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Kemal S, Ramgopal S, Macy ML. Traumatic Injuries and Radiographic Study Utilization Among Children With Drowning Presenting to U.S. Pediatric Hospitals. Acad Pediatr 2024; 24:677-685. [PMID: 37743013 DOI: 10.1016/j.acap.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE The role of traumatic injuries in fatal and nonfatal drownings is poorly described. We sought to characterize the incidence of traumatic injuries and diagnostic imaging performed among children who received pediatric hospital care for drowning. METHODS We conducted a retrospective study of children (≤18 years) with drowning encounters at 45 pediatric hospitals, October 2015 through December 2020. We described the presence of clinically important traumatic injuries to the following body regions: brain, spinal cord, thoracic and intra-abdominal organs, axial skeleton, pelvis, and long bones, and major vessels. We described patient characteristics and radiographic testing. We compared patients with and without traumatic injuries using the Fisher's exact and Wilcoxon signed rank tests. RESULTS We identified 10,397 children with a drowning encounter. Most (83.4%) were treated in the emergency department and 52.8% were admitted. There were 238 (2.3%) encounters with clinically important traumatic injuries. Intracranial injury was the most common (1.0%) with other traumatic injuries occurring in ≤0.5%. Less than 2% of children had a moderate or severe injury severity score and approximately half of these children had a clinically important traumatic injury. Among children with traumatic injuries, a higher proportion were 10 to 14 or 15 to 18 years old and from ZIP codes with lower median household income. Computerized tomography imaging was performed in the following proportions: brain (11.4%), cervical spine (3.7%), abdomen/pelvis (1.2%), chest (0.5%) and face/orbits (0.2%). CONCLUSIONS Clinically important traumatic injuries in children with drowning are rare. Further studies are needed to guide the optimal utilization of radiographic studies in this population.
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Affiliation(s)
- Samaa Kemal
- Division of Emergency Medicine (S Kemal, S Ramgopal, and ML Macy), Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Department of Pediatrics (S Kemal, S Ramgopal, and ML Macy), Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Sriram Ramgopal
- Division of Emergency Medicine (S Kemal, S Ramgopal, and ML Macy), Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Department of Pediatrics (S Kemal, S Ramgopal, and ML Macy), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center (S Ramgopal and ML Macy), Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Michelle L Macy
- Division of Emergency Medicine (S Kemal, S Ramgopal, and ML Macy), Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Department of Pediatrics (S Kemal, S Ramgopal, and ML Macy), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center (S Ramgopal and ML Macy), Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
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Ramgopal S, Crowe RP, Jaeger L, Fishe J, Macy ML, Martin-Gill C. Measures of Patient Acuity Among Children Encountered by Emergency Medical Services by the Child Opportunity Index. PREHOSP EMERG CARE 2024:1-9. [PMID: 38517514 DOI: 10.1080/10903127.2024.2333493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/13/2024] [Indexed: 03/24/2024]
Abstract
Background: Children have differing utilization of emergency medical services (EMS) by socioeconomic status. We evaluated differences in prehospital care among children by the Child Opportunity Index (COI), the agreement between a child's COI at the scene and at home, and in-hospital outcomes for children by COI. Methods: We performed a retrospective study of pediatric (<18 years) scene encounters from approximately 2,000 United States EMS agencies from the 2021-2022 ESO Data Collaborative. We evaluated socioeconomic status using the multi-dimensional COI v2.0 at the scene. We described EMS interventions and in-hospital outcomes by COI categories using ordinal regression. We evaluated the agreement between the home and scene COI. Results: Data were available for 99.8% of pediatric scene runs, with 936,940 included EMS responses. Children from lower COI areas more frequently had a response occurring at home (62.9% in Very Low COI areas; 47.1% in Very High COI areas). Children from higher COI areas were more frequently not transported to the hospital (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86-0.87). Children in lower COI areas had lower use of physical (OR 1.23, 95% CI 1.13-1.33) and chemical (OR 1.41, 95% CI 1.29-1.55) restraints for behavioral health problems. Among injured children with elevated pain scores (≥7), analgesia was provided more frequently to children in higher COI areas (OR 1.73, 95% CI 1.65-1.81). The proportion of children in cardiac arrest was lowest from higher COI areas. Among 107,114 encounters with in-hospital data, the odds of hospitalization was higher among children from higher COI areas (OR 1.14, 95% CI 1.11-1.18) and was lower for in-hospital mortality (OR 0.75, 95% CI 0.65-0.85). Home and scene COI had a strong agreement (Kendall's W = 0.81). Conclusion: Patterns of EMS utilization among children with prehospital emergencies differ by COI. Some measures, such as for in-hospital mortality, occurred more frequently among children transported from Very Low COI areas, whereas others, such as admission, occurred more frequently among children from Very High COI areas. These findings have implications in EMS planning and in alternative out-of-hospital care models, including in regional placement of ambulance stations.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Lindsay Jaeger
