1
|
Jafari K, Gupta A, Caglar D, Hartford E. Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness. Acad Pediatr 2024:S1876-2859(24)00289-4. [PMID: 39096998 DOI: 10.1016/j.acap.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 07/23/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Acute pediatric respiratory illness is one of the most common reasons for emergency department(ED) transfer however few studies have examined predictors of potentially avoidable ED transfer(PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness. METHODS Cross-sectional analysis of 8,402,577 visits for patients <17 years from 2018-2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a three-level generalized linear mixed model with adjustment for patient and hospital covariates. RESULTS Among 4,409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits(n=472, 42.0%). In the multivariable model, likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09 -3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes(OR 0.48 95% CI 0.26-0.88). CONCLUSIONS Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower three quartiles of pediatric volume.
Collapse
Affiliation(s)
- Kaileen Jafari
- Department of Pediatric, Division of Emergency Medicine, University of Washington, Seattle, WA; Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA.
| | - Apeksha Gupta
- Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA; Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Derya Caglar
- Department of Pediatric, Division of Emergency Medicine, University of Washington, Seattle, WA; Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA
| | - Emily Hartford
- Department of Pediatric, Division of Emergency Medicine, University of Washington, Seattle, WA; Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA
| |
Collapse
|
2
|
Pierantoni L, Andreozzi L, Stera G, Toschi Vespasiani G, Biagi C, Zama D, Balduini E, Scheier LM, Lanari M. National survey conducted among Italian pediatricians examining the therapeutic management of croup. Respir Med 2024; 226:107587. [PMID: 38522591 DOI: 10.1016/j.rmed.2024.107587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 02/10/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVES Practice-to-recommendations gaps exist in croup management and have not been critically investigated. This study examined the therapeutic management of croup among a national sample of Italian pediatric providers. METHODS A survey was administered online to a sample of primary care and hospital-based pediatricians. Demographic data, perception regarding disease severity, treatment and knowledge of croup, choices of croup treatment medications, and knowledge of and adherence to treatment recommendations were compared between hospital and primary care pediatricians. Oral corticosteroids alone, oral corticosteroids with or without nebulized epinephrine and nebulized epinephrine plus oral or inhaled corticosteroids were considered the correct management in mild, moderate and severe croup, respectively. The determinants for correct management were examined using multivariate logistic regression analysis. RESULTS Six hundred forty-nine pediatricians answered at least 50% of the survey questions and were included in the analysis. Providers reported extensive use of inhaled corticosteroids for mild and moderate croup. Recommended treatment for mild, moderate and severe croup was administered in 46/647 (7.1%), 181/645 (28.0%) and 263/643 (40.9%) participants, respectively. Provider's age and knowledge of Westley Croup Score were significant predictors for correct management of mild croup. Being a hospital pediatrician and perception of croup as a clinically relevant condition were significant for moderate croup. CONCLUSIONS Significant differences exist between recommended guidelines and clinical practice in croup management. This study suggests wide variability in both the treatment of croup and clinical decision making strategies among hospital and primary care pediatricians. Addressing this issue could lead to noteworthy clinical and economic benefits.
Collapse
Affiliation(s)
- Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Laura Andreozzi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Giacomo Stera
- Specialty School of Paediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Gaia Toschi Vespasiani
- Specialty School of Paediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Carlotta Biagi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Daniele Zama
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Elena Balduini
- Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | | | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| |
Collapse
|
3
|
Akcan Yildiz L, Akca H, Kurt F, Hanalioglu D, Cetin M, Senel S, Karacan CD. Improving croup management at a pediatric emergency department. Postgrad Med 2024; 136:438-445. [PMID: 38804969 DOI: 10.1080/00325481.2024.2360889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup. METHODS In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED. RESULTS NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001). CONCLUSION With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.
Collapse
Affiliation(s)
- Leman Akcan Yildiz
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Halise Akca
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| | - Funda Kurt
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, University of Health Sciences, Ankara, Türkiye
| | - Damla Hanalioglu
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Meltem Cetin
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Saliha Senel
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| | - Can Demir Karacan
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| |
Collapse
|
4
|
Collins ME, Hall M, Shah SS, Molloy MJ, Aronson PL, Cotter JM, Steiner MJ, McCoy E, Tchou MJ, Stephens JR, Markham JL. Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes. J Hosp Med 2024; 19:251-258. [PMID: 38348499 PMCID: PMC11155307 DOI: 10.1002/jhm.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/08/2023] [Accepted: 01/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure. OBJECTIVE To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes. DESIGN, SETTINGS AND PARTICIPANTS We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality. MAIN OUTCOME AND MEASURES We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups. RESULTS We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.
Collapse
Affiliation(s)
- Megan E. Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Samir S. Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J. Molloy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jillian M. Cotter
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael J. Tchou
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Jessica L. Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| |
Collapse
|
5
|
Kim BH, Ha EK, Yoo H, Lee S, Rha YH, Han MY, Kim JH. Trends in Incidence and Drug Prescriptions for Croup in Children Under 5 Years of Age: A 2002-2019 Population-Based Study. J Korean Med Sci 2024; 39:e95. [PMID: 38469967 PMCID: PMC10927388 DOI: 10.3346/jkms.2024.39.e95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/11/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Tracking national croup trends can provide important insights for childhood health management. This study aimed to analyze the incidence and drug prescription trends in Korean children over a two-decade period. METHODS This population-based study encompassed 479,783 children aged < 5 years from 2002-2019, utilizing the National Health Insurance Service-National Sample Cohort. We identified participants with a primary croup diagnosis who were admitted to or visited the emergency room. Age-specific and age-adjusted incidence rates/10,000 person-years were calculated. We assessed using orthogonal polynomial contrasts and stratified by various factors (sex, age, residential area, economic status, comorbidities, and healthcare facility types). We observed changes in the use of five medications: inhaled steroids, systemic steroids, inhaled epinephrine, antibiotics, and short-acting bronchodilators. Generalized binomial logistic regression was used to analyze factors influencing prescription strategies. RESULTS In 2002, the croup-related visits were 16.1/10,000 person-years, increasing to 98.3 in 2019 (P for trend < 0.001). This trend persisted, regardless of age, sex, region, and economic status. Children with comorbid atopic dermatitis or asthma maintained consistent croup rates, while those without comorbidities increased. Treatment trends showed decreasing antibiotic (73-47%) and oxygen use (21.3-3.4%), with increasing nebulized epinephrine (9.3-41.5%) and multiple drug prescriptions (67.8-80.3%). Primary care centers exhibited a greater increase in prescription usage and hospitalization duration than did tertiary healthcare institutions. CONCLUSION Over the past two decades, croup incidence has risen, accompanied by increased epinephrine use and decreased antibiotic prescriptions. Longer hospitalization and higher medication use were mainly observed in primary care facilities.
