Routine Emergency Department Screening to Decrease Subsequent Physical Abuse.

STUDY OBJECTIVE: Emergency department (ED) screening for child physical abuse has been widely implemented, with uncertain effects on child abuse identification. Our goal was to determine the effect of screening on referrals to child protective services (CPS) identifying abuse. METHODS: We performed a retrospective cohort study of children younger than 6 years old with an ED encounter at 1 of 2 large health care systems, one of which implemented routine child abuse screening. The main outcome was initial (<2 days) or subsequent (3 to 180 days) referral to CPS identifying child abuse using linked records. We compared outcomes for the 2-year period after screening was implemented to the preperiod and nonscreening EDs using generalized estimating equations to adjust for sex, age, race/ethnicity, payor and prior ED encounters and clustered by center. RESULTS: Of the 331,120 ED encounters, 41,589 (12.6%) occurred at screening EDs during the screening period. Screening was completed in 34,272 (82%) and was positive in 188 (0.45%). Overall, 7,623 encounters (2.3%) had a subsequent referral, of which 589 (0.2%) identified moderate or severe abuse. ED screening did not change initial (adjusted odds ratio [aOR]=1.01, 95% confidence interval [CI] 0.89 to 1.15) or subsequent referral to CPS when compared to the prescreening period (aOR=1.05, 95% CI 0.9 to 1.18) or to the nonscreening EDs (aOR=1.06, 95% CI 0.92 to 1.21). CONCLUSION: Routine screening did not affect initial or subsequent referrals to CPS.

Implementation of a Pediatric Emergency Telemedicine Program.

OBJECTIVES: Our goal was to describe the experiences after the launch of a pediatric emergency telemedicine program at a large, urban, academic medical center. METHODS: We launched 3 unique pediatric emergency telemedicine programs at an urban, academic medical center: direct-to-consumer pediatric virtual urgent care, pediatric emergency department (PED) telemedicine follow-up, and telemedicine medical screening examination in the PED. RESULTS: We evaluated 84 patients via direct-to-consumer pediatric virtual urgent care with the most common chief complaint related to fever, dermatologic, or respiratory systems; we referred 12% to the PED, and 20% of those required hospital admission. We evaluated 38 patients via PED telemedicine follow-up; we referred 19% back to the PED, and 43% of those required hospital admission. Median duration for a telemedicine encounter was 10 minutes. We screened 3809 patients in the PED using telemedicine medical screening examination. CONCLUSIONS: We offer a description of an innovative and comprehensive new pediatric emergency telemedicine program implemented at a large, urban, academic medical center. Our initial findings demonstrate short visit times, antibiotic stewardship, and low rates of PED referral and subsequent admission for patients who use a telemedicine service. We plan to further examine the impact of pediatric emergency telemedicine on the care of children as our program expands.

Low-risk criteria for pelvic radiography in pediatric blunt trauma patients.

CONTEXT: The American College of Surgeons recommends that any patient with blunt trauma undergoes radiographic evaluation, including a radiograph of the pelvis. Studies have questioned the use of such routine pelvic radiographs (PXR) in pediatrics. Selective elimination of PXR would save time, money and unshielded radiation exposure to the gonads. OBJECTIVE: To determine if a defined set of historical and clinical factors could predict low risk for pelvic fracture and incorporate these factors into a clinical decision guideline. DESIGN, SETTING, AND PATIENTS: A retrospective chart review of all blunt trauma patients 25 years or younger in whom a PXR was obtained from January 2002 to June 2006 presenting to an urban level 1 trauma center. A total of 579 patients underwent 580 trauma evaluations. MAIN OUTCOME MEASURES: Variables including sex, mechanism of injury, Glascow Coma Score, Pediatric Trauma Score, fall height, lower extremity injury, blood on rectal examination, blood at meatus, and clinical need for computed tomography (CT) were compared with outcomes of pelvic fracture and pelvic fracture requiring surgical intervention. RESULTS: There were 22 pelvic fractures identified, resulting in a fracture rate of 4%. The negative predictive value for pelvic fracture was 98.3% (95% confidence interval [95% CI], 96.9%-99.2%) if no lower extremity injury was present, 99% (95% CI, 98.2%-99.6%) if physical examination of the pelvis was normal, and 99.5% (95% CI, 98.6%-99.9%) if there was no need for abdominopelvic CT. The negative predictive value was 100% (95% CI, 98.8%-100%) if any one of these 3 factors is present. CONCLUSIONS: Using the clinical findings of (1) lack of lower extremity injury, (2) lack of an abnormal physical examination of the pelvis, and (3) no need for abdominopelvic CT, pelvic fracture can be reliably excluded. Pelvic radiography can be eliminated in the evaluation of these patients, potentially decreasing time expenditure, radiation exposure, and cost.

Paintball injuries in children: more than meets the eye.

OBJECTIVE: To describe the increasing incidence of ocular injuries in the pediatric population caused by paintballs. The awareness of this trend will help the physician who treats the child to give appropriate care as well as educate physicians, who counsel children, about this growing mechanism of pediatric injuries. METHODS: Previously unpublished data from the US Consumer Product Safety Commission were analyzed to find the frequency of ocular injuries in children. A review of the English-language literature was also conducted to describe trends with regard to age, sex, location at the time of injury, use of eye protection, types of injuries sustained, and long-term visual outcome. RESULTS: The incidence of paintball eye injuries treated in emergency departments has risen from an estimated 545 in 1998 to >1200 in 2000. The proportion of these injuries that occurred in the pediatric population may be well over 40%. These injuries are seen predominantly in boys, a growing proportion of whom are playing informally in unsupervised settings and not wearing eye protection. The cases previously reported include large numbers of hyphemas, retinal detachments, cataracts, corneal abrasions, vitreous hemorrhages, and commotio retina. Many of the patients in these cases sustained permanent visual impairment, with 43% having best vision at follow-up of 20/200 or worse. CONCLUSIONS: Pediatric eye injuries caused by paintballs are an unrecognized cause of severe injury and permanent visual loss. The advances in eye protection for participants in "war games" have had little if any effect on the youngest population. Children and teens are unlikely to wear eye protection voluntarily when playing at undesignated or unsupervised locations. Changes should be made to restrict availability of these very dangerous but easily acquired guns and ammunition. Practitioners must counsel young people and their caregivers to avoid injuries by wearing appropriate eye protection. Parents should supervise the use of paintball equipment as they would other activities that involve high-speed projectiles.

Accidental and abusive head injury in young children.

Children commonly present for medical care after sustaining head trauma. In children younger than 2 years of age, the practitioner must distinguish accidental head injury from abusive head injury. The following article discusses the evaluation of children with head injury and how to make the distinction between accidental and abusive head injury.