Point-of-care lung ultrasound in children with bronchiolitis in a pediatric emergency department

OBJECTIVES

This study assessed the association between findings of lung ultrasound (LUS) performed in the pediatric emergency department (PED) on infants with bronchiolitis and need for respiratory support.

METHODS

An observational study was carried out in the PED during the epidemic seasons in two consecutive years. Infants diagnosed with bronchiolitis who fulfilled the inclusion criteria were evaluated. A group of six pediatricians performed LUS and classified lung findings into four groups: normal pattern (A), moderate interstitial pattern (B1), severe interstitial pattern (B2), and isolated consolidation (C). The relationship between LUS findings and need for respiratory support was explored. An expert sonographer, blinded to the results, reviewed the ultrasound studies to determine the interobserver reliability.

RESULTS

A total of 200 infants were included (mean age 5.7 months±4.4 SD); 65 (32.5%) obtained moderate clinical scores, while 23 (11.5%) needed respiratory support at admission and 34 (17.0%) at 48h. The ultrasound findings in the PED were the following: A=89 (44.5%), B1=55 (27.5%), B2=34 (17%), and C=22 (11%). Age less than 6 weeks and moderate bronchiolitis were correlated with abnormal LUS (P<0.005). The severity of interstitial ultrasound pattern has some correlation with an increased need for respiratory support. The interobserver concordance was high (0.95, confidence interval: 0.92-0.98).

CONCLUSION

LUS is a feasible tool that may help to confirm the clinical impression and assess the need for respiratory support in children with bronchiolitis, but further multicenter studies are needed.

The rates of hospital admissions and return visits to a rapidly growing pediatric emergency department as measures of quality of care

Background

Return visits to the emergency department are viewed as a quality measure of patient management. Avoiding unnecessary admissions to the ward can potentially cause an increase in return visits, thus effecting quality assessment.

Methods

After implementing an educational process the relationship between admissions and return visits was assessed over time at a rapidly growing pediatric emergency department.

Results

There was a 264% increase in visits from 2004 to 2017. In the study period admission rates declined from 25 to 14%. This was achieved without a rise in return visits and with a stable percentage of admissions from return visits.

Conclusions

Interventions aimed at decreasing unnecessary admissions do not lead to increased return visits and return visit admissions.

Covid-19 pandemic and pediatric healthcare policy in Italy: time for a change

The outbreak of coronavirus disease 2019 pandemic forced the Italian Government to act extreme measures that put the entire country under lockdown. The citizens experimented a radical transformation of their lives while the healthcare system started building a novel COVID-system that quickly dissolved the former organization, included pediatric healthcare network. For a number of reasons COVID-19 pandemic is polite with children; however, the fear of this unknown disease drove to develop dedicated pathways in the Pediatric Emergency Departments for the suspected and diagnosed cases of COVID-19, together with their relatives. The combination of conflicting feelings resulted in an unexpected scenario: the number of accesses to the pediatric Hospital or Unit(s) sharply dropped to less than half. How do we explain this phenomenon? The authors believe that our health care system may learn a lesson from the catastrophe of COVID, if we will be able to redesign our way of providing our cares to children. Nothing should be taken for granted, because this might be a real "time for a change".

Trends in adult patients presenting to pediatric emergency departments

OBJECTIVE

Adults presenting to pediatric emergency departments (PEDs) include those with complex chronic conditions (CCCs) often still followed by pediatric providers, and those without CCCs (non-CCCs). This paper describes recent trends in adults seen within PEDs, both by age subgroups and CCC status.

METHODS

Data were retrospectively reviewed from the Pediatric Health Information System for PED visits between Jan 1, 2013 and Dec 31, 2017. Yearly visit rates were trended for all adult visits, age subgroups (18-21, 22-25, 26-40, and 41-95 years), and by CCC status. The most frequent diagnoses were reviewed for each adult age group and CCC category.

RESULTS

Rates of adult PED visits significantly increased from 3.7% in 2013 to 4.2% in 2017 (P < 0.0001). While the overall majority (88% overall and >70% for each age group) of adult PED patients were non-CCC, the rate of CCC patients increased overall (P < 0.0001), especially among older patients (41-95 years) from 8.7% in 2013 to 29% in 2017 (P < 0.0001). The most frequent CCC diagnoses were sickle cell disease (18-21 and 22-25 years), cardiac pathology (26-40 years), and hyperlipidemia (41-95 years). The most frequent non-CCC diagnoses were abdominal pain (18-21 years), pregnancy-related (22-25 and 26-40 years), and chest pain (41-95 years).

