RESUMO
OBJECTIVES: Pediatric diabetic ketoacidosis (DKA) is often treated in a PICU, but nonsevere DKA may not necessitate PICU admission. At our institution, nonsevere DKA was treated on the floor until policy change shifted care to the PICU. We describe outcomes in pediatric mild to moderate DKA by treatment location. METHODS: Patients aged 2 to 21 with mild to moderate DKA (pH <7.3 but >7.1), treated on the floor from January 1, 2018 to July 31, 2020 and PICU from August 1, 2020 to October 1, 2022 were included. We performed a single-center, retrospective cohort study; primary outcome was DKA duration (from emergency department diagnosis to resolution), secondary outcomes included hospital length of stay, and complication rates, based on treatment location. RESULTS: Seventy nine floor and 65 PICU encounters for mild to moderate pediatric DKA were analyzed. There were no differences in demographics, initial pH, or bicarbonate; PICU patients had more acute kidney injury on admission. Floor patients had a shorter DKA duration (10 hours [interquartile range 7-13] vs 11 hours [9-15]; P = .04), and a shorter median length of stay (median 43.5 hours [interquartile range 31-62] vs 49 hours [32-100]; P < .01). No patients had clinical signs of cerebral edema; other complications occurred at similar rates. PICU patients received significantly more intravenous electrolyte boluses, but there were no differences in dysrhythmia or electrolyte abnormalities on final serum chemistry. CONCLUSIONS: Our study did not find a clear benefit to admitting patients with mild to moderate DKA to the PICU instead of the hospital floor. Our findings suggest that some children with nonsevere DKA may be treated safely in a non-PICU setting.
Assuntos
Cetoacidose Diabética , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação , Humanos , Cetoacidose Diabética/terapia , Estudos Retrospectivos , Criança , Feminino , Masculino , Adolescente , Pré-Escolar , Tempo de Internação/estatística & dados numéricos , Adulto Jovem , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Although procedural pain is effectively treated with analgesics, managing anxiety during laceration repair is more challenging. OBJECTIVES: We examined the feasibility of using immersive virtual reality (VR) as anxiolysis during laceration repair in the pediatric emergency department (ED). METHODS: We conducted a non-blinded, observational, pilot study in an urban pediatric ED that enrolled a convenience sample of children aged 5-13 years undergoing sutured repair of non-facial lacerations. Subjects played an immersive VR game while undergoing laceration repair. Parents assessed their child's anxiety on a 100-mm visual analogue scale at enrollment and during laceration repair. The primary outcome measure was the percentage of children whose anxiety score did not increase by ≥ 20 mm from enrollment to the first stitch. RESULTS: Forty patients completed the study. Mean initial anxiety score was 54 mm (standard deviation 33 mm). Thirty-seven of forty patients (93%; 95% confidence interval [CI] 83-99%) had anxiety scores that did not increase by 20 mm or more from enrollment to the first stitch. Eighty percent (95% CI 64-91%) of patients' anxiety scores decreased between enrollment and first stitch. The mean change in anxiety score at first stitch was -39 mm (95% CI -51 mm to -27 mm; p < 0.001). Similar downward trends in anxiety scores were noted throughout the procedure. All laceration repairs were successfully completed without sedation or restraints. There were no adverse events noted, and the main barriers identified with VR use involved easily correctable technical difficulties with the equipment. CONCLUSION: Immersive VR is a safe and effective distractive technique to reduce procedural anxiety during laceration repair in the pediatric ED.
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Lacerações , Dor Processual , Realidade Virtual , Ansiedade/etiologia , Criança , Serviço Hospitalar de Emergência , Humanos , Lacerações/cirurgia , Dor Processual/etiologia , Dor Processual/prevenção & controle , Projetos PilotoRESUMO
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.
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Medicina de Emergência , Medicina de Emergência Pediátrica , Criança , Competência Clínica , Currículo , Educação de Pós-Graduação em Medicina , Medicina de Emergência/educação , Bolsas de Estudo , Humanos , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS: This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS: Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS: Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.
