Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A Systematic Review and Meta-analysis

IMPORTANCE

Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial.

OBJECTIVE

To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required.

DATA SOURCES

MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included.

STUDY SELECTION

Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up.

RESULTS

The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.

Reducing Pediatric ED Length of Stay by Reducing Diagnostic Testing: A Discrete Event Simulation Model

Supplemental Digital Content is available in the text.

Quality improvement efforts can require significant investment before the system impact of those efforts can be evaluated. We used discrete event simulation (DES) modeling to test the theoretical impact of a proposed initiative to reduce diagnostic testing for low-acuity pediatric emergency department (ED) patients.

Adherence to national paediatric bronchiolitis management guidelines and impact on emergency department resource utilization

Objective

To evaluate the association between the use of nonrecommended pharmacology (salbutamol and corticosteroids) per national bronchiolitis guidelines, either during the index visit or at discharge, and system utilization measures (frequency of return visits [RTED] and on paediatric emergency department [PED] length of stay [LOS]).

Study Design

We conducted a retrospective case control study of 185 infants (≤12 months old) who presented to the PED between December 2014 and April 2017 and discharged home with a clinical diagnosis of bronchiolitis. Inclusion criteria included ≥ 1 viral prodromal symptom and ≥ 1 physical exam finding of respiratory distress. Cases were defined as infants who had ≥ 1 RTED within 7 days of their index visit and controls were matched for age and acuity but without RTED. Logistic regression analysis and multivariable linear regression were used to assess the odds of RTED and PED LOS associated with nonadherence to pharmaceutical recommendations per AAP and CPS bronchiolitis guidelines.

Results

Use of nonrecommended pharmacology per national bronchiolitis guidelines was documented among 39% of the 185 study participants. Adjusting for acuity of index visit, age, severe tachypnea, oxygen desaturation, and dehydration, use of nonrecommended pharmacology was not associated with RTED (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.47 to 2.03). Use of salbutamol and corticosteroids, however, were each independently associated with increased PED LOS (58.3 minutes [P=0.01] and 116.7 minutes [P<0.001], respectively).

Conclusion

Nonadherence to the pharmaceutical recommendations of national bronchiolitis guidelines was not associated with RTED but salbutamol and corticosteroid use increased PED LOS.

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol

INTRODUCTION

Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

METHODS AND ANALYSIS

This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

TRIAL REGISTRATION NUMBER

NCT0419525.

83 Electrocardiogram in Syncope: An old habit or clinically helpful?

Background

Syncope affects up to 50% of individuals by age 21 years and accounts for 1% of presentations to the emergency department (ED). Cardiac causes of syncope, including structural heart defects and rhythm disorders, cannot always be ruled out by an electrocardiogram (ECG) as this test lacks sensitivity and specificity. Conflicting recommendations for the role of ECG in evaluation of pediatric syncope underscore the clinical equipoise of how ECG findings influence physicians’ clinical decisions.

Objectives

The primary objective of this study is to determine how ECG findings affect ED physicians’ management of children presenting with vasovagal syncope. Our secondary objective is to document the practice pattern variation among ED physicians regarding their decision to obtain an ECG for the evaluation of vasovagal syncope in children.

Design/Methods

We conducted a prospective cross-sectional survey study using the REDCap platform. Our sample frame consisted of practicing emergency physicians enrolled in the Pediatric Emergency Research Canada (PERC) network. Outcome measures included frequency investigations, specialist consultation, and disposition stratified by type of syncope presentation (low/high risk). We also evaluated which specific ECG findings were likely to change physicians’ management and explored factors influencing the decision to perform or not perform the ECG.

Results

We obtained data from 105/225 (47%) potential respondents. In a clinical scenario presenting a vasovagal syncope, 52% of respondents would order an ECG. Forty-five percent changed their management if the ECG interpretation was anything other than “Normal ECG”. In a high-risk syncope scenario, an ECG was performed by 96% of respondents. Cardiology referral was requested by 93% of respondents, despite normal ECG findings. Borderline ECG findings led to significant practice variation in management, for both low and high-risk presentations scenarios. Overall, 66% of respondents stated that performing an ECG is not important to rule out a cardiac etiology in a typical vasovagal syncope presentation, but 64% stated that performing an ECG is important to reassure the patient.

