Características epidemiológicas de las consultas pediátricas en el servicio de emergencia de un hospital público del interior del país: Uruguay 2019 / Epidemiological characteristics of pediatric consultations at the emergency services of a public hospital in the interior of Uruguay in 2019 / Características epidemiológicas das consultas pediátricas no serviço de emergência de um hospital público do interior do Uruguai no ano 2019

El Hospital Escuela del Litoral de Paysandú es un centro de referencia departamental y regional con un Servicio de Emergencia único. Asiste a 68.000 usuarios, 25% pediátrico. Objetivos: describir la epidemiología global de las consultas durante el año 2019 en el Servicio de Emergencia del Hospital Escuela del Litoral de Paysandú y las características de la población pediátrica que concurre al mismo. Analizar los principales motivos de consulta, demanda asistencial, nivel de gravedad, rol del médico que asiste al paciente pediátrico y destino del paciente. Material y métodos: estudio descriptivo retrospectivo de la demanda asistencial durante el año 2019. Descripción y análisis de las consultas pediátricas entre el 1 de enero y el 30 de junio de 2019. Resultados: 47.647 consultas, 11.411 pediátricas. Meses de mayor consulta: julio, agosto y octubre. N: 4.905, 34,4% preescolares. 89% de las consultas se clasificaron como nivel 4 y 5. La patología respiratoria predominó en todas las franjas etarias y meses del año. Los pacientes nivel 1 se derivaron a cuidados moderados o CTI, y uno falleció. Discusión y conclusiones: mayor demanda asistencial en los meses fríos por patologías respiratorias. 1 de cada 100 consultas corresponden a emergencia-urgencia y 1 de cada 5 menos urgentes. Inadecuado uso del Servicio de Emergencia con sobrecarga asistencial. Se confirma utilidad del triage como herramienta en un Servicio de Emergencia mixto

The School Hospital Hospital Escuela del Litoral de Paysandú is a departmental and regional reference center with a unique Emergency Service. It serves 68,000 users, 25% of which are pediatric users. Objectives: to describe the total epidemiology consultations in 2019 at the Emergency Service of the Hospital Escuela del Litoral de Paysandú and the characteristics of its emergency pediatric population. Analyze the key reasons for consultation, care demand, level of severity, the role of doctors who receive pediatric patients and patients' referral. Material and methods: retrospective descriptive study of the demand for care in 2019. Description and analysis of pediatric consultations between January 1 and June 30, 2019. Results: 47,647 consultations, 11,411 pediatric. Months of greater consultation: July, August and October. N: 4905. 34.4% preschool. 89% of the consultations were classified as level 4 and 5. Respiratory pathology prevailed in all age groups and months of the year. Level 1 patients were referred to moderate care or ICU and one died. Discussion and conclusions: higher demand for care in Winter months due to respiratory pathologies. 1 out of every 100 consultations belonged to Emergency-Urgency Services and 1 out of 5 were less urgent. Inadequate use of the Emergency Service with care overload. We confirm the effectiveness of Triage as a tool in a mixed Emergency Services patients' referral process.

O Hospital Escola do Litoral de Paysandú é um centro de referência departamental e regional com um Serviço de Emergência único. Atende 68.000 usuários, 25% pediátricos. Objetivos: descrever a epidemiologia geral das consultas durante o ano de 2019 no Serviço de Emergência do Hospital Escola de Paysandú e as características da população pediátrica que atende o Serviço de Emergência. Analisar os principais motivos de consulta, demanda de atendimento, grau de gravidade, atuação dos médicos que atendem os pacientes pediátricos e destino do paciente. Material e métodos: estudo descritivo retrospectivo da demanda de atendimento durante o ano de 2019. Descrição e análise das consultas pediátricas entre 1º de janeiro e 30 de junho. de 2019 Resultados: 47.647 consultas, 11.411 pediátricas. Meses de maior consulta: julho, agosto e outubro. N: 4.905. 34,4% pré-escolar. 89% das consultas foram classificadas como nível 4 e 5. A patologia respiratória prevaleceu em todas as faixas etárias e meses do ano. Pacientes nível 1 foram encaminhados para cuidados moderados ou UTI e um faleceu. Discussão e conclusões: maior procura de cuidados nos meses frios devido a patologias respiratórias. 1 em cada 100 consultas corresponde a Urgência-Emergência e 1 em cada 5 corresponde a consultas menos urgentes. Uso inadequado do Serviço de Emergência com sobrecarga de atendimento. Confirma-se a utilidade da Triagem como ferramenta em um Serviço de Emergência misto.