Collapse
Affiliation(s)
- Bo Hee Kim
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Eun Kyo Ha
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hana Yoo
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Soonchul Lee
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Yeong Ho Rha
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
| | - Ju Hee Kim
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea.
| |
Collapse
|
6
|
Oi T, Tsuboi N, Tsuboi K, Nakagawa S. Airway Management and Risk Factors for Prolonged Intubation in Patients with Severe Croup. J Pediatr Intensive Care 2024; 13:75-79. [PMID: 38571991 PMCID: PMC10987213 DOI: 10.1055/s-0041-1736548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022] Open
Abstract
Croup is a common respiratory illness in children with a substantial variation in the severity of symptoms. Most of the patients present with mild symptoms, but patients with severe croup require intensive care unit (ICU) management. The aim of this study was to investigate the airway management of patients with severe croup who required intubation and determine the risk factors for prolonged intubation. We performed an 18-year retrospective observational cohort study at the pediatric ICU of a tertiary children's hospital in Japan. A total of 16 patients with croup who were intubated for upper airway obstruction were included in the study. Most patients (13of 16, 81%) were intubated with an endotracheal tube (ETT) smaller than their age-appropriate size. The median difference in the internal diameter (ID) between the selected ETT and the age-appropriate size was 1.0 mm (interquartile range: 0.5-1.0). Multivariate analysis performed on factors affecting the cumulative incidence of extubation revealed that the difference in ID between the selected ETT and age-appropriate size (mm) significantly reduced the duration of intubation (hazard ratio: 0.092, p = 0.03). A downsized ETT without a cuff may be recommended for intubation of patients with croup.
Collapse
Affiliation(s)
- Tadashi Oi
- Department of Critical Care Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Norihiko Tsuboi
- Department of Critical Care Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Kaoru Tsuboi
- Department of Critical Care Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Satoshi Nakagawa
- Department of Critical Care Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| |
Collapse
|
7
|
Mendez DR, Rumph G, Richardson J, Paul KK, Jehle D. Outcomes of croup in children: COVID-19 versus non-COVID-19 cases. J Am Coll Emerg Physicians Open 2023; 4:e13053. [PMID: 37886717 PMCID: PMC10598511 DOI: 10.1002/emp2.13053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Objectives: The emergence of COVID-19 has revealed its association with croup. The objective of this study was to compare outcomes of COVID-19 related croup to non-COVID-19 related croup during the COVID-19 pandemic. Methods: This retrospective propensity matched study used data from 2020-2023 in the United States Cohort of the TriNetX database that includes 56 major health care organizations. The analysis compared the outcomes of 2 cohorts of patients between 2 months and 7 years of age: Cohort A had croup and a positive test for COVID-19 and Cohort B had croup without a positive COVID-19 test, both within 1 week before or after presentation with croup. Outcomes were death, admission to the hospital, intensive care unit (ICU) admission, respiratory rate >60, and oxygen saturation <90 within 7 days after the diagnosis of croup. Results: There were 2590 patients with COVID-19 related croup and 103,439 patients with non-COVID-19 croup. The final propensity matched cohort included 5180 patients evenly divided between groups. When both groups were compared based on outcomes after matching, there was twice the risk of the patient being admitted to the hospital with COVID-19 croup (risk ratio [RR] = 2.12; 95% confidence interval [CI] 1.59-2.84; P < 0.001). Those with COVID-19 related croup had significantly increased risk of being admitted to the ICU (RR = 4.90; 95% CI 3.11-7.73; P < 0.001). The patients with COVID-19 related croup were more likely to have a respiratory rate ≥60 (RR = 2.00; 95% CI 1.18-3.37; P = 0.008) and oxygen saturation ≤90% (RR = 2.12; 95% CI 1.21-3.70; P = 0.007). There were no deaths in the final cohorts. There were no worse outcomes in the Omicron COVID-19 related croup group. Conclusions: The patients with COVID-19 related croup exhibited more severe disease manifestations. These children were more likely to be admitted to the hospital/ICU and had more significant respiratory distress.
Collapse
Affiliation(s)
- Donna R. Mendez
- Department of Emergency MedicineUniversity of Texas Medical BranchGalvestonTexasUSA
| | - Gregory Rumph
- Department of Emergency MedicineUniversity of Texas Medical BranchGalvestonTexasUSA
| | - Joan Richardson
- Department of Emergency MedicineUniversity of Texas Medical BranchGalvestonTexasUSA
| | - Krishna K. Paul
- Department of Emergency MedicineUniversity of Texas Medical BranchGalvestonTexasUSA
| | - Dietrich Jehle
- Department of Emergency MedicineUniversity of Texas Medical BranchGalvestonTexasUSA
| |
Collapse
|
8
|
Lee EP, Mu CT, Yen CW, Hsia SH, Lin JJ, Chan OW, Chiu CC, Lai SH, Yang WC, Chen CY, Su YT, Wu HP. Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency department. Am J Emerg Med 2023; 72:20-26. [PMID: 37453221 DOI: 10.1016/j.ajem.2023.06.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/14/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Croup caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging disease, and data on the risk factors associated with disease severity are still limited. The Westley croup score (WS) is widely used to assess croup severity. The current study aimed to analyze biomarkers associated with the WS and clinical outcomes in patients with croup and coronavirus disease 2019 in the pediatric emergency department (PED). POPULATION AND METHOD Patients diagnosed with croup caused by SARS-CoV-2 were admitted at two PEDs. Clinical data including age, WS, length of hospital stay, initial laboratory data, and treatment were analyzed. Clinical parameters were evaluated via multivariate logistic regression analysis. The best cutoff values for predicting croup severity and outcomes were identified using the receiver operating characteristic curve. RESULT In total, 250 patients were assessed. Moreover, 128 (51.2%) patients were discharged from the PED, and 122 (48.8%) were admitted to the hospital. Mild, moderate, and severe croup accounted for 63.6% (n = 159), 32% (n = 80), and 4.4% (n = 11) of all cases, respectively. A high mean age (years), neutrophil count (%), neutrophil-to-lymphocyte ratio (NLR), ALT (U/L), procalcitonin (ng/mL), and hemoglobin (g/dL) level, and length of hospital stay (days), and a low lymphocyte count (%) and blood pH were associated with croup severity and need for intensive care. Based on the multivariate logistic regression model, the NLR remained independent factors associated with croup severity and prognosis. Further, NLR was significantly correlated with WS. The area under the receiver operating characteristic curve of NLR for predicting a WS of ≥3 was 0.895 (0.842-0.948, p < 0.001), and that for predicting ICU admission was 0.795 (0.711-0.879, p < 0.001). The best cutoff values for a WS of ≥3 and ICU admission were 1.65 and 2.06, respectively. CONCLUSION NLR is correlated with WS and is a reliable, easy-to-use, and cheap biomarker for the early screening and prognosis of croup severity in the PED. A higher NLR may indicate severe croup and the need for further treatment. And the WS score remains reliable for estimating the severity of croup caused by SARS-CoV-2 and the risk of intensive care.
