Examining Parental Acceptance of Confidential Contraception Initiation in a Pediatric Emergency Department.

BACKGROUND: The pediatric emergency department (PED) is a valuable site for contraceptive services among adolescents at risk for pregnancy. Studies have shown that adolescents are interested in such services; however, little is known about parental opinions on contraceptive care in the PED. We aimed to (1) assess parental acceptance of confidential provisions of contraception in the PED and (2) identify facilitators/barriers to parental acceptance of contraception in this setting. METHODS: This study included parents/guardians of females aged 14 to 19 years who presented to the PED with any chief complaint. Participants completed a self-administered 25-question survey based on previously validated questions to assess their acceptance of contraception provisions, both confidentially and with parental involvement, for their adolescent in the PED. χ 2 or Fisher exact tests were used to examine variables associated with parental acceptance of confidential contraception. RESULTS: Of the 102 parents/guardians surveyed, most parents (58/102, 57%) were accepting of confidential contraception for their adolescent. However, more parents (82/101, 81%) were accepting of contraception in the ED with their involvement, as opposed to confidentially without their involvement. Those accepting had an increased perceived risk of their adolescent having sex or becoming pregnant (mean [SD], 13 [20]; P = 0.02; odds ratio, 1.05; 95% confidence interval, 1.00-1.09), were aware of their adolescent's rights to confidential contraception (62%; P = 0.006; odds ratio, 3.18; 95% confidence interval, 1.39-7.28), and had slightly older teens (16 vs 15.5 years, P = 0.01). More parents accepted OCPs over IUDs in the PED (53/58, 91% vs 26/57, 46%). CONCLUSIONS: Although most parents were accepting of the PED provider offering confidential contraception to their adolescent, more parents preferred to be involved with decisions regarding contraception, in a collaborative approach. Further research is necessary to better elucidate parental/adolescent preferences.

Increased Fellow Scholarly Publication Rate After Implementation of a Comprehensive Research Curriculum and Milestone-Based Research Timeline for Pediatric Emergency Medicine Fellows.

OBJECTIVE: Pediatric subspecialty fellows are required to complete a scholarly product during training; however, many do not bring the work to publication. To amplify our fellows' publication success, our pediatric emergency medicine fellowship program implemented a comprehensive research curriculum and established a milestone-based research timeline for each component of a project. Our objective was to assess whether these interventions increased the publication rate and enhanced the graduated fellows' perceived ability to perform independent research. METHODS: Our study was conducted at a tertiary children's hospital affiliated with an academic university, enrolling 3 fellows each year in its pediatric emergency medicine program. A comprehensive research curriculum and a milestone-based research timeline were implemented in 2011. We analyzed the publication rate of our graduating fellows before (2004-2011) and after (2012-2016) our intervention. In addition, in 2017 we surveyed our previous fellows who graduated from 2004 to 2016 and analyzed factors favoring manuscript publication and confidence with various research skills. RESULTS: During the study period, 38 trainees completed the fellowship program. Publication rate increased from 26% ± 17% to 87% ± 30 % ( P < 0.05). When scoring the importance of various factors, fellows most valued mentorship (5 ± 0 vs 4.3 ± 1.0, P < 0.05, postintervention vs preintervention) for the completion of the fellowship study and manuscript. Fellows after the intervention reported greater confidence in performing an analysis of variance (89% vs 36%, odds ratio, 6.3; 95% confidence interval, 1.4-150.1). CONCLUSIONS: Implementation of a comprehensive research curriculum and a milestone-based research timeline was associated with an increase in the publication rate within 3 years of graduation of our pediatric emergency medicine fellows. After implementation, fellows reported an increased importance of mentorship and greater confidence in performing an analysis of variance. We provide a comprehensive curriculum and a research timeline that may serve as a model for other fellowship programs.