COVID-19 and abdominal pain: a pediatric case report and a point of view in pediatric emergency medicine.

COVID-19 is to date a global pandemic that can affect all age groups; gastrointestinal symptoms are quite common in patients with COVID-19 and a new clinical entity defined as Multisystem Inflammatory Syndrome in Children (MIS-C) has been described in children and adolescents previously affected by COVID-19. Presenting symptoms of this new disease include high fever and severe abdominal pain that can mimic more common causes of abdominal pain; patients can rapidly deteriorate presenting severe cardiac dysfunction and multiorgan failure. Some fatalities due to this serious illness have been reported. We describe the case of a ten-year-old patient presenting with persistent high fever associated with continuous and worsening abdominal pain. Various hypotheses were performed during his diagnostic workup and an initial appendectomy was performed in the suspect of acute appendicitis. As his clinical picture deteriorated, the child was subsequently diagnosed and successfully treated as a case of MIS-C. The objective of this case report and brief review of abdominal pain in children throughout the age groups is to provide the emergency pediatrician with updated suggestions in diagnosing abdominal pain in children during the COVID-19 pandemic.

Epidemiología de los casos pediátricos en la sala de emergencias de un hospital general / Epidemiology of pediatric cases in the emergency room of a general hospital

Objetivos El objetivo de este estudio es determinar a qué tipo de patologías nos enfrentamos. Utilizamos la Clasificación Internacional de Atención Primaria para asegurar una nomenclatura objetiva y comparable. Métodos Se realizó un estudio descriptivo, observacional y retrospectivo de una muestra de 108102 consultas de atención primaria de pacientes que acudieron a Urgencias de nuestro hospital para evaluar la epidemiología de la atención pediátrica brindada entre 2011 y 2019. Utilizamos el sistema de clasificación diagnóstica ICPC-2. Resultados El número de asistencias fue mayor en enero, febrero y marzo, así como los fines de semana. Tras ser atendidos, el 6,7% de los pacientes ingresaron en nuestro hospital. Las patologías más frecuentes fueron las infecciones del tracto respiratorio superior, gastroenteritis, fiebre y traumatismos / lesiones. Las patologías que con mayor frecuencia dieron lugar a ingresos hospitalarios fueron fiebre, bronquitis, gastroenteritis y vómitos (p> 0,001). En los ingresos hospitalarios de menores de 1 año, la bronquitis fue la patología más frecuente, mientras que entre los de 1 a 6 años fue la gastroenteritis y entre los de 7 a 14 años fue la apendicitis aguda (p <0,001). Conclusiones Las patologías pediátricas suponen un porcentaje importante de las visitas a urgencias, destacando las infecciones del tracto respiratorio superior, las infecciones intestinales y la fiebre. Sería aconsejable incrementar los recursos de personal en los fines de semana. Es necesario enfatizar en la educación sanitaria de la población para ajustar la demanda de asistencia en los servicios públicos. Se requiere más investigación para adaptar mejor la terminología ICPC-2.

Objectives The aim of this study is to determine what type of pathologies we are facing. We use the International Classification of Primary Care to ensure an objective and comparable nomenclature. Methods We carried out a descriptive, observational, and retrospective study of a sample comprising 108102 primary care encounters of patients presenting at our hospital's Emergency Room to assess the epidemiology of the pediatric care provided between 2011 and 2019. We used the ICPC-2 diagnosis classification system. Results The number of attendances was higher in January, February, and March, as well as at weekends. After being seen, 6.7% of patients were admitted to our hospital. The most frequent pathologies were upper respiratory tract infections, gastroenteritis, fever and trauma/injury. Pathologies most frequently resulting in hospital admissions were fever, bronchitis, gastroenteritis and vomiting (p>0.001). In hospital admissions involving patients under 1 year of age, bronchitis was the most frequent pathology, while among those aged between 1 and 6 years, it was gastroenteritis and among those aged between 7 and 14 years it was acute appendicitis (p<0.001). Conclusions Pediatric pathologies account for a significant percentage of visits to the emergency room, highlighting infections of the upper respiratory tract, intestinal infections, and fever. It would be necessary to increase staff resources on the weekends. It is highly recommended to emphasize the health education of the population to adjust the demand for assistance in public services. More research is required to better adapt the ICPC-2 terminology.