Collapse
Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Ting Mu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Wei Yen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Che Chiu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan
| | - Shen-Hao Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Chieh Yang
- Department of Pediatric Emergency, China Medical University Children's Hospital, China Medical University, Taichung City, Taiwan; Department of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Chun-Yu Chen
- Department of Pediatric Emergency, China Medical University Children's Hospital, China Medical University, Taichung City, Taiwan; Department of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Ya-Ting Su
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Han-Ping Wu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.
| |
Collapse
|
9
|
Garzon Mora N, Jaramillo AP, Briones Andriuoli R, Torres S, Revilla JC, Moncada D. An Overview of the Effectiveness of Corticoids in Croup: A Systematic Literature Review. Cureus 2023; 15:e46317. [PMID: 37916233 PMCID: PMC10616678 DOI: 10.7759/cureus.46317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 11/03/2023] Open
Abstract
Croup, also known as laryngotracheobronchitis, frequently leads to blockages in the upper respiratory tract in young children, presenting symptoms, such as a raspy voice, a distinctive cough, and noisy breathing during inhalation. Despite being a condition that often resolves on its own, it puts considerable strain on healthcare resources due to regular doctor visits, emergency room usage, and occasional hospital stays. Research focused on larger populations suggests that only a small percentage of children with croup end up requiring hospital admission for their condition. In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, we executed a meticulous systematic review by scouring databases, such as PubMed, Google Scholar, and the Cochrane Library. A total of 10 articles met our inclusion criteria and were selected for in-depth analysis. These scholarly works provided substantive insights into the pharmacological agents deployed in the treatment of croup. From a clinical standpoint, the management of croup is highly contingent on the patient's hemodynamic status. Our review discerned a pronounced preference for corticosteroids as the primary therapeutic intervention over other alternatives, which are largely relegated to second-line or emergency applications. Interestingly, we found negligible differences among the various corticosteroid treatment options in terms of statistical significance, underscoring their broad utility in ameliorating the condition. In addition to corticosteroids, our review also explored other therapeutic options, such as heliox, nebulized adrenaline, and even natural interventions, such as exposure to outdoor cold air. The efficacy of these treatments demonstrated variable results, reinforcing the notion that while they may be useful in specific circumstances, they are not universally applicable or as robustly effective as corticosteroids. Given the preponderance of evidence favoring corticosteroids, further research is warranted to solidify their status as the first-line treatment in different medical settings, be it inpatient hospitals, outpatient clinics, or even for home-based care. Such studies will not only add a layer of confidence in current medical practice but could also potentially optimize treatment protocols, contributing to improved patient outcomes. Therefore, advancing our understanding of the effectiveness of corticosteroids as the cornerstone of croup management remains an area of paramount scientific and clinical importance.
Collapse
Affiliation(s)
- Neyla Garzon Mora
- Medicine, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | | | | | - Sol Torres
- Medical School, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | | | - Denisse Moncada
- Medicine, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| |
Collapse
|
10
|
Bergmann KR, Lefchak B, Nickel A, Lammers S, Watson D, Hester GZ. Variation in Organizational Clinical Practice Guidelines for Croup. Hosp Pediatr 2023; 13:e241-e245. [PMID: 37545472 DOI: 10.1542/hpeds.2023-007221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition. OBJECTIVES To describe variation in CPGs across US children's hospitals. METHODS We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement. RESULTS Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores. CONCLUSIONS Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers.
Collapse
Affiliation(s)
- Kelly R Bergmann
- Departments of Pediatric Emergency Medicine
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| | - Brian Lefchak
- Departments of Pediatric Emergency Medicine
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| | - Amanda Nickel
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - Shea Lammers
- Departments of Pediatric Emergency Medicine
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| | - Dave Watson
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - Gabrielle Z Hester
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| |
Collapse
|
11
|
Lefchak B, Nickel A, Lammers S, Watson D, Hester GZ, Bergmann KR. Impact of Clinical Guidelines on Hospital Utilization in Children With Croup. Hosp Pediatr 2023; 13:768-774. [PMID: 37545468 DOI: 10.1542/hpeds.2023-007181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission. METHODS Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year. RESULTS Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant. CONCLUSIONS Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.
Collapse
Affiliation(s)
| | - Amanda Nickel
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | | | - Dave Watson
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | | | | |
Collapse
|
12
|
Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics 2023; 152:e2023061365. [PMID: 37525974 DOI: 10.1542/peds.2023-061365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVES Croup is the most common cause of acute upper airway obstruction in children. The benefits of treating croup with steroids are well established, with an onset of effect 30 minutes after administration. We investigated whether a 30-minute exposure to outdoor cold air might improve mild to moderate croup symptoms before the onset of action of steroids. METHODS This open-label, single-center, randomized controlled trial, enrolled children aged 3 months to 10 years with croup and a Westley Croup Score (WCS) ≥2 attending a tertiary pediatric emergency department. Participants were randomized (1:1) to either a 30-minute exposure to outdoor cold (<10°C) atmospheric air or to indoor ambient room air immediately after triage and administration of a single-dose oral dexamethasone. The primary endpoint was a decrease in WCS ≥2 points from baseline at 30 minutes. Analyses were intention to treat. RESULTS A total of 118 participants were randomly assigned to be exposed to outdoor cold air (n = 59) or indoor room temperature (n = 59). Twenty-nine of 59 children (49.2%) in the outdoor group and 14 of 59 (23.7%) in the indoor group showed a decrease in WCS ≥2 points from baseline at 30 minutes after triage (risk difference 25.4% [95% confidence interval 7.0-43.9], P = .007). Patients with moderate croup benefited the most from the intervention at 30 minutes (risk difference 46.1% [20.6-71.5], P < .001). CONCLUSIONS A 30-minute exposure to outdoor cold air (<10°C), as an adjunct to oral dexamethasone, is beneficial for reducing the intensity of clinical symptoms in children with croup, especially when moderate.
Collapse
Affiliation(s)
- Johan N Siebert
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Coralie Salomon
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Ilaria Taddeo
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Alain Gervaix
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christophe Combescure
- Division of Clinical Epidemiology, Department of Health and Community Medicine, University of Geneva and Geneva University Hospital, Geneva, Switzerland
| | - Laurence Lacroix
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
13
|
Hampton T, Ghazal Asswad R, Bhat J, Stevens K, Whitehall E, Milinis K, De S, Donne A, Krishnan M. Recurrent croup is a good indicator of underlying paediatric airway issues: A 10-year retrospective cohort study of airway endoscopy. EAR, NOSE & THROAT JOURNAL 2023:1455613231170087. [PMID: 37141917 DOI: 10.1177/01455613231170087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVE Children with a history of recurrent croup alert the ENT clinician to the potential for underlying laryngotracheal pathology. There is equipoise about the likelihood of identifying any underlying structural issues or subglottic stenosis in those children who undergo airway assessment. METHODS A retrospective cohort study in a tertiary UK paediatric hospital of a decade of children with recurrent croup who underwent a rigid laryngo-tracheo-bronchoscopy (airway endoscopy). MAIN OUTCOME(S) airway pathology seen on endoscopy and need for further airway surgery. RESULTS In ten years, 139 children underwent airway endoscopy for recurrent croup. Operative findings were abnormal in 62 (45 %) cases. Twelve cases (9%) had subglottic stenosis. Although recurrent croup was more common in males (78% of cases), this was not found to predispose them to operative findings. Children with previous intubations had >2 times the risk of abnormal findings and children born prematurely (<37 wks) had a trend towards abnormal operative findings versus children with no airway findings in our cohort. Even in those patients with abnormal findings, none necessitated further airway surgery. CONCLUSIONS Surgeons and parents can be reassured that rigid airway endoscopy for children with recurrent croup demonstrated high diagnostic utility but will rarely lead to further surgical intervention. Greater understanding about recurrent croup may require consensus clarification about definitions of recurrent croup and/or a universal adoption of a minimum standard operative record or grading system after rigid endoscopy for recurrent croup.
Collapse
Affiliation(s)
- Thomas Hampton
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Randa Ghazal Asswad
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- University of Liverpool School of Medicine, University of Liverpool, Liverpool, UK
| | - Jaya Bhat
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Kate Stevens
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Emma Whitehall
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Su De
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Adam Donne
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Madhan Krishnan
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
14
|
Kern-Goldberger AS, Dalton EM, Rasooly IR, Congdon M, Gunturi D, Wu L, Li Y, Gerber JS, Bonafide CP. Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists. JAMA Netw Open 2023; 6:e232648. [PMID: 36912837 PMCID: PMC10011930 DOI: 10.1001/jamanetworkopen.2023.2648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
IMPORTANCE Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices. OBJECTIVES To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023. EXPOSURES Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics. MAIN OUTCOMES AND MEASURES The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians. RESULTS We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.
