Clinical Implications of the Obstructive Pattern on Chest Radiography in Children Aged 3-59 Months With Severe Lower Respiratory Tract Infections

OBJECTIVES

To investigate the clinical implications of the obstructive pattern on plain chest radiography, defined as peribronchial cuffing or hyperinflation, in young children with severe lower respiratory tract infections (LRTIs).

METHODS

We reviewed all children aged 3‒59 months with LRTIs who underwent radiography and polymerase chain reaction in a Korean emergency department from 2016 through 2020. The radiographs were read as consolidation, peribronchial cuffing, or hyperinflation, with each interrater reliability computed. As per the obstructive pattern, we compared their clinical features, therapeutic interventions, outcomes, and microbiology.

RESULTS

Among 599 children with LRTIs, 465 were enrolled, of whom 98 (21.1%) had consolidation (κ = 0.60; 95% confidence interval, 0.50‒0.70), and 367 (78.9%) had peribronchial cuffing (0.55; 0.46‒0.65) or hyperinflation (0.59; 0.52‒0.67). The obstructive pattern was significantly associated with more frequent wheezing (obstructive, 28.6% vs. consolidation, 10.2%) and the use of inhaled albuterol or systemic steroids (39.0% vs. 23.5%), and lower median values or frequencies of age (22.0 vs. 35.0 months), crackle or diminished breath sound (42.0% vs. 61.2%), C-reactive protein (1.4 vs. 2.9 mg/dL), antibiotic therapy (72.2% vs. 93.9%), length of hospital stay (4.0 vs 5.0 days), fever lasting 3 days or longer (7.9% vs. 29.6%), and complications (0.5% vs. 9.2%). Microbiologically, viruses, such as respiratory syncytial virus, were more frequently detected in children with the obstructive pattern or at a younger age.

CONCLUSIONS

This study confirms an association of the obstructive pattern on radiography with viral infection and inflammatory airway obstruction-relieving therapy in young children with severe LRTIs.

Predictive validity of resource-adjusted Korean Triage and Acuity Scale in pediatric gastrointestinal tract foreign body patients

Although paediatric patients with gastrointestinal (GI) foreign bodies require multiple resources, they often present with few or no discernible symptoms and are typically assigned a low acuity level during triage. We compared the predictive accuracy of the revised Korean Triage and Acuity Scale (rKTAS), which elevates acuity by one step in relation to anticipated resource utilization, with that of the conventional KTAS for clinical outcomes. This was a retrospective study of National Emergency Department Information System data. Data on patient and ED characteristics, resources used, and clinical outcomes were collected from January 2018 to December 2021 for patients with GI foreign bodies aged under 19. The primary outcome was rKTAS accuracy in predicting hospitalization, ICU admission, operating room (OR) use, and ED length of stay (EDLOS). The AUROC was used to evaluate the performance via of the KTAS and rKTAS. In total, 25,324 paediatric patients visited the ED for GI tract foreign bodies. The mean age was 3.8 years, and 51% (12,923) were between 1 and 4 year old. Although most (23,658; 93.4%) were discharged, 4.9% required hospitalization. Two or more resources were utilized in 2514 (9.9%) cases, and 3,514 individuals had their triage levels increased by one step. Compared with those of the KTAS, the AUROCs of the rKTAS for predicting overall hospitalization (p < 0.05), admission to general wards (p < 0.05), ICU admission (p = 0.01), and admission via the OR (p < 0.05)were higher than KTAS. Compared with that with the KTAS, the EDLOS with the rKTAS was longer at levels 1, 2, and 3. The adjusted rKTAS is a better predictor of clinical outcomes for paediatric patients with GI tract foreign bodies than the KTAS.

Impact of social distancing policy on pediatric emergency ophthalmic severity during the coronavirus disease 2019 pandemic

BACKGROUND

We investigated the impact of social distancing policies (SDPs) on ophthalmic severity in children who underwent emergency ophthalmic referrals during the coronavirus disease 2019 pandemic period.