Child abuse and neglect in a pediatric emergency department: epidemiology and outcome.

INTRODUCTION: Managing child abuse and neglect in pediatric emergency departments (PEDs) is difficult because of the complexity of screening and the prolonged care process. This study's main objective was to measure the child protection activity in a PED. METHODS: A retrospective, single-center study was conducted in the PED of the Lille University Hospital from 16 September∫2017 to 11 February 2019. All patients who required a social evaluation by the PED staff were included. Children admitted at first to the PED but for whom social management was exclusively performed by other units were not included. The whole population was analyzed first and then by type of abuse. The primary endpoint was the rate of patients who needed social management in the PED. The length of stay in the PED, the number of reports for investigation by child protective services, and reports to a judge were secondary assessment criteria. RESULTS: The study involved 245 patients (median age, 5 years; interquartile range [IQR], 2-13; boys, 49%), accounting for 0.6% of the PED visits. The main reasons for visiting the PED were somatic complaints (31%), sexual assault (23%), and behavioral disorders (20%). The median length of care in the PED was 5 h (IQR, 3-13). Thirty-three percent of the patients were monitored in the short-stay unit of the PED; 78% returned home. The main social measures taken were reports to child protective services (34%) and reports to a judge (24%); 51% of the patients required further actions by the PED physician after discharge. CONCLUSION: Management of child abuse in the PED is important and time-consuming. A hospital team specialized in child protection is essential for the initial care and monitoring of child victims.

Impact of the Step-by-Step on febrile infants.

OBJECTIVE: To evaluate the impact of introducing the Step-by-Step approach on care quality in young febrile infants. DESIGN: Observational study including infants ≤90 days old with fever without source seen in a paediatric emergency department 5 years before (n=1222) and after (n=1151) its introduction. Quality of care was evaluated in terms of adherence to recommendations, resource use and safety. RESULTS: Adherence: percentages of infants undergoing both urine and blood tests and infants <15 days old receiving full sepsis evaluation increased (84.7% vs 91.0% and 23.9% vs 63.3%, respectively; p<0.01). Resource use: lumbar puncture and admission rates decreased (24.1% vs 18.7% and 43.6% vs 38.3%, respectively; p<0.01), while the rate of antibiotic therapy increased (30.2% vs 43.2%; p<0.01). SAFETY: the invasive bacterial infection rate among infants managed as outpatients was unchanged (0.7% vs 0.3%; p=0.24). CONCLUSION: The introduction of the Step-by-Step increased the quality of care provided to young febrile infants.

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study.

OBJECTIVE: Appendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED). METHODS: In this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013-2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses. RESULTS: During the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610-6.096); vomiting (OR: 2.346; 95% CI: 1.141-4.822); diarrhea (OR: 4.549; 95% CI: 1.850-11.181); fever (OR: 3.429; 95% CI: 1.765-6.663); elevated WBC (OR: 2.962; 95% CI: 1.491-5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267-7.396) were variables that predicted the PA in children. CONCLUSION: Our data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.

Evaluation of the 2020 Pediatric Emergency Physician Workforce in the US.

Importance: Given the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however. Objective: To describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US. Design, Setting, and Participants: This national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020. Main Outcomes and Measures: The Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates. Results: A total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population. Conclusions and Relevance: This study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.

Pediatric emergency department utilisation during Ramadan: a retrospective cross-sectional study.

