A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations.

Background: Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation. Methods: We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications. Results: The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months. Conclusions: This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Blood Clots Per Rectum in a Pediatric Patient With Salmonella Enteritis: A Case Report.

Infection is a common cause of hematochezia in children. While infectious diarrhea can present with bloody stools, it is rare to have the passage of frank blood clots per rectum in the pediatric population. This is a case of a seven-year-old male who presented with vomiting, diarrhea, severe abdominal pain, and passage of blood clots per rectum. As symptoms progressed, consideration of non-infectious causes was investigated and subsequently ruled out. The stool polymerase chain reaction (PCR) was positive for Salmonella species, while stool culture was negative for any enteropathogen. This report highlights the unusual occurrence of the passage of blood clots per rectum in a child with salmonella enterocolitis.

Ancillary Services in Pediatric Departments of USA.

It is well known that prolonged hospitalizations and medical procedures have adverse psychological impact on children. Ancillary services in the pediatric departments help in mitigating stress, improve patient satisfaction, reduce procedural time, and improve the quality of life. This can be translated to measurable outcomes such as less doctor's visits, fewer symptoms, early discharge and fewer medications. Other benefits include conserving staff time and energy, thereby increasing productivity, staff retention and decreasing burnout. As more free-standing children's hospitals emerge, the ancillary services will gain more recognition and popularity to give the best patient care experience.

Fever of Unknown Origin in a 17-Year-Old Girl.

Fever of unknown origin (FUO) is defined as fever (>101°F) that lasts more than three weeks and for which a cause is not found within seven days of hospital evaluation. FUO has a broad list of differentials - infection, inflammatory diseases, and malignancy. A detailed history and meticulous clinical examination with thorough and stepwise investigations lead to a diagnosis in only two-thirds of cases. In this article, we present a 17-year-old adolescent girl, with no significant past medical history, who presented with FUO during the COVID pandemic. A high index of suspicion and extensive investigations revealed the final diagnosis.

Poor neurological sequelae of herpes simplex virus encephalitis in an infant despite adequate antiviral and adjunct corticosteroid therapy.

A 2-month-old infant presented to our emergency department with fever, altered consciousness, and focal seizures of acute onset. He had vesicular skin lesions over the right preauricular region. CT brain showed a large hypodense lesion involving the left temporo-parietal region, left basal ganglia and left thalamus. MRI brain revealed bilateral multifocal corticomedullary lesions suggestive of encephalitis. CSF-PCR was positive for herpes simplex virus (HSV) type I. He was treated with standard dose intravenous acyclovir for 15 days along with a trial of pulse methylprednisolone, but was readmitted within a week with features of an early relapse. The infant survived but developed significant neurological sequelae. Although treatment of HSV is available, the neurological outcome is guarded even with adequate antiviral therapy. Adjunct corticosteroid therapy did not appear to attenuate the neurological sequelae.