Effect of illuminated musical mobile on sleep quality of children hospitalized in pediatric emergency departments

PURPOSE

The aim of this study is to evaluate the effect of an illuminated musical mobile on the sleep quality of children hospitalized in a pediatric emergency department.

DESIGN AND METHODS

In this randomized controlled study, 124 children presenting to a pediatric emergency department who met the inclusion criteria were included in the study. Patients were randomized into two equal groups. In the intervention group, an illuminated musical mobile was used to help facilitate sleep. In the control group, routine sleep routines were continued. Groups were compared according to sleep quality as evaluated by mothers' observations. Evaluation was performed twice (before intervention - 1st day of hospitalization and on the intervention day - 2nd day of hospitalization).

RESULTS

Average age of children was 1.86 ± 0.78 years. On the intervention day, nighttime sleep duration was longer in the intervention group (p < .0001). Also, the frequency of spontaneous awakening (p < .0001), time to fall asleep after spontaneous awakening (p < .0001) and sleep time problems (p < .0001) were less in the intervention group. CONCLUSıONS: An illuminated musical mobile was used for the first time in the pediatric emergency department and was found to be effective in improving the sleep quality of hospitalized children aged between 1 and 3 years.

PRACTICE IMPLICATIONS

During hospitalization, children's sleep quality can be increased by using methods and objects suitable for the child's developmental level.

Psychiatric comorbidities and dehydration are more common in children admitted to the emergency department for eating disorders in the COVID-19 era

PURPOSE

Since the beginning of COVID-19 pandemic, social distancing and home confinement had a significant impact on children, especially on those with eating disorders (ED). The primary objective of this retrospective study was to describe and analyze the demographic and clinical profiles of children presenting with ED during the COVID-19 pandemic.

METHODS

We conducted a retrospective review of clinical charts of patients with ED younger than 18 years who accessed the emergency department of the Bambino Gesù Children's Hospital, Rome, between March 2019 and March 2021. Of these, we reported and compared the demographic, clinical and laboratory data before and after the COVID-19 pandemic and looked for predictors of ED severity.

RESULTS

A total of 211 admissions for ED were recorded. The patients, mostly females (86.3%) were on average 14.1 years old. The mean weight loss on admission was 11 kg. Bradycardia was observed in 31.3% of the study sample. 16.6% of patients had an associated psychiatric disorder and 60.2% required psychotropic drugs. 68.7% of the patients required hospitalization. Respectively, 96 and 115 patients were admitted before and during the COVID-19 pandemic. The latter were hospitalized more (78.3 vs 57.3%; p = 0.001), yet for less time (19 vs 26 days; p = 0.004), had a higher mean serum creatinine (0.68 vs 0.47; p < 0.001) and were more frequently diagnosed with an associated psychiatric disorder (23.5 vs 8.3%; p = 0.003).

CONCLUSION

Our study shows a significant increase of hospitalizations of children with ED during the COVID-19 pandemic, along with a shorter length of stay, more psychiatric comorbidities, and some distinctive features at the laboratory work-up, such as an increase of serum creatinine and/or a reduction of serum albumin.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort or case-control analytic studies.

Using the Delphi method to establish pediatric emergency triage criteria in a grade A tertiary women's and children's hospital in China

BACKGROUND

We aimed to establish simplified and quantifiable triage criteria in pediatric emergency care, improving the efficiency of pediatric emergency triage and ensuring patient safety.

METHODS

We preliminarily determined the pediatric emergency triage criteria with references to pediatric emergency department characteristics and internationally recognized triage tools after literature review and discussion. The final determination of the triage criteria was reached after two rounds of Delphi surveys completed by18 experts from 3 hospitals in China.

