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.

Television-Related Head Injuries in Children: A Secondary Analysis of a Large Cohort Study of Head-Injured Children in the Pediatric Emergency Care Applied Research Network.

OBJECTIVE: The objective of the study was to describe the epidemiology, cranial computed tomography (CT) findings, and clinical outcomes of children with blunt head trauma after television tip-over injuries. METHODS: We performed a secondary analysis of children younger than 18 years prospectively evaluated for blunt head trauma at 25 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from June 2004 to September 2006. Children injured from falling televisions were included. Patients were excluded if injuries occurred more than 24 hours before ED evaluation or if neuroimaging was obtained before evaluation. Data collected included age, race, sex, cranial CT findings, and clinical outcomes. Clinically important traumatic brain injuries (ciTBIs) were defined as death from TBI, neurosurgery, intubation for more than 24 hours for the TBI, or hospital admission of 2 nights or more for the head injury, in association with TBI on CT. RESULTS: A total of 43,904 children were enrolled into the primary study and 218 (0.5%; 95% confidence interval [CI], 0.4% to 0.6%) were struck by falling televisions. The median (interquartile range) age of the 218 patients was 3.1 (1.9-4.9) years. Seventy-five (34%) of the 218 underwent CT scanning. Ten (13.3%; 95% CI, 6.6% to 23.2%) of the 75 patients with an ED CT had traumatic findings on cranial CT scan. Six patients met the criteria for ciTBI. Three of these patients died. All 6 patients with ciTBIs were younger than 5 years. CONCLUSIONS: Television tip-overs may cause ciTBIs in children, including death, and the most severe injuries occur in children 5 years or younger. These injuries may be preventable by simple preventive measures such as anchoring television sets with straps.

An Operational Framework to Study Diagnostic Errors in Emergency Departments: Findings From A Consensus Panel.

OBJECTIVE: To create an operational definition and framework to study diagnostic error in the emergency department setting. METHODS: We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting. RESULTS: The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis. CONCLUSIONS: The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis.

Bilateral Common Iliac Artery Aneurysm, a Case Report.

Patient is a 72-year-old male who presented with abdominal pain and hypertension. Through bedside point-of-care ultrasound (POCUS), patient was found to have markedly enlarged bilateral iliac artery aneurysms with signs of impending rupture, which was confirmed on computed tomography (CT) angiogram of the abdomen/pelvis. Patient was immediately taken to the operating room for emergent repair of aneurysm, and was discharged from the hospital the next day. Point-of-care ultrasound is critical in diagnosis and guiding treatment in patients in the emergency department and should be considered in those with undifferentiated abdominal pain. Topics: Abdominal pain, iliac artery aneurysm, point-of-care ultrasound.

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.

Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology.

INTRODUCTION: Despite the ever-increasing numbers of mental health patients presenting to United States emergency departments, there are large gaps in knowledge about acute care of the behavioral health patient. To address this important problem, the Coalition on Psychiatric Emergencies convened a research consensus conference in December 2016 consisting of clinical researchers, clinicians from emergency medicine, psychiatry and psychology, and representatives from governmental agencies and patient advocacy groups. METHODS: Participants used a standardized methodology to select and rank research questions in the order of importance to both researchers and patients. RESULTS: Three working groups (geriatrics, substance use disorders, and psychosis) reached consensus on 26 questions within their respective domains. These questions are summarized in this document. CONCLUSION: The research consensus conference is the first of its kind to include non-clinicians in helping identify knowledge gaps in behavioral emergencies. It is hoped that these questions will prove useful to prioritize future research within the specialty.

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients.

INTRODUCTION: Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness. METHODS: Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. RESULTS: Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. CONCLUSION: It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.

2018 Academic Emergency Medicine Consensus Conference: A Workforce Development Research Agenda for Pediatric Care in the Emergency Department.

Each year, more than 30 million children visit U.S. emergency departments (EDs). Although the number of pediatric emergency medicine specialists continues to rise, the vast majority of children are cared for in general EDs outside of children's hospitals. The diverse workforce of care providers for children must possess the knowledge, experience, skills, and systemic support necessary to deliver excellent pediatric emergency care. There is a crucial need to understand the factors that drive the professional development and support systems of this diverse workforce. Through the iterative process culminating with the 2018 Academic Emergency Medicine consensus conference, we have identified five key research themes and prioritized a specific research agenda. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce and allow for a prioritization of future research efforts. Only by more fully understanding the gaps in workforce needs, and the necessary steps to address these gaps, can outcomes be optimized for children in need of emergency care.

Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma.

OBJECTIVE: Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children. METHODS: We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14. RESULTS: Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate. CONCLUSIONS: Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.

Emergency medical services for children: the New Jersey model.

Identification of specific facilities within a community for the emergency department (ED) treatment of children is a traditional component of Emergency Medical Services for Children systems. In such models, these Emergency Departments Approved for Pediatrics are the preferred EDs to receive patients from Emergency Medical Services providers. This article examines an alternative model developed in New Jersey in which every ED in the state is required by regulation to meet the standards of a traditional Emergency Departments Approved for Pediatrics. The New Jersey model leads to more accessible care and more rapid stabilization of children regardless of their mode of delivery to the ED.

Intracranial hemorrhage after blunt head trauma in children with bleeding disorders.

OBJECTIVE: To determine computerized tomography (CT) use and prevalence of traumatic intracranial hemorrhage (ICH) in children with and without congenital and acquired bleeding disorders. STUDY DESIGN: We compared CT use and ICH prevalence in children with and without bleeding disorders in a multicenter cohort study of 43 904 children <18 years old with blunt head trauma evaluated in 25 emergency departments. RESULTS: A total of 230 children had bleeding disorders; all had Glasgow Coma Scale (GCS) scores of 14 to 15. These children had higher CT rates than children without bleeding disorders and GCS scores of 14 to 15 (risk ratio, 2.29; 95% CI, 2.15 to 2.44). Of the children who underwent imaging with CT, 2 of 186 children with bleeding disorders had ICH (1.1%; 95% CI, 0.1 to 3.8) , compared with 655 of 14 969 children without bleeding disorders (4.4%; 95% CI, 4.1-4.7; rate ratio, 0.25; 95% CI, 0.06 to 0.98). Both children with bleeding disorders and ICHs had symptoms; none of the children required neurosurgery. CONCLUSION: In children with head trauma, CTs are obtained twice as often in children with bleeding disorders, although ICHs occurred in only 1.1%, and these patients had symptoms. Routine CT imaging after head trauma may not be required in children without symptoms who have congenital and acquired bleeding disorders.

Development and implementation of a performance measure tool in an academic pediatric research network.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) is a federally funded multi-center research network. To promote high quality research within the network, it is important to establish evaluation tools to measure performance of the research sites. PURPOSE: To describe the collaborative development of a site performance measure tool "report card" in an academic pediatric research network. To display report card template information and discuss the successes and challenges of the report cards. DEVELOPMENT AND IMPLEMENTATION OF THE NETWORK PERFORMANCE MEASURE TOOL: The PECARN Quality Assurance Subcommittee and the PECARN data center were responsible for the development and implementation of the report cards. Using a Balanced Scorecard format, four key metrics were identified to align with PECARN's research goals. Performance indicators were defined for each of these metrics. After two years of development, the final report cards have been implemented annually since 2005. Protocol submission time to the Institutional Review Board (IRB) improved between 2005 and 2007. Mean overall report card scores for site report cards increased during this period with less variance between highest and lowest performing sites indicating overall improvement. CONCLUSIONS: Report cards have helped PECARN sites and investigators focus on performance improvement and may have contributed to improved operations and efficiencies within the network.

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.

BACKGROUND: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Job market survey of recent pediatric emergency medicine fellowship graduates.

OBJECTIVES: The American Academy of Pediatrics Section of Emergency Medicine's Subcommittee on Administration developed a survey tool targeting recent pediatric emergency medicine (PEM) fellowship graduates to assess the current PEM job market in a variety of areas including (1) the new positions accepted, (2) perspectives of fellowship training, and (3) the relationship between PEM and general emergency medicine practice. METHODS: The 40-question internet-based survey was developed through www.surveymonkey.com. Solicitations to PEM fellowship graduates who completed training between the years 2000 and 2005 were sent via the Section of Emergency Medicine member e-mail list as well as the PEM LISTSERV. Data collection occurred from April to May 2005. RESULTS: Of 125 survey respondents, 89% completed a 3-year pediatrics residency plus a 3-year PEM fellowship. Offers to graduates of positions with research expectations outnumbered clinical positions, 3:2, with an average of 5 total positions offered per respondent. Thirty-four percent remained at the institution of fellowship graduation, and 71% accepted faculty appointments with medical school affiliation. Seventy percent of work time was spent on clinical duties and 10% on research. Most felt better prepared in the areas of clinical training and teaching than in the areas of research and administration. Additional general emergency medicine exposure was not desired. Half of the respondents felt that a 2-year fellowship program would have met their career goals. CONCLUSIONS: Recent PEM fellowship graduates felt that job availability was good and were satisfied with their new positions. Respondents perceived better fellowship training in clinical and teaching aspects than in research and administration. New positions were heavily clinical and matched career goals.