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Competência Clínica , Treinamento por Simulação , Criança , Currículo , Humanos , Aprendizagem , Estudos ProspectivosRESUMO
BACKGROUND: The Bronx has the highest prevalence of asthma in the United States (US), and was also an early COVID-19 epicenter, making it a unique study location. Worldwide reports describe significant declines in pediatric emergency department (PED) visits during COVID-19. The ongoing impact of COVID-19 on all PED presentations, including asthma, at an early epicenter has not been studied beyond the pandemic peak and into the early phases of state re-opening. OBJECTIVES: To compare PED health-seeking behaviors and clinical characteristics during the 2020 pandemic and subsequent initial New York State (NYS) phased re-opening to the same period in 2019. METHODS: Retrospective chart review of children <21 years utilizing the PED at a high-volume quaternary children's hospital in The Bronx, NY from March 15th 2020 - July 6th 2020 (pandemic cohort) and the same interval in 2019 (comparison cohort). Visits were assigned to pre-determined diagnostic categories. Demographic and clinical data were compared. RESULTS: 19,981 visits were included. Visits declined by 66% during 2020. Proportions of asthma visits (2% vs. 7%, p < 0.0001) and minor medical problems (61% vs. 67%, p < 0.0001) had significant declines in the pandemic cohort, while major medical problems (13% vs. 8%, p < 0.0001), appendicitis (1% vs. 0.4%, p < 0.0001) and other surgical complaints (1% vs. 0.5%, p < 0.0001) had proportional increases in the pandemic cohort. No significant proportional changes were noted among psychosocial and trauma groups between the two cohorts. CONCLUSION: The pandemic cohort experienced a substantial decrease in PED volume, but an increase in acuity and admission rates, which was sustained through the NYS phase-II re-opening. Despite being located in an asthma hub, the incidence of asthma-related PED visits declined appreciably in the pandemic cohort. Future studies examining the effects of indoor allergens in isolation on pediatric asthma are warranted.
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Asma/epidemiologia , COVID-19/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Comportamentos Relacionados com a Saúde , Hospitais Pediátricos/estatística & dados numéricos , Pandemias , Adolescente , Criança , Pré-Escolar , Comorbidade , Feminino , Humanos , Incidência , Masculino , Cidade de Nova Iorque/epidemiologia , Prevalência , Estudos Retrospectivos , SARS-CoV-2RESUMO
OBJECTIVE: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. STUDY DESIGN: We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. RESULTS: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%. CONCLUSIONS: The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.
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Regras de Decisão Clínica , Serviço Hospitalar de Emergência , Infecções por Escherichia coli/diagnóstico , Síndrome Hemolítico-Urêmica/diagnóstico , Índice de Gravidade de Doença , Escherichia coli Shiga Toxigênica , Adolescente , Criança , Pré-Escolar , Infecções por Escherichia coli/complicações , Infecções por Escherichia coli/mortalidade , Feminino , Síndrome Hemolítico-Urêmica/complicações , Síndrome Hemolítico-Urêmica/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , América do Norte , Prognóstico , Estudos Retrospectivos , Medição de Risco , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: The mental health epidemic in pediatrics has resulted in a growing clinical burden on the health care system, including pediatric emergency departments (PED). Our objective was to describe the changing characteristics of visits to an urban PED, in particular length of stay, for emergency psychiatric evaluations (EPEs) over a 10-year period. METHODS: A retrospective study of children with an EPE in the PED at a large urban quaternary care children's hospital was performed during two discrete periods a decade apart: July 1, 2003-June 30, 2004 (period 1) and July 1, 2013-June 30, 2014 (period 2). Visit information, including length of stay and demographic data, were compared between groups. RESULTS: There was a significant increase in the percentage of PED visits for EPE from period 1 to period 2 (1.1% vs 2.2% P < 0.0001). Overall, the median (interquartile range [IQR]) length of stay for children requiring an EPE increased significantly for all visits (5.3 [3.2-15.4] hours vs 17.0 [6.0-26.0] hours, P < 0.0001), including for patients who were admitted (17.8 [7.4-24.6] hours vs 27.0 [21.0-36.0] hours, P < 0.0001) and for those who were discharged (4.5 [2.8-7.7] hours vs 8 [5-20] hours, P < 0.0001). CONCLUSIONS: Over a decade, the percentage of children with an EPE has doubled, with a significant increase in the amount of time spent in the PED. This highlights a continued surge in the utilization of PED resources for EPE.