RESULTS

Both round 1 and round 2 surveys had a 100% response rate. The overall expert authority coefficient in the two rounds of surveys was 0.872. The experts had 100% enthusiasm for participating in the surveys. Kendall's coefficients of concordance for conditions/symptoms in patients triaged to level 1, 2, 3, and 4 were 0.149, 0.193, 0.102, and 0.266, respectively. All p-values were less than 0.05. The coefficients of variation in conditions/symptoms, vital signs, and the Pediatric Early Warning Score (PEWS) ranged between 0.00 and 0.205, meeting the inclusion criteria. The pediatric emergency triage criteria containing conditions/symptoms, vital signs, PEWS scores, and other 4 level 1 indicators, 51 level 2 indicators and 23 level 3 indicators were built. The maximum waiting time to treatment for the patients triaged to level 1, 2, 3, and 4 was immediate, within 10 min, within 30 min, and within 240 min, respectively.

CONCLUSION

The pediatric emergency triage criteria established in this study was scientific and reliable. It can be used to quickly identify the patients requiring urgent and immediate care, thereby ensuring the priorities for the care of critically ill patients.

Reliability and feasibility of optic nerve point-of-care ultrasound in pediatric patients with ventricular shunts

PURPOSE

To determine the interrater reliability of optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) via ocular ultrasound by emergency and neurosurgery providers in children with ventricular shunts, and to explore the feasibility of acquiring and measuring images.

METHODS

Two novices who underwent focused training and one expert in ocular ultrasound independently acquired images and measured ONSD and ODE on the same children, 0-18 years with ventricular shunts, blinded to each other's images and measurements. Patient tolerance, image quality, and time-to-complete exams were recorded. Images meeting a priori defined quality metrics were included. Mixed models and bootstrap analysis were used to obtain inter-rater reliability and 95% confidence intervals.

RESULTS

Eighty-one children were enrolled from August 2016 to July 2017, with mean age 9.6 years (SD 5.25, range 5 months-17.7 years). High-quality images (≥ 4 on 7-point quality Likert scale) were obtained in 83% of ONSD assessments and 95% of ODE assessments. The ICC_ONSD was 0.82 (95% CI 0.76-0.91) for right eyes and 0.73 (95% CI 0.69-0.85) for left, while ICC_ODE was 0.81 (95% CI 0.75-0.89) for right eyes and 0.85 (95% CI 0.79-0.91) for left. Mean study duration (both eyes) was 2:52 min (SD 54 s).

CONCLUSION

Clinicians generated high-quality ocular ultrasound images with excellent interrater reliability when acquiring and measuring images of ONSD and ODE in children with ventricular shunts.

To embrace and be present: The lived experiences of nurse-led consultations in Sweden from the perspective of pediatric nurses

PURPOSE

This study describes the lived experiences of nurse-led consultations in pediatric emergency departments from the perspective of pediatric nurses.

DESIGN AND METHODS

A descriptive qualitative study with a reflective lifeworld research approach was used to explore nurses' experiences of nurse-led consultations. The study was conducted through meaning-oriented individual interviews with ten pediatric nurses.

RESULTS

The results are grouped into four themes: (a) embracing the encounter and being touched by it; (b) having time to be present and committed; (c) having the ability and trusting in one's intuition; and (d) negotiating between families' wishes and the organization's guidelines.

CONCLUSIONS

Our study shows that nurse-led consultations conducted in separate nurse-led reception areas promote a positive experience of the consultations from the perspective of pediatric nurses. In a nurse-led consultation, a nurse's confidence in their ability to provide care is connected to time, broad skills and knowledge, and a supportive organization.

PRACTICE IMPLICATIONS

As the rising global population increases the demand for healthcare services, pediatric emergency departments must streamline their services to provide patient-safe, high-quality health care. Nurse-led consultations are an effective means of meeting these growing demands. This study contributes to an understanding of pediatric nurses' experiences at both the individual level and a more structured level, namely that families' wishes and an organization's guidelines do not always coincide.

Pain management of upper limb fractures in pediatric emergency department versus general orthopedics emergency department

Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the "Meir" Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0-18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001).

COMPLICATIONS

Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups.

