Determination, categorization, and hierarchy of content for a pediatric emergency medicine curriculum designed for emergency medicine residents.

Background: Currently, the Accreditation Council of Graduate Medical Education requires time-based pediatric experiences for emergency medicine (EM) residents in both pediatric emergency medicine (PEM) and critical care settings. The American Board of Emergency Medicine has published the Model of the Clinical Practice of Emergency Medicine, which is a list of content an EM resident should learn. However, this list is large and without prioritization and therefore can be difficult to incorporate into time-limited curricula. Objectives: The primary objective of this study was to develop comprehensive categorization of PEM content using an EM lens. The second objective was to suggest a prioritization for the EM learner of the enumerated PEM elements. Methods: We first assembled a comprehensive list of PEM concepts, diagnoses, and procedures that might be taught to EM residents. We then convened focus groups composed of key stakeholders to help formulate content and concept themes important for EM resident training. Once the themes were identified, we divided the list of PEM topics into appropriate themes and then carried out a second round of focus groups expanded to include more diverse expert input for prioritizing the elements of the comprehensive list within each theme. Results: We prioritized 168 important PEM concepts from previous standards and emerging PEM literature among 10 identified themes: the pediatric normal, the bottom-line boil-it-down approach, common presentations, high-acuity pediatric cases and procedures, differences between children and adults, same between children and adults, red flags, infrequency of caring for a child compared with an adult, keep breadth but promote self-directed depth, and triage and disposition. Conclusions: Based on input from stakeholders in EM resident education, we identified key themes within PEM education and created a framework for the hierarchical categorization of PEM content for within an EM residency.

Critical Revisits Among Children After Emergency Department Discharge.

STUDY OBJECTIVE: Identifying higher risk groups could reveal ways to prevent critical emergency department (ED) revisits. The study objectives were to determine the rate of critical ED revisits among children discharged from the ED and to identify factors associated with critical revisits. METHODS: We performed a retrospective study using the Healthcare Cost and Utilization Project State ED Databases (SEDD) and the State Inpatient Databases (SID). We included data from 6 states from 2014 through 2017. Critical ED revisit was defined as either ICU admission or death within 3 days of the initial ED discharge. We included all patients younger than 21 years. The main outcome was the rate of critical ED revisit. We also determined the relative risk (RR) of a critical ED revisit for the most common index ED visit diagnoses. We used negative binomial regression to calculate incidence rate ratios (IRR) of a critical ED visit by pediatric volume and complex chronic conditions. RESULTS: A total of 16.3 million children were discharged from an ED over the 4-year study period. There were 18,704 (0.1%) critical ED revisits, 180 (0.00001%) of whom died. Asthma (RR 2.24, 95% confidence interval [CI] [2.11 to 2.38) had the highest relative risk of a critical revisit among all ED diagnoses. Adjusting for hospital volume and patient age, patients with complex chronic conditions were also more likely to have a critical ED revisit (IRR 11.03, 95% CI, 7.76 to 15.67). CONCLUSIONS: Critical revisits after ED discharge were uncommon among children in our study sample, with revisits resulting in patient death within 3 days of an ED discharge being rare. Given the short time interval between ED discharges, however, future research should focus on understanding higher risk patients among those with asthma and a history of complex chronic conditions.

Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments.

BACKGROUND: Seizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates. OBJECTIVE: To compare rates of head CT for pediatric seizure between general and pediatric EDs. METHODS: This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model. RESULTS: More than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3-16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0-31.9]), without fever (12.2% [95% CI 3.1-21.4]), and without trauma (10.6% [95% CI 4.4-16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0-3.2), 4.9 (95% CI 2.6-9.2), and 2.0 (95% CI 1.2-3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure. CONCLUSIONS: Children with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.