should further investigate if systematic referral to asthma specialists during/after an ED encounter would improve asthma outcomes.

Predictors of safe discharge for pediatric drowning patients in the emergency department.

OBJECTIVES: The purpose of this study is to determine if stable, well-appearing, drowning patients who have normal age-adjusted vital signs and pulse oximetry upon arrival to the emergency department may be safely discharged without a prolonged observation period. METHODS: Medical records were retrospectively reviewed for drowning patients presenting to a single pediatric emergency department from 1995 to 2014. Data were collected on vital signs and pulse oximetry at presentation, chest x-ray results, disposition and complications for each encounter. Patients were identified as having either normal or abnormal initial vital signs and pulse oximetry, and were compared based on disposition and complication rates. RESULTS: Two hundred seventy-six records were initially evaluated and 91 were excluded. Thirty-six percent had normal age-adjusted vital signs upon arrival. Patients with abnormal temperature, respiratory rate or pulse oximetry, as well as those with any abnormal initial cardiopulmonary physical exam findings, abnormal mental status, or chest radiograph findings, were more likely to be admitted to the hospital. Eight patients developed respiratory complications after presentation to the emergency department. Those with abnormal pulse oximetry readings on arrival were more likely to develop complications. Only two patients who developed complications had initially normal vital signs and each had evidence of clinical deterioration within 1h of arrival. CONCLUSIONS: The overall complication rate in initially stable, well-appearing drowning patients is low. An abnormal pulse oximetry reading at presentation may help predict subsequent complications. Those patients with normal age-adjusted vital signs and physical exam at presentation may not require a prolonged observation period.

Clinical Utility of Noninvasive Method to Measure Specific Gravity in the Pediatric Population.

BACKGROUND: Clinicians rely on any combination of signs and symptoms, clinical scores, or invasive procedures to assess the hydration status in children. Noninvasive tests to evaluate for dehydration in the pediatric population are appealing. OBJECTIVE: The objective of our study is to assess the utility of measuring specific gravity of tears compared to specific gravity of urine and the clinical assessment of dehydration. METHODS: We conducted a prospective cohort convenience sample study, in a pediatric emergency department at a tertiary care children's hospital. We approached parents/guardians of children aged 6 months to 4 years undergoing transurethral catheterization for evaluation of urinary tract infection for enrollment. We collected tears and urine for measurement of tear specific gravity (TSG) and urine specific gravity (USG), respectively. Treating physicians completed dehydration assessment forms to assess for hydration status. RESULTS: Among the 60 participants included, the mean TSG was 1.0183 (SD = 0.007); the mean USG was 1.0186 (SD = 0.0083). TSG and USG were positively correlated with each other (Pearson Correlation = 0.423, p = 0.001). Clinical dehydration scores ranged from 0 to 3, with 87% assigned a score of 0, by physician assessment. Mean number of episodes of vomiting and diarrhea in a 24-hour period were 2.2 (SD = 3.9) and 1.5 (SD = 3.2), respectively. Sixty-two percent of parents reported decreased oral intake. CONCLUSION: TSG measurements yielded similar results compared with USG. Further studies are needed to determine if TSG can be used as a noninvasive method of dehydration assessment in children.

Utilization of just-in-time training for nursing education using the LA Phonospirometry asthma tool.

OBJECTIVE: Just-in-time training (JITT) has been used to teach and re-teach known medical techniques, but has not been used to teach novel techniques. We aimed to assess the performance retention of JITT on a novel asthma exacerbation severity assessment technique known as Los Angeles (LA) Phonospirometry. METHODS: This was a prospective cohort study using a convenience sample of pediatric emergency department registered nurses (RNs) who were asked to watch a brief instructional digital video on LA Phonospirometry, and then asked to practice the technique on a research assistant (RA). A checklist was used to evaluate proficiency with the primary outcome being the number correct on the checklist. The secondary outcome included whether or not they could identify a common error demonstrated by the RA. RNs were re-tested after 4-6 months to assess skill retention. RESULTS: Forty RNs were enrolled in the study and six were lost to follow-up. The mean time from the first to second testing was 5.4 months ± 0.5 months. The mean score of the first part of the checklist on the initial testing was 4.6 ± 0.7 and on second testing was 3.8 ± 1.5 (p = 0.008). This represented a drop in scores and thus minimal knowledge decay of 18% (from 91% to 73%). The mean values for number of errors picked up for the first test and second test were 1.3 and 1.5, respectively (p = 0.2). CONCLUSIONS: JITT demonstrated feasibility as a rapid instructional tool for RNs, with a limited decay in cognitive knowledge surrounding the LA Phonospirometry technique.