CONCLUSIONS

 The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay.

WHAT IS KNOWN

• Pain management and control is a major issue to address in their treatment. • Traumatic injuries and especially fractures are common causes for ED admissions.

WHAT IS NEW

• Comparing pain management and upper limb fractures treatment between general and pediatric ED. • Pain is better treated in the PED than in the GED, without an increased rate of complications.

Triage travel screening in the pediatric emergency department: A cross-sectional analysis to evaluate current use and effectiveness in identifying travel related illness

OBJECTIVES

In 2014 the Center for Disease Control and Prevention recommended emergency departments (EDs) implement triage travel screening to identify persons at risk for Ebola Virus Disease (EVD). EVD remains rare in the United States, and in practice the triage travel screen serves as a de facto screen for all travel-related illnesses. This study seeks to determine the current use and effectiveness of the triage travel screen to detect travel-related illness in the pediatric ED.

METHODS

This was a retrospective, cross-sectional study of visits across three pediatrics EDs in 2019 in Atlanta, GA. Prevalences of travel-related illnesses were compared between patients with positive and negative travel screens. Patient charts with diagnoses of travel-related illness were then reviewed.

RESULTS

Out of 244,841 patient encounters during the study period, 13 patients with travel-related illness were identified. 5/13 cases of travel-related illness were not diagnosed at the initial ED visit. Of these 5 cases, 2 had correctly negative travel screens (as travel was not within the specified timeframe) and 3 had correctly positive travel screens, but none had a clinician-documented travel history in the ED clinical notes. Of the 8/13 cases that were diagnosed at the initial ED visit, 7/8 had a clinician-documented travel history in the ED note.

CONCLUSIONS

This study highlights the limitations of the current pediatric ED triage travel screen to detect travel-related illness and reinforces the importance of a provider-taken travel history. Strategies to increase provider-administered travel history documentation and revisions to increase triage travel-screen efficacy should be considered.

Missed Opportunities for Sexual History Documentation and Sexually Transmitted Infection Testing in the Pediatric Emergency Department

PURPOSE

Sexually transmitted infections (STIs) are disproportionally prevalent in adolescents, and adolescents often present to the pediatric emergency department (PED) for STI care. Prior studies have found low rates of sexual history documentation and STI testing in the PED. However, these studies have had limited sample sizes because of the burden of manual chart review. We aimed to estimate the rate of sexual history documentation and identify factors associated with STI testing in a large cohort of adolescents using natural language processing (NLP).

METHODS

We applied a validated NLP algorithm to all adolescent visits over a three-year period to the PED at a single large children's health care organization with a chief complaint potentially related to an STI. We utilized NLP to determine the prevalence of sexual history documentation in these patients. We applied logistic regression models to determine associations between sexual history documentation, patient demographic factors, and STI testing.

RESULTS

Of the 1,987 patient encounters included, only 56% had a sexual history documented, and only 40% of all patients were tested for STIs. Patients were more likely to have a sexual history documented and to be tested for STIs if they were of non-Hispanic black race/ethnicity, were >15 years of age, and had nonprivate insurance. Patients with a sexual history documented were seven times more likely to have STI testing ordered. Of patients tested (n = 728), 25% were positive for an STI.

CONCLUSIONS

Despite presenting to the PED with symptoms potentially related to an STI, many adolescents are not receiving recommended sexual health care. Rates of sexual history documentation and STI testing varied by demographic factors including race, age, and insurance status. Utilizing NLP technology allowed us to examine a larger sample size than previously documented in the adolescent sexual history and PED literature. This study highlights critical opportunities to improve sexual health provision and equity of care provided in the PED.

Evaluation of accidental and intentional pediatric poisoning: Retrospective analysis in an emergency Department of Turkey

INTRODUCTION

Childhood poisoning is one of the leading causes of applications to ED and is a preventable cause of morbidity and mortality. The characteristics of poisoning may differ by geographic region, season, and the sociocultural aspects of the community and age groups.

