Uses and complications of central venous catheters inserted in a pediatric emergency department.

OBJECTIVE: To describe the incidence, indications, insertion sites, duration, and complications of central venous catheter (CVC) insertion in patients in a pediatric emergency department (ED). DESIGN: Retrospective chart review. SETTING: ED of an urban pediatric teaching hospital. SUBJECTS: Patients who had a CVC inserted in the ED from January 1992 to July 1997. RESULTS: During the 5.5-year study period, 121 patients were identified. Indications for insertion were cardiac/respiratory arrest in 20 patients (17%), lack of peripheral vascular access in 78 (64%), and inadequate peripheral vascular access in 23 (19%). Presenting diagnoses included cardiac/respiratory arrest (20), dehydration (19), lower respiratory tract disease (15), seizure (15), sepsis (13), trauma (10), and other (29). Prior to the CVC insertion, 80 (66%) patients had no venous access, 28 (23%) had a peripheral intravenous catheter, and 13 (11%) had an intraosseous needle. One hundred one (83%) CVCs were inserted into the femoral vein, 12 (10%) into the subclavian, 7 (6%) into the internal jugular, and 1 (1%) into an axillary vein. There were four reported complications requiring the CVC to be removed, and all occurred with femoral line placement. There were no long-term sequelae or life-threatening or limb-threatening complications (95% CI = 0-2.5%). CONCLUSIONS: Central venous catheterization, particularly using the femoral approach, appears to a safe method of obtaining central venous access in the critically ill infant, child, or young adult.

Time to detection of positive cultures in 28- to 90-day-old febrile infants.

OBJECTIVE: To determine the time to detection of positive blood, urine, and cerebrospinal fluid (CSF) cultures among febrile 28- to 90-day-old infants. STUDY DESIGN: Retrospective cohort of consecutive 28- to 90-day-old infants presenting with a temperature of >/=38 degrees C to an urban pediatric emergency department. Positive cultures and times to detection were noted. Patients were categorized as being at high risk for serious bacterial illness (SBI) based on clinical and laboratory criteria. RESULTS: Of the 3166 febrile infants seen in the emergency department during the study, 2733 had blood (86%), 2517 had urine (80%), and 2361 had CSF (75%) specimens obtained for culture, and 2190 had all 3 cultures (69%) sent. There were 224 positive cultures in 214 patients; of these, 191 had all 3 cultures (89%) sent. Subsequent analyses were confined to those who had all 3 cultures sent. The detected rate of SBI was 8.7% (191/2190). There were 28 positive blood cultures (1. 3%), 165 positive urine cultures (7.5%), and 8 positive CSF cultures (.4%). Median time to detection of positive cultures was 16 hours for blood, 16 hours for urine, and 18 hours for CSF. Four blood cultures (.1%), 20 urine cultures (.9%), and 0 CSF cultures were noted to have growth of a pathogen >24 hours after the specimen was obtained. All 4 blood cultures and 17 of 20 urine cultures with growth noted after 24 hours occurred among high-risk patients. CONCLUSIONS: The risk of identifying SBI after 24 hours is 1.1% among all 28- to 90-day-old febrile infants and.3% in low-risk infants.

Failure of oxygen saturation and clinical assessment to predict which patients with bronchiolitis discharged from the emergency department will return requiring admission.

OBJECTIVE: To determine if there is a difference between patients with bronchiolitis who are discharged from the emergency department (ED) but return requiring admission and those who do not return. DESIGN: Retrospective, case control study. SETTING: Tertiary care children's hospital emergency department. PARTICIPANTS: Fifty-seven study patients under one year of age with bronchiolitis seen from November 1991 to April 1993 who were discharged but returned requiring admission within 96 hours, and 124 controls, matched by diagnosis, who did not return. RESULTS: No differences were found between cases and controls in duration of illness (3.0 vs 3.7 days, P = 0.08), gestational age (39.3 vs 38.8 weeks, P = 0.32), chronologic age (20.9 vs 22.9 weeks, P = 0.31), respiratory rate (49.9 vs 48.0 respirations/ min, P = 0.18), presence of retractions (54.8 vs 54.4%, P = 0.97), oxygen saturation (SaO2; 97.6 vs 98.0%, P = 0.29), or number of nebulized beta-agonists administered in the ED (1.4 vs 1.2 P = 0.35). Cases had higher mean heart rates (HR) than controls (154.8 vs 148.8, P = 0.006). Patients with HR > 150 were more likely to return requiring admission (odds ratio = 2.45, 95% confidence intervals 1.2-4.9). However, only 36 of 57 patients who returned requiring admission had HR > 150 (sensitivity = 0.63), and 73 of 124 who did not return had HR < or = 150 (specificity = 0.59). None of the returns required admission to the intensive care unit, and their mean duration of admission was 59-hours. At the time of admission the cases had lower SaO2 (95.9 vs 97.7%, P = 0.001) and a higher frequency of retractions (83.3 vs 52.6%, P = 0.02) than when seen initially. CONCLUSIONS: Oxygen saturation and clinical assessment failed to differentiate between patients with bronchiolitis who returned requiring admission and patients who did not return.

Intern learning and education in a short stay unit. A qualitative study.