Increasing Frequency of Affirmed Name and Pronoun Documentation in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: In a previous study of 204 transgender and gender diverse youth in our region, 44% reported being made to feel uncomfortable in the emergency department (ED) because of their gender identity. The objective of our study was to conduct a 2 year quality improvement project to increase affirmed name and pronoun documentation in the pediatric ED. METHODS: Using process mapping, we identified 5 key drivers and change ideas. The key driver diagram was updated as interventions were implemented over 3 Plan-Do-Study-Act cycles. Our primary outcome, the percentage of ED visits per month with pronouns documented, was plotted on a run chart with the goal of seeing a 50% increase in form completion from a baseline median of ∼14% over the 2 year study period. RESULTS: The frequency of pronoun documentation increased from a baseline median of 13.8% to a median of 47.8%. The most significant increase in pronoun documentation occurred in Plan-Do-Study-Act cycle 3, immediately after ED-wide dissemination of a near-miss case and subsequent call for improvement by ED leadership. Roughly 1.7% of all encounters during the study period involved patients whose pronouns were discordant from the sex listed in their electronic health record. CONCLUSIONS: This quality-improvement project increased the frequency of pronoun documentation in the ED. This has the potential to improve the quality of care provided to transgender and gender diverse youth in the ED setting and identify patients who may benefit from receiving a referral to a pediatric gender clinic for additional support.

Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows.

Ventricular tachycardia in pediatric emergency department patients is a high-risk, low-frequency event well suited for education through simulation. This technical report describes a simulation-based curriculum for Pediatric Emergency Medicine fellows and senior residents involving the evaluation and management of a 10-year-old female presenting with palpitations who is ultimately diagnosed with Belhassen tachycardia. The curriculum highlights the features that differentiate Belhassen tachycardia (idiopathic left posterior fascicular ventricular tachycardia) from supraventricular or other tachycardias, building upon foundational pediatric resuscitation skills and Pediatric Advanced Life Support (PALS) algorithms for advanced learners.

Guiding Fellows to Independent Practice: Current Trends in Pediatric Emergency Medicine Fellow Supervision.

BACKGROUND: Recent studies highlight the importance of physician readiness to practice beyond graduate training. The Accreditation Council for Graduate Medical Education mandates that pediatric emergency medicine (PEM) fellows be prepared for independent practice by allowing "progressive responsibility for patient care." Prior unpublished surveys of program directors (PDs) indicate variability in approaches to provide opportunities for more independent practice during fellowship training. OBJECTIVES: The aims of the study were to describe practices within PEM fellowship programs allowing fellows to work without direct supervision and to identify any barriers to independent practice in training. DESIGN/METHODS: An anonymous electronic survey of PEM fellowship PDs was performed. Survey items were developed using an iterative modified Delphi process and pilot tested. Close-ended survey responses and demographic variables were summarized with descriptive statistics. Responses to open-ended survey items were reviewed and categorized by theme. RESULTS: Seventy two of 84 PDs (88%) responded to the survey; however, not all surveys were completed. Of the 68 responses to whether fellows could work without direct supervision (as defined by the Accreditation Council for Graduate Medical Education) during some part of their training, 31 (45.6%) reported that fellows did have this opportunity. In most programs, clinical independence was conditional on specific measures including the number of clinical hours completed, milestone achievement, and approval by the clinical competency committee. Reported barriers to fellow practice without direct oversight included both regulatory and economic constraints. CONCLUSIONS: Current training practices that provide PEM fellows with conditional clinical independence are variable. Future work should aim to determine best practices of entrustment, identify ideal transition points, and mitigate barriers to graduated responsibility.

Putting Theory to Practice: Applying Cognitive Load Theory to Resident Medical Education.