METHOD

Poisoned patients age ≤ 18 years admitted to the ED January 2018-December 2019, were evaluated retrospectively.

RESULTS

Of 170 cases, mean age was 7.48 ± 5.54 years. Of the cases, 0-5 years (44.1%), 6-12 years (24.7%), and 13-18 years (31.2%); most were female (58.2%). Causes were accidental (72.9%), intentional (24.1%), and substance use (2.9%). Accidental cases were all patients age 0-5 years, 31.8% of age 6-12 years, and 24.5% of age 13-18 years. Drugs caused 72.9% of cases, primarily analgesics (22.4%), among which nonsteroidal anti-inflammatory drugs were most common (12.4%). Intentional poisoning by repeated drug intake caused 5.9% of cases. Rat poison caused 7.1% of non-drug cases. Treatment was gastric lavage (52.4%) and oral activated charcoal (45.9%).

CONCLUSION

As a result of the study, it was determined that accidental drug intake was the most common reason for children to apply to the ED due to acute poisoning in our region. Childhood poisoning can be prevented by measures to be taken by the environment, family, and healthcare professionals.

PRACTICE IMPLICATIONS

The fact that children's acute poisoning cases are mostly accidental in our region shows that it is important to raise the awareness of parents to reduce acute poisoning and alleviate its negative consequences.

Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework

Background

Pediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors.

Methods

Semi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles.

Results

Fifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling.

Conclusions

Study findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.

Prevalence of children witnessed violence in a pediatric emergency department

Witnessed violence is a form of child abuse with detrimental effects on child wellbeing and development, whose recognition relies on the assessment of their mother exposure to intimate partner violence (IPV). The aim of this study was to assess the frequency of witnessed violence in a population of children attending a pediatric emergency department (ED) in Italy, by searching for IPV in their mother, and to define the characteristics of the mother-child dyads. An observational cross-sectional study was conducted from February 2020 to January 2021. Participating mothers were provided a questionnaire, which included the Woman Abuse Screening Tool (WAST) and additional questions about their baseline data and health. Descriptive analysis was reported as frequency and percentage for the categorical variables and median and interquartile range (IQR) for quantitative variables. Mothers and children screened positive and negative for IPV and witnessed violence, respectively, were compared by the chi-square test or the exact Fisher test for categorical variables, and by the Wilcoxon-Mann-Whitney test for continuous variables. Out of 212 participating mothers, ninety-three (43.9%) displayed a positive WAST. Mothers tested positive were mainly Italian (71%, p 0.003), had a lower level of education (median age at school dropout 19, p 0.0002), and a higher frequency of unemployment (p 0.001) and poor personal health status (8.6%, p 0.001). The children of mothers tested positive showed a higher occurrence of abnormal psychological-emotional state (38.7%, p 0.002) and sleep disturbances (26.9%, p 0.04).

CONCLUSION

IPV was common in a population of mothers seeking care for their children in a pediatric ED.

WHAT IS KNOWN

• Witnessed violence is a form of child abuse, usually inferred by their mothers' exposure to IPV. The latter is suffered by one in three women worldwide.

WHAT IS NEW

• This study shows a 43.9% prevalence of IPV among mothers attending an Italian pediatric ED. • Positive mother-child dyads displayed a higher frequency of poor mothers' health status and children's abnormal emotional state and sleep disturbances.

A Comparison of Two Different Tactile Stimulus Methods on Reducing Pain of Children During Intramuscular Injection: A Randomized Controlled Study

INTRODUCTION

Pediatric patients in the emergency department often require intramuscular injection procedures, which may lead to pain, fear, and anxiety. The purpose of this study was to test a novel nonpharmacological intervention to reduce needle-related pain in the pediatric emergency department.

