Outcomes of Infants Who Are Febrile Aged 29-90 Days Discharged from the Emergency Department.

OBJECTIVE: To evaluate the characteristics and outcomes of infants aged 29-90 days who are febrile discharged from the pediatric emergency department (ED). STUDY DESIGN: This was a multicenter, retrospective cohort study of infants aged 29-90 days who visited any of the 7 Clalit Health Services pediatric EDs in Israel between January 1, 2019, and March 31, 2022. Infants who were febrile discharged from the ED after having blood and urine cultures taken were included. The primary outcome measure was the incidence of return visit (RV) to an ED. Secondary outcome measures were the incidence of invasive bacterial infection, urinary tract infection, pediatric intensive care unit admissions, and deaths. We assessed variables associated with the primary outcomes. RESULTS: A total of 1647 infants were included. Their median (IQR) age at ED visit was 58.5 (47.7, 72.7) days, 53.1% were male. A total of 329 patients (20%) returned to the ED within 120 hours. Overall, 7.8% of discharged infants had a positive urine culture, 4 (0.2%) had a positive blood culture, and none had meningitis. One patient was admitted to the pediatric intensive care unit, and there was no death. Abnormal C-reactive protein was associated with RV among 61- to 90-day-old infants. CONCLUSIONS: Infants aged 29-90 days who were febrile and discharged following a protocol-driven pathway from the pediatric ED had a relatively high RV rate. However, the rate of urinary tract infection was relatively low, and rate of invasive bacterial infection was extremely low. There were no deaths or serious sequelae.

Sedation for Forearm Fracture Reduction in the Pediatric Emergency Department: Impact on Hospitalization and Length of Stay.

BACKGROUND: Children with forearm fractures who present to the emergency department (ED) often need a closed reduction. In our institution, until 2017, pediatric trauma patients presented to the general trauma ED (GTED) where no sedation services for pediatric patients were available. From 2017, patients presented to the pediatric emergency department (PED) where closed reductions were performed under sedation when appropriate. OBJECTIVES: To compare GTED and PED with regard to length of stay (LOS) and hospitalization rates of pediatric patients with forearm fractures who needed a closed reduction. METHODS: Our retrospective observational study was conducted at a regional hospital. The study population consisted of all patients younger than 18 years of age who presented to the ED with a forearm fracture that needed a closed reduction. The primary outcome measure was the hospitalization rate. The secondary outcome measure was LOS in the ED. RESULTS: The study comprised 165 patients with forearm fractures who needed a closed reduction; 79 presented to the GTED, and 96 presented to the PED. Hospitalization rates were lower for patients undergoing closed reduction under sedation in the PED compared to the GTED (6.3% and 21.5%, respectively; P = 0.003). Median ED LOS was longer among patients undergoing sedation in the PED compared to the GTED (237 vs. 168 minutes respectively, P < 0.0001). CONCLUSIONS: Sedation for forearm fracture reduction in a hospital's PED was associated with a decrease of more than three times in hospitalization rate. Despite the need for more resources, PED LOS was only mildly increased.

High Rates of ESBL-producing and Gentamycin-resistant Gram-negative Bacteria During the First Week of Life: A Multicenter Cross-sectional Study Among Infants Younger Than 2 Months With Urinary Tract Infection.

