Improving Guideline-Concordant Care for Febrile Infants Through a Quality Improvement Initiative

OBJECTIVES

We aimed to examine the impact of a quality improvement (QI) collaborative on adherence to specific recommendations within the American Academy of Pediatrics' Clinical Practice Guideline (CPG) for well-appearing febrile infants aged 8 to 60 days.

METHODS

Concurrent with CPG release in August 2021, we initiated a QI collaborative involving 103 general and children's hospitals across the United States and Canada. We developed a multifaceted intervention bundle to improve adherence to CPG recommendations for 4 primary measures and 4 secondary measures, while tracking 5 balancing measures. Primary measures focused on guideline recommendations where deimplementation strategies were indicated. We analyzed data using statistical process control (SPC) with baseline and project enrollment from November 2020 to October 2021 and the intervention from November 2021 to October 2022.

RESULTS

Within the final analysis, there were 17 708 infants included. SPC demonstrated improvement across primary and secondary measures. Specifically, the primary measures of appropriately not obtaining cerebrospinal fluid in qualifying infants and appropriately not administering antibiotics had the highest adherence at the end of the collaborative (92.4% and 90.0% respectively). Secondary measures on parent engagement for emergency department discharge of infants 22 to 28 days and oral antibiotics for infants 29 to 60 days with positive urinalyses demonstrated the greatest changes with collaborative-wide improvements of 16.0% and 20.4% respectively. Balancing measures showed no change in missed invasive bacterial infections.

CONCLUSIONS

A QI collaborative with a multifaceted intervention bundle was associated with improvements in adherence to several recommendations from the AAP CPG for febrile infants.

Changing patterns of routine laboratory testing over time at children's hospitals

BACKGROUND

Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time.

OBJECTIVES

To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database.

MAIN OUTCOMES AND MEASURES

We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index.

RESULTS

Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.

Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes

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.

Contaminant Organism Growth in Febrile Infants at Low Risk for Invasive Bacterial Infection

In this multicenter, cross-sectional, secondary analysis of 4042 low-risk febrile infants, nearly 10% had a contaminated culture obtained during their evaluation (4.9% of blood cultures, 5.0% of urine cultures, and 1.8% of cerebrospinal fluid cultures). Our findings have important implications for improving sterile technique and reducing unnecessary cultures.

Predictors of Invasive Bacterial Infection in Febrile Infants Aged 2 to 6 Months in the Emergency Department

Our goal was to identify predictors of invasive bacterial infection (ie, bacteremia and bacterial meningitis) in febrile infants aged 2-6 months. In our multicenter retrospective cohort, older age and lower temperature identified infants at low risk for invasive bacterial infection who could safely avoid routine testing.

"Let us take care of the medicine": A qualitative analysis of physician communication when caring for febrile infants

BACKGROUND

Guidelines for the management of febrile infants emphasize patient-centered communication. Although patient-centeredness is central to high-quality healthcare, biases may impact physicians' patient-centeredness. We aimed to 1) identify physicians' assumptions that inform their communication with parents of febrile infants and 2) examine physicians' perceptions of bias.

METHODS

We recruited physicians from three academic pediatric emergency departments (EDs) for semi-structured interviews. We applied a constant comparative method approach to conduct a thematic analysis of interview transcripts. Two coders followed several analytical steps: 1) discovery of concepts and code assignment, 2) identification of themes by grouping concepts, 3) axial coding to identify thematic properties, and 4) identifying exemplar excerpts for rich description. Thematic saturation was based on repetition, recurrence, and forcefulness.

RESULTS

Fourteen physicians participated. Participants described making assumptions regarding three areas: 1) the parent's affect, 2) the parent's social capacity, and 3) the physician's own role in the parent-physician interaction. Thematic properties highlighted the importance of the physician's assumptions in guiding communication and decision-making. Participants acknowledged an awareness of bias, and specifically noted that language bias influenced the assumptions that informed their communication.

CONCLUSIONS

ED physicians described subjective assumptions about parents that informed their approach to communication when caring for febrile infants. Given the emphasis on patient-centered communication in febrile infant guidelines, future efforts are necessary to understand how assumptions are influenced by biases, the effect of such behaviors on health inequities, and how to combat this.

WHAT'S NEW

Physician communication drives health outcomes. In this qualitative investigation, physicians described making assumptions about parents, based on subjective assessments, which informed their communication and decision-making. This represents a step towards understanding how biases inform communication and result in health inequity.

Perspectives of Adolescents and Young Adults With Sickle Cell Disease and Clinicians on Improving Transition Readiness With a Video Game Intervention

We aimed to learn the experiences of clinicians and adolescents and young adults with sickle cell disease (AYA-SCD) with managing their disease at home and making medical decisions as they transition from pediatric to adult care, and their perceptions of a video game intervention to positively impact these skills. We conducted individual, semistructured interviews with patients (AYA-SCD ages 15 to 26 years) and clinicians who provide care to AYA-SCD at an urban, quaternary-care hospital. Interviews elicited patients' and clinicians' experiences with AYA-SCD, barriers and facilitators to successful home management, and their perspectives on shared decision-making and a video game intervention. To identify themes, we conducted an inductive analysis until data saturation was reached. Participants (16 patients and 21 clinicians) identified 4 main themes: (1) self-efficacy as a critical skill for a successful transition from pediatric to adult care, (2) the importance of patient engagement in making medical decisions, (3) multilevel determinants of optimal self-efficacy and patient engagement, and (4) support for a video game intervention which, by targeting potential determinants of AYA-SCD achieving optimal self-efficacy and engagement in decision-making, may improve these important skills.