CONCLUSION

Visits to PEDs by adult patients have increased over time, with the majority of the population being represented by non-CCC adults. The results of this study can be used to guide specifics in adult medicine training during Pediatric Emergency Medicine fellowship and assist in continuing education efforts.

Follow-up study of patients admitted to the pediatric emergency department for chest pain

Chest pain is a relatively common cause of admission to the Emergency Department, being related in most of the cases to benign conditions with only a minority of the cases affected by heart disease. Limited data are available about the follow up of these patients in terms of risk of recurrence of symptoms, Emergency Department re-admissions, level of impairment, and school absenteeism. We identified 761 children who visited our ED with the chief complaint of chest pain, equal to 0.68% of all admissions. Twenty-four patients were excluded for a previous history of cardiac disease. Eight (1%) patients were determined to have chest pain of cardiac origin. Ninety-seven percent of patients were successfully contacted by telephone: 69% agreed to answer the questionnaire. Of these, 33% experienced recurrent chest pain, up to 41% was forced to be absent from school, about 20% was limited in its daily activities, and about 20% repeated a cardiologic evaluation.Conclusion: Chest pain is mainly due to benign causes and is a recurrent symptom in a high percentage of patients, associated with re-admission and school absenteeism.What is Known:• Chest pain is a relatively common cause of admission to the Emergency Department.• It is mainly due to benign causes and is among the most common reasons for referral to the pediatric cardiologist.What is New:• Chest pain is a recurrent symptom associated with re-admission and school absenteeism.• As a family history of cardiac disease or exertional symptoms are a well-known red flag for chest pain of cardiac origin, school absenteeism should be considered a red flag for symptoms related to psychological distress in patients with non-cardiac chest pain.

Use of natural language processing to improve predictive models for imaging utilization in children presenting to the emergency department

OBJECTIVE

To examine the association between the medical imaging utilization and information related to patients' socioeconomic, demographic and clinical factors during the patients' ED visits; and to develop predictive models using these associated factors including natural language elements to predict the medical imaging utilization at pediatric ED.

METHODS

Pediatric patients' data from the 2012-2016 United States National Hospital Ambulatory Medical Care Survey was included to build the models to predict the use of imaging in children presenting to the ED. Multivariable logistic regression models were built with structured variables such as temperature, heart rate, age, and unstructured variables such as reason for visit, free text nursing notes and combined data available at triage. NLP techniques were used to extract information from the unstructured data.

RESULTS

Of the 27,665 pediatric ED visits included in the study, 8394 (30.3%) received medical imaging in the ED, including 6922 (25.0%) who had an X-ray and 1367 (4.9%) who had a computed tomography (CT) scan. In the predictive model including only structured variables, the c-statistic was 0.71 (95% CI: 0.70-0.71) for any imaging use, 0.69 (95% CI: 0.68-0.70) for X-ray, and 0.77 (95% CI: 0.76-0.78) for CT. Models including only unstructured information had c-statistics of 0.81 (95% CI: 0.81-0.82) for any imaging use, 0.82 (95% CI: 0.82-0.83) for X-ray, and 0.85 (95% CI: 0.83-0.86) for CT scans. When both structured variables and free text variables were included, the c-statistics reached 0.82 (95% CI: 0.82-0.83) for any imaging use, 0.83 (95% CI: 0.83-0.84) for X-ray, and 0.87 (95% CI: 0.86-0.88) for CT.

CONCLUSIONS

Both CT and X-rays are commonly used in the pediatric ED with one third of the visits receiving at least one. Patients' socioeconomic, demographic and clinical factors presented at ED triage period were associated with the medical imaging utilization. Predictive models combining structured and unstructured variables available at triage performed better than models using structured or unstructured variables alone, suggesting the potential for use of NLP in determining resource utilization.

[Profile of the child seen in the resuscitation room]

OBJECTIVE

The attention provided to the seriously ill represents a great challenge for health care professionals; familiarity with this profile will allow for the optimal use of resources and will also lead to an improvement in the training of the health professionals. We sought to understand the characteristics of patients seen in the resuscitation room (RR) of a pediatric emergency department (PED), and to determine the risk factors for a poor evolution.