INTRODUCTION: Reducing the risk of renal scarring in infants with urinary tract infection (UTI) necessitates timely and effective administration of antimicrobial treatment. The Israeli Medical Association recommends the empirical use of gentamicin and ampicillin for febrile infants younger than 2 months with suspected UTI. We aimed to assess the prevalence of Extended Spectrum Beta-Lactamase (ESBL)-producing and gentamicin-resistant Gram-negative UTI among infants younger than 2 months. METHODS: A multicenter retrospective cross-sectional study of infants younger than 2 months with UTI who visited Clalit Health Services pediatric emergency departments between January 1, 2016, and December 31, 2021. The primary outcome measure was the prevalence of ESBL-associated and gentamicin-resistant UTI. The secondary outcome measure was the factors associated with such resistant bacteria. RESULTS: Overall, 1142 infants were included. Sixty-five (5.7%) and 64 (5.6%) infants had gentamicin-resistant and ESBL-producing Gram-negative UTI, respectively. Forty-two percent of ESBL-associated UTI were gentamicin-resistant. Higher ESBL rates were found during first week of life (14.8% versus 4.1%-7.7%; P = 0.009). Similarly, higher rates of gentamicin resistance were found in this age group (11.2%). Admission rate to pediatric intensive care units (ICUs) was higher in infants with ESBL-associated UTI (9.8% versus 3.5%; P = 0.015). Gestational bacteriuria, previous neonatal ICU admission or gender were not associated with either gentamicin or ESBL-producing resistance. CONCLUSIONS: Our findings support the current recommendations for empirical intravenous treatment. However, modification of the treatment protocol should be considered for infants younger than 7 days, who had higher rates of ESBL-producing and gentamicin-resistant Gram-negative UTI.

Early unplanned return visits to pediatric emergency departments in Israel during the SARS-CoV-2 pandemic.

INTRODUCTION: During the SARS-CoV-2 pandemic there was a considerable drop in the number of visits to Pediatric Emergency Departments (PED). Unplanned return visits (URV) might represent inadequate emergency care. We assessed the impact of the pandemic on early URV to PEDs in Israel. METHODS: This multicenter cross-sectional study analyzed the 72-h URV to PEDs among patients under the age of 18 years during a one-year pandemic period (March 1st, 2020, to February 28th, 2021), and compared them with the 72-h URV of the corresponding pre-pandemic period (March 1st, 2019, to February 28th, 2020). Data was extracted from Clalit Health Services (CHS), the largest public health care organization in Israel. RESULTS: The pandemic and pre-pandemic early URV rates were 5465 (5.1%) and 8775 (5.6%), respectively (OR = 0.90, 95% CI 0.92-0.99). The rate of return-visit admissions to hospital wards during these periods were 29.5% and 32.1%, respectively (OR = 0.83, 95% CI 0.86-0.98). The rate of return-visit admissions to ICUs during these periods were 0.64% and 0.52%, respectively (OR = 1.11, 95% CI 0.67-1.62). On return-visit, 3 (0.055%) and 5 (0.057%) URV patients were declared dead on arrival during the pandemic and pre-pandemic periods, respectively (OR = 0.96, 95% CI 0.23-4.03). The distributions of the time interval from index visit to return visit remained consistent between the periods. DISCUSSION: In our study, early URV to PED's were only mildly influenced by the SARS-CoV-2 pandemic.

Latency of Symptom Progression in Mild Daboia palaestinae Envenomation.

INTRODUCTION: Daboia palestinae is the most common venomous snake in Israel. In most cases, snakebite does not develop into a systemic disease. Since the introduction of specific antivenom therapy, the mortality rate has declined sharply. Nevertheless, there is still no uniform therapeutic protocol in Israel for patients who have been envenomated, and there is no current data regarding latency of symptom development. We aimed to evaluate the latency of symptom development after D palaestinae snakebite in patients presenting to the emergency department (ED) with local reaction. METHODS: This was a retrospective single-center study of all patients who presented following a snakebite from 2015 to 2020. Patients with confirmed or suspected D palaestinae bite were included. Demographical and clinical data were extracted from each electronical medical record and subjected to descriptive and comparative analysis. RESULTS: Sixty-two patients met the inclusion criteria. Their median (IQR) age was 30 (17-48) y, and 75% were male. Forty-one percent presented with local reactions to the snakebite, 29% presented with advanced local reaction, and 29% presented with systemic symptoms. Antivenom was given to 22% of patients with advanced local reaction and 89% of patients with systemic reaction. The median (IQR) time from bite to antivenom and from ED arrival to antivenom were 2 (1.5-2.5) h and 1 (0.75-1.5) h, respectively. Antivenom was administered at the latest 3.5 h after presentation to the ED for progression of local symptoms. CONCLUSIONS: Our study may support a 4- to 6-h observation period in the ED for patients with mild clinical presentation after D palaestinae bite. Further larger prospective studies are needed.