Conclusion

There is substantial practice pattern variation among emergency physicians with regards to the frequency and motivations to order ECGs, and how ECG findings impact the management of pediatric syncope in the ED. Information provided by an ECG can lead to unnecessary change to clinical management, additional testing, and referrals to specialists for typical vasovagal syncope. This reinforces the importance of better knowledge translation surrounding evidence-based management of vasovagal syncope among ED physicians.

79 Acceptability and impact of psychosocial screening in the emergency department

Background

Psychosocial concerns in youth are prevalent and undertreated. Early identification through screening may promote appropriate management before youth present in crisis.

Objectives

Our primary objective was to assess the acceptability of psychosocial screening in the pediatric emergency department (ED) setting. Secondarily, we report the prevalence of psychosocial issues among youth with non-psychiatric ED presentations, and the impact of screening on mental health resource-seeking behaviour.

Design/Methods

We conducted a prospective cohort study of youth aged 10-17 years at two pediatric EDs. Youth with a mental health-related reason for visiting the ED were excluded. Eligible and consenting youth (and their families) completed a comprehensive psychosocial self-assessment delivered on an electronic tablet, followed by standardized clinician assessment. Consent to participate in the study was used as a proxy measure for acceptability of screening. Participants with identified psychosocial resource needs were followed up at 30 days with a semi-structured telephone/email interview to assess whether they had sought recommended resources and to explore barriers to accessing care.

Results

Of the 1432 eligible youth given the opportunity to enrol, 795 consented. Among the 637 youth who declined enrolment, 467 specified that they declined for reasons other than not wanting to conduct a psychosocial self-assessment. This suggests that at least 55.5% (95% CI = 52.9%, 58.1%) and up to 88.1% (95% CI = 86.4%, 89.8%) find screening acceptable.

Among the 760 participants who completed clinician assessment, 276 (36.3%) were identified as having a psychosocial resource need. Resources were already in place for 105 youth, leaving 171 (22.5%) with newly identified or unmet psychosocial needs. Only 41 (33.1%) of the 124 participants and/or their families who completed a 30-day follow up interview reported attempting to access the recommended resources, despite 92 (74.2%) stating they agreed with the original recommendations. The most common reason for not accessing care was the belief that the recommendations were not yet necessary or were not a priority. Of those who had attempted to access resources, 18 (43.9%) were unsuccessful at the time of interview, with the most common barrier being access delay (e.g. on a waitlist).

Conclusion

We found that previously unidentified/unmet psychosocial needs are prevalent among youth in the ED, and that screening is generally acceptable. However, a limited number of those who screened positive attempted to access resources, and when they did, access was often unsuccessful or delayed. More work is needed to address barriers to timely psychosocial care.

76 The predictive validity of MyHEARTSMAP for psychosocial screening in the emergency department

Background

Mental health concerns in childhood and adolescence are prevalent, affecting nearly one million Canadian youth. In the absence of screening, up to 98% of these concerns can go undiagnosed, leading to significant health, educational, and social consequences. Consequently, the American Academy of Pediatrics recommends the development of screening tools to facilitate early identification and access to treatment.

The Emergency Department (ED) represents a unique environment to implement such universal screening, as it is immediately accessible and may be the only point of contact for some vulnerable youth with undiagnosed illness. However, there are few existing instruments which take into account commonly cited barriers such as time constraints, disruption of ED flow, limited resources, and patient privacy.

Objectives

To facilitate efficient screening with minimal impact on ED flow, our team developed MyHEARTSMAP, an electronic self-administered screening tool. The tool is adapted from HEARTSMAP, a previously validated computerized assessment and management tool used by ED clinicians. MyHEARTSMAP has previously been evaluated for face validity and inter-rater reliability. Here, we measured the sensitivity and specificity of MyHEARTSMAP in identifying mental health concerns in youth.

Design/Methods

A prospective cohort study was conducted at two tertiary care pediatric EDs. Eligible youth aged 10-17 years presenting for a non-mental health complaint were invited to self-screen using MyHEARTSMAP. An accompanying parent/guardian could also complete an assessment of their child. The sensitivity and specificity was measured as the proportion of screened youth with mental health concerns identified through self-assessment by MyHEARTSMAP compared to assessment performed by a clinician (criteron standard).