METHODS

The study was conducted as a parallel-group, randomized controlled design. The study population consisted of 159 children aged 7 to 10 years cared for in the emergency department who received an intramuscular injection of ampicillin/sulbactam. The children were randomly assigned to Palm Stimulator, ShotBlocker, or control groups. The children's preprocedure fear levels were evaluated using the Children's Fear Scale, and their perceived pain levels during the procedure were evaluated using the Faces Pain Scale-Revised and Visual Analog Scale. Parents and observers also completed the pain level scores.

RESULTS

According to all raters (child, parent, and observer), the Palm Stimulator group had the lowest mean Faces Pain Scale-Revised score averages (P < .001). The Visual Analog Scale score averages of the children in the Palm Stimulator group (Visual Analog Scale: M = 27.94, standard deviation = 19.13) were statistically significantly lower than the ShotBlocker (Visual Analog Scale: M = 46.07, standard deviation = 24.96) and control group (Visual Analog Scale: M = 53.43, standard deviation = 29.01) score averages (F = 14.94, η² = 0.16, P = .001).

DISCUSSION

The results of this study support the effectiveness of the Palm Stimulator to reduce perceived pain in children during intramuscular injection administration in the pediatric emergency department.

Clinical decision support for tobacco screening and counseling parents of pediatric patients: A qualitative analysis of pediatric emergency department and urgent care professionals

Background

Clinical Decision Support Systems (CDSS) embedded into electronic medical records is a best practices approach. However, information is needed on how to incorporate a CDSS to facilitate parental tobacco cessation counseling and reduce child tobacco smoke exposure (TSE) in Pediatric Emergency Department (PED) and Urgent Care (UC) settings. The objective was to explore the barriers and enablers of CDSS use to facilitate child TSE screening and parental tobacco cessation counseling by PED/UC nurses and physicians.

Methods

We conducted 29 semi-structured, focused interviews with nurses (n = 17) and physicians (n = 12) at a children's hospital PED/UC. The interview guide included a brief presentation about the design and components of a prior CDSS tobacco intervention. Participants were asked their opinions about CDSS components and recommendations for adapting and implementing the CDSS tobacco intervention in the PED/UC setting. A thematic framework analysis method was used to code and analyze qualitative data.

Results

Participant mean (± SD) age was 42 (± 10.1) years; the majority were female (82.8%), non-Hispanic white (93.1%), and never tobacco users (86.2%); all were never electronic cigarette users. Four themes emerged: (1) explore optimal timing to complete CDSS screening and counseling during visits; (2) CDSS additional information and feedback needs; (3) perceived enablers to CDSS use, such as the systematic approach; and (4) perceived barriers to CDSS use, such as lack of time and staff.

Conclusions

The CDSS intervention for child TSE screening and parental tobacco cessation during PED/UC visits received endorsements and suggestions for optimal implementation from nurses and physicians.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes

BACKGROUND

While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED.

METHODS

We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major.

RESULTS

Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these.

CONCLUSIONS

APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

The Effect of Music-Moving Toys to Reduce Fear and Anxiety in Preschool Children Undergoing Intravenous Insertion in a Pediatric Emergency Department: A Randomized Clinical Trial

INTRODUCTION

Intravenous catheter insertion is a highly invasive medical procedure that causes fear and anxiety in children. This study aimed to analyze the effect of a toy (with music and movement) distraction method on fear and anxiety in children aged 4 to 6 years.

METHODS

This experimental, randomized clinical trial used parallel trial design guided by the Consolidated Standards of Reporting Trials checklist. Using simple randomization, eligible children (age 4-6; N = 60) were assigned to the intervention group (n = 30), who received the toy distraction method, or to the control group (n = 30), who received standard care. The Children's Fear Scale was used to evaluate the fear levels, and Children's State Anxiety Scale was used to evaluate anxiety levels. Physiological parameters (pulse, oxygen saturation) and crying time were monitored by the researcher as indicators of fear and anxiety. The chi-square test, repeated measures analysis of variance, Friedman test, t test, the Mann-Whitney U test, Wilcoxon test, and the intraclass correlation test were used for data analysis.