OBJECTIVE: To investigate the impact of Ramadan on patient characteristics, diagnoses and metrics in the paediatric emergency department (PED). DESIGN: Retrospective cross-sectional study. SETTING: PED of a tertiary care centre in Lebanon. PATIENTS: All paediatric patients. EXPOSURE: Ramadan (June 2016 and 2017) versus the months before and after Ramadan (non-Ramadan). MAIN OUTCOME MEASURES: Patient and illness characteristics and PED metrics including peak patient load; presentation timings; length of stay; and times to order tests, receive samples and report results. RESULTS: We included 5711 patients with mean age of 6.1±5.3 years and 55.4% males. The number of daily visits was 28.3±6.5 during Ramadan versus 31.5±7.3 during non-Ramadan (p=0.004). The peak time of visits ranged from 18:00 to 22:00 during non-Ramadan versus from 22:00 to 02:00 during Ramadan. During Ramadan, there were significantly more gastrointestinal (GI) and trauma-related complaints (39.0% vs 35.4%, p=0.01 and 2.9% vs 1.8%, p=0.005). The Ramadan group had faster work efficiency measures such as times to order tests (21.1±21.3 vs 24.3±28.1 min, p<0.0001) and to collect samples (50.7±44.5 vs 54.8±42.6 min, p=0.03). CONCLUSIONS: Ramadan changes presentation patterns, with fewer daily visits and a later peak time of visits. Ramadan also affects illness presentation patterns with more GI and trauma cases. Fasting times during Ramadan did not affect staff work efficiency. These findings could help EDs structure their staffing to optimise resource allocation during Ramadan.

The relation between regular outpatient follow-up and frequency of emergency department visits in sickle cell pediatric patients.

OBJECTIVE: To evaluate the relationship between the frequency of ED visits and outpatient department (OPD) follow-up in sickle cell disease (SCD) pediatric patients. METHODS:   A retrospective cohort study included 247 SCD pediatric patients between January 2016 and December 2018 at the Maternity and Children Hospital, Department of Pediatrics, Al Medinah Al Munawarah, Saudi Arabia. Data were extracted from electronic medical record system; patient demographics, medications, frequency of emergency department (ED) and OPD visits. Pearson correlation coefficient, linear regression and independent sample t-test were applied. RESULTS: There was no significant correlation (95% CI [-0.013- 0.233]; p=0.07) between the frequency of ED and OPD visits. However, a significant correlation was found between ED visits and missed OPD appointments. Thus, linear regression was applied and indicated that one missed OPD appointment is associated with 1.92 ED visits, (95% CI: 0.19-0.42; p less than 0.001). Also, a higher rate of ED visits was observed when compared with other studies, with a high ED reliance of 43%. CONCLUSION: This study found that regular OPD visits could improve SCD management, as a directly proportional relationship between the frequency of ED visits and missed OPD appointments along with high ED reliance.

[Comparative analysis of the incidence of alcohol intoxication in adolescents in a pediatric emergency department.] / Análisis comparativo de la incidencia de intoxicaciones etílicas en adolescentes en un servicio de Urgencias pediátricas.

OBJECTIVE: A retrospective study (2007-2012) of acute alcohol intoxication (AAI) in the paediatric Emergency Department (ED) (Hospital Sant Joan de Déu, Barcelona) demonstrated a decrease in the rates of AAI over the last two years. Aim: to determine if this decile continued during the following 5 years and to describe the profile and clinical management of these patients. METHODS: Descriptive, retrospective and observation study. Adolescents who presented to the ED (Hospital Sant Joan de Déu, Barcelona) with AAI were included (2007-2017). Patients were classified in two groups: mil and moderate/severe; we compared the differences in the clinical management (monitoring of vital signs, lab test and treatment). We defined the AAI incidence rate: number of AAI every 1000 ED adolescent consultations/year. RESULTS: We included 836 AII, incidence rate: 7.7;2007, 8.5;2008, 6.6;2009, 7.8;2010, 6.4;2011, 6.4;2012, 4.8;2013, 4.6;2014, 5.5;2015, 4.8;2016 and 3.4;2017. The mean age was 15.9 (SD 1.2) years, 54.9% (459) were women. 54.5% had mild AAI, 45.4% moderate/severe. The temperature was taken to 607 patients, capillary blood glucose to 573 and blood pressure to 633. We found no differences in the monitoring of vital signs regardless of the symptoms of the patients. Patients with moderate/severe AAI underwent blood test more frequently than those with mild AAI (ethanol levels 88.2% vs 50.4%; p<0.001; electrolytes 81.2% vs 48%, p<0.001; glucose levels 64.4% vs 37.1%, p<0.001). Four hundred and twelve patients (49.3%) received fluid therapy. Twenty-two patients were admitted. CONCLUSIONS: The incidence of AAI decreased over the last years. The profile of these patients remains unchanged (adolescents with moderate AAI during weekends). Even though lab test were performed more frequently to patients with moderate/severe AAI, clinical management should be improved by taking vital signs and capillary glycemia to all patients, keeping the blood analysis for moderate-severe AAI.