Results

760 youth and/or parents completed the study intervention. The sensitivity at identifying any psychiatric concerns was comparable between youth and guardian assessments: 92.7% (95%CI: 89.1, 95.4%) and 93.1% (95%CI: 89.5, 95.8%) respectively. The specificity at identifying youth without any psychiatric issues was also comparable between youth and their guardians: 42.2% (95%CI: 37.3, 47.3) and 37.0% (95%CI: 32.2,42.1), respectively.

Conclusion

MyHEARTSMAP is sensitive for identifying youth with mental health concerns. While it showed only modest specificity, false positives were almost entirely (98%) mild issues identified by youth and deemed to be normal by clinicians. This would not place a burdensome demand on mental health services and could be effectively assessed without specialized psychiatric training. Thus, MyHEARTSMAP may be an effective tool for early identification and management of mental health concerns.

72 Validating MyHEARTSMAP, an emergency psychosocial self-assessment and management tool, among youth with minor traumatic brain injuries or minor orthopaedic injuries seen in the Paediatric Emergency Department

Background

Fewer than 20% of the estimated 1.2 million Canadian youths living with mental health (MH) concerns receive adequate care. Paediatric emergency department (PED) visits related to MH are increasing across North America. The online self-assessment tool, MyHEARTSMAP, was developed to facilitate screening of MH concerns in the PED and general practice. MyHEARTSMAP assesses 10 psychosocial areas, mapping to four domains of MH (Psychiatry, Function, Social, and Youth Health) to provide domain-specific recommendations for patient management (Figure A).

Objectives

We evaluated the convergent validity of MyHEARTSMAP when compared to established psychosocial self-assessment tools: Paediatric Quality of Life (PedsQL) and Strengths and Difficulties Questionnaire (SDQ).

Design/Methods

We conducted a cross-sectional study among youths and parents enrolled in a larger cohort study: Advancing Concussion Assessment in Paediatrics (A-CAP). Participants were children aged 8 to 16 years old with mild traumatic brain injury or orthopaedic injury and their parents. Participants were recruited from two PEDs in Alberta and British Columbia and were asked to complete MyHEARTSMAP, in addition to the PedsQL and SDQ completed in their A-CAP study procedures. We evaluated three MH domains from MyHEARTSMAP (PSYCHIATRY FUNCTION, AND SOCIAL) to their corresponding score sections in PedsQL (EMOTIONAL, SCHOOL, and SOCIAL) and SDQ (EMOTIONAL, none, and CONDUCT and PEER). We calculated Pearson correlation coefficients between these corresponding domains and sections.

Results

We recruited 40 child and parent pairs from Alberta and 82 from BC. The children were on average aged 12.6 years old (SD 2.2) and 44% were female. The tools screened participants as “at-risk” for various MH concerns at a rate of 26.7% to 60.8% for MyHEARTSMAP, 2.5% to 13.9% for PedsQL, and 12.3% to 16.0% for SDQ. Overall, MyHEARTSMAP was moderately correlated with PedsQL (mean ±95% CI: r = 0.405±0.151) and SDQ (mean ±95% CI: r = 0.322±0.162). Correlations (±95% CI) by MyHEARTSMAP domain for the child and parent versions, respectively, were as follows: PSYCHIATRY PedsQL (r = 0.483±0.140 / 0.509±0.134) and SDQ (r = 0.417±0.150 / 0.598±0.116); FUNCTION PedsQL (r = 0.578±0.122 / 0.455±0.143); SOCIAL PedsQL (r = 0.249±0.170 / 0.158±0.175) and SDQ (r = 0.207±0.172 / 0.067±0.178).

Conclusion

In conclusion, MyHEARTSMAP PSYCHIATRY and FUNCTION domains have moderate convergent validity to PedsQL and SDQ. Unlike PedsQL and SDQ, the evaluation of social issues in MyHEARTSMAP is MH-specific, resulting in low convergent validity for the SOCIAL domain.

Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department

OBJECTIVES

To evaluate the utility of universal psychosocial screening in the emergency department (ED) using MyHEARTSMAP, a digital self-assessment and management guiding tool.