RESULTS

There was no statistically significant difference in terms of fear and anxiety scores, physiological parameters, and crying time during the procedure between the children in the intervention and control group.

DISCUSSION

We found that this method of toy distraction was not effective in reducing fear or anxiety during the intravenous catheter insertion procedure. Accordingly, we recommend that this distraction method be performed in different age groups and with larger samples in various painful and stressful practices in the future and that comparison be made with various distraction methods.

Over-the-Counter Medication Prescribing in a Pediatric Emergency Department: Health Records Review

OBJECTIVE

The purpose of this project was to describe patterns in over-the-counter medication prescribing for nonacute patients with Medicaid in a pediatric emergency department. Differences were also tested in visit time and charges between patients with and without over-the-counter medication prescriptions.

METHODS

Retrospective chart review of children with Missouri Medicaid presenting to a single site between January 1, 2018 and December 31, 2018. Low-acuity patients with common diagnoses were included. Over-the-counter medications prescribed, the cost of prescriptions, the time spent in the emergency department, provider care time, patient age, and the month of visit were extracted. Data were analyzed with descriptive statistics and t tests.

RESULTS

Approximately 37% of children were prescribed over-the-counter medications, most commonly antipyretics. When comparing visits in which an over-the-counter medication was prescribed to visits without an over-the-counter medication prescription, we found no significant difference in the associated charges, total time in the department, and provider care time.

CONCLUSION

Over-the-counter medications were prescribed for more than one-third of children cared for in the pediatric emergency department for low-acuity presentations. These visits may represent a substantial area for Medicaid access barriers, system redesign, and cost savings.

Feeling Informed Versus Being Informed: Mixed-Methods Analysis of Family Perceptions and Behavior Following a Pediatric Emergency Department Visit

PURPOSE

To examine perceptions of family-centered care, satisfaction, and quality of communication with health professionals during a pediatric emergency department visit, and to evaluate the perceived usefulness of the information received and whether provider treatment recommendations were followed after discharge.

DESIGN

Embedded mixed methods design with two concurrent phases. Participants in phase 1 were 385 adult relatives of children (age 6 days-17 years, mean 5.0 years, SD 4.5) seen in a pediatric emergency department. On the day of the visit, relatives completed questionnaires exploring perceptions of family-centered care, satisfaction (CSQ-8), and quality of communication with professionals (ad hoc instrument). For phase 2, we conducted daily structured telephone interviews with 37 of these parents over the six consecutive days following the emergency visit.

RESULTS

Satisfaction with the visit was significantly related to the perception of family-centered care (B = 0.25; 95% CI [0.20, 0.29]; p < .001). Follow-up interviews revealed that 45.9% (n = 17) of families did not follow the prescribed treatment and 32.4% (n = 12) made a further appointment with their primary care pediatrician. Qualitative analysis suggested that families lacked certain information from care providers.

CONCLUSIONS

Elements of a family-centered approach were rated positively and families believed that the information they received was useful. Importantly, more than half of the families who were followed up by telephone had doubts about provider treatment recommendations.

PRACTICE IMPLICATIONS

Family-centered care in the pediatric emergency department could enhance communication and help to ensure that treatment recommendations are followed at home.

COVID-19: Differences in sentinel injury and child abuse reporting during a pandemic

BACKGROUND AND OBJECTIVES

There is widespread concern that the COVID-19 pandemic has increased the incidence of child maltreatment. However, reports in the scientific literature documenting rates of child maltreatment during this period are scarce. This study was designed to explore whether the incidence of child maltreatment among patients presenting to a pediatric emergency department has increased during the COVID-19 pandemic.

METHODS

We conducted a retrospective review of patients of all ages presenting to a pediatric Emergency Department trauma center, who also had a child abuse report filing or a sentinel injury diagnosis related to their index visit. All such patients who presented to this institution from March through July of 2017 through 2020 were included in the study.