Febrile infants aged ≤60 days: evaluation and management in the emergency department

Emergency clinicians frequently provide care to febrile infants aged ≤60 days in the emergency department. In these very young infants, fever may be the only presenting sign of invasive bacterial infection and, if untreated, invasive bacterial infection can lead to severe outcomes. This issue reviews newer risk-stratification tools and the 2021 American Academy of Pediatrics clinical practice guideline to provide recommendations for the evaluation and management of febrile young infants. The most recent literature assessing the risk of concomitant invasive bacterial infection with urinary tract infections or positive viral testing is also reviewed.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants

Importance

Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language.

Objective

To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection.

Design, Setting, and Participants

This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source.

Exposures

Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English).

Main Outcomes and Measures

The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes.

Results

Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46).

Conclusions and Relevance

Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Clinician Management Practices for Infants With Hypothermia in the Emergency Department

BACKGROUND

Young infants with serious bacterial infections (SBI) or herpes simplex virus (HSV) infections may present to the emergency department (ED) with hypothermia. We sought to evaluate clinician testing and treatment preferences for infants with hypothermia.

METHODS

We developed, piloted, and distributed a survey of ED clinicians from 32 US pediatric hospitals between December 2022 to March 2023. Survey questions were related to the management of infants (≤60 days of age) with hypothermia in the ED. Questions pertaining to testing and treatment preferences were stratified by age. We characterized clinician comfort with the management of infants with hypothermia.

RESULTS

Of 1935 surveys distributed, 1231 (63.6%) were completed. The most common definition of hypothermia was a temperature of ≤36.0°C. Most respondents (67.7%) could recall caring for at least 1 infant with hypothermia in the previous 6 months. Clinicians had lower confidence in caring for infants with hypothermia compared with infants with fever (P < .01). The proportion of clinicians who would obtain testing was high in infants 0 to 7 days of age (97.3% blood testing for SBI, 79.7% for any HSV testing), but declined for older infants (79.3% for blood testing for SBI and 9.5% for any HSV testing for infants 22-60 days old). A similar pattern was noted for respiratory viral testing, hospitalization, and antimicrobial administration.

CONCLUSIONS

Testing and treatment preferences for infants with hypothermia varied by age and frequently reflected observed practices for febrile infants. We identified patterns in management that may benefit from greater research and implementation efforts.

Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay

BACKGROUND AND OBJECTIVES

High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS.

METHODS

In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors.

RESULTS

Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively.

CONCLUSIONS

We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.

Prevalence of Urinary Tract Infection, Bacteremia, and Meningitis Among Febrile Infants Aged 8 to 60 Days With SARS-CoV-2

Importance

The prevalence of urinary tract infection (UTI), bacteremia, and bacterial meningitis in febrile infants with SARS-CoV-2 is largely unknown. Knowledge of the prevalence of these bacterial infections among febrile infants with SARS-CoV-2 can inform clinical decision-making.

Objective

To describe the prevalence of UTI, bacteremia, and bacterial meningitis among febrile infants aged 8 to 60 days with SARS-CoV-2 vs without SARS-CoV-2.

Design, Setting, and Participants

This multicenter cross-sectional study was conducted as part of a quality improvement initiative at 106 hospitals in the US and Canada. Participants included full-term, previously healthy, well-appearing infants aged 8 to 60 days without bronchiolitis and with a temperature of at least 38 °C who underwent SARS-CoV-2 testing in the emergency department or hospital between November 1, 2020, and October 31, 2022. Statistical analysis was performed from September 2022 to March 2023.

Exposures

SARS-CoV-2 positivity and, for SARS-CoV-2-positive infants, the presence of normal vs abnormal inflammatory marker (IM) levels.

Main Outcomes and Measures

Outcomes were ascertained by medical record review and included the prevalence of UTI, bacteremia without meningitis, and bacterial meningitis. The proportion of infants who were SARS-CoV-2 positive vs negative was calculated for each infection type, and stratified by age group and normal vs abnormal IMs.

Results

Among 14 402 febrile infants with SARS-CoV-2 testing, 8413 (58.4%) were aged 29 to 60 days; 8143 (56.5%) were male; and 3753 (26.1%) tested positive. Compared with infants who tested negative, a lower proportion of infants who tested positive for SARS-CoV-2 had UTI (0.8% [95% CI, 0.5%-1.1%]) vs 7.6% [95% CI, 7.1%-8.1%]), bacteremia without meningitis (0.2% [95% CI, 0.1%-0.3%] vs 2.1% [95% CI, 1.8%-2.4%]), and bacterial meningitis (<0.1% [95% CI, 0%-0.2%] vs 0.5% [95% CI, 0.4%-0.6%]). Among infants aged 29 to 60 days who tested positive for SARS-CoV-2, 0.4% (95% CI, 0.2%-0.7%) had UTI, less than 0.1% (95% CI, 0%-0.2%) had bacteremia, and less than 0.1% (95% CI, 0%-0.1%) had meningitis. Among SARS-CoV-2-positive infants, a lower proportion of those with normal IMs had bacteremia and/or bacterial meningitis compared with those with abnormal IMs (<0.1% [0%-0.2%] vs 1.8% [0.6%-3.1%]).

Conclusions and Relevance

The prevalence of UTI, bacteremia, and bacterial meningitis was lower for febrile infants who tested positive for SARS-CoV-2, particularly infants aged 29 to 60 days and those with normal IMs. These findings may help inform management of certain febrile infants who test positive for SARS-CoV-2.

Racial and Ethnic Differences in Insurer Classification of Nonemergent Pediatric Emergency Department Visits

Importance

Government and commercial health insurers have recently enacted policies to discourage nonemergent emergency department (ED) visits by reducing or denying claims for such visits using retrospective claims algorithms. Low-income Black and Hispanic pediatric patients often experience worse access to primary care services necessary for preventing some ED visits, raising concerns about the uneven impact of these policies.