STUDY DESIGN

We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents' self-assessment, against a clinician's standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening.

RESULTS

We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians' sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up.

CONCLUSIONS

Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care.

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study

BACKGROUND

Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.

METHODS

We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.

RESULTS

A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).

INTERPRETATION

Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.

Discrete event simulation modelling to evaluate the impact of a quality improvement initiative on patient flow in a paediatric emergency department

OBJECTIVE

We developed a discrete event simulation model to evaluate the impact on system flow of a quality improvement (QI) initiative that included a time-specific protocol to decrease the time to antibiotic delivery for children with cancer and central venous catheters who present to a paediatric ED with fever.

METHODS

The model was based on prospective observations and retrospective review of ED processes during the maintenance phase of the QI initiative between January 2016 and June 2017 in a large, urban, academic children's hospital in New York City, USA. We compared waiting time for full evaluation (WT) and length of stay (LOS) between a model with and a model without the protocol. We then gradually increased the proportion of patients receiving the protocol in the model and recorded changes in WT and LOS.

RESULTS

We validated model outputs against administrative data from 2016, with no statistically significant differences in average WT or LOS for any emergency severity index (ESI). There were no statistically significant differences in these flow metrics between the model with and the model without the protocol. By increasing the proportion of total patients receiving this protocol, from 0.2% to 1.3%, the WT increased by 2.8 min (95% CI: 0.6 to 5.0) and 7.6 min (95% CI: 2.0 to 13.2) for ESI 2 and ESI 3 patients, respectively. This represents a 14.0% increase in WT for ESI 3 patients.

CONCLUSIONS

Simulation modelling facilitated the testing of system effects for a time-specific protocol implemented in a large, urban, academic paediatric ED, showing no significant impact on patient flow. The model suggests system resilience, demonstrating no detrimental effect on WT until there is a 7-fold increase in the proportion of patients receiving the protocol.

Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth

Background

This article describes the provincial dissemination of HEARTSMAP, an evidence-based emergency department (ED) psychosocial assessment and disposition decision tool for clinician use with children and youth.

Methods

HEARTSMAP was disseminated in partnership with local, child and youth mental health teams, as part of a quality improvement initiative implemented in British Columbia EDs. The target audience of education sessions were clinicians working in ED settings responsible for paediatric psychosocial assessments. We used the RE-AIM framework to evaluate the reach, effectiveness, adoption, implementation, and maintenance of HEARTSMAP dissemination, analyzing data from session evaluation forms and online tool data.

Results

Education sessions reached 475 attendees, in 52 of 95 British Columbia EDs. HEARTSMAP training was well received by clinicians with 96% describing effective content including increased comfort in conducting paediatric psychosocial assessments and confidence in disposition planning after training. Clinicians identified unclear processes and lack of local resources as the main barriers to implementation. One-third of the attendees expressed willingness to use the tool, and 27% of registered clinicians have used the tool postimplementation.

Conclusions

Our approach reached and effectively trained clinicians from over half of the province's EDs to use HEARTSMAP for emergency paediatric psychosocial assessments. For some, this provided greater comfort and confidence for these assessments and the following disposition decisions. This evaluation provides valuable insights on training clinicians to use a paediatric mental health tool within diverse ED settings and emphasized the need for ongoing support and institutional engagement to facilitate local, infrastructural, and operational processes for adoption and maintenance, postdissemination.

MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth

BACKGROUND

Paediatric mental health-related visits to the emergency department are rising. However, few tools exist to identify concerns early and connect youth with appropriate mental healthcare. Our objective was to develop a digital youth psychosocial assessment and management tool (MyHEARTSMAP) and evaluate its inter-rater reliability when self-administered by a community-based sample of youth and parents.

METHODS

We conducted a multiphasic, multimethod study. In phase 1, focus group sessions were used to inform tool development, through an iterative modification process. In phase 2, a cross-sectional study was conducted in two rounds of evaluation, where participants used MyHEARTSMAP to assess 25 fictional cases.

RESULTS

MyHEARTSMAP displays good face and content validity, as supported by feedback from phase 1 focus groups with youth and parents (n=38). Among phase 2 participants (n=30), the tool showed moderate to excellent agreement across all psychosocial sections (κ=0.76-0.98).