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Serviço Hospitalar de Emergência , Hospitais Pediátricos , Tempo de Internação , Transtornos do Neurodesenvolvimento/diagnóstico , Criança , Hospitalização , Humanos , Saúde Mental , Estudos RetrospectivosRESUMO
OBJECTIVES: Most children in the United States who visit the emergency department (ED) with fever have minor illnesses not requiring treatment or hospitalization. However, when a child has recently immigrated or traveled abroad, internationally acquired severe systemic infections (ISSIs) must be considered. We sought to describe children who have traveled internationally and present to the ED with a complaint of fever and to determine risk factors associated with ISSIs in these patients. METHODS: We conducted a retrospective study of children younger than 18 years who presented to 2 pediatric EDs in Bronx, NY (June 2007 to May 2017). Patients were included if they had both fever within 24 hours and international travel within 30 days. We compared groups using bivariate analyses and created a prediction model for ISSIs using multivariable logistic regression. RESULTS: Of the 353 children included, 44 (12%) had ISSI: 25 (57%), malaria; 6 (14%), dengue; and 13 (30%), bacteremia. Eight (18%) of those with ISSI presented with fever to another medical provider in the week prior but did not receive bloodwork. Four variables were independently associated with ISSIs: headache (odds ratio [OR], 21.7; 95% confidence interval [CI], 6.8-69.3), travel to Africa or Asia (OR, 18.8; 95% CI, 4.8-73.2), platelets of 150,000/µL or less (OR, 15.1; 95% CI, 4.7-48.6), and alanine aminotransferase level of 30 IU/L or greater (OR, 8.9; 95% CI, 3.1-25.3). CONCLUSIONS: Children who travel internationally and present with fever upon return are at substantial risk for developing ISSIs. The diagnosis of ISSIs is often overlooked, but certain risk factors have the potential to aid clinicians.
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Febre , Malária , Criança , Serviço Hospitalar de Emergência , Febre/etiologia , Humanos , Malária/diagnóstico , Malária/epidemiologia , Estudos Retrospectivos , Viagem , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Despite its life-saving potential in anaphylaxis, self-injectable epinephrine (SIE) is frequently not administered by caregivers prior to arrival in the emergency department (ED). Prescriptions from the ED often go unfilled which may contribute to the failure to receive SIE when needed. OBJECTIVE: To determine the prescription filling rate and accessibility of SIE devices among families discharged from the Pediatric ED with an SIE prescription. METHODS: A phone survey was administered to parents of children <18 years of age prescribed SIE in the pediatric ED over 12 months. The survey inquired if they own an SIE device, the device's expiration date as confirmation, and details of their child's allergy. Variables were analyzed for association with owning SIE, having SIE accessible when prompted, and having unexpired SIE accessible. RESULTS: 170 children received prescriptions for SIE and 100 (59%) completed the survey. Eighty-four of 100 (84%) had filled the initial SIE prescription. Sixty-five of 100 (65%) had proof of having SIE, of which 29% (19/65) were expired. Only 46% (46/100) of all respondents had an accessible unexpired SIE. Patients with food allergies and those who'd visited an allergist after their ED visit had higher odds of having unexpired accessible devices. CONCLUSION: A majority of patients prescribed SIE from the ED fill their prescription; however, less than half have unexpired SIE readily available despite high rates of recurrent anaphylactic emergencies. Focusing on post-discharge planning, particularly follow-up, may prevent children with allergies from being left dangerously unprepared.