METHODS

We reviewed all children with ophthalmic referrals in a single academic hospital emergency department during the period from February 2017 to December 2019 (prepandemic) or February 2020 to December 2022 (pandemic). Baseline features, diagnosis-based severity, and outcomes were compared between the two periods. The Government Response Stringency Index (GRSI), which ranges from 0 to 100, was used as a surrogate for the intensity of SDPs during the pandemic. Poisson regression was used to quantify the association of the GRSI with the severity.

RESULTS

Among 1074 children with ophthalmic referrals, 437 (40.7%) visited during the pandemic. This was 31.4% lower than that during the prepandemic period. In numbers, pandemic-related declines were more modest in high severity than in medium-to-low severity (35.1% vs. 55.0%), and for injury than for illness (28.5% vs. 36.1%). In percentages, high severity increased from 63.3% to 71.3% (p = 0.016). The hospitalization rate increased from 1.7% to 3.9% (p = 0.029). For every 10-point increase in GRSI, there was a 20.0% decrease in high severity (95% confidence interval, 5%-30%).

CONCLUSIONS

This study shows an inverse association of SDPs with ophthalmic severity and an increase in severe cases along with consistent flow of injury cases, amid the overall decline in eye-related visits to the emergency department during the pandemic period.

Clinical support system for triage based on federated learning for the Korea triage and acuity scale

Background and aims

This study developed a clinical support system based on federated learning to predict the need for a revised Korea Triage Acuity Scale (KTAS) to facilitate triage.

Methods

This was a retrospective study that used data from 11,952,887 patients in the Korean National Emergency Department Information System (NEDIS) from 2016 to 2018 for model development. Separate cohorts were created based on the emergency medical center level in the NEDIS: regional emergency medical center (REMC), local emergency medical center (LEMC), and local emergency medical institution (LEMI). External and temporal validation used data from emergency department (ED) of the study site from 2019 to 2021. Patient features obtained during the triage process and the initial KTAS scores were used to develop the prediction model. Federated learning was used to rectify the disparity in data quality between EDs. The patient's demographic information, vital signs in triage, mental status, arrival information, and initial KTAS were included in the input feature.

Results

3,626,154 patients' visits were included in the regional emergency medical center cohort; 8,278,081 patients' visits were included in the local emergency medical center cohort; and 48,652 patients' visits were included in the local emergency medical institution cohort. The study site cohort, which is used for external and temporal validation, included 135,780 patients visits. Among the patients in the REMC and study site cohorts, KTAS level 3 patients accounted for the highest proportion at 42.4% and 45.1%, respectively, whereas in the LEMC and LEMI cohorts, KTAS level 4 patients accounted for the highest proportion. The area under the receiver operating characteristic curve for the prediction model was 0.786, 0.750, and 0.770 in the external and temporal validation. Patients with revised KTAS scores had a higher admission rate and ED mortality rate than those with unaltered KTAS scores.

Conclusions

This novel system might accurately predict the likelihood of KTAS acuity revision and support clinician-based triage.

Predictive Validity of a New Triage System for Outcomes in Patients Visiting Pediatric Emergency Departments: A Nationwide Study in Korea

Triage is essential for rapid and efficient intervention in patients visiting an emergency department. In Korea, since 2016, the Pediatric Korean Triage and Acuity Scale (PedKTAS) has been implemented nationwide for the triage of patients visiting pediatric emergency departments (PEDs). The aim of this study was to evaluate the validity of the PedKTAS in patients who visit PEDs. This study was a retrospective observational study of national registry data collected from all emergency medical centers and institutions throughout Korea. We analyzed data from patients aged <15 years who visited emergency departments nationwide from January 2016 to December 2019. The hospitalization and intensive care unit (ICU) admission rates were analyzed on the basis of triage level. In total, 5,462,964 pediatric patients were included in the analysis. The hospitalization rates for PedKTAS Levels 1-5, were 63.5%, 41.1%, 17.0%, 6.5%, and 3.7%, respectively, and were significantly different (p < 0.001). The ICU admission rates for PedKTAS Levels 1-5 were 14.4%, 6.0%, 0.3%, 0.1%, and 0.1%, respectively, and were significantly different (p < 0.001). The hospitalization and ICU admission rates were highest for PedKTAS Level 1, and differences were significant based on the level. We identified that the PedKTAS is suitable for predicting the emergency status of pediatric patients who visit PEDs.