OBJETIVO: Una revisión retrospectiva (período 2007-2012) de las intoxicaciones etílicas agudas (IEA) en el Servicio de Urgencias Pediátrico (SUP) del Hospital San Joan de Déu, de Barcelona, evidenció un descenso de las visitas por IEA los últimos dos años. El objetivo de este trabajo fue comprobar si este descenso se había mantenido los 5 años posteriores, así como describir el perfil y manejo de estos pacientes. METODOS: Se realizó un estudio descriptivo, retrospectivo y observacional. Se incluyeron consultas de adolescentes en el SUP del Hospital San Joan de Déu, de Barcelona, por IEA (período 2007-2017). Se dividieron los pacientes en IEA leve y moderada-grave. Se valoraron las diferencias en su manejo (toma de constantes, analítica y tratamiento.) Se definió la tasa de incidencia de IEA cada 1.000 visitas a Urgencias de adolescentes/año. RESULTADOS: Se incluyeron 836 IEA. Las tasas de incidencia por años fueron: 7,7% (2007); 8,5% (2008); 6,6% (2009); 7,8% (2010); 6,4% (2011); 6,4% (2012); 4,8% (2013); 4,6% (2014); 5,5% (2015); 4,8% (2016) y 3,4% (2017). La edad media fue de 15,9 (DE 1,2) años, siendo mujeres el 54,9%. Presentó IEA leve un 54,5% y moderada-grave un 45,4%. Se determinó temperatura a 607, glicemia capilar a 573 y tensión arterial a 633. No hubo diferencias significativas en la determinación de las tres constantes según la clínica de intoxicación. A los pacientes con IEA moderada-grave se les realizó analítica sanguínea con mayor frecuencia que a los de IEA leve (niveles de etanol del 88,2% frente al 50,4%; p<0,001 / EAB-ionograma del 81,2% contra el 48%, p<0,001 / glicemia venosa del 64,4% respecto al 37,1%, p<0,001). Se administró sueroterapia a 412 (49,3%). Precisaron ingreso 22 pacientes. CONCLUSIONES: La incidencia de IEA en SUP disminuye. Se mantiene el perfil de adolescentes (IEA moderadas el fin de semana). Aunque se realizó analítica con mayor frecuencia a los pacientes con IEA moderada, el manejo de las IAE presenta aspectos mejorables, debiendo preconizar la toma de constantes y la glicemia capilar en todos los pacientes, reservando la analítica para los pacientes moderados-graves.

COVID-19 Pandemic: Perspective From Italian Pediatric Emergency Physicians.

OBJECTIVES: To document the lived experience of Italian pediatric emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We developed a structured interview to collect the lived experience of the staff of the pediatric emergency department (PED) of a tertiary referral university hospital in Northern Italy. The open-ended questions were draft according to the suggestions of Canadian colleagues and administered by 1 interviewer, who was part of the PED staff, at the end of March 2020. All the PED staff was interviewed, on a voluntary basis, using purposive sampling. RESULTS: Most respondents declared to be afraid of becoming infected and of infecting their families. The number of patients seen in the PED has decreased, and the cases tend to be more severe. A shift in the clinical approach to the ill child has occurred, the physical examination is problem-oriented, aiming to avoid un-necessary maneuvers and to minimize the number of practitioners involved. The most challenging aspects reported are: (1) performing a physical examination in personal protective equipment (PPE), (2) being updated with rapidly evolving guidelines, and (3) staying focused on the possible COVID-19 clinical presentation without failing in differential diagnosis. CONCLUSIONS: During the COVID-19 pandemic, it seems that pediatric emergency physicians are radically changing their clinical practice, aiming at prioritizing essential interventions and maneuvers and self-protection.

COVID-19: the effects on the practice of pediatric emergency medicine.

An informal survey of 65 pediatric emergency department leaders in North America-from 30 U.S. states and 4 Canadian provinces-revealed changes in operations, infrastructure, staffing, and clinical care that were undertaken as a result of the COVID-19 pandemic. The changes identified by the survey respondents were driven by reductions in pediatric patient volumes, a surge of adult patients, clinical considerations related to containment of infection, and financial factors. Survey respondents also reported effects of the pandemic on academic training programs and provider wellness. This report uses the survey responses to provide a snapshot of the adaptability of pediatric emergency medicine departments and clinicians during a public health emergency.