METHODS

An observational analytical study was carried out in the PED of a third-level pediatric hospital from September 2016 through August 2017. Included were those patients attended to in the RR; we analyzed their demographic variables, where they were from, how they arrived at the hospital, their reasons for seeking care (medical vs accident), procedures applied, treatments given, diagnoses, and discharge destination. We used logistic regression analysis to determine the independent risk factors for poor evolution.

RESULTS

Included were 114 patients. Their median age was 9.9 years (p25-75=4.0-14.7); 65.8% were male. The patients arrived from the street (51.8%) and from home (31.6%); more than two thirds arrived by ambulance (69.3%). Some 42.1% presented with an unstable pediatric assessment triangle (PAT). Some 64.9% were seen for polytrauma (87.8% with stable PAT). Procedures were carried out on 79.8% of the patients. The most frequent diagnoses were polytrauma (64.9%) and convulsive status (14%). The discharge destinations were: home (28.1%), hospital ward (35.1%), intensive care unit (30.7%), and surgery (4.4%); two patients died in the RR. With the univariate study, we identified risk factors for poor outcome: internal medical condition (52.5% vs 21.6%, p=0.001) and age <2 years (55.6% vs 28.1%, p=0.023). In the multivariate study, the medical cause was maintained as an independent risk factor (OR 4 (CI 95% 1.7-9.2), p=0.001).

CONCLUSIONS

The profile of the patient seen in the RR is of a school-age child in stable condition, arriving by ambulance for polytrauma. The children seen for internal medical reasons had poorer outcomes.

ICU admission following an unscheduled return visit to the pediatric emergency department within 72 hours

INTRODUCTION

The purpose of this study was to describe the demographic characteristics and prognosis of children admitted to the intensive care unit (ICU) after a pediatric emergency department (PED) return visit within 72 h.

METHOD

We conducted this retrospective study from 2010 to 2016 in the PED of a tertiary medical center in Taiwan and included patients under the age of 18 years old admitted to the ICU after a PED return visit within 72 h. Clinical characteristics were collected to perform demographic analysis. Pediatric patients who were admitted to the ICU on an initial visit were also enrolled as a comparison group for outcome analysis, including mortality, ventilator use, and length of hospital stay.

RESULTS

We included a total of 136 patients in this study. Their mean age was 3.3 years old, 65.4% were male, and 36.0% had Chronic Health Condition (CHC). Disease-related return (73.5%) was by far the most common reason for return. Compared to those admitted on an initial PED visit, clinical characteristics, including vital signs at triage and laboratory tests on return visit with ICU admission, demonstrated no significant differences. Regarding prognosis, ICU admission on return visit has a higher likelihood of ventilator use (aOR:2.117, 95%CI 1.021~4.387), but was not associated with increased mortality (aOR:0.658, 95%CI 0.150~2.882) or LOHS (OR:-1.853, 95%CI -4.045~0.339).

CONCLUSION

Patients who were admitted to the ICU on return PED visits were associated with an increased risk of ventilator use but not mortality or LOHS compared to those admitted on an initial visit.

Predictors of Primary Intracranial Hypertension in Children Using a Newly Suggested Opening Pressure Cutoff of 280 mm H2O

OBJECTIVES

We assessed the clinical characteristics of primary intracranial hypertension (PIH) in children using a newly recommended threshold for cerebrospinal fluid opening pressure (280 mm H₂O).

METHOD

Cross-sectional study of patients age ≤21 years who had a lumbar puncture done for evaluation of PIH. Patients were excluded if lumbar puncture was done for a suspected infection, seizure, mental status changes, multiple sclerosis, or Guillain-Barre syndrome. Cases were identified using a text-search module followed by manual review. We performed χ2 analysis for categorical data and Mann-Whitney U test for continuous data, followed by a binary logistic regression.

RESULTS

We identified 374 patients of whom 67% were female, median age was 13 years interquartile range (11 to 16 years), and admission rate was 24%. Using an opening pressure cutoff of 250 mm H₂O, 127 patients (34%) were identified as having PIH, whereas using the new cutoff 105 patients (28%) met PIH criteria. Predictors for PIH included optic disc edema or sixth nerve palsy using both old, odds ratio (OR) 7.6 (4.3, 13.5), and new cutoffs, OR 9.7 (95% confidence interval 5.1, 18.5). Headache duration ≤61 days is predictive of PIH using the new cutoff OR 4.1 (95% confidence interval 1.3, 12.8). A model is presented which stratifies patients into groups with low (7%), medium (18%), and high (greater than 42%) risk of PIH.