Collapse
Affiliation(s)
- Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatric Hospital Medicine, Cleveland Clinic, Cleveland, Ohio
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Evan M. Dalton
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Irit R. Rasooly
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Morgan Congdon
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Deepthi Gunturi
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lezhou Wu
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yun Li
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeffrey S. Gerber
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| |
Collapse
|
15
|
Croup associated with COVID-19: A case series. JEM REPORTS 2023; 2:100011. [PMID: 36865663 PMCID: PMC9899123 DOI: 10.1016/j.jemrpt.2023.100011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/10/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Abstract
Background Croup encounters substantially decreased when the pandemic first began, specifically between March and September 2020, before croup cases dramatically spiked again with the Omicron variant. There is a dearth of information concerning children at risk for severe or refractory COVID-19-associated croup and their outcomes. Objective The objective of this case series was to describe the clinical characteristics and outcomes of croup associated with the Omicron variant in children, with a focus on cases refractory to treatment. Methods The case series includes children from birth to 18 years old who presented to a freestanding children's hospital emergency department in the Southeastern United States between December 1, 2021 and January 31, 2022 with a diagnosis of croup and a laboratory-confirmed diagnosis of COVID-19. We used descriptive statistics to summarize patient characteristics and outcomes. Results Of the total 81 patient encounters, 59 patients (72.8%) were discharged from the ED, with one patient requiring two revisits to the hospital. Nineteen patients (23.5%) were admitted to the hospital, and three of these patients represented to the hospital after discharge from the hospital. Three patients (3.7%) were admitted to the intensive care unit, none of whom represented after discharge. Conclusions This study reveals a wide age range of presentation as well as a relatively higher rate of admission and fewer coinfections compared to pre-pandemic croup. Reassuringly, the results also show a low postadmission intervention rate as well as a low revisit rate. We discuss four refractory cases to highlight nuances for management and disposition decisions.
Collapse
|
16
|
Walsh PS, Zhang Y, Lipshaw MJ. Variation in Emergency Department Use of Racemic Epinephrine and Associated Outcomes for Croup. Hosp Pediatr 2023; 13:167-173. [PMID: 36651069 DOI: 10.1542/hpeds.2022-006905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Racemic epinephrine (RE) is commonly administered for croup in the emergency department (ED). Our objectives were to examine variation in RE use between EDs, to determine whether ED variation in RE use is associated with hospital or patient factors, and to evaluate the associations between the rates of hospital-specific ED RE use and patient outcomes. METHODS We performed a retrospective cohort study using the Pediatric Heath Information System of children aged 3 months to 10 years with croup in the ED. We used mixed-effects regression to calculate risk-standardized proportions of patients receiving RE in each ED and to analyze the relationship between risk-standardized institutional RE use and individual patient odds of hospital admission, ICU admission, and ED revisits. RESULTS We analyzed 231 683 patient visits from 39 hospitals. ED administration of RE varied from 14% to 48% of visits (median, 24.5%; interquartile range, 20.0%-27.8%). A total of 8.6% of patients were hospitalized and 1% were admitted to the ICU. After standardizing for case mix and site effects, increasing ED use of RE per site was associated with increasing patient odds of hospital admission (odds ratio [OR], 1.39-95%; confidence interval [CI], 1.01-1.91), but not ICU admission (OR, 1.39; 95% CI, 0.99-1.97) or ED revisit (OR, 1.00; 95% CI, 0.92-1.09). CONCLUSIONS In this large, observational study, RE administration varied widely across EDs. Increased RE use by site was associated with increased odds of hospital admission for individual patients when controlling for patient factors. These results suggest further standardization of RE use in children with croup is warranted.
Collapse
Affiliation(s)
- Patrick S Walsh
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yin Zhang
- Divisions of Biostatistics and Epidemiology
| | - Matthew J Lipshaw
- Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
17
|
Walsh PS, Lipshaw MJ. Diurnal Variation in Frequency and Severity of Croup in the Emergency Department. Hosp Pediatr 2022; 12:e2022006682. [PMID: 36130916 DOI: 10.1542/hpeds.2022-006682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emergency department (ED) presentation for croup is thought to occur more often at night, but evidence for its diurnal variation is sparse. Our objectives were to describe the diurnal patterns of ED presentation in children with croup and to determine whether time of arrival associated with severe clinical outcomes. METHODS We conducted a retrospective cohort study using the Pediatric Health Information System. We included children 3 months to 11 years of age with an ED encounter for croup from 2016 through 2020. We quantified ED encounters by arrival hour and used generalized linear mixed-effects models to determine association between arrival time and racemic epinephrine use, hospitalization, intensive care unit (ICU) admission, and revisits. RESULTS There was considerable diurnal variation in ED visits for croup. A total of 126 186 children (60.1%) presented to the ED at night (between 8 pm and 8 am), and 83 763 children presented during the day (39.9%). Peak arrival time was 12:00 am (14 189 encounters) and the nadir was at 2:00 pm (5231 encounters). Children presenting during overnight hours had increased odds of the use of racemic epinephrine (odds ratio [OR] 1.33; 95% confidence interval [95% CI], 1.30-1.36), but reduced odds of hospitalization (OR 0.76; 95% CI, 0.73-0.78), ICU admission (OR 0.61; 95% CI, 0.58-0.68), and 3 day ED revisits (OR 0.86; 95% CI, 0.83-0.90). CONCLUSIONS Children with croup present to the ED more commonly at night. Children presenting to the ED with croup at night have greater odds of being treated with racemic epinephrine, but reduced odds of hospitalization, ICU admission, and return visits.
Collapse
Affiliation(s)
- Patrick S Walsh
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
18
|
Hester G, Nickel AJ, Watson D, Maalouli W, Bergmann KR. Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup. Pediatrics 2022; 150:188776. [PMID: 35970819 DOI: 10.1542/peds.2021-053507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department. METHODS At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures. RESULTS There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits. CONCLUSIONS Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.
Collapse
Affiliation(s)
| | | | | | - Walid Maalouli
- University of Minnesota Masonic Children's Hospital, Minneapolis, Mennesota
| | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| |
Collapse
|
19
|
Lefchak B, Nickel A, Lammers S, Watson D, Hester GZ, Bergmann KR. Analysis of COVID-19-Related Croup and SARS-CoV-2 Variant Predominance in the US. JAMA Netw Open 2022; 5:e2220060. [PMID: 35796213 PMCID: PMC9250054 DOI: 10.1001/jamanetworkopen.2022.20060] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This cross-sectional study investigates the association of dominant SARS-CoV-2 variants with COVID-19–related croup.