Trends in Mental Health Presentations to a Paediatric Emergency Department.

Aims This study aimed to analyse trends in mental health presentations to the Emergency Department (ED), which anecdotally had increased over the past decade. Methods The ED's electronic 'Symphony' system was used to identify the annual number of presentations categorised as having a mental health complaint from 2006-2017. A detailed analysis was performed on presentations over a one-year period. Results The number of presentations increased from 69 in 2006 to a peak of 432 in 2016 (526% increase). The overall admission rate was 33.3%(n=99), while 52.5%(n=156) of presentations occurred outside of standard working hours. Similar increases were documented by other ED's worldwide, and the WHO estimate that neuropsychiatric disorders will become one of the top five causes of morbidity, mortality and disability among children by 2020. Conclusion With the number of mental health presentations dramatically increasing, carefully designed and integrated strategies are required to pro-actively tackle this growing epidemic.

Educational Benefits of Allowing Pediatrician Supervision of Emergency Medicine Residents.

BACKGROUND: According to the Accreditation Council for Graduate Medical Education emergency medicine (EM) program requirements, EM residents on EM rotations must be supervised by board-certified/board-prepared EM or pediatric EM (PEM) faculty. OBJECTIVE: We sought to understand the effect of allowing EM residents to be supervised by attending pediatricians while caring for pediatric urgent care patients. METHODS: The EM residents were permitted to staff pediatric urgent care patients with either an EM/PEM attending or an attending pediatrician from August 2017 to July 2018. Outcomes were assessed through resident focus groups, a mixed-methods survey of EM residents and EM/PEM/pediatrician attendings, and clinical outcomes, including length of stay, best evidence/clinical care guideline adherence, and 48-hour return visits requiring admission. Qualitative data were inductively coded using a phenomenological framework, with themes emerging from consensus discussion. RESULTS: Ninety percent of residents participated in 1 of 7 focus groups. Four key themes emerged from qualitative analysis of focus group transcripts: (1) pediatricians have unique skills that complement those of EM physicians; (2) EM resident education improved; (3) patients may get better care with dual staffing; and (4) other PEM department and urgent care team members may have benefited from the change. The survey response rate was 72%, and it did not uncover additional themes. Length of stay was shorter for patients supervised by attending pediatricians (114 versus 128 minutes, P < .001); there was no difference in best evidence/clinical care guideline adherence or 48-hour return visits requiring admission. CONCLUSIONS: Physicians' perceived education was improved by adding complementary perspectives without significant negative consequences for learners or patients.

Burnout Rates in Pediatric Emergency Medicine Physicians.

OBJECTIVE: Burnout is a syndrome in which a reduced sense of personal accomplishment, depersonalization, and emotional exhaustion develop in response to prolonged stress. It is well known that physicians suffer high rates of burnout; emergency medicine physicians experience significantly increased rates of burnout, whereas physicians in other specialties, like pediatrics, may be spared. Pediatric emergency medicine physicians are on the frontline of care for the critically ill child, which could put them at high risk for burnout. This study evaluates the rate of burnout in pediatric emergency medicine physicians. METHODS: We conducted a survey assessing burnout using a sample of pediatric emergency medicine physicians who subscribe to an open Listserv server maintained by Brown University. Burnout was measured using a validated instrument, the Maslach Burnout Inventory-Human Services Survey, which was distributed by e-mail to the study group. RESULTS: Respondents averaged a score of 9 (95% confidence interval [CI], 8-10), 23 (95% CI, 21-25), and 39 (95% CI, 38-40) in the subscales of depersonalization, emotional exhaustion, and personal accomplishment, respectively. This placed our cohort into the average range for all subscales. The percentage of respondents who scored in the high levels of burnout (moderate to high scores in both depersonalization and emotional exhaustion and low to moderate scores in personal accomplishment) was 25% (95% CI, 18-32). CONCLUSIONS: Unlike previous literature showing burnout prevalence in excess of 60% in emergency medicine physicians and 38% in pediatricians, our pediatric emergency medicine physicians fared better with only 25% (95% CI, 18-32), showing elevated levels of burnout.