OBJECTIVE: We built 2 versions of an asynchronous pediatric orthopedic educational intervention for emergency medicine residents and sought to compare the two. We hypothesized that the version incorporating more instructional scaffolding in the form of a cognitive aid (CA) would optimize germane cognitive load for our target novice learners and result in higher test scores. METHODS: Learners were block randomized to either a "CA" or "non-CA" arm, each containing a random set of 18 modules. The CA arm incorporated an orthopedic fracture classification chart embedded within the diagnostic questions to guide the learner in forming a diagnosis. The non-CA arm was designed with more active learning as the classification chart was provided only after each diagnostic answer submission. For both arms, the final 6 modules completed per learner were scored. Learners also completed a perceived cognitive load assessment tool measured on a 10-point Likert scale. RESULTS: Learners in the non-CA arm had a mean total score on the testing modules of 33% correct compared with a mean total score of 44% correct for learners in the CA arm (mean difference, 11; 95% confidence interval, 4%-19%, P = 0.005). There was a trend for the CA arm to have lower perceived overall cognitive load scores; however, this did not reach statistical significance. CONCLUSIONS: Emergency medicine residents performed better after completing the CA version of our educational intervention. Applying cognitive load theory to an educational intervention may increase its success among target learners.

Pediatric emergency medicine fellowship point-of-care ultrasound training in 2020.

OBJECTIVES: The primary objective was to survey pediatric emergency medicine (PEM) leaders and fellows regarding point-of-care ultrasound (POCUS) training in PEM fellowship programs, including teaching methods, training requirements, and applications taught. Secondary objectives were to compare fellows' and program leaders' perceptions of fellow POCUS competency and training barriers. METHODS: This was a cross-sectional survey of U.S. PEM fellows and fellowship program leaders of the 78 fellowship programs using two online group-specific surveys exploring five domains: program demographics; training strategies and requirements; perceived competency; barriers, strengths, and weaknesses of POCUS training; and POCUS satisfaction. RESULTS: Eighty-three percent (65/78) of programs and 53% (298/558) of fellows responded. All participating PEM fellowship programs included POCUS training in their curriculum. Among the 65 programs, 97% of programs and 92% of programs utilized didactics and supervised scanning shifts as educational techniques, respectively. Sixty percent of programs integrated numerical benchmarks and 49% of programs incorporated real-time, hands-on demonstration as training requirements. Of the 19 POCUS applications deemed in the literature as core requirements for fellows, at least 75% of the 298 fellows reported training in 13 of those applications. Although less than half of fellows endorsed competency for identifying intussusception, ultrasound-guided pericardiocentesis, and transvaginal pregnancy evaluation, a higher proportion of leaders reported fellows as competent for these applications (40% vs. 68%, p ≤ 0.001; 21% vs. 39%, p = 0.003; and 21% vs. 43%, p ≤ 0.001). Forty-six percent of fellows endorsed a lack of PEM POCUS evidence as a training barrier compared to 31% of leaders (p = 0.02), and 39% of leaders endorsed a lack of local financial support as a training barrier compared to 23% of fellows (p = 0.01). CONCLUSIONS: Although most PEM fellowship programs provide POCUS training, there is variation in content and requirements. Training does conform to many of the expert recommended guidelines; however, there are some discrepancies and perceived barriers to POCUS training remain.

Pediatric emergency medicine fellows' milestone evaluations: Do they all meet the targets for graduation?

BACKGROUND: The ACGME Milestone Project created a competency-based trainee assessment tool. Subcompetencies (SCs) are scored on a 5-point scale; level 4 is recommended for graduation. The 2018 Milestones Report found that across subspecialties, not all graduates attain level 4 for every SC. OBJECTIVE: The objective was to describe the number of pediatric emergency medicine (PEM) fellows who achieve ≥ level 4 in all 23 SCs at graduation and identify SCs where level 4 is not achieved and factors predictive of not achieving a level 4. METHODS: This is a multicenter, retrospective cohort study of PEM fellows from 2014 to 2018. Program directors provided milestone reports. Descriptive analysis of SC scores was performed. Subanalyses assessed differences in residency graduation scores, first-year fellowship scores, and the rate of milestone attainment between fellows who did and did not attain ≥ level 4 at graduation. RESULTS: Data from 392 fellows were obtained. There were no SCs in which all fellows attained ≥ level 4 at graduation; the range of fellows scoring < level 4 per SC was 7% to 39%. A total of 67% of fellows did not attain ≥ level 4 on one or more SC. While some fellows failed to attain ≥ level 4 on up to all 23 SCs, 26% failed to meet level 4 on only one or two. In 19 SCs, residency graduation and/or first year fellow scores were lower for fellows who did not attain ≥ level 4 at graduation compared to those who did (mean difference = 0.74 points). Among 10 SCs, fellows who did not attain ≥ level 4 at graduation had a faster rate of improvement compared to those who did attain ≥ level 4. CONCLUSION: In our sample, 67% of PEM fellows did not attain level 4 for one or more of the SCs at graduation. Low scores during residency or early in fellowship may predict difficulty in meeting level 4 by fellowship completion.

