Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome.

STUDY OBJECTIVE: To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines. METHODS: A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed. RESULTS: We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in 2021. CONCLUSION: Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.

Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value.

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

Facilitators and barriers for parental consent to pediatric emergency research.

BACKGROUND: Obtaining informed consent for clinical research in the pediatric emergency department (ED) is challenging. Our objective was to understand the factors that influence parental consent for ED studies. METHODS: This was a cross-sectional survey assessing parents' willingness to enroll their children into an ED research study. Parents reporting a willingness to enroll in ED studies were presented with two hypothetical scenarios, a low-risk and a high-risk study, and then asked about decision influencers affecting consent. Parents expressing a lack of willingness to enroll were asked which decision influencers impacted their consent decision. RESULTS: Among 118 parents, 90 (76%) stated they would be willing to enroll their child into an ED study; of these, 86 (96%) would consent for a low-risk study and 54 (60%) would consent for a high-risk study. Caucasian parents, and those with previous research exposure, were more likely to report willingness to participate. Those who would consent to the high-risk study cited "benefits that research would provide to future children" most strongly influenced their decision to agree. CONCLUSIONS: ED investigators should highlight the benefits for future children and inquire about parents' previous exposure to research to enhance ED research enrollment. Barriers to consent in non-Caucasian families should be further investigated. IMPACT: Obtaining consent for pediatric emergency research is challenging and this study identified factors influencing parental consent for research in EDs. Benefits for future children and parents' previous research experience were two of the most influential factors in parents' willingness to consent to ED research studies. These findings will help to improve enrollment in ED research studies and better our understanding of how to promote the health and well-being of pediatric patients.

"These Are Our Kids": Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care.

STUDY OBJECTIVE: Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. METHODS: In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. RESULTS: Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. CONCLUSION: Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.

Adolescent alcohol use predicts cannabis use over a three year follow-up period.

Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children.

OBJECTIVE: When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. METHODS: Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. RESULTS: There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/µL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. CONCLUSIONS: Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Racial/Ethnic Differences in Pediatric Emergency Department Wait Times.

OBJECTIVES: Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. METHODS: We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. RESULTS: Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. CONCLUSIONS: In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

Prescribing Patterns of Oral Opioid Analgesic for Acute Pain at a Tertiary Care Children's Hospital Emergency Departments and Urgent Cares.

OBJECTIVES: Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days. METHODS: A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded. RESULTS: Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4-3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for >7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received >3 days of opioids were younger (P < 0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications. CONCLUSIONS: Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.

Prescribing Patterns of Oral Opioid Analgesic for Long Bone Fracture at Tertiary Care Children's Hospital Emergency Departments and Urgent Cares.

OBJECTIVES: Disparities in opioid prescribing in children can lead to underprescribing and poorly controlled pain. On the contrary, unnecessary overprescribing can increase the risk for misuse, abuse, and diversion. The primary objective of this study was to compare the demographics and clinical characteristics of children with an extremity fracture who did and did not receive an opioid prescription from a tertiary care children's hospital. METHODS: This was a retrospective cohort study of children younger than 22 years with extremity fracture evaluated at a tertiary care children's hospital emergency department (ED) and surrounding satellite locations (3 EDs and 4 urgent cares), from January 1, 2017, to December 31, 2017. RESULTS: There were 3325 patients younger than 22 years who were seen for evaluation of an extremity fracture. The overall median age of patients was 8 years (interquartile range [IQR], 4-11), and 1976 (59.4%) were male. Patients with extremity fractures who received opioid analgesics were older than those who did not receive opioids (median age of 10 years [IQR, 6-13 years] vs 7 years [IQR, 4-11 years], P < 0.001). There was a significant difference found between insurance types, specifically those patients receiving Medicaid and private insurance. Patients who received opioid analgesics had a higher initial pain score (7 [IQR, 4-9] vs 5 [IQR, 2-7], P < 0.001), were more likely to have an physician (MD/DO) provider (P < 0.001), and were more likely to present to the ED (P < 0.001). CONCLUSIONS: Younger patients, patients with Medicaid insurance, patients treated by an advanced care provider, and patients who presented to an urgent care were less likely to receive opioid analgesics upon discharge. These findings demonstrate that more standardization and guidance on opioid prescribing are needed in pediatrics, to both adequately treat pain and reduce harms from overprescribing of opioid analgesics.