Collapse
Affiliation(s)
- Brian Lefchak
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Amanda Nickel
- Children’s Minnesota Research Institute, Children’s Minnesota, Minneapolis
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Dave Watson
- Children’s Minnesota Research Institute, Children’s Minnesota, Minneapolis
| | - Gabrielle Z. Hester
- Department of Value and Clinical Excellence, Children’s Minnesota, Minneapolis
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| |
Collapse
|
20
|
Choi YY, Kim YS, Lee SY, Sim J, Choe YJ, Han MS. Croup as a Manifestation of SARS-CoV-2 Omicron Variant Infection in Young Children. J Korean Med Sci 2022; 37:e140. [PMID: 35607737 PMCID: PMC9127433 DOI: 10.3346/jkms.2022.37.e140] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/31/2022] [Indexed: 11/20/2022] Open
Abstract
Croup is an acute upper respiratory disease primarily caused by the parainfluenza virus. Owing to inflammation and edema of the upper airways, children present with barky cough and stridor, and some may experience respiratory distress. We investigated children aged < 5 years with coronavirus disease 2019 (COVID-19) admitted to two hospitals in Seoul, South Korea, and observed a spike in croup cases during the omicron surge. Among the 569 children admitted from March 1, 2021 to February 25, 2022, 21 children (3.7%) had croup, and the proportion of croup cases was significantly higher during the omicron wave than that during the delta wave (12.4% vs. 1.2%, P < 0.001). With the immediate administration of corticosteroids and epinephrine via nebulizer, the symptoms improved rapidly. During the current omicron surge, careful monitoring of the symptoms of croup in young children is needed for the diagnosis of COVID-19 and its timely management.
Collapse
Affiliation(s)
- Youn Young Choi
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - You Sun Kim
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - Seong Yong Lee
- Department of Pediatrics, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jiwoo Sim
- Infectious Disease Control Division, Seoul Metropolitan Government, Seoul, Korea
| | - Young June Choe
- Department of Pediatrics, Korea University Anam Hospital, Seoul, Korea
| | - Mi Seon Han
- Department of Pediatrics, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.
| |
Collapse
|
21
|
Syamkumar S, Jani S, Browning Carmo K. Management and referral of acute laryngotracheitis - Croup: The New South Wales Neonatal and Paediatric Emergency Transport Service experience. J Paediatr Child Health 2022; 58:415-421. [PMID: 34523768 DOI: 10.1111/jpc.15729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 06/22/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the experience of NETS (The Newborn and paediatric Emergency Transport Service) New South Wales (NSW) with children referred with a provisional diagnosis of croup. To examine the adherence of referral hospitals to NSW Health policy guidelines and to establish criteria for the need to transfer and the level of escort required for a child with croup to a higher level of care. METHODS A retrospective audit of all children with a provisional diagnosis of croup referred to NETS over the epoch: 2005-2015. The NETS database was searched for keywords: croup and laryngotracheitis. Demographics, retrieval characteristics and management strategies were collected. RESULTS A total of 432 patients were identified. The number of children triaged to a medically led NETS team for transfer decreased (P < 0.001) whilst those transferred into more local regional or metropolitan hospitals (P < 0.001) increased. The number of adrenaline doses was not associated with intensive care admissions or the need for invasive ventilation. CONCLUSION Medically led retrieval teams are not necessary for safe transfer of children with a provisional diagnosis of croup unless the airway is secured with an endotracheal tube. Transfer to more local hospitals for paediatric care should be considered and time allowed for medications to take effect prior to movement.
Collapse
Affiliation(s)
- Suma Syamkumar
- Newborn and Paediatric Emergency Transport Service, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Shefali Jani
- Emergency Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kathryn Browning Carmo
- Newborn and Paediatric Emergency Transport Service, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
22
|
Tyler A, Bryan MA, Zhou C, Mangione-Smith R, Williams D, Johnson DP, Kenyon CC, Rasooly I, Neubauer HC, Wilson KM. Variation in Dexamethasone Dosing and Use Outcomes for Inpatient Croup. Hosp Pediatr 2022; 12:22-29. [PMID: 34846064 PMCID: PMC8882347 DOI: 10.1542/hpeds.2021-005854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup. METHODS This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs >1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS. RESULTS Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving >1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, >1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, >1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation. CONCLUSIONS We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, >1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses.
Collapse
Affiliation(s)
- Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO and Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS)
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | | | - Derek Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P. Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Irit Rasooly
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Hannah C. Neubauer
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Karen M. Wilson
- Kravis Children’s Hospital at the Icahn School of Medicine at Mount Sinai, New York City, NY
| |
Collapse
|
23
|
Abstract
OBJECTIVE This pilot study aims to identify potential predictors of postadmission interventions of hospitalized croup patients and derive a risk model aimed at reducing hospitalizations for croup. METHODS Data were collected on all croup hospitalizations for patients aged 1 month to 17 years admitted through a community hospital's emergency department (ED) between 2012 and 2017. Potential predictors were obtained from the electronic medical records including demographics, vital signs, ED length of stay, preintervention and postintervention Westley Croup Score (WCS), number of racemic epinephrine nebulizations administered, time to dexamethasone administration, preexisting conditions, and additional interventions during hospitalization. Statistical analysis used the outcome "patient received racemic epinephrine after hospital admission (yes/no)" to identify characteristics of the child or ED visit associated with that outcome. Preliminary analyses using stepwise logistic regression, tree models, and random forests suggested predictors, interactions among predictors, and the form of their association with the outcome. A final analysis used logistic regression. RESULTS A total of 116 croup admissions were included, of which 19 (16%) received racemic epinephrine posthospitalization. These characteristics were identified as having some predictive power: sex, preexisting conditions, and preintervention and postintervention WCS, along with the interaction between sex and postintervention WCS. Logistic regression estimated an equation describing the probability of postadmission intervention, permitting the choice among admission thresholds giving different sensitivities and specificities. CONCLUSIONS There appear to be promising predictors in croup patients presenting to the ED, which might help stratify risk for interventions after the ED encounter and thus reduce the number of potentially avoidable admissions.
Collapse
Affiliation(s)
| | - James S Hodges
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| |
Collapse
|
24
|
Tsuboi N, Oi T, Tsuboi K, Ebihara N, Nakagawa S. Dexmedetomidine for patients with croup. Respir Med Case Rep 2021; 34:101509. [PMID: 34522603 PMCID: PMC8426286 DOI: 10.1016/j.rmcr.2021.101509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/24/2021] [Accepted: 09/01/2021] [Indexed: 12/01/2022] Open
Abstract
Agitation exacerbates symptoms in patients with croup, but the reports on the therapeutic effects of sedation in these patients without intubation are scarce. We describe a typical case of croup wherein light sedation with dexmedetomidine was effective in treating and discuss how agitation exacerbates and sedation improves symptoms from the viewpoint of fluid dynamics theory in addition to the conventional explanation. The mechanism of dynamic airway collapse during inspiration in these patients supports the effectiveness of sedation with dexmedetomidine. We describe a typical case of croup in which light sedation with dexmedetomidine was effective. How agitation exacerbates symptoms of croup can be explained by fluid dynamics theory in addition to the conventional explanation. The negative pressure produced by the patient's inspiration and the static pressure drop leads to dynamic airway collapse.