- Department of Pediatrics, Section of Emergency Medicine, University of Chicago School of Medicine, Chicago, Illinois
| | - Jennifer Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ramgopal S, Sepanski RJ, Gorski JK, Chaudhari PP, Spurrier RG, Horvat CM, Macy ML, Cash R, Martin-Gill C. Centiles for the shock index among injured children in the prehospital setting. Am J Emerg Med 2024; 80:149-155. [PMID: 38608467 DOI: 10.1016/j.ajem.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE The shock index (SI), the ratio of heart rate to systolic blood pressure, is a clinical tool for assessing injury severity. Age-adjusted SI models may improve predictive value for injured children in the out-of-hospital setting. We sought to characterize the proportion of children in the prehospital setting with an abnormal SI using established criteria, describe the age-based distribution of SI among injured children, and determine prehospital interventions by SI. METHODS We performed a multi-agency retrospective cross-sectional study of children (<18 years) in the prehospital setting with a scene encounter for suspected trauma and transported to the hospital between 2018 and 2022 using the National Emergency Medical Services (EMS) Information System datasets. Our exposure of interest was the first calculated SI. We identified the proportion of children with an abnormal SI when using the SI, pediatric age-adjusted (SIPA); and the pediatric SI (PSI) criteria. We developed and internally validated an age-based distributional model for the SI using generalized additive models for location, scale, and shape to describe the age-based distribution of the SI as a centile or Z-score. We evaluated EMS interventions (basic airway interventions, advanced airway interventions, cardiac interventions, vascular access, intravenous fluids, and vasopressor use) in relation to both the SIPA, PSI, and distributional SI values. RESULTS We analyzed 1,007,863 pediatric EMS trauma encounters (55.0% male, median age 13 years [IQR, 8-16 years]). The most common dispatch complaint was for traffic/transport related injury (32.9%). When using the PSI and SIPA, 13.1% and 16.3% were classified as having an abnormal SI, respectively. There were broad differences in the percentage of encounters classified as having an abnormal SI across the age range, varying from 5.1 to 22.8% for SIPA and 3.7-20.1% for PSI. The SIPA values ranged from the 75th to 95th centiles, while the PSI corresponded to an SI greater than the 90th centile, except in older children. The centile distribution for SI declined during early childhood and stabilized during adolescence and demonstrated a difference of <0.1% at cutoff values. An abnormal PSI, SIPA and higher SI centiles (>90th centile and >95th centiles) were associated with interventions related to basic and advanced airway management, cardiac procedures, vascular access, and provision of intravenous fluids occurred with greater frequency at higher SI centiles. Some procedures, including airway management and vascular access, had a smaller peak at lower (<10th) centiles. DISCUSSION We describe the empiric distribution of the pediatric SI across the age range, which may overcome limitations of extant criteria in identifying patients with shock in the prehospital setting. Both high and low SI values were associated with important, potentially lifesaving EMS interventions. Future work may allow for more precise identification of children with significant injury using cutpoint analysis paired to outcome-based criteria. These may additionally be combined with other physiologic and mechanistic criteria to assist in triage decisions.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Robert J Sepanski
- Department of Quality and Safety, Children's Hospital of The King's Daughters, Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jillian K Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ryan G Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California Los Angeles, Los Angeles, CA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rebecca Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Shapiro DJ, Hall M, Ramgopal S, Alpern ER, Chaudhari PP, Eltorki M, Badaki-Makun O, Bergmann KR, Macy ML, Foster CC, Neuman MI. Acute care utilization for ambulatory care-sensitive conditions among publicly insured children. Acad Emerg Med 2024; 31:346-353. [PMID: 38385565 PMCID: PMC11014776 DOI: 10.1111/acem.14867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home. METHODS We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care. RESULTS Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting. CONCLUSIONS Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.