Variation in ancillary testing among pediatric asthma patients seen in emergency departments.

BACKGROUND: Variation in the management of acute pediatric asthma within emergency departments is largely unexplored. OBJECTIVES: To investigate whether ancillary testing for patients with asthma would be associated with patient, physician, and hospital characteristics. METHODS: The authors performed an analysis of a subset of patients from an extensive retrospective chart review of randomly selected charts at all 25 member emergency departments of the Pediatric Emergency Care Applied Research Network. Patients with a diagnosis of asthma were selected for supplemental review and included in this study. Ancillary tests analyzed were chest radiographs and selected blood tests. Hierarchical analyses were performed to describe the associations between ancillary testing and the variables of interest. RESULTS: A total of 12,744 chart abstractions were completed, of which 734 (6%) were patients with acute exacerbations of asthma. Overall, 302 patients with asthma (41%) had ancillary testing. Of the 734 patients with asthma, 198 (27%) had chest radiographs and 104 (14%) had blood tests. Chest radiographs were more likely to be ordered in patients with fever. Less blood testing was associated with physician subspecialty training in pediatric emergency medicine, patients treated at children's hospitals, higher patient oxygen saturation, and patient disposition to home. CONCLUSIONS: Ancillary testing occurred in more than one third of children with asthma, with chest radiographs ordered most frequently. Efforts to reduce the use of chest radiographs should target the management of febrile patients with asthma, whereas efforts to reduce blood testing should target providers without subspecialty training in pediatric emergency medicine and patients treated in nonchildren's hospitals who are more ill.

Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial.

CONTEXT: The Broselow Pediatric Resuscitation Tape has been shown to be effective in reducing medication dosing error among pediatric emergency providers. However, the tape has often been used inappropriately or incorrectly. OBJECTIVE: To evaluate whether a Web-based education program on proper use of the tape could reduce medication dosing errors and time to determine dose. DESIGN, SETTING, AND PARTICIPANTS: A randomized, controlled trial conducted among 89 pediatric emergency providers from 3 study sites. INTERVENTION: All study subjects participated in a videotaped simulated stabilization scenario and were then randomly assigned to control or education group. After the intervention, all subjects participated in another simulation. MAIN OUTCOMES MEASURES: The primary outcomes included dosing deviation from accepted dose range for each medication prescribed and dosing deviation summary, calculated by averaging dosing deviation for all medications. The secondary outcomes included time to determine a dose for each medication prescribed, and dosing time summary; that is, the average time to determine doses for all medications prescribed. RESULTS: No significant difference was observed in the demographic characteristics of the 2 groups. After the educational intervention, the average (12.6% vs. 24.9%) and median (7.1% vs. 20.1%) dosing deviation summary were much lower in the education group than in the control group. The difference in the median dosing deviation summary between the 2 groups was statistically significant (P = 0.0002). Similar results were observed for the dosing time. The education group demonstrated a lower average (16 vs. 20 seconds) and lower median (15 vs. 18 seconds) dosing time summary than the control group. The difference in the median dosing time summary between the 2 groups was statistically significant (P = 0.02). Analysis of each medication prescribed indicated that the decrease in the dosing deviation and dosing time in the education group was most obvious for several specific medications. CONCLUSIONS: The Web-based education program on the proper use of the Broselow Pediatric Resuscitation Tape could improve dosing accuracy and reduce dosing time.

Procedural sedation for children with special health care needs.

Children with special health care needs represent a growing percentage of pediatric patients treated in all emergency departments. Substantial literature exists concerning the medical treatment of these patients, but there is little written describing the management of procedural sedation or analgesia in this population. This article examines the unique anatomic and physiologic implications of procedural sedation or analgesia management in children with special health care needs.