Objective

To estimate potential racial and ethnic disparities in outcomes of Medicaid policies for reducing ED professional reimbursement based on a retrospective diagnosis-based claims algorithm.

Design, Setting, and Participants

This simulation study used a retrospective cohort of pediatric ED visits (aged 0-18 years) for Medicaid-insured children and adolescents appearing in the Market Scan Medicaid database between January 1, 2016, and December 31, 2019. Visits missing date of birth, race and ethnicity, professional claims data, and Current Procedural Terminology codes of billing level of complexity were excluded, as were visits that result in admission. Data were analyzed from October 2021 to June 2022.

Main Outcomes and Measures

Proportion of ED visits algorithmically classified as nonemergent and simulated per-visit professional reimbursement after applying a current reimbursement reduction policy for potentially nonemergent ED visits. Rates were calculated overall and compared by race and ethnicity.

Results

The sample included 8 471 386 unique ED visits (43.0% by patients aged 4-12 years; 39.6% Black, 7.7% Hispanic, and 48.7% White), of which 47.7% were algorithmically identified as potentially nonemergent and subject to reimbursement reduction, resulting in a 37% reduction in ED professional reimbursement across the study cohort. More visits by Black (50.3%) and Hispanic (49.0%) children were algorithmically identified as nonemergent when compared with visits by White children (45.3%; P < .001). Modeling the impact of the reimbursement reductions across the cohort resulted in expected per-visit reimbursement that was 6% lower for visits by Black children and 3% lower for visits by Hispanic children relative to visits by White children.

Conclusions and Relevance

In this simulation study of over 8 million unique ED visits, algorithmic approaches for classifying pediatric ED visits that used diagnosis codes identified proportionately more visits by Black and Hispanic children as nonemergent. Insurers applying financial adjustments based on these algorithmic outputs risk creating uneven reimbursement policies across racial and ethnic groups.

Variation in stool testing for children with acute gastrointestinal infections

BACKGROUND AND OBJECTIVE

Children with gastrointestinal infections often require acute care.The objectives of this study were to describe variations in patterns of stool testing across children's hospitals and determine whether such variation was associated with utilization outcomes.

DESIGN, SETTINGS AND PARTICIPANTS

We performed a multicenter, cross-sectional study using the Pediatric Health Information System (PHIS) database. We identified stool testing (multiplex polymerase chain reaction [PCR], stool culture, ova and parasite, Clostridioides difficile, and other individual stool bacterial or viral tests) in children diagnosed with acute gastrointestinal infections.

MAIN OUTCOME AND MEASURES

We calculated the overall testing rates and hospital-level stool testing rates, stratified by setting (emergency department [ED]-only vs. hospitalized). We stratified individual hospitals into low, moderate, or high testing institutions. Generalized estimating equations were then used to examine the association of hospital testing groups and outcomes, specifically, length of stay (LOS), costs, and revisit rates.

RESULTS

We identified 498,751 ED-only and 40,003 encounters for hospitalized children from 2016 to 2020. Compared to ED-only encounters, stool studies were obtained with increased frequency among encounters for hospitalized children (ED-only: 0.1%-2.3%; Hospitalized: 1.5%-13.8%, all p < 0.001). We observed substantial variation in stool testing rates across hospitals, particularly during encounters for hospitalized children (e.g., rates of multiplex PCRs ranged from 0% to 16.8% for ED-only and 0% to 65.0% for hospitalized). There were no statistically significant differences in outcomes among low, moderate, or high testing institutions in adjusted models.

CONCLUSIONS

Children with acute gastrointestinal infections experience substantial variation in stool testing within and across hospitals, with no difference in utilization outcomes. These findings highlight the need for guidelines to address diagnostic stewardship.

Trends in Prevalence of Bacterial Infections in Febrile Infants During the COVID-19 Pandemic

OBJECTIVES

Our objective was to describe the prevalence of urinary tract infection (UTI) and invasive bacterial infection (IBI) in febrile infants during the coronavirus disease 2019 pandemic.

METHODS

We conducted a multicenter cross-sectional study that included 97 hospitals in the United States and Canada. We included full-term, well-appearing infants 8 to 60 days old with a temperature of ≥38°C and an emergency department visit or hospitalization at a participating site between November 1, 2020 and March 31, 2022. We used logistic regression to determine trends in the odds of an infant having UTI and IBI by study month and to determine the association of COVID-19 prevalence with the odds of an infant having UTI and IBI.

RESULTS

We included 9112 infants; 603 (6.6%) had UTI, 163 (1.8%) had bacteremia without meningitis, and 43 (0.5%) had bacterial meningitis. UTI prevalence decreased from 11.2% in November 2020 to 3.0% in January 2022. IBI prevalence was highest in February 2021 (6.1%) and decreased to 0.4% in January 2022. There was a significant downward monthly trend for odds of UTI (odds ratio [OR] 0.93; 95% confidence interval [CI]: 0.91-0.94) and IBI (OR 0.90; 95% CI: 0.87-0.93). For every 5% increase in COVID-19 prevalence in the month of presentation, the odds of an infant having UTI (OR 0.97; 95% CI: 0.96-0.98) or bacteremia without meningitis decreased (OR 0.94; 95% CI: 0.88-0.99).

CONCLUSIONS

The prevalence of UTI and IBI in eligible febrile infants decreased to previously published, prepandemic levels by early 2022. Higher monthly COVID-19 prevalence was associated with lower odds of UTI and bacteremia.

Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections

BACKGROUND

Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP).

OBJECTIVES

We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes.

DESIGN, SETTING AND PARTICIPANTS

This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals.

MAIN OUTCOME AND METHODS

We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes.

RESULTS

We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs.

CONCLUSION

There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.

Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19

OBJECTIVES

To describe the epidemiology of pediatric injury-related visits to children's hospital emergency departments (EDs) in the United States during early and later periods of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

METHODS

We conducted a cross-sectional study using the Pediatric Health Information System, an administrative database to identify injury-related ED visits at 41 United States children's hospitals during the SARS-CoV-2 pandemic period (March 15, 2020 to March 14, 2021) and a 3 year comparator period (March 15-March 14, 2017-2020). For these 2 periods, we compared patient characteristics, injury type and severity, primary discharge diagnoses, and disposition, stratified by early (March 15, 2020 to June 30, 2020), middle (July 1, 2020 to October 31, 2020), and late (November 1, 2020 to March 14, 2021) pandemic periods.

RESULTS

Overall, ED injury-related visits decreased by 26.6% during the first year of the SARS-CoV-2 pandemic, with the largest decline observed in minor injuries. ED injury-related visits resulting in serious-critical injuries increased across the pandemic (15.9% early, 4.9% middle, 20.6% late). Injury patterns with the sharpest relative declines included superficial injuries (41.7% early) and sprains/strains (62.4% early). Mechanisms of injury with the greatest relative increases included (1) firearms (22.9% early; 42.8% middle; 37% late), (2) pedal cyclists (60.4%; 24.9%; 32.2%), (3) other transportation (20.8%; 25.3%; 17.9%), and (4) suffocation/asphyxiation (21.4%; 20.2%; 28.4%) and injuries because of suicide intent (-16.2%, 19.9%, 21.8%).

CONCLUSIONS

Pediatric injury-related ED visits declined in general. However, there was a relative increase in injuries with the highest severity, which warrants further investigation.

Analysis of Racial and Ethnic Diversity of Population Served and Imaging Used in US Children's Hospital Emergency Departments

Importance

Lower rates of diagnostic imaging have been observed among Black children compared with White children in pediatric emergency departments. Although the racial composition of the pediatric population served by each hospital differs, it is unclear whether this is associated with overall imaging rates at the hospital level, and in particular how it may be associated with the difference in imaging rates between Black and White children at a given hospital.

Objective

To examine the association between the diversity of the pediatric population seen at each pediatric ED and variation in diagnostic imaging.

Design, Setting, and Participants

Cross-sectional analysis of ED visits by patients younger than 18 years at 38 children's hospitals from January 1, 2016, through December 31, 2019, using data from the Pediatric Health Information System. Data were analyzed from April to September 2021.

Exposures

Proportion of patients from minoritized groups cared for at each hospital.

Main Outcomes and Measures

The primary outcome was receipt of an imaging test defined as radiography, ultrasonography, computed tomography, or magnetic resonance imaging; adjusted odds ratios (aORs) were calculated to measure differences in imaging by race and ethnicity by hospital, and the correlation between the proportion of patients from minoritized groups cared for at each hospital and the aOR for receipt of diagnostic imaging by race and ethnicity was examined.

Results

There were 12 310 344 ED visits (3 477 674 [28.3%] among Hispanic patients; 3 212 915 [26.1%] among non-Hispanic Black patients; 4 415 747 [35.9%] among non-Hispanic White patients; 6 487 660 [52.7%] among female patients) by 5 883 664 pediatric patients (mean [SD] age, 5.84 [5.23] years) to the 38 hospitals during the study period, of which 3 527 866 visits (28.7%) involved at least 1 diagnostic imaging test. Diagnostic imaging was performed in 1 508 382 visits (34.2%) for non-Hispanic White children, 790 961 (24.6%) for non-Hispanic Black children, and 907 222 (26.1%) for Hispanic children (P < .001). Non-Hispanic Black patients were consistently less likely to receive diagnostic imaging than non-Hispanic White patients at each hospital, and for all imaging modalities. There was a significant correlation between the proportion of patients from minoritized groups cared for at the hospital and greater imaging difference between non-Hispanic White and non-Hispanic Black patients (correlation coefficient, -0.37; 95% CI, -0.62 to -0.07; P = .02).

Conclusions and Relevance

In this cross-sectional study, hospitals with a higher percentage of pediatric patients from minoritized groups had larger differences in imaging between non-Hispanic Black and non-Hispanic White patients, with non-Hispanic White patients consistently more likely to receive diagnostic imaging. These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine.

Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures

BACKGROUND

Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures.

OBJECTIVES

(1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care.

OUTCOME MEASURES

Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs.

RESULTS

We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization.

CONCLUSIONS

Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Stakeholder Perspectives on Hospitalization Decisions and Shared Decision-Making in Bronchiolitis

OBJECTIVES

Our objective was to elicit clinicians' and parents' perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions.

METHODS

We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children's hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians' and parents' perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups.

RESULTS

We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents' preferences for engaging in SDM, and parents' emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician's decision when adequately informed.

CONCLUSIONS

Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.

Breaking through barriers: the need for effective research to promote language-concordant communication as a facilitator of equitable emergency care

Individuals with limited English proficiency (LEP) are at high risk for adverse outcomes in the US health care system. This is particularly true for patients with LEP seeking care in the emergency department (ED). Although professional language interpretation improves the quality of care for these patients, it remains underused. The dynamic, discontinuous nature of an ED visit poses distinct challenges and opportunities for providing equitable, high-quality care for patients with LEP. Evidence-based best practices for identifying patients with LEP and using professional interpretation are well described but inadequately implemented. There are few examples in the literature of rigorous interventions to improve quality of care and outcomes for patients with LEP. There is an urgent need for high-quality research to improve communication with patients with LEP along the continuum of emergency care in order to achieve equity in outcomes.

Development of a Parent-Reported Outcome Measure for Febrile Infants ≤60 Days Old

OBJECTIVE

We aimed to develop a parent-reported outcome measure for febrile infants 60 days or younger evaluated in the emergency department.