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Affiliation(s)
- Daniel J Shapiro
- Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Hospital Minnesota, South Minneapolis, Minnesota, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carolyn C Foster
- Division of Advanced Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Money N, Ramgopal S. Is it time to incorporate viral testing results within clinical practice guidelines for febrile infants? Emerg Med J 2024; 41:226-227. [PMID: 38176889 DOI: 10.1136/emermed-2023-213779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Nathan Money
- Department of Pediatrics, The University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Sriram Ramgopal
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Saper JK, Macy ML, Martin-Gill C, Ramgopal S. Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers. Acad Pediatr 2024:S1876-2859(24)00107-4. [PMID: 38492632 DOI: 10.1016/j.acap.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/01/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE National efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs. METHODS We performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019-2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed. RESULTS Of 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital. CONCLUSIONS EMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.
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Affiliation(s)
- Jennifer K Saper
- Division of Advanced General Pediatrics and Primary Care (JK Saper), Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics (JK Saper, ML Macy, and S Ramgopal), Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center (JK Saper and ML Macy); Stanley Manne Children's Research Institute; Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Michelle L Macy
- Department of Pediatrics (JK Saper, ML Macy, and S Ramgopal), Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center (JK Saper and ML Macy); Stanley Manne Children's Research Institute; Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Emergency Medicine (ML Macy and S Ramgopal); Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Christian Martin-Gill
- Department of Emergency Medicine (C Martin-Gill), University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sriram Ramgopal
- Department of Pediatrics (JK Saper, ML Macy, and S Ramgopal), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Emergency Medicine (ML Macy and S Ramgopal); Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Ramgopal S, Owusu-Ansah S, Crowe RP, Okubo M, Martin-Gill C. Association of midazolam route of administration and need for recurrent dosing among children with seizures cared for by emergency medical services. Epilepsia 2024. [PMID: 38470335 DOI: 10.1111/epi.17940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE National guidelines in the United States recommend the intramuscular and intranasal routes for midazolam for the management of seizures in the prehospital setting. We evaluated the association of route of midazolam administration with the use of additional benzodiazepine doses for children with seizures cared for by emergency medical services (EMS). METHODS We conducted a retrospective cohort study from a US multiagency EMS dataset for the years 2018-2022, including children transported to the hospital with a clinician impression of seizures, convulsions, or status epilepticus, and who received an initial correct weight-based dose of midazolam (.2 mg/kg intramuscular, .1 mg/kg intravenous, .2 mg/kg intranasal). We evaluated the association of route of initial midazolam administration with provision of additional benzodiazepine dose in logistic regression models adjusted for age, vital signs, pulse oximetry, level of consciousness, and time spent with the patient. RESULTS We included 2923 encounters with patients who received an appropriate weight-based dose of midazolam for seizures (46.3% intramuscular, 21.8% intranasal, 31.9% intravenous). The median time to the first dose of midazolam from EMS arrival was similar between children who received intramuscular (7.3 min, interquartile range [IQR] = 4.6-12.5) and intranasal midazolam (7.8 min, IQR = 4.5-13.4) and longer for intravenous midazolam (13.1 min, IQR = 8.2-19.4). At least one additional dose of midazolam was given to 21.4%. In multivariable models, intranasal midazolam was associated with higher odds (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.10-1.76) and intravenous midazolam was associated with similar odds (OR = 1.00, 95% CI = .80-1.26) of requiring additional doses of benzodiazepines relative to intramuscular midazolam. SIGNIFICANCE Intranasal midazolam was associated with greater odds of repeated benzodiazepine dosing relative to initial intramuscular administration, but confounding factors could have affected this finding. Further study of the dosing and/or the prioritization of the intranasal route for pediatric seizures by EMS clinicians is warranted.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sylvia Owusu-Ansah