Milestone achievements in a national sample of pediatric emergency medicine fellows: impact of primary residency training.

BACKGROUND: Pediatric emergency medicine (PEM) fellowships recruit trainees from both pediatric and emergency medicine (EM) residencies. The Accreditation Council for Graduate Medical Education (ACGME) defines separate training pathways for each. The 2015 PEM milestones reflect a combination of subcompetencies from the two residencies. This project aims to compare the milestone achievement of PEM fellows based on their primary residency training. We hypothesize that fellows trained in pediatrics achieve PEM milestones at different rates than EM-trained fellows in the ACGME domains of patient care, medical knowledge, systems-based practice, practice-based learning, professionalism, and interpersonal and communication skills. METHODS: This is a multicenter, retrospective cohort study of fellows from a national sample of U.S. PEM fellowship programs. Basic demographic information and deidentified, biannual milestone scores for 23 competencies were collected for fellows training between 2015 and 2018. Subcompetencies are scored on a 5-point milestone scale. Descriptive and multivariable analyses for longitudinal data were performed to compare milestone assessments by primary residency training. RESULTS: Complete data were obtained for 600 fellows; 95% (570) and 5% (30) completed pediatric and EM residency, respectively. In both year 1 and year 2 of fellowship, the mean milestone scores of EM-trained fellows were statistically higher than pediatrics-trained fellows across the majority of subcompetencies. By the final year of training, there were no statistically significant differences in milestone scores for any of the subcompetencies. CONCLUSIONS: Fellow milestone achievement between groups was not significantly different by graduation. However, fellows entering PEM training from an EM background attained higher scores on the milestones than fellows from a pediatric background in the first year of fellowship.

Milestones comparisons from residency to pediatric emergency medicine fellowship: Resetting expectations.

BACKGROUND: Pediatric emergency medicine (PEM) fellowships accept trainees who have completed a residency in either emergency medicine (EM) or pediatrics and have adopted 17 subcompetencies with accompanying set of milestones from these two residency programs. This study aims to examine the changes in milestone scores among common subcompetencies from the end of EM or pediatrics residency to early PEM fellowship and evaluates time to reattainment of scores for subcompetencies in which a decline was noted. METHODS: This is a national, retrospective cohort study of trainees enrolled in PEM fellowship programs from July 2014 to June 2018. PEM fellowship program directors voluntarily submitted deidentified milestone reports within the study time frame, including end-of-residency reports. Descriptive analyses of milestone scores between end of residency and PEM fellowship were performed. RESULTS: Forty-eight U.S. PEM fellowship programs (65%) provided fellowship milestone data on 638 fellows, 218 (34%) of whom also had end-of-residency milestone scores submitted. Of 218 fellows eligible for analysis, 210 (96%) had completed a pediatrics residency and eight (4%) had completed an EM residency. Pediatric-trained fellows had statistically significant decreases in mean milestone scores in all 10 shared subcompetencies. Reattainment of milestone scores across all common subcompetencies for both EM and pediatric-trained PEM fellows occurred by the end of fellowship. CONCLUSIONS: This study demonstrated declines in milestone scores from the end of primary residency training in pediatrics to early PEM fellowship in shared subcompetencies, which may suggest that performance expectations are reset at the beginning of PEM fellowship. Changes in subcompetency milestone anchors to provide subspecialty-specific context may be needed to more accurately define skills acquisition in the residency-to-fellowship transition.