METHODS

We conducted a 3-part study: (1) individual, semistructured interviews with parents of febrile infants 60 days or younger to generate potential items for the measure; (2) expert review with pediatric emergency medicine physicians and member checking with parents, who rated each item's clarity and relevance using 4-point scales; and (3) cognitive interviews with a new sample of parents, who gave feedback and rated the measure's ease of use on a 4-point scale. The measure was iteratively revised during each part of the development process.

RESULTS

In part 1, we interviewed 24 parents of 21 infants. Interviews revealed several themes: parents' experiences with medical care, communication, and decision making; parents' emotions, particularly worry, fear, and stress; the infant's outcomes valued by parents; and the impact of the infant's illness on the family. From these themes, we identified 22 potential items for inclusion in the measure. In part 2, 10 items were revised for clarity based on feedback from physicians and parents, primarily under the domains of parents' emotions and the infant's outcomes. In part 3, we further revised the measure for clarity and added an item. The final measure included 23 items and was rated as excellent in its ease of use.

CONCLUSIONS

The 23-item parent-reported outcome measure includes the experiences and outcomes important to parents. Further studies are needed to evaluate the measure's psychometric properties.

A Workplace Procedure Training Cart to Augment Pediatric Resident Procedural Learning

OBJECTIVE

Our primary aim was to describe pediatric residents' use of a workplace procedural training cart. An exploratory aim was to examine if the cart associated with increased resident procedural experiences with real patients.

METHODS

Guided by the procedural training construct of "Learn, See, Practice, Prove, Do, Maintain," we created a novel workplace procedural training cart with videos (learn and see) and simulation equipment (practice and prove). An electronic logbook recorded resident use data, and a brief survey solicited residents' perceptions of the cart's educational impact. We queried our electronic medical record to compare the proportion of real procedures completed by residents before and after the intervention.

RESULTS

From August 1 to December 31, 2019, 24 pediatric residents (10 interns and 14 seniors) rotated in the pediatric emergency department. Twenty-one cart encounters were logged, mostly by interns (67% [14/21]). The 21 cart encounters yielded 32 learning activities (8 videos watched and 24 procedures practiced), reflecting the residents' interest in laceration repair (50% [4/8], 54% [13/24]) and lumbar puncture (38% [3/8], 33% [8/24]). All users agreed (29% [6/21]) or strongly agreed (71% [15/21]) the cart encouraged practice and improved confidence in independently performing procedures. No changes were observed in the proportion of actual procedures completed by residents.

CONCLUSIONS

A workplace procedural training cart was used mostly by pediatric interns. The cart cultivated residents' perceived confidence in real procedures but was not used by all residents or influenced residents' procedural behaviors in the pediatric emergency department.

Parents' Perspectives on Communication and Shared Decision Making for Febrile Infants ≤60 Days Old

OBJECTIVES

Decisions about the management of febrile infants ≤60 days old may be well suited for shared decision making (SDM). Our objectives were to learn about parents' experiences with receiving and understanding information in the emergency department (ED) and their perspectives on SDM, including for decisions about lumbar puncture (LP).

METHODS

We conducted semistructured interviews with 23 parents of febrile infants ≤60 days old evaluated in the pediatric ED at an urban, academic medical center. Interviews assessed parents' experiences in the ED and their perspectives on communication and SDM. Two investigators coded the interview transcripts, refined codes, and identified themes using the constant comparative method.

RESULTS

Parents' unmet need for information negatively impacted parents' understanding, stress, and trust in the physician. Themes for parents' perspectives on SDM included the following: (1) giving parents the opportunity to express their opinions and concerns builds confidence in the decision making process, (2) parents' preferences for participation in decision making vary considerably, and (3) different perceptions about risks influence parents' preferences about having their infant undergo an LP. Although some parents would defer decision making to the physician, they still wanted to be able to express their opinions. Other parents wanted to have the final say in decision making. Parents valued risks and benefits of having their child undergo an LP differently, which influenced their preferences.

CONCLUSIONS

Physicians need to adequately inform parents to facilitate parents' understanding of information and gain their trust. Shared decision making may be warranted for decisions about whether to perform an LP, although parents' preferences for participating in decision making vary.

Predictors of Invasive Herpes Simplex Virus Infection in Young Infants

OBJECTIVES

To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection.

METHODS

In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively.

RESULTS

Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4-24.5] <14 and 6.4 [95% CI: 2.3 to 17.8] 14-28 days, respectively, compared with >28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0-17). Infants with invasive HSV had a higher median score (6, interquartile range: 4-8) than those without invasive HSV (3, interquartile range: 1.5-4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80-0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43).

CONCLUSIONS

A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.

Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old

OBJECTIVES

Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals.

METHODS

We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions.

RESULTS

We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70).

CONCLUSIONS

The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.

Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury

OBJECTIVE

To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT).

STUDY DESIGN

We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits.

RESULTS

There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS.

CONCLUSIONS

Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.

Research environment and resources to support pediatric emergency medicine fellow research

BACKGROUND

There is a need for pediatric emergency medicine (PEM) researchers, but the current state of PEM fellow research training is not well described. We sought to (1) describe resources and gaps in PEM fellowship research training and (2) assess agreement between fellow and program director (PD) perceptions of these in fellow research experience.

METHODS

Surveys were distributed electronically to U.S. PEM fellows and PDs from March to April 2020. Fellows and PDs were queried on program research infrastructure and current gaps in fellow research experience. For programs that had at least one fellow and PD response, each fellow response was compared to their PD's corresponding response (reference standard). For each binary survey item, we determined the percent of responses with agreement between the fellow and PD.