The role of fundoscopy in pediatric seizures.

Fundoscopy can guide clinicians in the decision to perform neuroimaging. Our aim was to evaluate the rate of abnormal neuroimaging following fundoscopy in children presenting with seizures to the pediatric emergency department (PED). This was a retrospective single-center study. Patients with a discharge diagnosis of seizures were evaluated. Outcome measures were the rate of abnormal brain imaging following a finding of papilledema, and the rate of repeat fundoscopies due to an inconclusive initial examination. A total of 646 patients with seizures underwent fundoscopy. Out of 3 patients who were diagnosed initially with papilledema, only one patient had an abnormal brain CT. He was diagnosed with papilledema previously, and neuroimaging was previously recommended. A total of 7.6% (49/646) of patients underwent a second fundoscopic evaluation. In view of the limited yield and accuracy of fundoscopy in the PED, its role in the clinical decision making in children with seizures is questionable. What is Known: • Seizures are not described as an isolated presenting symptom of increased ICP. • Fundoscopy in children requires skill, time, cooperation. What is New: • Papilledema was found in only one patient who presented with seizures. • Fundoscopy in the PED has limited yield and accuracy in children with seizures.

The effect of in situ simulation training on the performance of tasks related to patient safety during sedation.

In many countries, procedural sedation outside of the operating room is performed by pediatricians. We examined if in situ sedation simulation training (SST) of pediatricians improves the performance of tasks related to patient safety during sedation in the Emergency Department (ED). We performed a single-center, quasi-experimental, study evaluating the performance of sedation, before-and-after SST. Sixteen pediatricians were evaluated during sedation as part of their usual practice, using the previously validated Sedation-Performance-Score (SPS). This tool evaluates physician behaviors during sedation that are conducive to safe patient outcomes. Following the sedation, providers completed SST, followed by a structured debriefing. They were then re-evaluated with the SPS during a subsequent patient sedation in the ED. Using multivariate regression, odds ratios were calculated for each SPS component, and were compared before and after the SST. Thirty-two sedations were performed, 16 before and 16 after SST. SPS scores improved from a median of 4 (IQR 2-5) to 6 (IQR 4-7) following SST (p < 0.0009, median difference 2, 95% CI 1-3). SST was associated with improved performance in four SPS components. The findings of this pilot study suggest that sedation simulation training of pediatricians improves several tasks related to patient safety during sedation.

A comparison of actual to estimated weights in Australian children attending a tertiary children's' hospital, using the original and updated APLS, Luscombe and Owens, Best Guess formulae and the Broselow tape.

INTRODUCTION: During paediatric resuscitation it is essential to be able to estimate the child's weight as it determines drug doses and equipment sizes. Age and length-based estimations exist, with age-based estimations being especially useful in the preparation phase and the length-based Broselow tape having weight-based drug doses and equipment already assigned via a colour code system. The aim of this study was to compare the actual recorded weights of Australian children to the predicted weights using the original and updated APLS, Luscombe and Owens and Best Guess formulae and the Broselow tape. METHOD: A retrospective observational study of children attending an Australian tertiary children's hospital. RESULTS: From 49,565 patients extracted from the database, 37,114 children with age and weight and 37,091 children with age and height recorded were included in the analysis. Best Guess was the most accurate, with the smallest overall mean difference 0.86 kg. For <1 year old, Broselow tape was the most accurate (mean difference -0.43 kg), Best Guess was the most accurate for ages 1-5 years and 11-14 years (mean difference 0.27 and 0.20 kg respectively), and the updated APLS formula was the most accurate for 6-10 year-old (mean difference 0.42 kg). The Broselow tape was able to only classify 48.9% of children into the correct weight colour band. CONCLUSIONS: For an age-based weight estimation, in infants less than one year the new APLS formula is the most accurate and over one year the Best Guess formulae should be used.

Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios.