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Ramgopal S, Naik VV, Komukai S, Owusu-Ansah S, Crowe RP, Okubo M, Martin-Gill C. The association of prehospital systemic corticosteroids with emergency department and in-hospital outcomes for patients with asthma exacerbations. Acad Emerg Med 2024. [PMID: 38456349 DOI: 10.1111/acem.14890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Timely administration of systemic corticosteroids is a cornerstone of asthma exacerbation treatment, yet little is known regarding potential benefits of prehospital administration by emergency medical services (EMS) clinicians. We examined factors associated with prehospital corticosteroid administration with hospitalization and hospital length of stay (LOS). METHODS We performed a retrospective study of EMS encounters for patients 2-50 years of age with suspected asthma exacerbation from a national data set. We evaluated factors associated with systemic corticosteroid administration using generalized estimating equations. We performed propensity matching based on service level, age, encounter duration, vital signs, and treatments to evaluate the association of prehospital corticosteroid administration with hospitalization and LOS using weighted logistic regression. We evaluated the association of prehospital corticosteroid administration with admission using Bayesian models. RESULTS Of 15,834 encounters, 4731 (29.9%) received prehospital systemic corticosteroids. Administration of corticosteroids was associated with older age; sex; urbanicity; advanced life support provider; vital sign instability; increasing doses of albuterol; and provision of ipratropium bromide, magnesium, epinephrine, and supplementary oxygen. Within the matched sample, prehospital corticosteroids were not associated with hospitalization (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.73-1.01) or LOS (multiplier 0.76, 95% CI 0.56-1.05). Administration of corticosteroids was associated with lower odds of admission and shorter LOS in longer EMS encounters (>34 min), lower admission odds in patients with documented wheezing, and shorter LOS among patients treated with albuterol. In a Bayesian model with noninformative priors, the OR for admission among encounters given corticosteroids was 0.86 (95% credible interval 0.77-0.96). CONCLUSIONS Prehospital systemic corticosteroid administration was not associated with hospitalization or LOS in the overall cohort of asthma patients treated by EMS, though they had a lower probability of admission within Bayesian models. Improved outcomes were noted among subgroups of longer EMS encounters, documented wheezing, and receipt of albuterol.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vishal V Naik
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sylvia Owusu-Ansah
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Ramgopal S. Using Outcome-Based Vital Sign Ranges can Enhance the Identification of Major Trauma in Children. J Pediatr Surg 2024:S0022-3468(24)00148-9. [PMID: 38508970 DOI: 10.1016/j.jpedsurg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 62 Chicago 60611, IL, USA.
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Ramgopal S, Sepanski RJ, Crowe RP, Okubo M, Callaway CW, Martin-Gill C. Correlation of vital sign centiles with in-hospital outcomes among adults encountered by emergency medical services. Acad Emerg Med 2024; 31:210-219. [PMID: 37845192 DOI: 10.1111/acem.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Vital signs are a critical component of the prehospital assessment. Prior work has suggested that vital signs may vary in their distribution by age. These differences in vital signs may have implications on in-hospital outcomes or be utilized within prediction models. We sought to (1) identify empirically derived (unadjusted) cut points for vital signs for adult patients encountered by emergency medical services (EMS), (2) evaluate differences in age-adjusted cutoffs for vital signs in this population, and (3) evaluate unadjusted and age-adjusted vital signs measures with in-hospital outcomes. METHODS We used two multiagency EMS data sets to derive (National EMS Information System from 2018) and assess agreement (ESO, Inc., from 2019 to 2021) of vital signs cutoffs among adult EMS encounters. We compared unadjusted to age-adjusted cutoffs. For encounters within the ESO sample that had in-hospital data, we compared the association of unadjusted cutoffs and age-adjusted cutoffs with hospitalization and in-hospital mortality. RESULTS We included 13,405,858 and 18,682,684 encounters in the derivation and validation samples, respectively. Both extremely high and extremely low vital signs demonstrated stepwise increases in admission and in-hospital mortality. When evaluating age-based centiles with vital signs, a gradual decline was noted at all extremes of heart rate (HR) with increasing age. Extremes of systolic blood pressure at upper and lower margins were greater in older age groups relative to younger age groups. Respiratory rate (RR) cut points were similar for all adult age groups. Compared to unadjusted vital signs, age-adjusted vital signs had slightly increased accuracy for HR and RR but lower accuracy for SBP for outcomes of mortality and hospitalization. CONCLUSIONS We describe cut points for vital signs for adults in the out-of-hospital setting that are associated with both mortality and hospitalization. While we found age-based differences in vital signs cutoffs, this adjustment only slightly improved model performance for in-hospital outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert J Sepanski