Teaching Splinting Techniques Using a Just-in-Time Training Instructional Video.

OBJECTIVE: Splinting is a multistep procedure that is seldom performed by primary care physicians. Just-in-time training (JITT) is an emerging teaching modality and can be an invaluable asset for infrequently performed procedures or in locations where teaching resources and trained professionals are limited. Our objective was to determine the utility of JITT for teaching medical students the short-arm (SA) volar splinting technique. METHODS: This was a prospective randomized controlled pilot study. An instructional video on SA volar splinting was produced. Students viewed the video or had access to standard medical textbooks (control group) immediately before applying an SA volar splint. The students were assessed for the quality of the splint via a standard 6-point skills checklist. The times required for presplinting preparation and for completion of the splint were also measured. RESULTS: Just-in-time training group students scored higher on the splint checklist (mean [SD], 5.45 [1.06]; 95% confidence interval [CI], 4.99-5.92 vs mean [SD], 1.58 [1.12]; 95% CI, 1.04-2.12; P < 0.0001), had higher pass rates (73%; 95% CI, 53%-93% vs 0%; P < 0.0001), and required less time (minutes) for presplinting preparation (mean [SD], 7.86 [2.45]; 95% CI, 6.78-8.94 vs mean [SD], 9.89 [0.46]; 95% CI, 9.67-10.12; P < 0.0001) compared with the control group. No difference was seen in the time required to complete a splint, successful or not. CONCLUSIONS: In comparison with reading standard textbooks, watching a brief JITT instructional video before splinting yielded faster learning times combined with more successful procedural skills. The use of a JITT instructional video may have potential applications, including globally, as an alternative resource for teaching and disseminating procedural skills, such as SA volar splinting.

Altered Level Of Consciousness: Evidence-Based Management In The Emergency Department.

A child who presents to the emergency department with an altered level of consciousness can be clinically unstable and can pose a great diagnostic challenge. The emergency clinician must quickly develop a wide differential of possible etiologies in order to administer potentially life-saving medications or interventions. The history, physical examination, and appropriate diagnostic tests can aid greatly in rapidly narrowing the differential diagnosis. Once initial stabilization, workup, and first-line interventions are completed, most patients who present with unresolved or unidentified altered level of consciousness should be admitted for further evaluation and close monitoring. This issue provides a review of the etiologies of altered level of consciousness as well as guidance for the management and disposition of patients with this condition.

The Broselow and Handtevy Resuscitation Tapes: A Comparison of the Performance of Pediatric Weight Prediction.

OBJECTIVES: To assess the performance of two pediatric length-based tapes (Broselow and Handtevy) in predicting actual weights of US children. METHODS: In this descriptive study, weights and lengths of children (newborn through 13 years of age) were extracted from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Using the measured length ranges for each tape and the NHANES-extracted length data, every case from the study sample was coded into Broselow and Handtevy zones. Mean weights were calculated for each zone and compared to the predicted Broselow and Handtevy weights using measures of bias, precision, and accuracy. A sub-sample was examined that excluded cases with body mass index (BMI)≥95th percentile. Weights of children longer than each tape also were examined. RESULTS: A total of 3,018 cases from the NHANES database met criteria. Although both tapes underestimated children's weight, the Broselow tape outperformed the Handtevy tape across most length ranges in measures of bias, precision, and accuracy of predicted weights relative to actual weights. Accuracy was higher in the Broselow tape for shorter children and in the Handtevy tape for taller children. Among the sub-sample with cases of BMI≥95th percentile removed, performance of the Handtevy tape improved, yet the Broselow tape still performed better. When assessing the weights of children who were longer than either tape, the actual mean weights did not approximate adult weights; although, those exceeding the Handtevy tape were closer. CONCLUSIONS: For pediatric weight estimation, the Broselow tape performed better overall than the Handtevy tape and more closely approximated actual weight. Lowe CG , Campwala RT , Ziv N , Wang VJ . The Broselow and Handtevy resuscitation tapes: a comparison of the performance of pediatric weight prediction. Prehosp Disaster Med. 2016;31(4):364-375.

Intravenous Fluid Bolus Prior to Neonatal and Infant Lumbar Puncture: A Sonographic Assessment of the Subarachnoid Space After Intravenous Fluid Administration.

