High-risk Pediatric Emergencies

A Performance-Based Competency Assessment of Pediatric Chest Radiograph Interpretation Among Practicing Physicians

INTRODUCTION

There is limited knowledge on pediatric chest radiograph (pCXR) interpretation skill among practicing physicians. We systematically determined baseline interpretation skill, the number of pCXR cases physicians required complete to achieve a performance benchmark, and which diagnoses posed the greatest diagnostic challenge.

METHODS

Physicians interpreted 434 pCXR cases via a web-based platform until they achieved a performance benchmark of 85% accuracy, sensitivity, and specificity. Interpretation difficulty scores for each case were derived by applying one-parameter item response theory to participant data. We compared interpretation difficulty scores across diagnostic categories and described the diagnoses of the 30% most difficult-to-interpret cases.

RESULTS

240 physicians who practice in one of three geographic areas interpreted cases, yielding 56,833 pCXR case interpretations. The initial diagnostic performance (first 50 cases) of our participants demonstrated an accuracy of 68.9%, sensitivity of 69.4%, and a specificity of 68.4%. The median number of cases completed to achieve the performance benchmark was 102 (interquartile range 69, 176; min, max, 54, 431). Among the 30% most difficult-to-interpret cases, 39.2% were normal pCXR and 32.3% were cases of lobar pneumonia. Cases with a single trauma-related imaging finding, cardiac, hilar, and diaphragmatic pathologies were also among the most challenging.

DISCUSSION

At baseline, practicing physicians misdiagnosed about one-third of pCXR and there was up to an eight-fold difference between participants in number of cases completed to achieve the standardized performance benchmark. We also identified the diagnoses with the greatest potential for educational intervention.

Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation

OBJECTIVES

Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity.

METHODS

Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department.

RESULTS

Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity.

CONCLUSIONS

Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.

Current risk landscape of point-of-care ultrasound in pediatric emergency medicine in medical malpractice litigation

BACKGROUND

Point-of-care ultrasound (PoCUS) is expanding as a diagnostic tool in pediatric emergency medicine. Pediatricians are apprehensive to take on the risk of malpractice from incorrect interpretation of PoCUS imaging, therefore limiting its use. Although current studies provide reassurance to this concern, none look directly at the risk for pediatric emergency medicine physicians. Our study aims to evaluate the current medicolegal risk landscape posed by PoCUS in pediatric emergency medicine.

METHODS

A search of case law was performed utilizing the LexisNexis caselaw database for the period of January 2011 through December 2021. Initial search results were reviewed by the attorney co-authors for relevance to medical malpractice surrounding PoCUS. The remaining cases were reviewed by physician co-authors to ensure their relevance to both ultrasound and the acute care setting. Identified cases were then classified into categories as per the reason for the claim.

RESULTS

No cases of malpractice litigation were identified that directly related to PoCUS. Ten cases of ultrasound in the acute care setting were identified, 7 of which were in pediatric patients. The majority of these cases related to appendicitis or testicular torsion. Of these 10 cases, 2 cases claimed failure to consider the ultimate diagnosis, but ultrasound would have been an appropriate study had the diagnosis been considered. Of the 8 remaining cases, 6 were based on failure to perform or delay performing ultrasound, 1 claimed that improper ultrasound study was initially performed, and 1 case was based on an improper diagnosis made by ultrasound.

DISCUSSION

PoCUS does not appear to pose a significant risk of malpractice litigation in pediatric emergency medicine.

Delaying Urgent Exploration in Neonatal Testicular Torsion May Have Significant Consequences for the Contralateral Testis: A Critical Literature Review

OBJECTIVE

To assess the optimal management strategy for boys with neonatal testicular torsion (NTT) in the first 30 days of life, and to stratify outcomes for prenatal, postnatal, unilateral, synchronous, and asynchronous events METHODS: All articles including case reports published between 1946 and 2020 in Embase/Scopus/Medline/Pubmed and Web of Science that had a defined diagnosis of NTT within the first 30 days of life were reviewed. Data and outcomes were analyzed individually, and together as pooled data, using a random effect model.

RESULTS

There was a total of 152 studies representing 1336 patients. Outcome data was available on 974 patients (1121 testes). NTT was unilateral in 829 cases, synchronous bilateral in 80 cases, and asynchronous in 66 cases. There were a total of 1107 orchiectomies, and 229 salvage orchiopexies. A total of 2.5% synchronous NTT underwent successful salvage. A total of 95.7% of prenatal unilateral torsions underwent orchiectomy, compared with 92% postnatal torsions. 11.8% of all NTT events were asynchronous with a median time to second torsion of 1 day (Range 1-8). The contralateral orchiectomy rate in this group was 31.8%, with a 40% atrophy rate following orchiopexy. The number needed to treat to avoid bilateral orchiectomy was 1.6, and the number needed to treat to avoid solitary atrophy was 2.6.

CONCLUSION

NTT is an important condition carrying a significant risk for testicular loss and endocrine insufficiency. Given the potential catastrophic risk of asynchronous extravaginal torsion, we recommend urgent, safe, surgical intervention with both unilateral and bilateral NTT.