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Assistência ao Convalescente , Anafilaxia/tratamento farmacológico , Prescrições de Medicamentos/estatística & dados numéricos , Epinefrina/administração & dosagem , Acessibilidade aos Serviços de Saúde , Injeções/instrumentação , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Humanos , Lactente , Masculino , Inquéritos e QuestionáriosRESUMO
The global pandemic novel coronavirus 2019 has upended healthcare and medical education, particularly in disease epicenters such as New York City. In this piece, we seek to describe the collective experiences and lessons learned by the New York City pediatric emergency medicine fellowship directors in clinical, educational, investigative, and psychological domains, in hopes of engendering conversation and informing future disaster response efforts.
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Betacoronavirus , Infecções por Coronavirus/epidemiologia , Educação de Pós-Graduação em Medicina/métodos , Pandemias , Medicina de Emergência Pediátrica/educação , Pediatria/educação , Pneumonia Viral/epidemiologia , COVID-19 , Criança , Humanos , Cidade de Nova Iorque/epidemiologia , SARS-CoV-2RESUMO
BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. METHODS: We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. RESULTS: Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69-.85] per year), leukocyte count ≥13.0 × 103/µL (2.54 [1.42-4.54]), higher hematocrit (1.83 [1.21-2.77] per 5% increase) and serum creatinine (10.82 [1.49-78.69] per 1 mg/dL increase), platelet count <250 × 103/µL (1.92 [1.02-3.60]), lower serum sodium (1.12 [1.02-1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14-5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54-.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14-4.50]), younger age (0.83 [.74-.92] per year), lower serum sodium (1.15 [1.04-1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/µL (2.35 [1.17-4.72]) and creatinine (7.75 [1.20-50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18-6.21]). CONCLUSIONS: The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.
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Infecções por Escherichia coli , Síndrome Hemolítico-Urêmica , Escherichia coli Shiga Toxigênica , Adolescente , Criança , Estudos de Coortes , Diarreia/epidemiologia , Infecções por Escherichia coli/epidemiologia , Feminino , Síndrome Hemolítico-Urêmica/epidemiologia , Síndrome Hemolítico-Urêmica/terapia , Humanos , Terapia de Substituição RenalRESUMO
BACKGROUND: Children presenting to the emergency department with acute psychosis or hallucinations sometimes undergo a head CT to evaluate for a causative lesion. The diagnostic yield of head CT in this scenario has not been reported. OBJECTIVE: To determine the yield for head CT in children with acute psychosis or hallucinations. MATERIALS AND METHODS: We retrospectively searched the radiology report database over a 7.5-year period for head CT reports for pediatric emergency department patients using the following keywords: hallucination, psychosis, psychotic or "hearing voices." All reports were categorized as normal or abnormal, and we reviewed and categorized the abnormal cases. We calculated the 95% confidence interval for abnormal CTs using the method of Clopper and Pearson. RESULTS: We identified 397 pediatric emergency department head CTs. We excluded one non-diagnostic exam. We excluded 34 additional cases (which were all normal) because of clinical indications that might have independently triggered a head CT. Of the remaining 362 cases, 12 reports described abnormalities or variants and we reviewed them individually. Based on consensus review, four were normal, four had congenital malformations, three had encephalomalacia versus demyelination and one demonstrated cortical atrophy. There were no cases with actionable findings such as mass, hemorrhage, infection or hydrocephalus. The 95% confidence interval for a CT demonstrating causative findings was calculated at 0-0.82%. CONCLUSION: In the absence of concerning factors such as focal neurological deficits, evidence of central nervous system infection, trauma or headache, routine screening head CT might not be warranted in children presenting with acute psychosis or hallucinations.