Gender Differences Among Milestone Assessments in a National Sample of Pediatric Emergency Medicine Fellowship Programs.

BACKGROUND: Understanding gender gaps in trainee evaluations is critical because these may ultimately determine the duration of training. Currently, no studies describe the influence of gender on the evaluation of pediatric emergency medicine (PEM) fellows. OBJECTIVE: The objective of our study was to compare milestone scores of female versus male PEM fellows. METHODS: This is a multicenter retrospective cohort study of a national sample of PEM fellows from July 2014 to June 2018. Accreditation Council for Medical Education (ACGME) subcompetencies are scored on a 5-point scale and span six domains: patient care (PC), medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills (ICS). Summative assessments of the 23 PEM subcompetencies are assigned by each program's clinical competency committee and submitted semiannually for each fellow. Program directors voluntarily provided deidentified ACGME milestone reports. Demographics including sex, program region, and type of residency were collected. Descriptive analysis of milestones was performed for each year of fellowship. Multivariate analyses evaluated the difference in scores by sex for each of the subcompetencies. RESULTS: Forty-eight geographically diverse programs participated, yielding data for 639 fellows (66% of all PEM fellows nationally); sex was recorded for 604 fellows, of whom 67% were female. When comparing the mean milestone scores in each of the six domains, there were no differences by sex in any year of training. When comparing scores within each of the 23 subcompetencies and correcting the significance level for comparison of multiple milestones, the scores for PC3 and ICS2 were significantly, albeit not meaningfully, higher for females. CONCLUSION: In a national sample of PEM fellows, we found no major differences in milestone scores between females and males.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics.

Importance: Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. Objective: To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. Design, Setting, and Participants: This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. Exposures: Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. Results: A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). Conclusions and Relevance: In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.

Management and Outcome of Pediatric Patients With Transient Small Bowel-Small Bowel Intussusception.

OBJECTIVE: The aim of this study was to assess the management and outcomes of healthy pediatric patients diagnosed radiologically with transient and benign small bowel-small bowel intussusception (SB-SBI). METHODS: Retrospective cohort study of healthy patients 0 to 18 years of age who presented to a children's hospital emergency department from January 1, 2005, to June 30, 2015, and had transient and benign SB-SBI characterized by spontaneous resolution (ie, transient), diameter of less than 2.5 cm, no lead point, normal bowel wall thickness, nondilated proximal small bowel, and no colonic involvement (ie, benign radiographic features). Charts were reviewed for demographics, clinical presentation, radiologic studies obtained, outcomes, and further management. Medical and radiologic records were also reviewed for 1 year after presentation for any subsequent pathologic diagnoses. RESULTS: Sixty-eight patients were included in our study, with a total of 87 episodes of transient and benign SB-SBI on initial or follow-up examination. Overall, 39 patients (57%) were admitted to the hospital, and 38 patients (56%) had a surgical consultation. Twenty-four patients (35%) had further radiologic studies obtained, including computed tomography scans, esophagogastroduodenoscopy, Meckel's scan, barium swallow studies, and magnetic resonance imaging. All studies were negative for concerning pathology including apparent lead points. None of the patients required surgical intervention or had any complications. CONCLUSIONS: Transient and benign SB-SBIs with reassuring radiologic and clinical features diagnosed in healthy pediatric patients are likely incidentally found and are unlikely to be associated with a pathologic lead point.

Management and Outcomes of Spontaneous Pneumomediastinum in Children.

OBJECTIVES: Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes. METHODS: This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database. RESULTS: We identified 183 patients with spontaneous pneumomediastinum. The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinal-associated pneumomediastinum (31, 17%), and secondary respiratory-associated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information. CONCLUSIONS: Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.