CONCLUSIONS

A higher cerebrospinal fluid opening pressure threshold in the criteria of PIH is associated with PIH patients with a different symptom profile. Children with optic disc edema, bulging fontanel or sixth nerve palsy, are at increased risk for PIH.

In situ simulation in the management of anaphylaxis in a pediatric emergency department

Anaphylaxis is a potentially life-threatening, rapid-onset hypersensitive reaction, usually treated in the emergency department (ED). Failure to recognize anaphylaxis leads to under-treatment with epinephrine and even when correctly diagnosed, epinephrine is not always administered. In addition, often patients who are treated in the ED are not referred for allergy work-up. Simulation is a tool that increases exposure to events in a safe environment, allowing trainers to develop skills without harming patients. The main purpose of our study was to determine whether in situ simulation training increases the frequency of epinephrine use. The secondary aim was to observe whether simulation modifies the number of children investigated over the years before and after the setting up of the simulation training. All patients with anaphylaxis referred to the Pediatric Emergency Department (PED) of the Anna Meyer Children's Hospital from 2004 to 2010 [pre-simulation (PRE-s) period], and from 2011 to 2016 [post-simulation (POST-s) period], were retrospectively included in this observational study. Simulation was carried out using a high-fidelity patient simulator mannequin (SimBaby, Laerdal Medical, Inc, Stavanger, NY). The diagnosis of anaphylaxis was based on the EAACI guidelines. The use of epinephrine significantly increased (p < 0.05) between the PRE-s and POST-s time periods: 2.4% versus 10% patients, respectively. During the two time periods, we also observed a significant increase (p = 0.011) in the number of patients who underwent a complete allergy work-up: 36% versus 51% patients, respectively. According to our results, the in situ simulation program improved the correct management of anaphylaxis in terms of prompt use of epinephrine, and it also led to a higher number of patients being referred to the allergy unit for evaluation.

Pediatric Emergency Department Staff Preferences for a Critical Incident Stress Debriefing

INTRODUCTION

There are significant and negative psychological effects that can occur in nursing staff caring for pediatric patients experiencing critical incidents. Debriefings can provide relief from the stressors caused by critical incidents. Adapting a pre-existing critical incident stress debriefing (CISD) process to ED staff is 1 way to provide staff debriefing.

METHODS

This qualitative study used an emerging, descriptive design. Focus groups, (n = 3, total participant n = 19), consisting of pediatric emergency nurses and a nursing assistant, met for a minimum of 63 to a maximum of 83 minutes. Participants provided feedback on current debriefing strategies and suggestions for adapting a currently existing critical incident stress- debriefing process. Focus group questions included "Have you participated in a structured debriefing process? If so, tell us about it" and "What would you like to see in a structured debriefing process?"

RESULTS

A theoretical orientation content analysis revealed 1 main theme-Clearing the Air and Finding Answers-and 6 subthemes: Current Debriefing Strategies; Positive Reinforcement; Constructive Critique; Clinical, Not Emotional; I've already moved on; and CISD Structure.

DISCUSSION

Pediatric ED staff de-stress in a variety of ways, and a nonmandatory, formalized CISD process-open to staff involved and facilitated by an emergency nurse-could provide additional relief from stress. This debriefing process should include positive feedback and critiques to help improve care processes, information about mechanism of injury, and should occur before the end of shift or within 12 to 24 hours of the incident. Staff may deal with personal feelings outside of debriefing.

Impact of the Sofia® Influenza A+B FIA rapid diagnostic test in a pediatric emergency department

OBJECTIVE

The objective of this study was to evaluate the impact of a rapid diagnostic test for influenza (the Sofia^® Influenza A+B FIA rapid diagnostic test [RDT]) in a pediatric emergency department (PED).

METHODS

A retrospective, observational, cross-sectional study was conducted in the PED of the Lille University Hospital between 2013 and 2015. All patients under 18 years of age for whom influenza RDT was administered were included. Clinical data, management, and related hospitalizations were compared between positive and negative RDT groups. The length of stay in the PED (main outcome) and the number of additional tests (biological and radiographic tests) between the two groups were compared.

RESULTS

A total of 238 tests were reported: 119 positive, 110 negative, nine invalid. The mean length of stay in the PED was significantly lower in the positive RDT group: 4.0h vs. 7.4h (P<10^-6). Patients with positive RDT had significantly fewer biological tests (20% vs. 56%; P<10^-7) and radiographs (23% vs. 52%; P<10^-5). The prevalence of hospitalizations in a short-stay unit was significantly lower in patients with positive RDT (0.8% vs. 9.1%; P=0.009).