Collapse
Affiliation(s)
- Norihiko Tsuboi
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tadashi Oi
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kaoru Tsuboi
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Naoki Ebihara
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
25
|
Pound CM, Knight BD, Webster R, Benchimol EI, Radhakrishnan D. Predictors of Hospitalization for Children With Croup, a Population-Based Cohort Study. Hosp Pediatr 2020; 10:1068-1077. [PMID: 33203748 DOI: 10.1542/hpeds.2020-001362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We sought to determine predictors of hospitalization for children presenting with croup to emergency departments (EDs), as well as predictors of repeat ED presentation and of hospital readmissions within 18 months of index admission. We also aimed to develop a practical tool to predict hospitalization risk upon ED presentation. METHODS Multiple deterministically linked health administrative data sets from Ontario, Canada, were used to conduct this population-based cohort study between April 1, 2006 and March 31, 2017. Children born between April 1, 2006, and March 31, 2011, were eligible if they had 1 ED visit with a croup diagnosis. Multivariable logistic regression was used to determine factors associated with hospitalization, subsequent ED visits, and subsequent croup hospitalizations. A multivariable prediction tool and associated scoring system were created to predict hospitalization risk within 7 days of ED presentation. RESULTS Overall, 1811 (3.3%) of the 54 981 eligible children who presented to an Ontario ED were hospitalized. Significant hospitalization predictors included age, sex, Canadian Triage and Acuity Scale score, gestational age at birth, and newborn distress. Younger patients and boys were more likely to revisit the ED for croup. Our multivariable prediction tool could forecast hospitalization up to a 32% probability for a given patient. CONCLUSIONS This study is the first population-based study in which predictors of hospitalization for croup based on demographic and historical factors are identified. Our prediction tool emphasized the importance of symptom severity on ED presentation but will require refinement before clinical implementation.
Collapse
Affiliation(s)
- Catherine M Pound
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada;
- Divisions of Pediatrics
- Department of Pediatrics and
| | - Braden D Knight
- ICES uOttawa, Ottawa, Canada
- Clinical Research Unit
- Ontario Child Health Support Unit, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Richard Webster
- Clinical Research Unit
- Ontario Child Health Support Unit, Ontario, Canada; and
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Department of Pediatrics and
- ICES uOttawa, Ottawa, Canada
- Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Dhenuka Radhakrishnan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Department of Pediatrics and
- ICES uOttawa, Ottawa, Canada
- Respirology, and
| |
Collapse
|
26
|
Waler A, Sanchez K, Cervantes SS, Chen C. Management of pediatric laryngeal webs secondary to severe croup and traumatic intubation. Int J Pediatr Otorhinolaryngol 2020; 139:110409. [PMID: 33068948 DOI: 10.1016/j.ijporl.2020.110409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022]
Abstract
Laryngotracheobronchitis is a common, typically self-limiting viral infection. However, severe laryngotracheobronchitis can require urgent intubation to prevent imminent airway obstruction. The concurrent inflammation and urgency make laryngeal trauma more likely. We report two cases of children who underwent emergent intubation for acute respiratory distress due to viral laryngotracheobronchitis and subsequently developed anterior laryngeal webs. Both underwent laryngoplasty with keel placement, with resolution of their laryngeal webs. These cases describe pediatric laryngeal web formation as a rare complication of traumatic intubation and a novel technique for endoscopic keel placement.
Collapse
Affiliation(s)
- Alex Waler
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Kyle Sanchez
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Sergio Santino Cervantes
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA; Department of Pediatric Otolaryngology, Nemours Children's Hospital, Orlando, FL, USA.
| | - Cynthia Chen
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA; Department of Pediatric Otolaryngology, Nemours Children's Hospital, Orlando, FL, USA.
| |
Collapse
|
27
|
Asmundsson AS, Arms J, Kaila R, Roback MG, Theiler C, Davey CS, Louie JP. Hospital Course of Croup After Emergency Department Management. Hosp Pediatr 2020; 9:326-332. [PMID: 30988017 DOI: 10.1542/hpeds.2018-0066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe inpatient management of patients with croup admitted from the emergency department (ED). METHODS In a multicentered, cross-sectional observational study based on retrospective chart review, we identified children 6 months to 5 years of age with a discharge diagnosis of croup. All patients were evaluated in the ED and treated with at least 1 dose of racemic epinephrine (RE) before admission. Children with hypoxia or directly admitted to the PICU were excluded. RESULTS We identified 628 admissions for croup. Significant interventions, defined as additional RE, helium-oxygen use, or PICU transfer, occurred in 142 patients (22.6%). A total of 137 children received additional RE on the inpatient ward, and 5 received RE and were transferred to the PICU. No patient was treated with helium-oxygen. A total 486 (77.4%) of patients did not receive significant interventions postadmission. Length of stay for children not requiring significant intervention was, on average, <24 hours (18.8 hours [SD 9.3]; range 1.2-111 hours). Children with tachypnea (odds ratio = 2.5; P = .002) on arrival to ED and patients who had ED radiographs (odds ratio = 1.7; P = .018) had increased odds of receiving a significant intervention after admission. CONCLUSIONS Less than one-quarter of children admitted to the general wards for croup received significant interventions after admission. Tachypnea in the ED and use of radiograph were associated with an increased use of significant interventions.
Collapse
Affiliation(s)
| | - Joseph Arms
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota; and
| | - Rahul Kaila
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Mark G Roback
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Carly Theiler
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota; and
| | - Cynthia S Davey
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey P Louie
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| |
Collapse
|
28
|
Bryan MA, Hofstetter AM, Simon TD, Zhou C, Williams DJ, Tyler A, Kenyon CC, Vachani JG, Opel DJ, Mangione-Smith R. Vaccination Status and Adherence to Quality Measures for Acute Respiratory Tract Illnesses. Hosp Pediatr 2020; 10:199-205. [PMID: 32041781 PMCID: PMC7041553 DOI: 10.1542/hpeds.2019-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses. METHODS We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models. RESULTS Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference -0.3; 95% confidence interval: -1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (-4.6; 95% confidence interval: -7.5 to -1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status. CONCLUSIONS We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians "do more" for hospitalized children who are not UTD.
Collapse
Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington
| | - Annika M Hofstetter
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Chén C Kenyon
- Department of Pediatrics, School of Medicine, University of Pennsylvania and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Joyee G Vachani
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Douglas J Opel
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| |
Collapse
|
29
|
Prentice B, Moloney S, Hort J, Hibbert P, Wiles LK, Molloy CJ, Arnolda G, Ting HP, Braithwaite J, Jaffe A. Assessing the adherence to guidelines in the management of croup in Australian children: a population-based sample survey. Int J Qual Health Care 2019; 31:759-767. [PMID: 31665290 DOI: 10.1093/intqhc/mzz088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/28/2019] [Accepted: 07/17/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To determine the extent to which care received by Australian children presenting with croup is in agreement with Clinical Practice Guidelines (CPGs). DESIGN Retrospective population-based sample survey. Croup clinical indicators were derived from CPGs. DATA SOURCES/STUDY SETTING Medical records from three healthcare settings were sampled for selected visits in 2012 and 2013 in three Australian states. DATA COLLECTION Data were collected by nine experienced paediatric nurses, trained to assess eligibility for indicator assessment and adherence to CPGs. Surveyors undertook criterion-based medical record reviews using an electronic data collection tool. RESULTS Documented guideline adherence was lower for general practitioners (65.9%; 95% CI: 60.8-70.6) than emergency departments (91.1%; 95% CI: 89.5-92.5) and inpatient admissions (91.3%; 95% CI: 88.1-93.9). Overall adherence was very low for a bundle of 10 indicators related to assessment (4.5%; 95% CI: 2.4-7.6) but higher for a bundle of four indicators relating to the avoidance of inappropriate therapy (83.1%; 95% CI: 59.5-96.0). CONCLUSIONS Most visits for croup were characterized by appropriate treatment in all healthcare settings. However, most children had limited documented clinical assessments, and some had unnecessary tests or inappropriate therapy, which has potential quality and cost implications. Universal CPG and clinical assessment tools may increase clinical consistency.