CONCLUSIONS

Our findings show that MyHEARTSMAP is an approachable and interpretable psychosocial assessment and management tool that can be reliably applied by a diverse community sample of youth and parents.

Practice Patterns in Pharmacological and Non-Pharmacological Therapies for Children with Mild Traumatic Brain Injury: A Survey of 15 Canadian and United States Centers

Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study

BACKGROUND

Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.

METHODS

We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.

RESULTS

A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).

INTERPRETATION

Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.

Management practice-related and modifiable factors associated with paediatric emergency return visits

OBJECTIVES

We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED).

METHODS

We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors.

RESULTS

There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process.

CONCLUSIONS

Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.

Factors and outcomes associated with paediatric emergency department arrival patterns through the day

Introduction

Steadily increasing emergency department (ED) utilization has prompted efforts to increase resource allocation to meet demand. Little is known about the distribution and characteristics of patient arrivals by time of day. This study describes the variability and patterns of ED resource utilization related to patient, acuity, clinical, and disposition characteristics over a 24-hour period.

Methods

Retrospective cross-sectional study of all visits to a tertiary children's hospital over a 1-year period. We use descriptive statistics to present ED visit details stratified by shift of arrival, and multivariable regression to explore the association between shift of presentation and hospital admission at index and 7-day return ED visits.

Results

Of 46,942 visits during the study period, 12% arrived overnight, 42% during the day, and 45% during the evening with variability in pattern of shift arrival by day of week. Overnight arrivals had a higher acuity (Canadian Triage and Acuity Scale [CTAS]) and different presenting complaints (more viral infection, less minor trauma) than day and evening arrivals, but similar ED length of stay. Shift of arrival was not associated with admission to hospital, but age, gender, socioeconomic status (SES), and day of week were.

Discussion

ED utilization patterns vary by shift of arrival. Though overnight arrivals represent a smaller proportion of total daily arrivals, their acuity is higher, and the spectrum of disease differs from day or evening arrivals.

Conclusions

Understanding variations and patterns of ED utilization by shift of arrival and day of week may be helpful in tailoring resource allocation to more accurately and specifically meet demands.

Reliability of HEARTSMAP as a Tool for Evaluating Psychosocial Assessment Documentation Practices in Emergency Departments for Pediatric Mental Health Complaints

OBJECTIVES

The goal of this study was to assess the reliability of HEARTSMAP as a standardized tool for evaluating the quality of psychosocial assessment documentation of pediatric mental health (MH) presentations to the emergency department (ED). In addition, we report on current documentation practices.

METHODS

We conducted a retrospective cross-sectional study of pediatric (up to age 17) MH-related visits to four EDs between April 1, 2013, and March 31, 2014. The primary outcome was the inter-rater agreement when evaluating the completeness of pediatric emergency psychosocial assessments using the HEARTSMAP tool. The secondary outcome was to describe the adequacy of documentation of emergency pediatric MH assessments, using HEARTSMAP as a guide for a complete assessment.

RESULTS

A total of 400 medical records (100 from each site) were reviewed. We observed near-perfect inter-rater agreement (κ = 0.99-1.00) regarding the presence of documentation and good-to-perfect agreement (κ = 0.71-1.00) regarding whether sufficient information was documented to score a severity level for every component of an emergency psychosocial assessment. Inter-rater agreement regarding whether referrals or resources were documented for identified needs was observed to be good to very good (κ = 0.62-0.98). Current psychosocial documentation practices were found to be inconsistent with significant variability in the presence of documentation pertaining to HEARTSMAP sections between medical centers and initial clinician assessor and whether specialized MH services were involved prior to discharge.

CONCLUSIONS

The HEARTSMAP tool can be reliably used to assess pediatric psychosocial assessment documentation across a diverse range of EDs. Current documentation practices are variable and often inadequate, and the HEARTSMAP tool can aid in quality improvement initiatives to standardize and optimize care for the growing burden of pediatric mental illness.

Pediatric Falls: Are Monkey Bars Bad News?

Background

Falls are a leading cause of childhood trauma and are the most common mechanism of injury seen in the emergency department (ED). Playground injuries represent a significant fraction of these falls.