Evidence-Based Medicine Curriculum Improves Pediatric Emergency Fellows' Scores on In-Training Examinations.

OBJECTIVES: The aim of this study was to determine if implementation of our evidence-based medicine (EBM) curriculum had an effect on pediatric emergency medicine fellows' scores on the relevant section of the in-training examination (ITE). METHODS: We obtained deidentified subscores for 22 fellows over 6 academic years for the Core Knowledge in Scholarly Activities (SA) and, as a balance measure, Emergencies Treated Medically sections. We divided the subscores into the following 3 instruction periods: "baseline" for academic years before our current EBM curriculum, "transition" for academic years with use of a research method curriculum with some overlapping EBM content, and "EBM" for academic years with our current EBM curriculum. We analyzed data using the Kruskal-Wallis test, the Mann-Whitney U test, and multivariate mixed-effects linear models. RESULTS: The SA subscore median was higher during the EBM period in comparison with the baseline and transition periods. In contrast, the Emergencies Treated Medically subscore median was similar across instruction periods. Multivariate modeling demonstrated that our EBM curriculum had the following independent effects on the fellows' SA subscore: (1) in comparison with the transition period, the fellows' SA subscore was 21 percentage points higher (P = 0.005); and (2) in comparison to the baseline period, the fellows' SA subscore was 28 percentage points higher during the EBM curriculum instruction period (P < 0.001). CONCLUSIONS: Our EBM curriculum was associated with significantly higher scores on the SA section of the ITE. Pediatric emergency medicine educators could consider using fellows' scores on this section of the ITE to assess the effect of their EBM curricula.

Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury.

OBJECTIVE: To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner. RESULTS: Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships <1 year were also associated with an increased risk of abuse. CONCLUSIONS: We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.

Seasonal, Weather, and Temporal Factors in the Prediction of Admission to a Pediatric Trauma Center.

BACKGROUND: Our objective is to identify seasonal and weather trends associated with pediatric trauma admissions. METHODS: We reviewed all trauma activations leading to admission in patients ≤18 years admitted to a regional pediatric trauma center from January 1, 2000, to December 31, 2015. We reviewed climatologic measures of the mean temperature, mean visibility, and precipitation for each admission in the 6 h prior to each presentation in addition to time of arrival, weekday/weekend presentation, and season. We used a negative binomial regression model with multivariable analysis to estimate associations between weather and rate of trauma admissions. Results were presented as incidence rate ratios (IRR) with 95% confidence intervals (CI). RESULTS: In total, 3856 encounters [2539 males (65.8%), mean age 10.2 years ± SD 5.1 years] were included. Results from multivariable analysis (IRR, 95% CI) suggested an association of admissions with rain (0.82, 0.75-0.90) and overnight hours (23:51-05:50; 0.69, 0.58-0.82) as compared to morning (05:51-11:50). The IRR of trauma increased during the afternoon (11:51-17:50; 4.05, 3.57-4.61), night periods (17:51-23:50; 5.59, 4.94-6.33), and weekends (1.24, 1.15-1.32), and with every 1 °C increase in temperature (1.04, 1.03-1.04). After accounting for other variables, season was not found to be independently predictive of trauma admission. CONCLUSION: Trauma admissions had a higher rate during afternoon, evening hours, and weekends. The presence of rain lowered the rate of pediatric trauma admission. Each degree increase in temperature increased the rate of trauma admissions by 4%. The findings provide information from the perspective of emergency preparedness, resource utilization, and staffing to pediatric trauma centers.

Risk of Serious Bacterial Infection in Infants Aged ≤60 Days Presenting to Emergency Departments with a History of Fever Only.