IMPORTANCE: Neonatal and infant lumbar puncture is a commonly performed procedure in emergency departments, yet traumatic and unsuccessful lumbar punctures occur 30% to 50% of the time. Dehydration may be a risk factor for unsuccessful lumbar punctures, but to our knowledge, no studies have investigated the use of intravenous (IV) fluid bolus prior to lumbar puncture. OBJECTIVE: To investigate the association of IV fluid bolus administration with the sonographic measure of the neonatal and infant lumbar subarachnoid space. We hypothesized that IV fluids would increase subarachnoid space size. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study conducted from August 2012 to April 2015.The study took place at the emergency department of the Children's Hospital Los Angeles, an urban pediatric emergency department with an annual census of 76,000 visits.A convenience sample of patients aged 0 to 3 months were enrolled if they had a clinical presentation consistent with pyloric stenosis. This population was used as a proxy because they are similar in age to patients undergoing lumbar puncture for evaluation of neonatal fever and are routinely given IV fluids for dehydration. EXPOSURES: Patients with a sonographic diagnosis of pyloric stenosis underwent additional ultrasonography evaluation to determine the size of the subarachnoid space before and after IV fluids. MAIN OUTCOMES AND MEASURES: Primary outcomes included the difference in the size of the subarachnoid space in millimeters squared before and 1 hour after administration of an IV fluid bolus in the emergency department. Interobserver consistency for the subarachnoid space measurement between attending radiologists was measured using intraclass correlation coefficient. The Wilcoxon signed-rank test was used to examine changes in subarachnoid space measurements (millimeters squared). RESULTS: The study sample consisted of 40 patients with a mean (SD) age of 37 (11.3) days (range, 15-71 days). The mean (SD) size of the subarachnoid space before and 1 hour after IV fluid bolus was 37.8 (11.1) mm(2) and 36.9 (11.2) mm(2) respectively (P = .42). The intraclass correlation coefficient ranged from 0.96 to 0.99 (95% CI, 0.90-0.99). CONCLUSIONS AND RELEVANCE: Intravenous fluid boluses were not associated with a significant increase in the sonographic measure of the neonatal and infant subarachnoid space.

Management Of Fever And Suspected Infection In Pediatric Patients With Central Venous Catheters.

The use of indwelling central venous catheters is essential for pediatric patients who require hemodialysis, parenteral nutrition, chemotherapy, or other medications. Fever is a common chief complaint in the emergency department, and fever in a patient with a central venous catheter may be related to a common cause of fever, or it may be due to a catheter-associated bloodstream infection. Catheter-associated bloodstream infections may also lead to additional complications such as sepsis, septic shock, or septic complications including suppurative thrombophlebitis, endocarditis, osteomyelitis, septic emboli, and abscesses. Early resuscitation as well as timely and appropriate antibiotic therapy have been shown to improve outcomes. This issue focuses on the approach to fever in pediatric patients with central venous catheters and the management and disposition of patients with possible catheter-associated bloodstream infections.

Assessing the Utility of Urine Testing in Febrile Infants Aged 2 to 12 Months With Bronchiolitis.

OBJECTIVES: The aims of the study were to investigate whether the prevalence of urinary tract infections (UTIs) in febrile infants aged 2 to 12 months with bronchiolitis is higher than the presumed prevalence of asymptomatic bacteriuria (1%) in similarly aged patients and thus to determine whether UTI testing is necessary for these patients. METHODS: This was a prospective cohort study in which we enrolled a convenience sample of febrile infants aged 2 to 12 months with a clinical diagnosis of bronchiolitis. All patients were seen in the emergency department at a large children's hospital between November 1, 2011 and April 15, 2012, had reported or documented fever higher than 38°C, and had urine collected for determination of the presence of UTI. After the conclusion of enrollment, a chart review was conducted to assess missed cases. RESULTS: Positive urine cultures were found in 6/90 (6.7%) patients (confidence interval, 2.5%-13.9%). The positive urine cultures and urinalysis results were found in 4/90 (4.5%) patients (confidence interval, 1.2%-11%). CONCLUSIONS: In our patient population, a significant proportion of infants aged 2 to 12 months who present with bronchiolitis and fever have a concurrent UTI. Obtaining a urine specimen for UTI testing should be considered in infants aged 2 to 12 months with bronchiolitis and fever. A larger multicenter study is needed to further assess the risk factors for UTIs in this patient population.