CONCLUSIONS

This study showed a significant medical impact of the use of Sofia^® Influenza RDT A+B FIA in a PED regarding the length of stay and the number of additional explorations.

Management of Adult Patients in the Pediatric Emergency Department

Adult patients often present to the pediatric emergency department (ED) for treatment of a wide variety of diseases. However, pediatric emergency medicine physicians are primarily trained to provide specialized care for children. Studies have shown that the number of adult patients presenting to pediatric EDs has increased significantly since the introduction of the Emergency Medicine Transfer and Active Labor Act in 1986. This article discusses the management of common adult complaints presenting to the pediatric ED. The focus is on stabilization in the pediatric ED and safe transfer to a more appropriate facility.

Current Pediatric Emergency Department Innovative Programs to Improve the Care of Psychiatric Patients

Emergency departments (EDs) across North America have become a safety net for patients seeking mental health (MH) services. The prevalence of families seeking treatment of children in MH crisis has become a national emergency. To address MH access and improve quality and efficient management of children with MH conditions, the authors describe ED projects targeting this vulnerable population. Five North American health care systems volunteered to feature projects that seek to reduce ED visits and/or improve the care of MH patients: Allina Health, Nationwide Children's Hospital, Children's Hospital of Eastern Ontario, Connecticut Children's Medical Center, and Rhode Island Hospital.

Preliminary Evaluation of an Electronic Patient Prioritization Tool for Pediatric Emergency Department

The study presents the evaluation of the reliability of the information displayed on the user interface of a homegrown electronic patient prioritization tool dedicated to pediatric emergency department (namely Optimum). Two ergonomists shadowed physicians and nurses throughout their shift in order to (i) identify consistencies and discrepancies between the actual step of the patients in the care process and their assigned step in Optimum and (ii) to understand the causes of the discrepancies. Even if some discrepancies are noted, results show that Optimum provides a quite good reflection of the actual position of the patients in the care process. The use of ethnographic methods allows to understand the cause of the discrepancies.

Is this child sick? Usefulness of the Pediatric Assessment Triangle in emergency settings

OBJECTIVE

The Pediatric Assessment Triangle is a rapid assessment tool that uses only visual and auditory clues, requires no equipment, and takes 30-60s to perform. It's being used internationally in different emergency settings, but few studies have assessed its performance. The aim of this narrative biomedical review is to summarize the literature available regarding the usefulness of the Pediatric Assessment Triangle in clinical practice.

SOURCES

The authors carried out a non-systematic review in the PubMed®, MEDLINE®, and EMBASE® databases, searching for articles published between 1999-2016 using the keywords "pediatric assessment triangle," "pediatric triage," "pediatric assessment tools," and "pediatric emergency department."

SUMMARY OF THE FINDINGS

The Pediatric Assessment Triangle has demonstrated itself to be useful to assess sick children in the prehospital setting and make transport decisions. It has been incorporated, as an essential instrument for assessing sick children, into different life support courses, although little has been written about the effectiveness of teaching it. Little has been published about the performance of this tool in the initial evaluation in the emergency department. In the emergency department, the Pediatric Assessment Triangle is useful to identify the children at triage who require more urgent care. Recent studies have assessed and proved its efficacy to also identify those patients having more serious health conditions who are eventually admitted to the hospital.

CONCLUSIONS

The Pediatric Assessment Triangle is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperative to promote research for clinical validation, especially for clinical use by emergency pediatricians and physicians.

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics

BACKGROUND/OBJECTIVE

Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia.

METHODS

We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated.

RESULTS

We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90).

CONCLUSIONS

For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.

Unscheduled return visits to a pediatric emergency department

BACKGROUND AND OBJECTIVE

Return visits (RVs) to a pediatric emergency department (ED) within a short period after discharge have an influence on overcrowding of the ED and reveal some weaknesses of the health care system. The aim of this study was to determine the rate of RVs and factors related to RVs to the pediatric ED in Lithuania.

MATERIALS AND METHODS

A retrospective study in an urban, tertiary-level teaching hospital was carried out. Electronic medical records of all patients (n=44097) visiting the ED of this hospital between 1 January and 31 December 2013 were analyzed. Demographic and clinical characteristics of patients who return to the ED within 72h and those who had not visited the ED were compared. Factors associated with RVs were determined by multivariable logistic regression.