Development and Validation of a Predictive Model of the Risk of Pediatric Septic Shock Using Data Known at the Time of Hospital Arrival.

OBJECTIVE: To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival. STUDY DESIGN: This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set. RESULTS: Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set. CONCLUSIONS: This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.

Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry.

OBJECTIVE: To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN: This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS: Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS: In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.

A Multiyear Cross-sectional Study of Guideline Adherence for the Timeliness of Opioid Administration in Children With Sickle Cell Pain Crisis.

STUDY OBJECTIVE: The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. METHODS: We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. RESULTS: A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both). CONCLUSION: Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.

Opioid Prescription Patterns at Emergency Department Discharge for Children with Fractures.

OBJECTIVE: To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. DESIGN: A retrospective cohort study of pediatric ED visits in 2015. SETTING: Four pediatric EDs. SUBJECTS: Children aged four to 18 years with a long-bone fracture discharged from the ED. METHODS: A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. RESULTS: There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9-9.7%), B = 12.1% (95% CI = 10.5-14.0%), C = 16.9% (95% CI = 15.2-18.8%), D = 23.8% (95% CI = 21.7-26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12-18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. CONCLUSIONS: For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.

Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries.

STUDY OBJECTIVE: To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors. METHODS: This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries. RESULTS: The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support. CONCLUSION: Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries.

Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use?

BACKGROUND: The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse. OBJECTIVE: A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs. METHODS: Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer. RESULTS: A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

Methodology and Demographics of a Brief Adolescent Alcohol Screen Validation Study.

OBJECTIVE: The aim of this study was to determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network pediatric emergency departments. This article describes the study methodology, sample characteristics, and baseline outcomes of the NIAAA 2-question screen. METHODS: Participants included 12- to 17-year-olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA 2-question screen and other measures of alcohol, drug use, and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA 2-question screen. RESULTS: There were 4834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across sex and age. Forty-six percent of the participants identified as white, and 26% identified as black. Approximately one quarter identified as Hispanic. Using the NIAAA 2-question screen algorithm, approximately 8% were classified as low risk, 12% were classified as moderate risk, and 4% were classified as highest risk. Alcohol use was less likely to be reported by black participants, non-Hispanic participants, and those younger than 16 years. DISCUSSION: This study successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race within pediatric emergency departments.

The Sensitivity of Clinician Diagnosis of Sepsis in Tertiary and Community-Based Emergency Settings.

OBJECTIVES: To assess whether the risk of missed clinician diagnosis of pediatric sepsis requiring care in the intensive care unit (ICU) was greater in community vs tertiary pediatric emergency care settings with sepsis pathways. STUDY DESIGN: An observational cohort study in a tertiary pediatric emergency department (ED) staffed by pediatric emergency physicians and 4 affiliated community pediatric ED/urgent care sites staffed by general pediatricians. Use of an institutional sepsis order set or pathway was considered clinician diagnosis of sepsis. Risk of missed diagnosis was compared for 2 outcomes: suspected infection plus ICU admission (sepsis-ICU) and suspected infection plus vasoactive agent/positive-pressure ventilation (sepsis-VV). RESULTS: From January 1, 2014 to December 31, 2015, there were 141 552 tertiary and 139 332 community emergency visits. Clinicians diagnosed sepsis in 1136 visits; median age was 5.7 (2.4, 12.0) years. In the tertiary ED, there were 306 sepsis-ICU visits (0.2%) and 112 sepsis-VV visits (0.08%). In community sites, there were 46 sepsis-ICU visits (0.03%) and 20 sepsis-VV visits (0.01%). The risk of missed diagnosis in community vs tertiary sites was significantly greater for sepsis-ICU (relative risk 4.30, CI 2.15-8.60) and sepsis-VV (relative risk 14.0, CI 2.91-67.24). Sensitivity for sepsis-ICU was 94.4% (91.3%-96.5%) at the tertiary site and 76.1% (62.1%-86.1%) at community sites. CONCLUSIONS: The risk of missed diagnosis of sepsis-ICU was greater in community vs tertiary emergency care settings despite shared pathways and education, but with differences in resources, providers, and sepsis incidence. More research is needed to optimize diagnostic approaches in all settings.