Los Angeles phonospirometry technique: creating a normogram that correlates with peak expiratory flow measurements in children.

OBJECTIVE: Measurement of peak expiratory flow (PEF) is recommended in the assessment of patients with asthma. However, the use of PEF involves multiple barriers, which have limited its use. Phonospirometry, as assessed by a novel Los Angeles phonospirometry technique, has shown good correlation to standard PEF measurements in a pilot study on symptomatic patients with asthma. We sought to develop a normogram for phonospirometry, and to validate the PEF normogram. METHODS: A convenience sample of asymptomatic children ages 3-17 years old was approached for participation in the Emergency Department. Sample size calculations determined that at least 30 children per age group (n = 450) were needed. Children were asked to perform PEF measurements and phonospirometry, measured as the length of time (in s) the child was able to chant "lalala" in a single breath. RESULTS: 510 children were enrolled. Spearman's rho between PEF and phonospirometry was 0.722. Phonospirometry correlated with both age and height, with a Spearman rho of 0.697 and 0.696, respectively. This was slightly lower than the correlation of PEF with age and height with Spearman rhos of 0.877 and 0.902, respectively. A normogram was developed for phonospirometry based on age and height. CONCLUSIONS: This study determined normal value ranges for the Los Angeles phonospirometry technique for age and height, and also showed that the technique has good correlation with PEF. This technique may be used to assess a pediatric patient with an acute asthma exacerbation.

Clinical factors and incidence of acute chest syndrome or pneumonia among children with sickle cell disease presenting with a fever: a 17-year review.

OBJECTIVES: The objectives of this study were to determine the incidence of acute chest syndrome (ACS) in children with sickle cell disease (SCD) presenting with fever before and after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) and to determine clinical factors associated with ACS for a febrile child with SCD. METHODS: A retrospective chart review was undertaken for children with SCD from 1993 to 2009 in a single, urban, tertiary-care pediatric center. Clinical and laboratory data for each febrile event for each child with SCD were recorded. We compared incidence of ACS for the 3 PCV7 eras: pre-PCV7, inter-PCV7, and post-PCV7. Univariate analysis and stepwise logistic regression were used to identify clinical factors most associated with ACS in the post-PCV7 era. RESULTS: Of 2504 febrile events in 466 children with SCD, we found 492 diagnoses of ACS. The incidence of ACS cumulatively decreased over time from 27.0% to 17.4% among febrile children with SCD (P < 0.001), although no change was seen in children younger than 2 years (P = 0.89). Independent predictors of ACS in the post-PCV7 era include history of previous ACS, upper respiratory tract infection symptoms, noncompliance to penicillin, male sex, hypoxemia, an absolute neutrophil count greater than 9 × 10/L, and hemoglobin less than 8.6 g/dL. CONCLUSIONS: The incidence of ACS has decreased over time in febrile children with SCD. No effect was seen in those 2 years or younger. Children with SCD presenting with a fever had higher odds of developing ACS when accompanied by certain clinical, demographic, and laboratory features.

Predictors for bacteremia in febrile sickle cell disease children in the post-7-valent pneumococcal conjugate vaccine era.

OBJECTIVES: The objective of this study was to determine the incidence of bacteremia in febrile sickle cell disease (SCD) children before and after the 7-valent pneumococcal vaccine (PCV7), and to determine clinical factors associated with bacteremia following PCV7. PATIENTS AND METHODS: We reviewed all febrile events in SCD children from 1993 to 2009 at a tertiary care pediatric center, comparing general bacteremia and pneumococcal bacteremia incidence for 3 time periods around the PCV7. Univariate analysis and stepwise logistic regression identified clinical factors most associated with bacteremia in this population. RESULTS: Of 466 SCD children identified, there were 2504 febrile events. We found 84 cases of bacteremia; 8 were pneumococcal. The general bacteremia incidence decreased significantly from 5.60% to 2.44% (P<0.001) over time. Pneumococcal bacteremia incidence did not decrease (P=0.13). Following PCV7, we identified 4 significant independent risk factors associated with general bacteremia: the presence of a central venous line, higher absolute band count, toxic appearance, and older age. CONCLUSIONS: In febrile SCD children, the incidence of general bacteremia decreased over time. No decrease in pneumococcal bacteremia was found. The presence of a central venous line, absolute band count, clinical appearance, and age may help predict bacteremia in this population.