RESULTS

Of the overall ED population, 33889 patients were discharged home after the initial assessment. A total of 1015 patients returned to the ED within 72h, giving a RV rate of 3.0%. Being a 0-7-year old, visiting the ED during weekdays, having a GP referral, receiving of laboratory tests and ultrasound on the initial visit were associated with greater likelihoods of returning to the ED. Patients who arrived to the ED from 8:01a.m. to 4:00p.m. and underwent radiological test were less likely to return to the ED within 72h. Diseases such as gastrointestinal disorders or respiratory tract/earth-nose-throat (ENT) diseases and symptoms such as fever or pain were significantly associated with returning to the ED. The initial diagnosis corresponded to the diagnosis made on the second visit for only 44.1% of the patients, and the highest rate of the congruity in diagnosis was for injuries/poisoning, surgical pathologies (77.2%) and respiratory tract diseases (76.9%).

CONCLUSIONS

RVs accounted for only a small proportion of visits to the ED. RVs were more prevalent among younger patients and patients with a GP referral as well as performed more often after discharging from the ED in the evening and at night.

Agents endowed with uncertainty management behaviors to solve a multiskill healthcare task scheduling

Health organizations are complex to manage due to their dynamic processes and distributed hospital organization. It is therefore necessary for healthcare institutions to focus on this issue to deal with patients' requirements. We aim in this paper to develop and implement a management decision support system (DSS) that can help physicians to better manage their organization and anticipate the feature of overcrowding. Our objective is to optimize the Pediatric Emergency Department (PED) functioning characterized by stochastic arrivals of patients leading to its services overload. Human resources allocation presents additional complexity related to their different levels of skills and uncertain availability dates. So, we propose a new approach for multi-healthcare task scheduling based on a dynamic multi-agent system. Decisions about assignment and scheduling are the result of a cooperation and negotiation between agents with different behaviors. We therefore define the actors involved in the agents' coalition to manage uncertainties related to the scheduling problem and we detail their behaviors. Agents have the same goal, which is to enhance care quality and minimize long waiting times while respecting degrees of emergency. Different visits to the PED services and regular meetings with the medical staff allowed us to model the PED architecture and identify the characteristics and different roles of the healthcare providers and the diverse aspects of the PED activities. Our approach is integrated in a DSS for the management of the Regional University Hospital Center (RUHC) of Lille (France). Our survey is included in the French National Research Agency (ANR) project HOST (Hôpital: Optimisation, Simulation et évitement des Tensions (ANR-11-TecSan-010: http://host.ec-lille.fr/wp-content/themes/twentyeleven/docsANR/R0/HOST-WP0.pdf)).

Nitrous Oxide, From the Operating Room to the Emergency Department

Nitrous oxide is a gas inhalation agent that has a long history of administration in procedures requiring analgesia and sedation. Although use may be limited by patient condition, patient comorbidities, and appropriate scavenging equipment, nitrous is a proven and safe tool for use in many health care settings—from the dental office to the operating room to the emergency department.

The mortality of patients in a pediatric emergency department at a tertiary medical center in China: An observational study

BACKGROUND

The quality of treatment for critically ill children varies widely at different hospitals. This study aimed to analyze the characteristics of mortality in a pediatric emergency department (PED) at a tertiary children's hospital in Guangzhou, China and to investigate the risk factors associated with the mortality.

METHODS

The mortality of pediatric patients at the hospital from 2011 to 2013 was retrospectively analyzed using descriptive statistics.

RESULTS

Altogether 466 919 patients visited the PED during the period and 43 925 of them were admitted for further observation. In 230 deaths, the ratio of boys to girls was 1.4:1, and their age ranged from 2 hours to 16 years (median, 5 months). The time from admission to death ranged from 0 to 216 hours (median, 1.5 hours). There were 92 (40%) patients who died within 24 hours after admission and 104 (45.2%) patients who died on arrival. The prominent causes of the deaths were respiratory diseases, neuromuscular disorders, cardiovascular diseases, and sepsis, most of which were ascribed to severe infection. Sixty-five deaths were associated with more than one concomitant problem. The top concomitant problems were congenital malformation, low gestational age, and severe birth asphyxia.