Collapse
Affiliation(s)
- Bernadette Prentice
- Department of Respiratory Medicine, Sydney Children's Hospital, High St., Randwick, NSW, 2031, Australia.,School of Women's and Children's Health, University of New South Wales, High St., Randwick, NSW, 2031, Australia
| | - Susan Moloney
- Department of Paediatrics, Gold Coast University Hospital, Hospital Blvd., Southport, QLD, 4215, Australia.,School of Medicine, Griffith University, Parklands Dr., Gold Coast, QLD, 4222, Australia.,Faculty of Health Sciences and Medicine, Bond University, University Dr., Gold Coast, QLD, 4226, Australia
| | - Jason Hort
- Emergency Department, Sydney Children's Hospital, Harkesbury Rd. and Hainsworth St., Westmead, NSW, 2145, Australia.,Children's Hospital Westmead Clinical School, Sydney Medical School, University of Sydney, Manning Rd., Sydney, NSW, 2050, Australia
| | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Talavera Rd., North Ryde, NSW, 2109, Australia.,Australian Centre for Precision Health, University of South Australia Cancer Research Institute (UniSA CRI), School of Health Sciences, University of South Australia, Currie St., Adelaide, SA, 5000, Australia.,South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia
| | - Louise K Wiles
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Talavera Rd., North Ryde, NSW, 2109, Australia.,Australian Centre for Precision Health, University of South Australia Cancer Research Institute (UniSA CRI), School of Health Sciences, University of South Australia, Currie St., Adelaide, SA, 5000, Australia.,South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia
| | - Charlotte J Molloy
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Talavera Rd., North Ryde, NSW, 2109, Australia.,Australian Centre for Precision Health, University of South Australia Cancer Research Institute (UniSA CRI), School of Health Sciences, University of South Australia, Currie St., Adelaide, SA, 5000, Australia.,South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia
| | - Gaston Arnolda
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Talavera Rd., North Ryde, NSW, 2109, Australia
| | - Hsuen P Ting
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Talavera Rd., North Ryde, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Talavera Rd., North Ryde, NSW, 2109, Australia
| | - Adam Jaffe
- Department of Respiratory Medicine, Sydney Children's Hospital, High St., Randwick, NSW, 2031, Australia.,School of Women's and Children's Health, University of New South Wales, High St., Randwick, NSW, 2031, Australia
| |
Collapse
|
30
|
Bryan MA, Hofstetter AM, deHart MP, Simon TD, Opel DJ. Vaccination Status and Resource Use During Hospital Visits for Respiratory Illnesses. Pediatrics 2019; 144:e20190585. [PMID: 31624218 PMCID: PMC6855809 DOI: 10.1542/peds.2019-0585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To evaluate variation in resource use for children with acute respiratory tract illness (ARTI) by vaccination status. METHODS We conducted a retrospective cohort study of children 0 to 16 years of age at 5 children's hospitals with 1 of 4 ARTI diagnoses (pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status (yes or no). Outcomes were receipt of each of the following tests or treatments (yes or no): complete blood cell count, blood cultures, C-reactive protein (CRP) level testing, viral testing, influenza testing, pertussis testing, chest radiographs, neck radiographs, antibiotics, and corticosteroids. We generated multivariable logistic regression models to examine the associations between our predictor and outcomes. RESULTS Of the 2302 participants included in analysis, 568 (25%) were diagnosed with pneumonia, 343 (15%) were diagnosed with croup, 653 (28%) were diagnosed with asthma, and 738 (32%) were diagnosed with bronchiolitis. Most (92%) vaccination statuses were documented as UTD. Across conditions, children whose vaccination status was documented as not UTD had higher adjusted odds of receiving a complete blood cell count, blood culture, CRP level testing, and influenza testing (P < .001). Children with pneumonia whose vaccination status was documented as not UTD had higher adjusted odds of receiving CRP level testing and influenza testing (P < .001). Children with croup whose vaccination status was documented as not UTD had higher adjusted odds of receiving blood cultures (P < .001). CONCLUSIONS Children with ARTI whose vaccination status was documented as not UTD had higher odds of undergoing laboratory testing compared with children whose vaccination status was documented as UTD.
Collapse
Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Annika M Hofstetter
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | | | - Tamara D Simon
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Douglas J Opel
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| |
Collapse
|
31
|
Weatherly J, Song Y, Meister K, Berg M. The Runaway Croup Train: Off the Pathway and Through the Woods. Hosp Pediatr 2019; 9:820-823. [PMID: 31492686 DOI: 10.1542/hpeds.2019-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Yohan Song
- Otolaryngology, School of Medicine, Stanford University, Palo Alto, California
| | - Kara Meister
- Otolaryngology, School of Medicine, Stanford University, Palo Alto, California
| | | |
Collapse
|
32
|
Hester G, Barnes T, O'Neill J, Swanson G, McGuinn T, Nickel A. Rate of Airway Intervention for Croup at a Tertiary Children's Hospital 2015-2016. J Emerg Med 2019; 57:314-321. [PMID: 31416651 DOI: 10.1016/j.jemermed.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/20/2019] [Accepted: 06/08/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Croup admission decision making is challenging because the rate of further interventions after stabilization is unclear. OBJECTIVE We sought to describe rates of inpatient racemic epinephrine (IRE) and additional inpatient airway interventions (IAI) (oxygen or heliox therapy, intubation, or transfer to an intensive care unit) among patients presenting to a tertiary children's hospital with croup. METHODS This was a retrospective descriptive study including patients (3 months to 8 years of age) with an emergency department (ED)/inpatient encounter for croup from January 1, 2015 to December 31, 2016 at a tertiary children's hospital. We excluded intensive care unit direct admissions and patients with bronchiolitis/asthma/pneumonia. We compared 3 groups (a weighted random 5% sample of patients evaluated in ED only, and those admitted with or without IRE/IAI) using Kruskal-Wallis, Pearson χ2, or the Fischer exact test, where appropriate. We used multivariate analysis to compare demographics and preadmission racemic epinephrine (RE) with rates of IRE/IAI in admitted patients. RESULTS We included 588 patients (194 discharged from the ED, 394 admitted). In admitted patients, 20.8% (82/394) had IRE/IAI, most commonly IRE (20.0%, 79/394). Three admitted patients (0.76%) had IAI. Overall, patients with 2 outside hospital/ED doses of RE had a 12.1% rate of IRE/IAI (23.5% if ≥3 RE doses). Patients with ≥3 preadmission RE doses were more likely to have IRE/IAI compared with 2 RE (adjusted odds ratio = 2.08 [95% confidence interval 1.15-3.76]; p = 0.02); there were no other significant associations. CONCLUSIONS We found a low rate of IRE/IAI after ED management in patients with croup and no significant associations aside from preadmission RE doses. These findings may be considered in admission decisions.
Collapse
Affiliation(s)
| | - Timothy Barnes
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | - Jodi O'Neill
- Hospital Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Gloria Swanson
- Hospital Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Tracey McGuinn
- Hospital Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Amanda Nickel
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
| |
Collapse
|
33
|
Tchou MJ, Hall M, Shah SS, Johnson DP, Schroeder AR, Antoon JW, Genies MC, Quinonez R, Miller CW, Shah SP, Brady PW. Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses. Pediatrics 2019; 144:e20181644. [PMID: 31171587 PMCID: PMC6615522 DOI: 10.1542/peds.2018-1644] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts. METHODS We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing. RESULTS In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis. CONCLUSIONS Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.