RESULTS

Analysis demonstrated an increase in the incidence of child maltreatment in May and June of 2020 and that there was an overall shift in distribution of types of child maltreatment during the COVID-19 pandemic. There was a significant increase in the proportion of emotional/psychological abuse (2.52 % before the pandemic to 7.00 % during the pandemic, p ≤ 0.0001) and non-medical neglect (31.5%-40.0%, p ≤ 0.0001).

CONCLUSIONS

We observed an increase in specific types of child maltreatment during the COVID-19 pandemic. These findings highlight the need for increased attention to children at risk for child abuse and neglect.

Pediatric non-urgent emergency department visits and prior care-seeking at primary care

BACKGROUND

We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits.

METHODS

We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics.

RESULTS

Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit.

CONCLUSIONS

Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.

Neurological disorders encountered in a pediatric emergency department

AIM

Neurological disorders are one of the reasons for admission in pediatric emergency departments (PEDs). We aimed to evaluate the frequency of neurological disorders seen in a large tertiary PED.

METHODS

We conducted a one-year retrospective study that included 1471 medical records. Inclusion was based on the main complaint recorded by nurses at triage. We also retrieved the final diagnoses and the investigations performed in the PED.

RESULTS

About 3.4% of the yearly admissions was based on a neurologic complaint on arrival. The final diagnosis was of a neurologic disorder in 1237 children, 2% of which were admitted to the pediatric intensive care unit. An opinion from a child neurologist was requested for 33% of the children. Seizures were the most frequent reason for admission, followed by headaches. A previous visit to the PED in the past six months was a frequent finding (40%), and about one third of the patients with a neurologic diagnosis (except headaches) was already being followed by a child neurologist.

INTERPRETATION

Neurological disorders are frequent in our PED and are mainly represented by seizures and headaches. Appropriate training in epileptology might be helpful for healthcare professional working in PEDs.

Factors associated with pediatric firearm injury and enrollment in a violence intervention program

PURPOSE

To identify factors associated with firearm injury (FI) and willingness to enroll in a violence intervention program amongst pediatric victims of violence.

METHODS

Cross-sectional study of victims of violence age 6-19 years presenting to a children's hospital emergency department from 2014 to 2017. Participants were interviewed by social workers prior to being offered enrollment in a violence intervention program. We used multivariate logistic regression analyses to identify factors associated with FI and enrollment in the violence intervention program.

RESULTS

Four hundred seven patients were analyzed, 156 (38%) of which were victims of FI and 251 (62%) were victims of non-firearm-related physical assaults (PA). Multiple factors were associated with FI including older adolescent age, male sex, separated/divorced parents, losses in family/social network due to violence, being on probation, illicit substance use, gang affiliation, and lack of school enrollment. One hundred four patients (26%) enrolled in the violence intervention program. There was no difference in enrollment between FI and PA. However, older adolescent age, illicit substance use and probation were associated with significantly decreased odds of enrolling in the program.

CONCLUSIONS

Multiple identifiable and potentially actionable risk factors exist amongst pediatric victims of acute FI. More specific targeting of at-risk groups may improve enrollment in violence interventions programs.

LEVEL OF EVIDENCE

This is a prognostic study, investigating the natural history of pediatric firearm injuries, factors associated with firearm injuries as well as those associated with patient propensity to enroll in a violence intervention program. This study is observational in nature and utilizes patients with non-firearm-related physical assaults as a control group, making this study Level III evidence.

How to recognize and manage psychosomatic pain in the pediatric emergency department

Aim

Children and adolescents affected by somatization and somatic symptom disorder commonly refer to emergency services. Due to the absence of specific guidelines for the emergency setting and to a possible lack of knowledge, these patients are at risk of being unrecognized and mismanaged. This study aims at proposing a clinical practice to approach and manage these patients and their families in the emergency setting.