CONCLUSIONS

In our center, 40% of the patients in the PED died of fatal acute diseases, and pneumonia was the first leading cause of the deaths. Almost half of the deaths occurred on arrival and the rest were due to end-stage malignant diseases. This study emphasized the importance of prevention of birth deficits by reducing deaths in infants and children.

High prevalence and antimicrobial resistance of urinary tract infection isolates in febrile young children without localizing signs in Taiwan

BACKGROUND

Antimicrobial susceptibility and prevalence of pediatric urinary tract infection (UTI) is very useful for pediatricians in selecting effective antibiotics in time to improve outcomes in patients. This study aimed to determine the prevalence rate, bacterial distribution, and antimicrobial susceptibility of UTI in febrile young children at a teaching hospital in northern Taiwan.

METHODS

From January 2011 to December 2011, all urinary isolates from suspected cases of UTI in febrile young children aged from 1 day to 36 months visiting the Pediatric Emergency Room of Chang Gung Children's Hospital, Taoyuan, Taiwan were identified by conventional methods. Antibiotic susceptibility was determined according to the Clinical and Laboratory Standards Institute.

RESULTS

A total of 5470 (78%) from 7009 eligible children were enrolled in the study, and 619 (11.3%) had a diagnosis of UTI. The most prevalent bacterium was Escherichia coli (68%) followed by Klebsiella pneumoniae (8.1%) and Proteus mirabilis (6.8%). Ampicillin, piperacillin, and trimethoprim-sulfamethoxazole (TMP-SMX) showed a higher resistance rate in the three predominant bacteria. All tested bacteria showed higher resistance to ampicillin (79.3%) and TMP-SMX (44.1%), and lower resistance to cefazolin (17.7%) and gentamicin (13.0%). Fourteen percent of the isolates produced extended spectrum β-lactamase (ESBL), among which 93.33% were E. coli isolates.

CONCLUSION

The overall prevalence of UTI in this study was higher than previously reported in febrile children. Higher antimicrobial resistance was found in ampicillin and TMP-SMX. Among commonly used antibiotics, cefazolin and gentamicin are recommended to treat UTI in febrile children aged < 3 years without localizing signs.

Appropriate use of vancomycin in a pediatric emergency department through the use of a standardized electronic guideline

OBJECTIVES

(a) Compare utilization of vancomycin in the ED prior to and after implementation of standardized treatment guideline and order template (STGOT); (b) assess the appropriate use as initial therapy based on indication versus admitting diagnosis.

METHODS

Chart audits on all patients who received vancomycin and were admitted. Overall utilization and appropriateness of starting therapy were compared pre-and post-STGOT implementation.

RESULTS

Overall utilization of vancomycin was 4% pre-STGOT compared to 3% post-STGOT; 98% of patients pre-STGOT compared to 99% post-STGOT received vancomycin appropriately.

CONCLUSION

There was no difference in vancomycin utilization and appropriateness of initiating therapy after STGOT implementation.

Impact of 2011 French guidelines on antibiotic prescription for acute otitis media in infants

OBJECTIVE

In 2011, new guidelines on antibiotic prescription for acute otitis media (AOM) were published in France to decrease the use of third generation cephalosporins that promote the carriage of extended-spectrum beta-lactamase producing Escherichia coli. Our objective was to assess the impact of the 2011 French recommendations on the type of antibiotics prescribed for AOM.

METHODS

Fourteen thousand six hundred and sixty-one children, 6 to 24 months of age, presenting with AOM were included in 2 studies, between November 1, 2009 and October 31, 2012. The first one was conducted with the support of 62 private practice pediatricians; the second one was conducted in 7 pediatric emergency departments. Three periods of 1 year each were defined.

RESULTS

Antibiotics were prescribed in 12,471 (85.1%) of cases of AOM during the study period. Amoxicillin prescriptions was multiplied by 25, between the first year (2.6%) and the last year (66.1%). Conversely, prescriptions of cefpodoxime proxetil and amoxicillin-clavulanic acid decreased from 33.6% and 62.0% in the first year to 5.2% and 27.7% in the last year, respectively. This trend was observed in both private practices and in the pediatric emergency departments.

CONCLUSION

Amoxicillin became the most frequently prescribed antibiotic for AOM in 2012, complying with the 2011 French guidelines, while the proportion of prescribed broad-spectrum antibiotics decreased. Our study highlights the importance of guidelines to decrease the prescription of broad-spectrum antibiotics, a crucial factor in the prevention of antibiotic resistance.