Collapse
Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - James W Antoon
- Children's Hospital, University of Illinois, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Christopher W Miller
- Division of Pediatric Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
34
|
Tyler A, Anderson L, Moss A, Graham J, Dempsey A, Carpenter T. Predictors of Symptom Rebound in Critically Ill Patients With Croup. Hosp Pediatr 2019; 9:447-454. [PMID: 31076458 DOI: 10.1542/hpeds.2018-0195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES There are no data to inform the ideal length of in-hospital observation after symptom improvement or to inform the ideal dexamethasone dose in critically ill children with croup. We describe a cohort of critically ill children with croup who rebound (have return of symptom(s) after meeting hospital discharge criteria) and examine the association between the cumulative dexamethasone dose before PICU discharge and both the odds and timing of rebound. METHODS In this single-center retrospective cohort study of subjects 6 months to 13 years of age admitted to the PICU with a primary diagnosis of croup, we employed multivariable logistic regression to evaluate the association between cumulative pre-PICU discharge dexamethasone dose and rebound. In the model, we controlled for subject age and sex, insurance, season, and history of prematurity, croup, or intubation. Kaplan-Meier curves were used to compare time to rebound between subjects receiving ≤2 standard (0.6 mg/kg) doses and those receiving >2 standard doses of dexamethasone before PICU discharge. RESULTS Data were analyzed over 69 months (January 2011-October 2016), and 275 unique subjects met inclusion criteria. The median cumulative dose of dexamethasone in the hospital was 1.57 mg/kg (interquartile range 0.98-2.63). Thirty-seven percent (n = 102) of subjects developed rebound croup symptoms after meeting hospital discharge criteria. The median time to rebound was 13.1 hours (interquartile range 6.1-23.7). There was no association between cumulative pre-PICU discharge dexamethasone dose and the odds (odds ratio = 1.00; 95% confidence interval 0.83-1.19; P = .96) or timing of rebound. CONCLUSIONS A clinically significant number of critically ill patients with croup rebounded. Total pre-PICU discharge dexamethasone dose did not predict either the odds or timing of rebound.
Collapse
Affiliation(s)
- Amy Tyler
- Children's Hospital Colorado, Aurora, Colorado; .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Lauren Anderson
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Jessica Graham
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Amanda Dempsey
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Todd Carpenter
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| |
Collapse
|
35
|
April MD, Long B. Do Glucocorticoids Improve Symptoms and Reduce Return Visits or Admission Rates Among Children With Croup? Ann Emerg Med 2019; 73:459-461. [DOI: 10.1016/j.annemergmed.2018.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Indexed: 11/25/2022]
|
36
|
Lee YJ, Kim HB, Kim BS, Kim CK, Kim CH, Kim HY, Kim S, Kim Y, Park C, Seo JH, Sol IS, Sung M, Song MS, Song DJ, Ahn YM, Oh HL, Yu J, Lee KS, Lee E, Lee JS, Jang GC, Jang YY, Chung EH, Chung HL, Choi SM, Choi YJ, Han MY, Yang HJ, Shim JY, Kim JT. Seasonal patterns and etiologies of croup in children during the period 2010–2015: A multicenter retrospective study. ALLERGY ASTHMA & RESPIRATORY DISEASE 2019. [DOI: 10.4168/aard.2019.7.2.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yong Ju Lee
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hyo-Bin Kim
- Department of Pediatrics, Asthma and Allergy Center, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Bong-Seong Kim
- Department of Pediatrics, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Chang-Keun Kim
- Department of Pediatrics, Asthma and Allergy Center, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Cheol Hong Kim
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Hyung Young Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sangyoung Kim
- SCH Biomedical Informatics Research Unit, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Yunsun Kim
- SCH Biomedical Informatics Research Unit, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Chorong Park
- SCH Biomedical Informatics Research Unit, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Ju-Hee Seo
- Department of Pediatrics, Dankook University Hospital, Cheonan, Korea
| | - In Suk Sol
- Department of Pediatrics, Yonsei University Severance Hospital, Seoul, Korea
| | - Myongsoon Sung
- Department of Pediatrics, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Min Seob Song
- Department of Pediatrics, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Dae Jin Song
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Young Min Ahn
- Department of Pediatrics, Eulji University Eulji General Hospital, Seoul, Korea
| | - Hea Lin Oh
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Jinho Yu
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Suk Lee
- Department of Pediatrics, Hanyang University Guri Hospital, Guri, Korea
| | - Eun Lee
- Department of Pediatrics, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Suk Lee
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Gwang Cheon Jang
- Department of Pediatrics, National Health Insurance Service, Ilsan Hospital, Ilsan, Korea
| | - Yoon Young Jang
- Department of Pediatrics, Daegu Catholic University Medical Center, Daegu, Korea
| | - Eun Hee Chung
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Hai Lee Chung
- Department of Pediatrics, Daegu Catholic University Medical Center, Daegu, Korea
| | - Sung-Min Choi
- Department of Pediatrics, Dongguk University Gyungju Hospital, Gyungju, Korea
| | - Yun Jung Choi
- Department of Pediatrics, Sowha Children's Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University Children Hospital, Seoul, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA University CHA Bundang Medical Center, Seongnam, Korea
| | - Hyeon-Jong Yang
- SCH Biomedical Informatics Research Unit, Soonchunhyang University Seoul Hospital, Seoul, Korea
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jung Yeon Shim
- Division of Pediatric Allergy & Pulmonology, Department of Pediatrics, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jin-Tack Kim
- Department of Pediatric Allergy & Pneumology, Catholic University Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | | |
Collapse
|
37
|
Palmu S, Mecklin M, Heikkilä P, Backman K, Peltola V, Renko M, Korppi M. National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals. Acta Paediatr 2018; 107:1966-1970. [PMID: 29752817 DOI: 10.1111/apa.14397] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
AIM Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. METHODS This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. RESULTS There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. CONCLUSION The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.
Collapse
Affiliation(s)
- Sauli Palmu
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Minna Mecklin
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Paula Heikkilä
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Katri Backman
- Department of Paediatrics; Kuopio University Hospital; University of Eastern Finland; Kuopio Finland
| | - Ville Peltola
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; University of Turku; Turku Finland
| | - Marjo Renko
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
- PEDEGO Research Unit; University of Oulu; Oulu University Hospital; Oulu Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| |
Collapse
|
38
|
Simmonds JC, Tuomi A, Groblewski JC. High rates of subglottic stenosis seen in African-American children admitted with severe croup to hospitals in the United States between 2003 and 2013. Respir Med 2018; 143:56-60. [DOI: 10.1016/j.rmed.2018.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 12/14/2022]
|
39
|
Argent AC. Considerations for Assessing the Appropriateness of High-Cost Pediatric Care in Low-Income Regions. Front Pediatr 2018; 6:68. [PMID: 29637061 PMCID: PMC5880905 DOI: 10.3389/fped.2018.00068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022] Open
Abstract
It may be difficult to predict the consequences of provision of high-cost pediatric care (HCC) in low- and middle-income countries (LMICs), and these consequences may be different to those experienced in high-income countries. An evaluation of the implications of HCC in LMICs must incorporate considerations of the specific context in that country (population age profile, profile of disease, resources available), likely costs of the HCC, likely benefits that can be gained versus the costs that will be incurred. Ideally, the process that is followed in decision making around HCC should be transparent and should involve the communities that will be most affected by those decisions. It is essential that the impacts of provision of HCC are carefully monitored so that informed decisions can be made about future provision medical interventions.
Collapse
Affiliation(s)
- Andrew C Argent
- Paediatric Critical Care, Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| |
Collapse
|