OBJECTIVE: To compare the risk of serious bacterial infection between infants aged ≤60 days who are febrile in the emergency department (ED) and those who have only a history of fever and are afebrile on arrival to the ED. STUDY DESIGN: In this secondary analysis of a multicenter prospective study using data collected between December 2008 and May 2013, we compared the rate of serious bacterial infection (urinary tract infection [UTI], bacteremia, and/or bacterial meningitis) between infants who have a history of fever but are afebrile on arrival to the ED and those with fever documented in the ED (rectal temperature ≥38.0 °C) using relative risk (RR) with 95% CI. Stratified analyses were performed for age (≤28 and 29-60 days) and serious bacterial infection type. Infants born prematurely and those with a clinical focal infection or serious illness were excluded. RESULTS: A total of 3825 infants (mean age, 35.2 days; 56.9% male) were included. Of the 1233 (32.2%) who were afebrile in the ED, 108 (8.8%) had a serious bacterial infection (UTI, n = 94 [7.6%]; bacteremia, n = 19 [1.5%]; bacterial meningitis, n = 8 [0.6%]). Of the 2592 infants (67.8%) who were febrile in the ED, 331 (12.8%) had a serious bacterial infection (UTI, n = 285 [11.0%]; bacteremia, n = 61 [2.4%]; bacterial meningitis, n = 17 [0.7%]). The RR for serious bacterial infection for afebrile vs febrile infants was 0.68 (95% CI, 0.56-0.84). A lower risk of serious bacterial infection was also seen among afebrile vs febrile infants aged ≤28 days (RR, 0.69; 95% CI, 0.52-0.93) and age 29-60 days (RR, 0.67; 95% CI, 0.50-0.89). CONCLUSIONS: The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making.

Improving the Evaluation and Management of Abnormal Uterine Bleeding in Female Adolescents Presenting for Emergency Care.

STUDY OBJECTIVE: We sought to improve emergency care for adolescents with abnormal uterine bleeding (AUB) by developing a clinical effectiveness guideline (CEG) and assessing its effect on quality of care. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: A stakeholder engagement group designed a CEG algorithm for emergency AUB management. Pediatric residents received CEG training and their knowledge and attitudes were assessed using pre- and post intervention surveys. International Classification of Diseases ninth and 10th revision codes identified electronic health record data for patients who presented to the pediatric emergency department for AUB 6 months before and after CEG implementation. A weighted, 20-point scoring system consisting of prioritized aspects of history, laboratory studies, and management was developed to quantify the quality of care provided. MAIN OUTCOME MEASURES: Descriptive statistics, χ2 test, Wilcoxon rank sum test, and a run chart were used for analysis. RESULTS: Pediatric residents reported higher confidence and knowledge scores post CEG implementation. Of the 91 patients identified, 62 met inclusion criteria. Median score was 14 ± 7 before CEG implementation and 15.5 ± 6 after. The Wilcoxon rank sum test showed a difference in AUB evaluation and management scores (P = .09) after implementation of the CEG. Run chart data showed no shifts or trends (overall median score, 14 points). Pre- and post implementation, points were deducted most frequently for not assessing personal/family clotting disorder history. The largest improvements in care were with appropriate medication dosing and disposition. CONCLUSION: We designed a CEG and educational intervention for AUB management in a pediatric emergency department. These findings suggest our CEG might be an effective tool to improve emergency AUB care for adolescents and could increase trainees' confidence in managing this condition, although additional cycles are needed.

Sternoclavicular Arthritis as a Clinical Presentation for Lyme Disease.

Lyme disease is caused by Borrelia burgdorferi and can lead to dermatologic, neurologic, cardiac, and musculoskeletal manifestations. The arthritis of Lyme disease is typically monoarticular, with the knee being most commonly involved. Lyme arthritis of small joints has not previously been well described. We report 3 children who presented with sternoclavicular joint swelling and who were found to have Lyme disease based on enzyme-linked immunosorbent assay and Western blot. This description of sternoclavicular Lyme arthritis highlights the importance of considering Lyme disease in the differential and diagnostic workup of new onset, small joint arthritis in patients presenting from or with travel to Lyme endemic regions.