Objectives

This study aims to compare the frequencies of fractures from monkey bars to other types of falls and to explore the statistical associations between the types of injuries.

Methods

We conducted a cross-sectional study through a retrospective chart review of all British Columbia Children’s Hospital ED visits between March 2011 and February 2012. We manually extracted data from ED visits for falls in children two to 17 years of age and used descriptive statistics to report the frequencies of injuries and outcomes. We conducted multivariate logistic regression analyses to compare the odds of fractures associated with various types of falls.

Results

We reviewed 43,579 ED visits, of which 3,184 (7.3%) were falls. The most common types were from a standing height (42.5%), falls at home (16.2%), and at the playground (14.3%). Peaking in school-age children, these falls resulted in a diagnosis of fracture (37.3%), soft tissue contusion (20.1%), laceration/abrasion (19.4%), and minor head injury (15.8%). We identified 151 falls from monkey bars, among which 64.2% resulted in a fracture. The odds of a fracture following a fall from monkey bars was 3.1 times that of falls from all other causes.

Conclusions

ED physicians should have a higher suspicion for a diagnosis of fracture if a child reportedly fell from monkey bars. It is warranted to educate parents and educators on the risks associated with the play on these climbing structures.

Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study

Background

We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations.

Methods

We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4).

Results

We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation.

Conclusion

We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.

Reliability testing of the HEARTSMAP psychosocial assessment tool for multidisciplinary use and in diverse emergency settings

Objective

HEARTSMAP is a tool developed to facilitate assessment and management of paediatric mental health (MH) patients by emergency department (ED) clinicians. We evaluate the inter-rater reliability of HEARTSMAP when administered by clinicians of various backgrounds.

Methods

In a cross-sectional study initiated in 2016, collaborating clinician evaluators (n=16) applied the HEARTSMAP tool to evaluate a set of 50 fictional clinical vignettes, digitally in an approach consistent with the anticipated tool's access and usage in clinical settings. Evaluators came from different types of health centres from across the province of British Columbia (Canada), including remote/rural, regional and urban academic health centres.

Results

We report moderate to near excellent agreement, overall among clinicians for all 10 of the tool's psychosocial sections (κ=0.43 to 0.93) and domain scores (κ=0.75 to 0.90), with acceptable agreement across all tool-triggered service recommendations (κ=0.36 to 0.65).

Conclusions

Our findings show that HEARTSMAP may be reliably used by ED clinicians in assessing MH issues among youth. Results from this study will assist in informing the wider clinical implementation of HEARTSMAP as a standard assessment tool, in diverse emergency care settings.

The association of exposure to suicide-related Internet content and emergency department visits in children: A population-based time series analysis

OBJECTIVES

Suicide-related emergency department (ED) visits by children are increasing in tandem with suicide-related Internet content. Following the announcement of Amanda Todd's suicide, her YouTube video received widespread views, providing an opportunity to explore this association.

METHODS

Our research question was: Among Ontario children age 11-17 years, was the release of Amanda Todd's YouTube video following her death announcement in October 2012 associated with an increase in average monthly ED visit rates for suicide-related diagnoses? We performed an interrupted time series analysis from April 2002 to December 2013, with the primary outcome as a composite of the average monthly rate of initial ED visits for suicidal ideation, intentional self-poisoning, and intentional self-harm. Secondary outcomes were average monthly rates of intensive care unit (ICU) admission and death resulting from the index visit.

RESULTS

There was a statistically significant increase in the monthly ED visit rate for the composite outcome (p = 0.02) and death or ICU admission (p = 0.006) from April 2002 to December 2013. There was no significant change in ED visit rate for the composite outcome before and after the announcement of Amanda Todd's death, overall (119.8 versus 219.2 respectively, p = 0.5), among females (167.4 versus 316.8 respectively, p = 0.47) or among males (74.7 versus 116.9 respectively, p = 0.33).

CONCLUSIONS

Ontario ED visits for suicide-related diagnoses in 11-17 year olds increased from 2002 to 2013. However, the increase from October 2012 to December 2013 could not be attributed to a highly publicized adolescent suicide. Our findings suggest that suicide-related Internet content is not associated with the increase in ED visits for suicidal behaviour.