OBJECTIVE: To study interns' perceptions of their learning during their rotation through a short stay unit (SSU). DESIGN: Case-based, qualitative research study. SETTING: A tertiary care pediatric hospital (The Children's Hospital, Boston, Mass). PARTICIPANTS: Ten interns who had worked in the SSU in the 3 months prior to June 1, 1995, and on a general medical team in the previous 12 months. INTERVENTION: None. MAIN OUTCOME MEASURES: In July 1995, the interns participated in focused, open-ended interviews lasting about 40 to 60 minutes to document their perceptions of their learning during their SSU rotation. The interviews were recorded on audiotape and transcribed prior to analysis. Data were analyzed to discern and categorize themes from the interns' responses. RESULTS: All interns responded favorably to their educational and learning experiences during their rotation through the SSU. Two major themes emerged: (1) the interns' learning, which was affected by the role of the attending physician, the organization and structure of the SSU, and the teaching strategies in the SSU; and (2) the interns' collaborative work with the nursing staff in the SSU, which affected patient care but did not facilitate the interns' learning. CONCLUSION: Clustering in the SSU of patients whose symptoms suggested straightforward diagnoses enhanced interns' educational experiences.

Impact of a short stay unit on asthma patients admitted to a tertiary pediatric hospital.

A short stay unit (SSU) was opened at the Children's Hospital, Boston, with the aim of better fulfilling the needs of pediatric patients with straightforward diagnoses. Using historical and simultaneous comparison groups and controlling for disease severity, the opening of the SSU led to a decrease of between 16.5 and 28.4 percent in the mean length of stay for asthma patients without any increase in the rate of hospital readmission.

Clinical and cost-effectiveness of outpatient strategies for management of febrile infants.

Young infants with fever are at risk for serious bacterial infection, but no consensus exists on the optimal approach to diagnosis and treatment. Although the traditional recommendation is always to perform all sepsis tests, including lumbar puncture, and administer intravenous (IV) antibiotics until culture results are negative, recent studies suggest administering intramuscular (IM) ceftriaxone with outpatient follow-up or using laboratory and clinical data to exclude low-risk patients from hospitalization, further testing, and antibiotic treatment. A decision analysis model was used to evaluate six strategies for the diagnosis and treatment of infants aged 28 to 90 days with temperature greater than or equal to 38.0 degrees C. Data from the literature, data from a 1991 study of 503 febrile infants, and direct, short-term costs from the Children's Hospital of Philadelphia were used as model inputs. The model was run for a hypothetical cohort of 100,000 febrile infants who did not require admission for focal infection or for other reasons that clearly necessitated admission. The model included six strategies: (1) no intervention; (2) all sepsis tests (lumbar puncture, blood culture, urine culture, white blood cell count, and urinalysis) followed by hospitalization and IV antibiotics for all infants; (3) all sepsis tests followed by IM ceftriaxone and outpatient management for most infants; (4) blood and urine cultures with white blood cell count and urinalysis followed by either lumbar puncture and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants; (5) white blood cell count and urinalysis followed by either lumbar puncture, blood and urine cultures, and IV antibiotics for high-risk infants or outpatient management without antibiotics for low risk infants; and (6) clinical judgment followed by either all sepsis tests and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants. The two "all sepsis tests" strategies prevented the most cases of death or neurologic impairment, 78% (when IV antibiotics were used) and 76% (when IM ceftriaxone was used) of all potential cases. The most cost-effective strategy was to use all sepsis tests followed by IM ceftriaxone for all patients without meningitis, at an incremental cost of only $3900 per sequela prevented relative to no intervention. Strategies under which only those patients selected as high-risk by laboratory criteria received antibiotic treatment were less effective but incurred lower rates of antibiotic complications. Clinical judgment alone was the least clinically effective and the second least cost-effective strategy.(ABSTRACT TRUNCATED AT 400 WORDS)

Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone.

STUDY OBJECTIVE: To determine the outcome of outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. DESIGN: Prospective consecutive cohort study. SETTING: Urban emergency department. PATIENTS: Five hundred three infants 28 to 89 days of age with temperatures greater than or equal to 38 degrees C who did not appear ill, had no source of fever detected on physical examination, had a peripheral leukocyte count less than 20 x 10(9) cells/L, had a cerebrospinal fluid leukocyte count less than 10 x 10(6)/L, did not have measurable urinary leukocyte esterase, and had a caretaker available by telephone. Follow-up was obtained for all but one patient (99.8%). INTERVENTION: After blood, urine, and cerebrospinal fluid cultures had been obtained, the infants received 50 mg/kg intramuscularly administered ceftriaxone and were discharged home. The infants returned for evaluation and further intramuscular administration of ceftriaxone 24 hours later; telephone follow-up was conducted 2 and 7 days later. RESULTS: Twenty-seven patients (5.4%) had a serious bacterial infection identified during follow-up; 476 (94.6%) did not. Of the 27 infants with serious bacterial infections, 9 (1.8%) had bacteremia (8 of these had occult bacteremia and 1 had bacteremia with a urinary tract infection), 8 (1.6%) had urinary tract infections without bacteremia, and 10 (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections. All infants with serious bacterial infections received an appropriate course of antimicrobial therapy and were well at follow-up. One infant had osteomyelitis diagnosed 1 week after entry into the study, received an appropriate course of intravenous antimicrobial therapy, and recovered fully. CONCLUSIONS: After a full evaluation for sepsis, outpatient treatment of febrile infants with intramuscular administration of ceftriaxone pending culture results and adherence to a strict follow-up protocol is a successful alternative to hospital admission.