RESULTS

Of 79 fellowship programs, 70 (89%) were represented with at least one response, including responses from 59 PDs (75%) and 218 fellows (39% of all fellows, representing 80% of programs). Fellows and PDs identified mentorship and faculty engagement as the most important needs for successful fellowship research; for every one fellow there was a median of 0.8 potential faculty mentors in the division. Twenty percent of fellows were not satisfied with mentorship opportunities. There was no association between fellow career research intent (high, defined as ≥20% dedicated time, or low) with current year of training (p = 0.88), program size (p = 0.67), and area of research focus (p = 0.40). Fellows were often unaware of research being performed by division faculty.

CONCLUSION

PEM fellows were not consistently aware of resources available to support research training. To better support PEM fellows' research training, many programs may need to expand mentorship and increase fellows' awareness of local and external resources and opportunities.

Height of fever and invasive bacterial infection

OBJECTIVE

We aimed to evaluate the association of height of fever with invasive bacterial infection (IBI) among febrile infants <=60 days of age.

METHODS

In a secondary analysis of a multicentre case-control study of non-ill-appearing febrile infants <=60 days of age, we compared the maximum temperature (at home or in the emergency department) for infants with and without IBI. We then computed interval likelihood ratios (iLRs) for the diagnosis of IBI at each half-degree Celsius interval.

RESULTS

The median temperature was higher for infants with IBI (38.8°C; IQR 38.4-39.2) compared with those without IBI (38.4°C; IQR 38.2-38.9) (p<0.001). Temperatures 39°C-39.4°C and 39.5°C-39.9°C were associated with a higher likelihood of IBI (iLR 2.49 and 3.40, respectively), although 30.4% of febrile infants with IBI had maximum temperatures <38.5°C.

CONCLUSIONS

Although IBI is more likely with higher temperatures, height of fever alone should not be used for risk stratification of febrile infants.

Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic.

METHODS

We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children's hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017-2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low-resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed.

RESULTS

ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017-2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low-resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period.

CONCLUSIONS

The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.

Antibiotic Regimens and Associated Outcomes in Children Hospitalized With Staphylococcal Scalded Skin Syndrome

BACKGROUND

Controversy exists regarding the optimal antibiotic regimen for use in hospitalized children with staphylococcal scalded skin syndrome (SSSS). Various regimens may confer toxin suppression and/or additional coverage for methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S aureus (MRSA).

OBJECTIVES

To describe antibiotic regimens in hospitalized children with SSSS and examine the association between antistaphylococcal antibiotic regimens and patient outcomes.

DESIGN/METHODS

Retrospective cohort study of children hospitalized with SSSS using the Pediatric Health Information System database (2011-2016). Children who received clindamycin monotherapy, clindamycin plus MSSA coverage (eg, nafcillin), or clindamycin plus MRSA coverage (eg, vancomycin) were included. The primary outcome was hospital length of stay (LOS); secondary outcomes were treatment failure and cost. Generalized linear mixed-effects models were used to compare outcomes among antibiotic groups.

RESULTS

Of 1,259 children included, 828 children received the most common antistaphylococcal antibiotic regimens: clindamycin monotherapy (47%), clindamycin plus MSSA coverage (33%), and clindamycin plus MRSA coverage (20%). Children receiving clindamycin plus MRSA coverage had higher illness severity (44%) compared with clindamycin monotherapy (28%) and clindamycin plus MSSA (32%) (P =.001). In adjusted analyses, LOS and treatment failure did not differ among the 3 regimens (P =.42 and P =.26, respectively). Cost was significantly lower for children receiving clindamycin monotherapy and highest in those receiving clindamycin plus MRSA coverage (mean, $4,839 vs $5,348, respectively; P <.001).

CONCLUSIONS

In children with SSSS, the addition of MSSA or MRSA coverage to clindamycin monotherapy was associated with increased cost and no incremental difference in clinical outcomes.

Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019

IMPORTANCE

Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown.

OBJECTIVE

To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019.

EXPOSURES

Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses.

RESULTS

A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category.

CONCLUSIONS AND RELEVANCE

In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media

OBJECTIVES

To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).

METHODS

We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.

RESULTS

Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.

CONCLUSION

Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Development of an App to Facilitate Communication and Shared Decision-making With Parents of Febrile Infants ≤ 60 Days Old

OBJECTIVES

We aimed to develop and test a tool to engage parents of febrile infants ≤ 60 days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision-making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60 days of age.

METHODS

We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a "storyboard" of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e-Care; and 4) usability testing of e-Care, using qualitative assessment and the system usability scale (SUS).

RESULTS

We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web-based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e-Care for infants ≤ 28 days and 29 to 60 days of age, in both English and Spanish. The e-Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60 days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e-Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval = 84 to 96.6), representing "excellent" usability.

CONCLUSIONS

The e-Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants ≤ 60 days of age in the ED.

Characteristics of Afebrile Infants ≤60 Days of Age With Invasive Bacterial Infections

OBJECTIVES

To describe the characteristics and outcomes of afebrile infants ≤60 days old with invasive bacterial infection (IBI).

METHODS

We conducted a secondary analysis of a cross-sectional study of infants ≤60 days old with IBI presenting to the emergency departments (EDs) of 11 children's hospitals from 2011 to 2016. We classified infants as afebrile if there was absence of a temperature ≥38°C at home, at the referring clinic, or in the ED. Bacteremia and bacterial meningitis were defined as pathogenic bacterial growth from a blood and/or cerebrospinal fluid culture.

