The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The role of telehealth in pediatric emergency care.

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice.

Objectives: The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. Materials and Methods: After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). Results: At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. Discussion: CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. Conclusions: When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment.

The Complex Dynamic of Phase I Drug Metabolism in the Early Stages of Doxorubicin Resistance in Breast Cancer Cells.

The altered activity of drug metabolism enzymes (DMEs) is a hallmark of chemotherapy resistance. Cytochrome P450s (CYPs), mainly CYP3A4, and several oxidoreductases are responsible for Phase I metabolism of doxorubicin (DOX), an anthracycline widely used in breast cancer (BC) treatment. This study aimed to investigate the role of Phase I DMEs involved in the first stages of acquisition of DOX-resistance in BC cells. For this purpose, the expression of 92 DME genes and specific CYP-complex enzymes activities were assessed in either sensitive (MCF-7 parental cells; MCF-7/DOXS) or DOX-resistant (MCF-7/DOXR) cells. The DMEs genes detected to be significantly differentially expressed in MCF-7/DOXR cells (12 CYPs and eight oxidoreductases) were indicated previously to be involved in tumor progression and/or chemotherapy response. The analysis of CYP-mediated activities suggests a putative enhanced CYP3A4-dependent metabolism in MCF-7/DOXR cells. A discrepancy was observed between CYP-enzyme activities and their corresponding levels of mRNA transcripts. This is indicative that the phenotype of DMEs is not linearly correlated with transcription induction responses, confirming the multifactorial complexity of this mechanism. Our results pinpoint the potential role of specific CYPs and oxidoreductases involved in the metabolism of drugs, retinoic and arachidonic acids, in the mechanisms of chemo-resistance to DOX and carcinogenesis of BC.

Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record.

BACKGROUND: Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. METHODS: Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. RESULTS: Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. CONCLUSIONS: Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Novel Approach to Emergency Departments' Pediatric Readiness Across a Health System.

STUDY OBJECTIVE: A gap analysis of emergency departments' (EDs') pediatric readiness across a health system was performed after the appointment of a service line health system pediatric emergency medicine (PEM) quality director. METHODS: A 55-question survey was completed by each eligible ED to generate a weighted pediatric readiness score (WPRS). The survey included questions regarding volume, ED configuration, presence of a pediatric emergency care coordinator (PECC), quality initiatives, policies and procedures, and equipment. Surveys were completed from June 1 to November 12, 2016.Analysis of variance was used to compare the 4 groups of EDs based upon their annual pediatric volume as a continuous measure (low, <1800 visits; medium, 1800-4999 visits; medium-high, 5000-9999 visits; high, >10,000 visits). The Fisher exact test was used to compare the 4 groups for the remaining categorical variables represented as frequencies and percentages. A result was considered statistically significant at the P < 0.05 level of significance. RESULTS: There were a total of 16 hospitals (after the exclusion of the children's hospital, the hub for pediatric care in the health system, and 1 adult-only hospital) with the following pediatric capability: 7 basic (no inpatient pediatrics), 7 general (inpatient pediatrics, with/without a neonatal intensive care unit), and 2 comprehensive (inpatient pediatrics, pediatric intensive care unit, and a neonatal intensive care unit). In 12 EDs, adults and children are treated in the same space. These EDs see a total of 800,000 annual visits including 120,000 pediatric visits. Two low pediatric volume EDs had a median WPRS of 69, range of 62 to 76 (national median, 61.4); 6 medium pediatric volume EDs had a median WPRS of 51, range of 42 to 81 (national median, 69.3); 4 medium-high pediatric volume EDs had a median WPRS of 69.3, range of 45 to 98 (national medium, 74.8); 4 high pediatric volume EDs had a WPRS score of 84.5, range of 58 to 100 (national medium, 89.8). There were 4 sites with PECCs: 1 medium-high volume and 3 high volume, with a median WPRS of 98.5, range of 81 to 100 (national medium, 89.8). Two low-volume EDs have Neonatal Resuscitation Program training for nurses (P < 0.0083). One medium-high volume ED requires specific pediatric competency evaluations for advanced level practitioners staffing the ED. Pediatric-specific quality programs are present in the 2 low volume EDs, 3 of the 6 EDs in the medium group, 3 of 4 EDs in the medium-high group, and all 4 high volume hospitals. After the implementation of the health system PEM quality director, all EDs have a doctor and nurse PECC with a median WPRS of 81. In additiona, a committee was formed with the following key stakeholders: PECCs, pediatric nursing educators, pediatric quality, pharmacy, obstetrics, behavioral health, and neonatology. The committee is part of the health system quality program within both pediatrics and emergency medicine and is spearheading the standardization of code carts and medications, dissemination of pediatric clinical guidelines, and the development of a pediatric quality program across the health system. CONCLUSIONS: Pediatric emergency care coordinators play an important role in ED readiness to care for pediatric patients. In a large health system, a service line PEM quality director with the support of emergency medicine and pediatrics, a committee with solid frontline ED base, and a diverse array of stakeholders can foster the engagement of all EDs and improve compliance with published guidelines.

