Pediatric Emergency Department Challenges and Response to COVID-19.

Severe acute respiratory syndrome coronavirus 2, the virus causing the pandemic illness coronavirus disease 2019, was first detected in the United States in January 2020. As the illness spread across the country, all aspects and venues of health care were significantly impacted. This article explores the challenges and response of one children's emergency medicine division related to surge planning, personal protective equipment, screening, testing, staffing, and other operational challenges, and describes the impact and implications thus far. [Pediatr Ann. 2021;50(4):e172-e177.].

Academic Medical Center Visits by Adolescents Preceding Emergency Department Care for Suicidal Ideation or Suicide Attempt.

OBJECTIVE: Suicide is a leading cause of death in children and adolescents, and healthcare encounters relating to suicidal ideation (SI) and suicide attempt (SA) are steadily increasing. Studies examining healthcare utilization by adolescents prior to emergency department (ED) evaluation for SI/SA are lacking and may guide risk assessment. METHODS: We performed a descriptive study of patients 10 to 18 years evaluated for SI/SA in either of our 2 academic, pediatric EDs between January 1 and December 31, 2016. We quantified and characterized healthcare encounters in the year preceding ED evaluation for SI/SA by obtaining data from the electronic health record. RESULTS: We identified 599 patients with an index ED visit for evaluation of SI/SA. Mean age was 14.1 years (SD 2.0 years); 69.8% female, 61.9% White, 55.4% publicly insured. Fifty-six percent (336/599) had at least one previous encounter within our healthcare system in the year preceding their index ED visit (median 3, maximum 40, IQR: 2, 7), most commonly among Black/African American and Hispanic adolescents. Among all patients we identified 1409 previous encounters, and 55.4% (780/1409) occurred within 6 months of the index ED visit. Sixty-two percent (880/1409) of previous encounters were to an outpatient clinic, primarily nonmental health, subspecialty clinics. CONCLUSIONS: Adolescent healthcare encounters in the year preceding ED evaluation for SI/SA occur in a variety of settings. A broad approach to suicide risk screening may improve opportunities for early identification and intervention.

A Novel Pediatric Emergency Department Intervention to Improve Adolescent Sexual Health Care.

OBJECTIVE: The aim of this study was to evaluate a novel educational intervention for physician trainees to improve sexual health care provision, including condom distribution, in the pediatric emergency department. METHODS: Resident physicians and medical students in an urban pediatric emergency department viewed an evidence-based educational video on sexual health care provision. It featured role-plays and a description of the condom distribution process, and targeted trainees who provide health care to patients aged 14 years or more with potential genitourinary complaints. Trainees completed pre- and postintervention surveys to assess attitudes, motivation, and confidence for 4 recommended practices (Likert scale, 1 = not at all to 4 = extremely). We used Wilcoxon signed rank tests to assess differences in paired responses to motivation and confidence statements. A subset of 33 trainees completed a brief survey to assess condom distribution during emergency department clinical encounters. RESULTS: Of 56 trainees, 51 (91%) participated: 53% female, 58% from pediatrics. At baseline, participants reported high levels of confidence and motivation to provide sexual health care. Postintervention, there were significant increases in the proportion of participants who reported greater motivation and confidence to (1) ask a parent to step out of the room, (2) obtain sexual history, (3) discuss condom use, and (4) offer condoms (all P < 0.05). Postintervention, fewer participants "agreed/strongly agreed" that there is inadequate time to obtain sexual histories (22% vs 45%; P < 0.05). Most (60%) sexually active patients accepted condoms during clinical care. CONCLUSION: In this pediatric emergency department, a low-cost intervention showed promise to improve trainee attitudes, motivation, and confidence toward adolescent sexual health care provision. These data may inform strategies to improve access to care for this population.

Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study.

PURPOSE: Pediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception. METHODS: A prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011-9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR). RESULTS: 115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%-89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort. CONCLUSION: ED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization. LEVEL OF EVIDENCE: III.

Increasing ED Use of Jet Injection of Lidocaine for IV-Related Pain Management.

BACKGROUND AND OBJECTIVE: Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement-related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months. METHODS: We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) order set changes, (2) online education, (3) hands-on workshops, (4) improved accessibility, (5) standing order policy revision, and (6) reminders. We collected biweekly data on IV placements for all ED patients, except level 1 (critical) triage patients. We used standard quality improvement methodology and statistical process control for statistical analysis. RESULTS: JIL use with IV placement increased to 54% over 7 months and has remained >50% for >12 months. For all eligible IV placements (n = 12 791), 76.4% of those where JIL was used were successful on the first attempt compared with 75.8% without JIL (χ21degrees of freedom = 0.33, P = .56), with no significant difference in the success at IV placement. CONCLUSIONS: We sustainably increased JIL use with IV placement. The use of JIL was not associated with a difference in first-attempt IV placement success rates. We are expanding the project to other parts of the institution.

Interexaminer agreement in physical examination for children with suspected soft tissue abscesses.

OBJECTIVE: This study aimed to measure interexaminer agreement for physical examination (PE) findings in children with a suspected soft tissue abscess. METHODS: A prospective study was conducted from March 1 to July 31, 2007, at an urban, tertiary care children's hospital emergency department. Children presenting to the emergency department with a suspected local skin abscess were independently examined by 2 physicians. Interrater agreement of 7 PE findings for children with a suspected soft tissue abscess was assessed. Interrater agreement was calculated for the diagnosis of the lesion and decision to incise and drain. RESULTS: A total of 105 paired observations were completed by a total of 27 physicians. The patients examined were aged 2 weeks to 18 years, with a mean age of 80 months. Lesions were most frequently encountered on the buttocks (38%). Incision and drainage was attempted in 75% of cases, with purulent material obtained in 92% of all attempts. Interrater agreement was substantial for erythema (κ = 0.66) and size of the lesion (intraclass correlation coefficient = 0.78), moderate for drainage (κ = 0.57) and tenderness (κ = 0.40), fair for fluctuance (κ = 0.35), and poor for warmth (κ = 0.15) and showed no agreement for induration (κ = -0.08). There was moderate agreement on diagnosing the lesion as an abscess (κ = 0.48) and determination if the lesion required incision and drainage (κ = 0.44). CONCLUSIONS: Interexaminer agreement of examination findings and diagnosis of an abscess was fair to moderate, implying a lack of precision of PE as the primary means for diagnosis. Future studies of diagnostic adjuncts, such as bedside ultrasonography, may lead to improved management of soft tissue infections in children.