RESULTS

Of 440 infants with IBI, 78 (18%) were afebrile. Among afebrile infants, 62 (79%) had bacteremia without meningitis and 16 (20%) had bacterial meningitis (10 with concomitant bacteremia). Five infants (6%) died, all with bacteremia. The most common pathogens were Streptococcus agalactiae (35%), Escherichia coli (16%), and Staphylococcus aureus (16%). Sixty infants (77%) had an abnormal triage vital sign (temperature <36°C, heart rate ≥181 beats per minute, or respiratory rate ≥66 breaths per minute) or a physical examination abnormality (ill appearance, full or depressed fontanelle, increased work of breathing, or signs of focal infection). Forty-three infants (55%) had ≥1 of the following laboratory abnormalities: white blood cell count <5000 or >15 000 cells per μL, absolute band count >1500 cells per μl, or positive urinalysis. Presence of an abnormal vital sign, examination finding, or laboratory test result had a sensitivity of 91% (95% confidence interval 82%-96%) for IBI.

CONCLUSIONS

Most afebrile young infants with an IBI had vital sign, examination, or laboratory abnormalities. Future studies should evaluate the predictive ability of these criteria in afebrile infants undergoing evaluation for IBI.

Febrile Infants ≤60 Days Old With Positive Urinalysis Results and Invasive Bacterial Infections

OBJECTIVES

We aimed to describe the clinical and laboratory characteristics of febrile infants ≤60 days old with positive urinalysis results and invasive bacterial infections (IBI).

METHODS

We performed a planned secondary analysis of a retrospective cohort study of febrile infants ≤60 days old with IBI who presented to 11 emergency departments from July 1, 2011, to June 30, 2016. For this subanalysis, we included infants with IBI and positive urinalysis results. We analyzed the sensitivity of high-risk past medical history (PMH) (prematurity, chronic medical condition, or recent antimicrobial receipt), ill appearance, and/or abnormal white blood cell (WBC) count (<5000 or >15 000 cells/μL) for identification of IBI.

RESULTS

Of 148 febrile infants with positive urinalysis results and IBI, 134 (90.5%) had bacteremia without meningitis and 14 (9.5%) had bacterial meningitis (11 with concomitant bacteremia). Thirty-five infants (23.6%) with positive urinalysis results and IBI did not have urinary tract infections. The presence of high-risk PMH, ill appearance, and/or abnormal WBC count had a sensitivity of 53.4% (95% confidence interval: 45.0-61.6) for identification of IBI. Of the 14 infants with positive urinalysis results and concomitant bacterial meningitis, 7 were 29 to 60 days old. Six of these 7 infants were ill-appearing or had an abnormal WBC count. The other infant had bacteremia with cerebrospinal fluid pleocytosis after antimicrobial pretreatment and was treated for meningitis.

CONCLUSIONS

The sensitivity of high-risk PMH, ill appearance, and/or abnormal WBC count is suboptimal for identifying febrile infants with positive urinalysis results at low risk for IBI. Most infants with positive urinalysis results and bacterial meningitis are ≤28 days old, ill-appearing, or have an abnormal WBC count.

The Champagne Tap: Time to Pop the Cork?

BACKGROUND

A "champagne tap" is a lumbar puncture with no cerebrospinal fluid (CSF) red blood cells (RBCs). Clinicians disagree whether the absence of CSF white blood cells (WBCs) is also required.

AIMS

As supervising providers frequently reward trainees after a champagne tap, we investigated how varying the definition impacted the frequency of trainee accolades.

MATERIALS & METHODS

We performed a secondary analysis of a retrospective cross-sectional study of infants ≤60 days of age who had a CSF culture performed in the emergency department (ED) at one of 20 centers participating in a Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) endorsed study. Our primary outcomes were a champagne tap defined by either a CSF RBC count of 0 cells/mm³ regardless of CSF WBC count or both CSF RBC and WBC counts of 0 cells/mm³ .

RESULTS

Of the 23,618 eligible encounters, 20,358 (86.2%) had both a CSF RBC and WBC count obtained. Overall, 3,147 (13.3%) had a CSF RBC count of 0 cells/mm³ and 377 (1.6%) had both CSF WBC and RBC counts of 0 cells/mm³ (relative rate 8.35, 95% confidence interval 7.51 to 9.27).

CONCLUSIONS

In infants, a lumbar puncture with a CSF RBC count of 0 cells/mm³ regardless of the CSF WBC count occurred eight-times more frequently than one with both CSF WBC and RBC counts of 0 cells/mm³ . A broader champagne tap definition would allow more frequent recognition of procedural success, with the potential to foster a supportive community during medical training, potentially protecting against burnout.

United States' Emergency Department Visits for Fever by Young Children 2007-2017

Introduction

Our goal in this study was to estimate rates of emergency department (ED) visits for fever by children <2 years of age, and evaluate frequencies of testing and treatment during these visits.

Methods

We performed a cross-sectional study of ED encounters from 2007–2017 using the National Hospital Ambulatory Medical Care Survey, a cross-sectional, multi-stage probability sample survey of visits to nonfederal United States EDs. We included encounters with a visit reason of “fever” or recorded fever in the ED. We report demographics and management strategies in two groups: infants ≤90 days in age; and children 91 days to <2 years old. For patients 91 days to <2 years, we compared testing and treatment strategies between general and pediatric EDs using chi-squared tests.

Results

Of 1.5 billion encounters over 11 years, 2.1% (95% confidence interval [CI], 1.9–2.2%) were by children <2 years old with fever. Two million encounters (95% CI, 1.7–2.4 million) were by infants ≤90 days, and 28.4 million (95% CI, 25.5–31.4 million) were by children 91 days to <2 years. Among infants ≤90 days, 27.6% (95% CI, 21.1–34.1%) had blood and 21.3% (95% CI, 13.6–29.1%) had urine cultures; 26.8% (95% CI, 20.9–32.7%) were given antibiotics, and 21.1% (95% CI, 15.3–26.9%) were admitted or transferred. Among patients 91 days to <2 years in age, 6.8% (95% CI, 5.8–7.8%) had blood and 7.7% (95% CI 6.1–9.4%) had urine cultures; 40.5% (95% CI, 40.5–40.5%) were given antibiotics, and 4.4% (95% CI, 3.5–5.3%) were admitted or transferred. Patients 91 days to <2 years who were evaluated in general EDs had higher rates of radiography (27.1% vs 15.2%; P<0.01) and antibiotic utilization (42.3% vs 34.2%; P<0.01), but lower rates of urine culture testing (6.4% vs 11.6%, p = 0.03), compared with patients evaluated in pediatric EDs.