Hemofilia: naturaleza de las visitas a urgencias pediátricas / Haemophilia: Reasons for visits to the paediatric emergency department

Introducción: La hemofilia es una enfermedad rara, por lo que su abordaje en Urgencias puede suponer un reto para los pediatras. Objetivos: Describir la frecuencia y motivos de consulta de los niños hemofílicos en Urgencias. Material y métodos: Estudio retrospectivo longitudinal realizado en Urgencias Pediátricas de un hospital de tercer nivel. Se incluyeron hemofílicos A y B, desde el nacimiento hasta los 16 años, que consultaron por cualquier motivo durante 6 años (2011-2016). Se analizaron: edad, tipo y gravedad de hemofilia, motivo de consulta, profilaxis domiciliaria frente a sangrados, pruebas complementarias, diagnóstico establecido, tratamiento y número de visitas a Urgencias. Resultados: Se analizaron 116 varones con un total de 604 visitas. La media de edad fue de 5,5 años y la mediana de 5,3. De ellos, 101 pacientes eran hemofílicos A (38 leves, 4 moderados, 59 graves) y 15 hemofílicos B (9 leves, 3 moderados, 3 graves). Los principales motivos de consulta (clasificados en triaje) fueron: problema musculoesquelético/traumático o sangrado (66,7%), causas no relacionadas con hemofilia (29%), sospecha de infección de catéter central (2,8%) y administración rutinaria de factor (1,5%). Se realizaron pruebas complementarias en 335 visitas (55,5%). Del total, 317 consultas (52,5%) requirieron factor; 103 episodios (17,1%) precisaron ingreso, cuyos principales motivos fueron: traumatismo craneoencefálico (35,9%), infección de catéter venoso central (13,6%), hemartrosis (8,7%), hematoma muscular (6,8%) y hematuria (5,8%). Conclusión: Los pacientes consultaron por causas habituales de la edad pediátrica, pero también lo hicieron por motivos específicos de su enfermedad; lo más frecuente fue el problema musculoesquelético/traumático o sangrado. El Servicio de Urgencias es un componente indispensable en su atención

Introduction: Haemophilia is a rare disease and its management can pose a challenge to Emergency Department paediatricians. Aim: To describe the frequency and reasons for consultation by haemophilic children in the ED. Materials and methods: Longitudinal retrospective study was conducted in a paediatric Emergency Department of a tertiary care hospital. The study included haemophiliacs A and B, ages 0 to 16 years old, and who had consulted the Emergency Department for whatever reason over a span of 6 years (2011-2016). The data analysed include: age, type and severity of haemophilia, reason for query, prophylactic status, complementary examinations, established diagnosis, treatment, and number of visits to the Emergency Department. Results: The analysis included 116 males with a total of 604 Emergency Department visits. The mean age was 5.5 years, and the median age was 5.3 years. A total of 101 patients were categorised as haemophiliac A (38 mild, 4 moderate, 59 severe), and 15 as haemophiliac B (9 mild, 3 moderate, 3 severe). The main reasons for initial Emergency Department visits (ranked by triage) were: musculoskeletal problems/injury or bleeding (66.7%), causes unrelated to haemophilia (29%), suspected central venous catheter related infection (2.8%), and routine clotting factor infusion (1.5%). Additional tests were conducted during 335 visits (55.5%). Factor replacement was undertaken in 317 visits (52.5%). A total of 103 episodes (17.1%) required hospital admission, due to: head trauma (35.9%), central venous catheter -related infection (13.6%), haemarthrosis (8.7%), muscle haematoma (6.8%), and haematuria (5.8%). Conclusion: Haemophilic patients went to the Emergency Department for common paediatric causes, but also requested consultation on specific problems related to haemophilia, with musculoskeletal problems/injury or bleeding being the main issues. The paediatric Emergency Department is an indispensable component of haemophilia care

Compassion Fatigue in Pediatric Emergency Department Staff.