Impact of COVID-19 Pandemic on Children Visiting Emergency Department for Mental Illness: A Multicenter Database Analysis from Korea

We aimed to identify changes in the proportion of pediatric emergency department (PED) visits due to mental illness during the coronavirus disease 2019 (COVID-19) pandemic. This was a retrospective observational study of visits to the PED at six university hospitals from January 2017 to December 2020. We included children aged 5−17 years who were diagnosed with a mental illness. We used segmented regression analysis to identify the change in the proportion of patients with mental illness. A total of 845 patients were included in the analysis. After the first case of COVID-19 was reported in Korea, the number of PED visits significantly decreased by 560.8 patients per week (95% confidence interval (CI): −665.3 to −456.3, p < 0.001). However, the proportion of patients with mental illness increased significantly, by 0.37% per week (95% CI: 0.04% to 0.70%, p = 0.03), at this time point. Subgroup analyses revealed that emotional disorders significantly increased by 0.06% per month (95% CI: 0.02% to 0.09%, p < 0.001) during the pandemic. Our study revealed that an increased proportion of patients with mental illness visited the PED during the COVID-19 pandemic. Specifically, we identified that the proportion of emotional disorders continues to rise during this pandemic.

Impact of Intubator's Training Level on First-Pass Success of Endotracheal Intubation in Acute Care Settings: A Four-Center Retrospective Study

(1) Background: First-pass success (FPS) of endotracheal intubation is more challenging in children than in adults. We aimed to identify factors associated with FPS of intubation in acute care settings. (2) Methods: We analyzed data of children aged <10 years who underwent intubation within ≤24 h of arrival at four Korean emergency departments (2016−2019). Variables were compared according to FPS. A logistic regression was performed to quantify the association of factors with FPS. An experienced intubator was defined as a senior resident or a specialist. (3) Results: Of 280 children, 169 (60.4%) had FPS. The children with FPS were older (median age, 23.0 vs. 11.0 months; p = 0.018), were less frequently in their infancy (36.1% vs. 50.5%; p = 0.017), and were less likely to have respiratory compromise (41.4% vs. 55.0%; p = 0.030). The children with FPS tended to be more often intubated by experienced intubators than those without FPS (87.0% vs. 78.4%; p = 0.057). Desaturation was rarer in those with FPS. Factors associated with FPS were experienced intubators (aOR, 1.93; 95% CI, 1.01−3.67) and children’s age ≥12 months (1.84; 1.13−3.02). (4) Conclusion: FPS of intubation can be facilitated by deploying or developing clinically competent intubators, particularly for infants, in acute care settings.

One-year changes in the pediatric emergency department caused by prolonged coronavirus disease 2019 pandemic

BACKGROUND

With the coronavirus disease 2019 (COVID-19) pandemic lasting for more than a year, it is imperative to identify the associated changes in the use of emergency medical care for efficient operation of the pediatric emergency department (PED). This study was conducted to determine the long-term impact of the COVID-19 pandemic on patterns of PED visits.

METHODS

This is a retrospective observational study of visits to the PED of six hospitals, between January 1, 2017, and December 31, 2020. We compared changes in the characteristics of patients before and during the COVID-19 pandemic.