Characteristics of Pediatric Patient Transferred From Hospital-Based General Emergency Departments to Acute-Care Facilities: An Analysis of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample.

STUDY OBJECTIVE: The objective of this study was to analyze the characteristics of pediatric patients transferred from a hospital-based general emergency department (ED) to an acute care facility. METHODS: Study data were abstracted from the 2010 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database. A multivariate logistic regression was constructed for pediatric patients (<18 years old) who require a transfer to an acute care facility from a general ED. Independent variables included in the model were age (<1, 1-4, 5-9, 10-14, 15-17 age in years), sex, insurance/payment method, and diseases/body systems using International Classification of Diseases, Ninth Revision, coding. RESULTS: In the Healthcare Cost and Utilization Project/Nationwide Emergency Department Sample, 5.5 million ED visits were for children less than 18 years. About 1.5% of visits resulted in transfer. Children younger than 1 year had higher transfer rates as compared with 15 to 17 year old group (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.089-1.146). Patients with Medicaid and self-pay compared with private insurance/health maintenance organization had 4% (OR, 0.96; 95% CI, 0.944-0.976) and 9% (OR, 0.91; 95% CI, 0.886-0.945), respectively, lower likelihood of being transferred. Patients with circulatory (OR, 8.43; 95% CI, 7.8-9.1), endocrine (OR, 5.9; 95% CI, 5.6-6.2), mental (OR, 5.44; 95% CI, 5.3-5.6), nervous system (OR, 5.2; 95% CI, 4.9-5.5), congenital anomalies (OR, 5.14; 95% CI, 4.5-5.9), hematology-oncology (OR, 4.49; 95% CI, 4.2-4.8), digestive, (OR, 1.52; 95% CI, 1.5-1.6), and other disorders (OR, 1.33; 95% CI, 1.3-1.4) had a higher odds of being transferred as compared with trauma/injury and poisoning, whereas patients with disorders related to genitourinary (OR, 0.96; 95% CI, 0.91-1.0), respiratory (OR, 0.79; 95% CI, 0.77-0.81), musculoskeletal (OR, 0.63; 95% CI, 0.58-0.68), skin (OR, 0.47; 95% CI, 0.45-0.50), infectious and parasitic (OR, 0.23; 95% CI, 0.22-0.25), and eyes/ears/nose/throat (OR, 0.09; 95% CI, 0.079-0.094) had a lower odds of being transferred as compared with trauma/injury and poisoning. CONCLUSIONS: Children younger than 1 year had relatively higher transfer rates. Patients covered by Medicaid and self-pay had the lowest likelihood of transfer. Transfer rates varied significantly by condition and the high-transfer diagnostic categories were related to circulatory, endocrine, nervous, hematology-oncology, and mental disorders as well as congenital anomalies, which may be related to a lack of ED or inpatient resources to care for children with problems that require more complex care.

Increased access to urgent care centers decreases low acuity diagnoses in a nearby hospital emergency department.