INTRODUCTION: Compassion fatigue, a product of burnout (BO), secondary traumatic stress (STS), and compassion satisfaction (CS), is reduced capacity and interest in being empathetic for suffering individuals. Our objective was to determine prevalence of compassion fatigue in the pediatric emergency department. METHODS: We administered the Professional Quality of Life instrument, including BO, STS, and CS scales, to a convenience sample of pediatric emergency department staff (physicians, nurses, technicians, social workers, child life specialists). We categorized participants as having BO (high BO, low CS, moderate-low STS scores), STS (high STS, moderate-low BO, low CS), compassion fatigue (high STS and BO, low CS), and high-risk fatigue (high STS, moderate-low BO, low CS) and low risk (moderate-high CS, moderate-low BO, low STS) of compassion fatigue. RESULTS: One hundred seventy-seven staff (50% response rate) participated. The majority were white (90%) and female (88%), with participation highest among physicians (97%). Twenty-six percent had low CS scores, 26% had high BO scores, and 20% had high STS scores. Five percent met criteria for categorization as compassion fatigue, 24% for BO, and 24% for low risk of compassion fatigue. Current personal stress was associated with higher BO scores (P = 0.008) and secondary categorization as BO (P = 0.05). Recent work stress was associated with high STS scores (P = 0.03). DISCUSSION: Five percent of participants met criteria for compassion fatigue; a significant proportion had BO, STS, or CS scores, placing them at risk of compassion fatigue. Future studies should explore factors contributing to and interventions to minimize compassion fatigue.

Mordeduras de perro, un problema vigente en nuestro entorno / Dog Bites, a current problem in our environment

Objetivos. Las mordeduras de perro son motivo de consulta habitual en urgencias pediátricas. Si bien en nuestro medio raramente son letales, algunas conllevan secuelas estéticas graves. El objetivo del trabajo es analizar la casuística de mordeduras de perro y su repercusión en nuestro entorno Material y métodos. Revisión retrospectiva de pacientes atendidos por mordedura de perro en un centro pediátrico terciario entre 2013-2018. Estudiamos variables demográficas, localización de mordedura, relación perro-paciente, antibioterapia, necesidad de ingreso, complicaciones y secuelas derivadas. Resultados. Se analizaron 256 casos (edad media 6,4 años), 133 niños (51,9%) y 123 niñas (48%). En 153 casos el perro agresor era del entorno del paciente (59,8%). La localización más frecuente de heridas fue cabeza y cuello (94,1%), seguida de extremidades (4,7%) y genitales (1,6%). En 227 casos (88,7%) se administró antibiótico. La complicación más frecuente fue la infección de herida en 5 pacientes (2%). Precisaron ingreso hospitalario 20 pacientes (7,8%) con estancia media de 1,6 días. Se describieron secuelas estéticas en 10 casos (3,9%), 7 precisaron cirugía correctora. Conclusiones. Las mordeduras de perro persisten como motivo frecuente de consulta, produciéndose mayoritariamente por perros del entorno del paciente. La infección de herida representa la complicación más común, y la secuela estética facial supone la indicación más fre-cuente de intervención quirúrgica. Consideramos que por la cantidad de mordeduras y sus secuelas, la inclusión de medidas preventivas ante estos accidentes en guías de prevención del hogar, podría ser de utilidad para concienciar a la población y disminuir la incidencia de estas lesiones

Aims. Dog bites are frequent reason for consultation in pediatrics emergency department. Despite in our environment dog bites are rarely lethal, some of these accidents can have serious aesthetics consequences. The main goal of this article is to analyze dog bites casuistry and their impact in our community. Material and methods. Retrospective review of patients treated for dog bite in a tertiary pediatric center between 2013-2018. We studied patient’s demographic variables, bite localization, dog-patient relation-ship, antibiotic therapy, need for admission, complications and secondary sequelae. Results. 256 cases were analyzed (average age 6.4 years), 133 boys (51.9%) and 123 girls (48%). In 153 cases, the aggressor dog was from the patient’s familiar environment (59.8%). The most frequent location of the wounds was head and neck (94.1%), followed by extremities (4.7%) and genitals (1.6%). In 227 cases (88.7%) antibiotics were administered. Wound infection was the most frequent complication, occurring in 5 patients (2%). 20 patients (7.8%) required hospital admission with a mean stay of 1.6 days. Aesthetic sequelae were described in 10 cases (3.9%), 7 of which required correcting surgery. Conclusions. Dog bites persist as a frequent reason for medical consultation, most of them are provoked by patient familiar dogs. Wound infection represents the major complication, and the facial aesthetic sequelae are the most frequent indication for surgical intervention. We consider due to the amount of dog bites and their sequelae, the inclusion of preventive measures against these accidents in home prevention guidelines could be useful to reduce the incidence of these injuries