AIM: Life threatening paediatric emergencies are relatively uncommon events. When they do occur staff caring for these children must have the ability to recognise the deterioration, evaluate and simultaneously treat these patients. The aim of this study was to identify suboptimal care during standardised simulated scenarios and to identify the potential causation factors. METHODS: Participants were emergency department and operating theatre staff in Sydney, Australia. Incidents of suboptimal care were identified during scenarios and were analysed by thematic qualitative assessment methods. Potential causation factors were elicited both during and immediately after the scenarios and during facilitated debriefings. Causation factors were attributed to any of seven pre-defined categories. RESULTS: Seventy-three simulations occurred over 9 month period in 2011. 270 doctors, 235 nurses and 11 students participated. 194 incidents of suboptimal care were observed and attributed to 325 causation factors. There were 76 knowledge deficits, 39 clinical skill deficits, 36 leadership problems, 84 communication failures, 20 poor resource utilisations, 23 preparation and planning failures and 47 incidents of a loss of situational awareness. Clinically important themes were: paediatric life support, drug choice and doses, advanced airway and ventilation, intravenous fluids and recognition of the deteriorating patient. Recurring incidents included the failure to recognise a cardiac arrest, inadequate fluid resuscitation and incorrect medication dose administration. CONCLUSIONS: During standardised paediatric simulations multiple incidents of suboptimal care have been identified and multiple causation factors attributed to these. Educators should use this information to adapt current training programs to encompass these factors.

Pentraxin 3 is a marker of early joint inflammation in patients with juvenile idiopathic arthritis.

Pentraxin 3 (PTX3) is an acute phase protein produced in different body tissues. The aims of this study were to characterize PTX3 secretion in synovial fluid (SF) of juvenile idiopathic arthritis (JIA) patients and to analyze the correlation of PTX3 levels in SF with clinical characteristics and the course of the disease. SF-PTX3 levels were measured in a cohort of 75 consecutive JIA patients followed in a single center. Patients' clinical characteristics, disease course, and therapies were analyzed for their correlation with SF-PTX3 levels. A synovial cell line was used to study the kinetics of PTX3 secretion by synoviocytes. SF-PTX3 levels varied over a wide range. Elevated SF-PTX3 levels were detected in patients who subsequently required treatment with disease-modifying antirheumatic drugs during the follow-up period. SF-PTX3 levels were found to be inversely correlated with the length of time from onset of joint swelling. No correlation was found between synovial and serum PTX3 or C-reactive protein (CRP). Following in vitro stimulation of synovial cell line with TNFa or IL1, the secretion of PTX3 increases transiently in the first 48-72 h. A similar increase was obtained in patients' synovial fluids but not with IL6. Higher SF-PTX3 levels were found when tested closer to arthritis exacerbation and 48-72 h after in vitro stimulation of cells from a synovial cell line, implying that PTX3 plays a role in early stages of inflammation. Higher SF-PTX3 levels were associated with several clinical features reflecting disease severity and prognostic data. Measuring SF-PTX3 levels may help in providing a more focused and patient-adjusted treatment.

Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department.

OBJECTIVE: Inpatient paediatric clinical observation charts that have predefined physiological criteria, which when reached might generate a mandatory medial review, are to be introduced into EDs in New South Wales. The present study estimated the increased workload of introducing these charts. METHODS: The present study was carried out in the ED of The Children's Hospital at Westmead, Sydney, Australia. All patients admitted directly to the inpatient wards or to the Emergency Medical Unit for a 2 week period in April 2010 were included. The last set of clinical observations prior to the child being transferred out of the ED were recorded. These data were compared to the review criteria defined by the observation charts. The primary outcome was a possible activation of a review. Secondary outcomes were an attempt to quantify the extra time in the ED required before the review would be completed and the patient would be ready for transfer. RESULTS: There were 1822 presentations. Two hundred and fifty-three were admitted to the wards and 109 to the Emergency Medical Unit. There were 126 possible activations. Fifty-seven (52%) of Emergency Medical Unit patients and 69 (28%) of ward patients met review criteria at the time of transfer. The review activations might have generated an extra 7060 min of additional workload. CONCLUSIONS: Individual units must decide where in the patient journey to introduce the charts for acute paediatric admissions based on the number of acute paediatric admissions and their severity as well as the availability and ability of staff to respond to calls.