Methods

This manuscript derived from the work of a research group of italian pediatric emergency physicians and anesthesiologists, with an expertise in pain management, members of the PIPER group. The research group reviewed the literature about psychosomatic pain and somatic symptom disorder and developed a clinical practice specific for the pediatric emergency setting.

Results

The manuscript provides information about the main clinical features shared by patients with psychosomatic pain and about current diagnostic criteria and appropriate management in the emergency setting. Furthermore, it highlights the possible pitfalls in which the emergency physician may run into dealing with these patients.

Conclusion

This clinical practice should be seen as a starting point toward a better understanding of patients with psychosomatic pain and a standardization of care in the pediatric emergency setting.

Effectiveness of Standard Combination Therapy in Pediatric Migraine

BACKGROUND

A combination of parenteral medications (often referred to as standard combination therapy) is frequently used in the treatment of acute migraine in the pediatric emergency department (PED). The primary aim of this study was to evaluate the two-hour, 24-hour, and seven-day impact of one such regimen on pain in children who present to the PED. Standard combination therapy for purposes of our study is defined as a bolus of intravenous saline, and a combination of intravenous ketorolac, prochlorperazine, and diphenhydramine.

METHODS

This prospective observational study included 120 children between the ages seven and 18 years who presented to the PED with migraine, whose parents could read and understand the consent form in English, and who were treated with standard combination therapy. The primary outcome measure for this study was the change in severity of pain as noted by the child using the Faces Pain Scale-Revised. We analyzed normally distributed continuous variables by mean and standard deviation, whereas non-normally distributed continuous variables are reported by median and interquartile range.

RESULTS

Nonparametric Friedman testing on the entire cohort (n = 120) noted that there was a statistically significant change in the Faces pain scale from before administration of standard combination therapy to the two-hour, 24-hour, and one-week time point with a reduction in pain score of 87.5%, 100%, and 50%, respectively, at the three time points.

CONCLUSIONS

This study noted moderate relief of pain after administration of standard combination therapy, which persisted at one-week after administration.

A cross-sectional study of screening for coronavirus disease 2019 (COVID-19) at the pediatric emergency department in Vilnius during the first wave of the pandemic

Screening for COVID-19 is based on clinical and epidemiological factors. Children infected with SARS-CoV-2 may have a few or many non-specific symptoms or may be asymptomatic. The aim of this study was to analyze clinical features and exposure to SARS-CoV-2 characteristics of children screened for COVID-19 at the pediatric emergency department in Vilnius during the first 3 months (March-May) of the COVID-19 pandemic in Lithuania. SARS-CoV-2 PCR was positive for 0.6% (8/1348) of all screened children and for 0.9% (7/811) of symptomatic patients, more among children with fever and cough (2.6%, 4/154). There were also COVID-19 cases among children without cough but with other respiratory symptoms (0.5%, 2/409) or gastrointestinal symptoms (1.2%, 3/257). Only one child with positive SARS-CoV-2 did not meet COVID-19 clinical criteria-he presented with vomiting and dehydration only. All COVID-19 cases (n = 8) had a contact with a confirmed COVID-19 family member. There were no COVID-19 cases among children without known exposure to SARS-CoV-2 or among asymptomatic children.Conclusion: Screening for COVID-19 in children is exceptionally challenging due to the diverse and non-specific symptoms of infection they present. Testing strategies should not only focus on the typical COVID-19 symptoms of fever or cough, but also include other symptoms, especially gastrointestinal symptoms, which are also important. The greatest attention should be paid to known exposure to SARS-CoV-2, especially in family clusters. Screening of asymptomatic children with no known exposure should be weighed for medical necessity and cost-effectiveness. What is Known: • Diagnosis of COVID-19 in children is challenging because the disease does not always manifest with typical symptoms. What is New: • Children in our study who did not have symptoms of acute infection and contact with another person infected with COVID-19 were not diagnosed with COVID-19, so the benefit of PCR testing is questionable. Such testing may only be useful for infection control purposes, and to limit intra-hospital transmission.