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.

BACKGROUND: The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. OBJECTIVE: Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). METHODS: This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. RESULTS: Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. CONCLUSIONS: We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Psychological Factors Associated with Delayed Symptom Resolution in Children with Concussion.

OBJECTIVE: To characterize the psychological factors associated with persistent symptoms after pediatric concussion. STUDY DESIGN: Longitudinal cohort study of 179 children with concussion 8-18 years old evaluated in a pediatric emergency department. Participants were followed for 1 month for delayed symptom resolution, defined as ≥3 symptoms that were new/worse than preinjury symptoms measured by the use of graded symptom inventory. Preinjury psychological traits were measured by parental report on subscales of the Personality Inventory for Children-2 (maladjustment, cognitive abilities, somatization). Child report of postinjury anxiety and injury perception were measured with the State-Trait Anxiety Inventory for Children and Children's Illness Perception Questionnaire. Psychological instrument scores were compared between those with and without delayed symptom resolution via a Kruskal-Wallis test. Associations between psychological traits and delayed symptom resolution were investigated by the use of logistic regression. RESULTS: Delayed symptom resolution occurred in 21% of participants. Score distributions were significantly worse on the State-Trait Anxiety Inventory for Children (38 [IQR 33-40] vs 35 [IQR 31-39]; P = .04) and somatization subscale (1 [IQR 0-3] vs 1 [IQR 0-1]; P = .01) among children with delayed symptom resolution compared with children with early symptom resolution. Somatization was associated with delayed symptom resolution (aOR 1.35, 95% CI 1.08-1.69). The proportion of children with abnormal somatization scores was significantly greater in the delayed symptom resolution group (34.2%) than the early symptom resolution group (12.8%; P < .01). Other psychological measures were not different between groups. CONCLUSION: Somatization is associated with delayed symptom resolution in this cohort of children with concussion. Postconcussive symptoms lasting at least 1 month may warrant referral to a neuropsychologist familiar with postconcussion care.

Lactate Clearance and Normalization and Prolonged Organ Dysfunction in Pediatric Sepsis.

OBJECTIVES: To evaluate whether lactate clearance and normalization during emergency care of pediatric sepsis is associated with lower rates of persistent organ dysfunction. STUDY DESIGN: This was a prospective cohort study of 77 children <18 years of age in the emergency department with infection and acute organ dysfunction per consensus definitions. In consented patients, lactate was measured 2 and/or 4 hours after an initial lactate; persistent organ dysfunction was assessed through laboratory and physician evaluation at 48 hours. A decrease of ≥ 10% from initial to final level was considered lactate clearance; a final level < 2 mmol/L was considered lactate normalization. Relative risk (RR) with 95% CIs, adjusted in a log-binomial model, was used to evaluate associations between lactate clearance/normalization and organ dysfunction. RESULTS: Lactate normalized in 62 (81%) patients and cleared in 70 (91%). The primary outcome, persistent 48-hour organ dysfunction, was present in 32 (42%). Lactate normalization was associated with decreased risk of persistent organ dysfunction (RR 0.46, 0.29-0.73; adjusted RR 0.47, 0.29-0.78); lactate clearance was not (RR 0.70, 0.35-1.41; adjusted RR 0.75, 0.38-1.50). The association between lactate normalization and decreased risk of persistent organ dysfunction was retained in the subgroups with initial lactate ≥ 2 mmol/L and hypotension. CONCLUSIONS: In children with sepsis and organ dysfunction, lactate normalization within 4 hours was associated with decreased persistent organ dysfunction. Serial lactate level measurement may provide a useful prognostic tool during the first hours of resuscitation in pediatric sepsis.