RESULTS

A total of 245 022 visits were included in this analysis. After the first case of COVID-19 was reported in Korea, we observed a significant decrease (54.2%) in PED visits compared with the annual average number of visits in the previous 3 years. Since then, the weekly number of PED visits decreased by 11.9 person/week (95% CI: -15.3--8.4, P < 0.001), which included an increase of 0.21% (95% CI: 0.15%-0.26%, P < 0.001) per week in high acuity patients. From 2017 to 2020, the proportion of infectious respiratory diseases by year was 25.9%, 27.0%, 28.6%, and 16.3%, respectively, demonstrating a significant decrease in 2020 (P < 0.001).

CONCLUSIONS

During the COVID-19 pandemic, the number of patient visits to PEDs continues to decline, especially among those with infectious diseases. However, the disease severity of patients has gradually increased. There has been a change in the characteristics of visits to PEDs after COVID-19 which will require an appropriate response from a long-term perspective.

Factors associated with difficult intravenous access in the pediatric emergency department

Background:

Successful intravenous catheter placement plays a vital role in the pediatric emergency department. We assessed pediatric emergency department–related factors associated with difficult intravenous catheter placement.

Method:

We retrospectively reviewed the electronic medical records of patients younger than 18 years who had an intravenous catheter placement attempt during their pediatric emergency department stay. Difficult intravenous access was defined as intravenous catheter placement requiring more than one attempt. The demographic-, clinical- and procedure-related factors were collected, and a logistic regression analysis was used to evaluate the factors associated with difficult intravenous access.

Result:

In total, 925 patients were enrolled, and 77 (8.32%) cases had difficult intravenous access. The median age of the patients was 3.0 (interquartile range = 1–9) years, and 496 (53.6%) patients were male. After adjustment, we found that age (odds ratio = 0.91, 95% confidence interval = (0.85–0.98), p = 0.01); a history of prematurity (odds ratio = 2.31, 95% confidence interval (1.08–4.98), p = 0.03); the intravenous catheter insertion site (foot versus hand odds ratio = 5.65, 95% confidence interval = (2.97–10.75); p < 0.001); and the experience of the provider (<6 months versus ⩾12 months odds ratio = 4.59, 95% confidence interval = (1.92–11.01), p = 0.01) were associated with difficult intravenous access. However, the acuity of disease, crowdedness at the pediatric emergency department, sex, vein visibility, vein palpability, intravenous catheter size, patients’ experience with intravenous access, and time of day were not significantly correlated with difficult intravenous access.

Conclusion:

The success rate of intravenous catheter placement at the pediatric emergency department could be improved by experienced providers. The acuity of disease and crowdedness at the pediatric emergency department were not significantly associated factors.

Clinical Considerations When Applying Vital Signs in Pediatric Korean Triage and Acuity Scale

Initial vital signs of children at the emergency department may be abnormal because of anxiety and irritability, resulting in unrealistic triage levels. This study aimed to evaluate the effectiveness of pediatric triage by clinical decision based on the patient's general condition. The Pediatric Korean Triage and Acuity Scale (PedKTAS) has been used nationwide for triage since 2016. The triage level, as assessed by an experienced triage nurse and based on the patient's clinical condition, was defined as the 'real practice (RP)-level,' while the re-calculated triage level, as assessed by the direct application of initial vital signs, was defined as the 'simulation (S)-level.' A total of 22,841 patients were triaged during the study period. The hospitalization rate according to RP-PedKTAS levels exhibited a significant correlation with the expected hospitalization rate suggested by the Pediatric Canadian Triage and Acuity Scale (CTAS) (P = 0.002), whereas the S-PedKTAS levels did not (P = 0.151). Compared with the previously reported pediatric CTAS level-specific hospitalization rate and intensive care unit (ICU) admission rate, RP-PedKTAS was significantly correlated with both hospitalization rate and ICU admission rate (P = 0.001 and P = 0.012, respectively). However, S-PedKTAS showed no significant correlation in both (P = 0.267 and P = 0.188, respectively). The determination of triage levels based on clinical decision rather than the direct application of abnormal initial vital signs to PedKTAS is more accurate in predicting the hospitalization rate and ICU admission rate.