Conclusion

Approximately 180,000 patients ≤90 days old and 2.6 million patients 91 days to <2 years in age with fever present to US EDs annually. Given existing guidelines, blood and urine culture performance was low for infants ≤90 days old. For children 91 days to <2 years, rates of radiography and antibiotic use were higher in general EDs compared to pediatric EDs. These findings suggest opportunities to improve care among febrile young children in the ED.

Updates on pediatric sepsis

Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.

Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018

Importance

There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use.

Objective

To evaluate changes over time and hospital variation in advanced imaging use.

Design, Setting, and Participants

This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018.

Exposures

Imaging.

Main Outcomes and Measures

The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay.

Results

There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period.

Conclusions and Relevance

This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.

Outcomes of Young Infants with Hypothermia Evaluated in the Emergency Department

OBJECTIVE

To assess the prevalence of serious infections and mortality among infants ≤90 days of age presenting to the emergency department with hypothermia.

STUDY DESIGN

We performed a cross-sectional cohort study of infants ≤90 days presenting to any of 40 EDs in the Pediatric Health Information Systems between January 1, 2009, and December 31, 2018. Infants with an International Classification of Diseases, ninth or tenth edition, admission/discharge diagnosis code of hypothermia were included. We determined the prevalence of serious bacterial infection (urinary tract infection, bacteremia, and/or bacterial meningitis), pneumonia, herpes simplex virus (HSV) infection, and emergency department/hospital mortality.

RESULTS

We included 3565 infants (1633 male [50.9%] and 3225 ≤30 days of age [90.5%]). Most (65.0%) presented in the first week of life. There were 389 infants (10.8%) with a complex chronic condition. The prevalence of serious bacterial infection was 8.0% (n = 284), including 2.4% (n = 87) with urinary tract infection, 5.6% (n = 199) with bacteremia, and 0.3% (n = 11) with bacterial meningitis. There were 7 patients (0.2%) with neonatal HSV and 9 (0.3%) with pneumonia; 0.2% (n = 6) died. The presence of a complex chronic condition was associated with the presence of serious bacterial infection (P < .001) and was present in 3 of 6 patients who died. In a sensitivity analysis including patients with any diagnosis code of hypothermia (n = 8122), 14.9% had serious bacterial infection, 0.6% had HSV, and 3.3% had pneumonia; 2.0% died.

CONCLUSIONS

Of infants with hypothermia ≤90 days of age, 8.3% had serious bacterial infections or HSV. Compared with literature from febrile infants, hypothermia is associated with a high mortality rate. Complex chronic conditions were particularly associated with poor outcomes. Additional research is required to risk stratify young infants with hypothermia.

Application of the Bacterial Meningitis Score for Infants Aged 0 to 60 Days

In 4292 infants aged ≤60 days with cerebrospinal fluid (CSF) pleocytosis, the bacterial meningitis score had excellent sensitivity (121 of 121 [100.0%] [95% confidence interval, 96.5%-100.0%]) but low specificity (66 of 4171 [1.6%] [95% confidence interval, 1.3%-2.0%]) and therefore should not be applied clinically to infants in this age group.

Cerebrospinal Fluid Profiles of Infants ≤60 Days of Age With Bacterial Meningitis

OBJECTIVES

We aimed to describe the cerebrospinal fluid (CSF) profiles of infants ≤60 days old with bacterial meningitis and the characteristics of infants with bacterial meningitis who did not have CSF abnormalities.

METHODS

We included infants ≤60 days old with culture-positive bacterial meningitis who were evaluated in the emergency departments of 11 children's hospitals between July 1, 2011, and June 30, 2016. From medical records, we abstracted clinical and laboratory data. For infants with traumatic lumbar punctures (CSF red blood cell count of ≥10 000 cells per mm³), we used a red blood cell count/white blood cell (WBC) count correction factor of 1000:1 to determine the corrected CSF WBC count. We calculated the sensitivity for bacterial meningitis of a CSF Gram-stain and corrected CSF pleocytosis (≥16 WBCs per mm³ for infants ≤28 days old and ≥10 WBCs per mm³ for infants 29-60 days old).

RESULTS

Among 66 infants with bacterial meningitis, the sensitivity of a CSF Gram-stain was 71.9% (95% confidence interval [CI]: 59.2-82.4), and the sensitivity of corrected CSF pleocytosis was 80.3% (95% CI: 68.7-89.1). The sensitivity of combining positive Gram-stain results with corrected CSF pleocytosis was 86.4% (95% CI: 75.7-93.6). Of 9 infants with meningitis who had a negative Gram-stain result and no corrected CSF pleocytosis, 8 (88.9%) had either an abnormal peripheral WBC count (>15 000 or <5000 cells per μL) or bandemia >10%.

CONCLUSIONS

Most infants ≤60 days old with bacterial meningitis have CSF pleocytosis or a positive Gram-stain result. Infants with no CSF pleocytosis and a negative Gram-stain result are unlikely to have bacterial meningitis in the absence of other laboratory abnormalities.

Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections

OBJECTIVES

To determine the association between parenteral antibiotic duration and outcomes in infants ≤60 days old with bacteremic urinary tract infection (UTI).

METHODS

This multicenter retrospective cohort study included infants ≤60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as ≤7 days, and long-course parenteral antibiotic duration was defined as >7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay).

RESULTS

Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non-Escherichia coli organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6).

CONCLUSIONS

Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.