OBJECTIVE: We studied the impact four new urgent care centers (UCCs) had on a hospital emergency department (ED) in terms of overall census and proportion of low acuity diagnoses from 2009 to 2016. We hypothesized that low acuity medical problems frequently seen in UCCs would decrease in the ED population. Since Medicaid was not accepted at these UCCs, we also studied the Medicaid vs non-Medicaid discharged populations to see if there were some differences related to access to urgent care. METHODS: We conducted a retrospective review of computerized billing data. We included all patients from 2009 to 2016 who were seen in the ED. We used the Cochran-Armitage Trend Test to examine trends over time. RESULTS: As hypothesized, the proportion of ED patients with a diagnosis of pharyngitis decreased significantly over this time period from 1% to 0.6% (p < 0.0001). The rate of bronchitis in the total ED population also decreased significantly (0.5% to 0.13%, p < 0.0001).When we looked at the discharged patients with and without Medicaid, we found that significantly more Medicaid than non-Medicaid patients presented with pharyngitis to the ED with an increasing trend from 2009 to 2016: OR = 2.33, p < 0.0001. The overall census of the ED rose over the period 2009 to 2016 (80,478 to 85,278/year). Overall admission rates decreased significantly: 36.9% to 34.5% (p < 0.0001). CONCLUSION: With the introduction of four new urgent care centers (UCCs) within 5 miles of the hospital, the ED diagnoses of pharyngitis and bronchitis, two of the most common diagnoses seen in UCCs, decreased significantly. Significantly more Medicaid discharged patients presented to the ED with pharyngitis than in the non-Medicaid discharged group, likely because Medicaid patients had no access to UCCs.

Executive Summary: The 2018 Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps.

Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.

A Research Agenda to Advance Pediatric Emergency Care Through Enhanced Collaboration Across Emergency Departments.

In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.

Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department.

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review.

INTRODUCTION: Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries. METHODS: We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper. RESULTS: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated). CONCLUSION: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.

Role of Pediatric Emergency Physicians in Identifying Bullying.

BACKGROUND: Bullying is an important public health issue with broad implications. Although this issue has been studied extensively, there is limited emergency medicine literature addressing bullying. The emergency department (ED) physician has a unique opportunity to identify children and adolescents that are victims of bullying, and make a difference in their lives. OBJECTIVE: Our aim is to discuss the role of the emergency physician (EP) in identifying patients who have been victims of bullying and how to provide effective management as well as referral for further resources. DISCUSSION: This document provides a framework for recognizing, stabilizing, and managing children who have experienced bullying. With the advent of social media, bullying behavior is not limited to in-person situations, and often occurs via electronic communication, further complicating recognition because it may not impart any physical harm to the child. Recognition of bullying requires a high level of suspicion, as patients may not offer this history. After the stabilization of any acute or overt indications of physical injury, along with obtaining a history of the mechanism of injury, the EP has the opportunity to identify the existence of bullying as the cause of the injury, and can address the issue in the ED while collaborating with "physician-extenders," such as social workers, toward identifying local resources for further support. CONCLUSIONS: The ED is an important arena for the assessment and management of children who have experienced bullying. It is imperative that EPs on the front lines of patient care address this public health epidemic. They have the opportunity to exert a positive impact on the lives of the children and families who are the victims of bullying.

Choledochal Cyst Mimicking Gallbladder with Stones in a Six-Year-Old with Right-sided Abdominal Pain.

Choledochal cysts are rare but serious bile duct abnormalities are found in young children, usually during the first year of life.1 They require urgent surgical intervention due to the risk of developing cholangiocarcinoma.2 Clinicians should consider this diagnosis and perform a point-of-care ultrasound (POCUS) when a child presents to the emergency department (ED) with findings of jaundice, abdominal pain, and the presence of an abdominal mass. We present the case of a six-year-old child presenting only with abdominal pain upon arrival to our ED and was ultimately diagnosed by POCUS to have a choledochal cyst.

Best practices for improving flow and care of pediatric patients in the emergency department.

This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department.

Death of a child in the emergency department.

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.

Death of a child in the emergency department.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Death of a child in the emergency department.

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.

Death of a child in the emergency department.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.