- Department of Quality & Safety, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Ramgopal S, Horvat CM, Macy ML, Cash RE, Sepanski RJ, Martin-Gill C. Establishing outcome-driven vital signs ranges for children in the prehospital setting. Acad Emerg Med 2024; 31:230-238. [PMID: 37943118 DOI: 10.1111/acem.14837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Vital signs are frequently used in pediatric prehospital assessments and guide protocol utilization. Common pediatric vital sign classification criteria identify >80% of children in the prehospital setting as having abnormal vital signs, though few receive lifesaving interventions (LSIs). We sought to identify data-driven thresholds for abnormal vital signs by evaluating their association with prehospital LSIs. METHODS We evaluated prehospital care records for children (<18 years) transported to the hospital during 2022 from a large, national repository of emergency medical services (EMS) patient encounters. Predictors of interest were heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), and pulse oximetry. HR, RR, and SBP were converted to Z-scores using age-based distributional models. Our outcome was potential LSIs, defined as performance of selected respiratory procedures, resuscitative interventions, or medication administrations. Using cut point analysis, we identified higher specificity (maximal specificity with a minimum of 25% sensitivity) and higher sensitivity (maximal sensitivity with a minimum of 25% specificity) ranges for each vital sign and evaluated measures of diagnostic accuracy. RESULTS We included 987,515 children (median age 10 years, IQR 2-15 years). An LSI occurred in 4.3% (2.1% with respiratory procedures, 1.2% with resuscitative interventions, and 2.0% with medication administration). HR, RR, and SBP demonstrated a U-shaped association with LSIs. Specificities ranged from 84.1% to 93.7% for higher specificity criteria, with RR demonstrating the best performance (sensitivity 84.6%, specificity 27.0%). Sensitivities ranged from 62.3% to 84.4% for higher sensitivity criteria. CONCLUSIONS Cut points for pediatric vital signs were associated with LSIs. Specific age-adjusted ranges can identify children at higher and lower risk for receipt of LSI. These ranges may be combined with other objective measures to improve the assessment of children in the prehospital setting, assist in optimizing protocol utilization, improve transport decision making, and guide destination selection.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christopher M Horvat
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rebecca E Cash
- Department of Emergency Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Sepanski
- Department of Quality and Safety, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Money NM, Lo YHJ, King H, Graves C, Holland JL, Rogers A, Hashikawa AN, Cruz AT, Lorenz DJ, Ramgopal S. Predicting Serious Bacterial Infections Among Hypothermic Infants in the Emergency Department. Hosp Pediatr 2024; 14:153-162. [PMID: 38312010 PMCID: PMC10896741 DOI: 10.1542/hpeds.2023-007356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
BACKGROUND There is insufficient evidence to guide the initial evaluation of hypothermic infants. We aimed to evaluate risk factors for serious bacterial infections (SBI) among hypothermic infants presenting to the emergency department (ED). METHODS We conducted a multicenter case-control study among hypothermic (rectal temperature <36.5°C) infants ≤90 days presenting to the ED who had a blood culture collected. Our outcome was SBI (bacteremia, bacterial meningitis, and/or urinary tract infection). We performed 1:2 matching. Historical, physical examination and laboratory covariables were determined based on the literature review from febrile and hypothermic infants and used logistic regression to identify candidate risk factors. RESULTS Among 934 included infants, 57 (6.1%) had an SBI. In univariable analyses, the following were associated with SBI: age > 21 days, fever at home or in the ED, leukocytosis, elevated absolute neutrophil count, thrombocytosis, and abnormal urinalysis. Prematurity, respiratory distress, and hypothermia at home were negatively associated with SBI. The full multivariable model exhibited a c-index of 0.91 (95% confidence interval: 0.88-0.94). One variable (abnormal urinalysis) was selected for a reduced model, which had a c-index of 0.82 (95% confidence interval: 0.75-0.89). In a sensitivity analysis among hypothermic infants without fever (n = 22 with SBI among 116 infants), leukocytosis, absolute neutrophil count, and abnormal urinalysis were associated with SBI. CONCLUSIONS Historical, examination, and laboratory data show potential as variables for risk stratification of hypothermic infants with concern for SBI. Larger studies are needed to definitively risk stratify this cohort, particularly for invasive bacterial infections.
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Affiliation(s)
- Nathan M. Money
- Division of Pediatric Hospital Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Yu Hsiang J. Lo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Weill Cornell Medicine, New York, New York
| | - Hannah King
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher Graves
- Division of Emergency Medicine, Children’s Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia
| | - Jamie Lynn Holland
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Andrew N. Hashikawa
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Andrea T. Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Douglas J Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville (DJ Lorenz), Louisville, Kentucky
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ramgopal S, Cotter JM, Navanandan N, Ambroggio L, Michelson KA, Florin TA. Radiographic uncertainty and outcomes of children with lower respiratory tract infections. Pediatr Pulmonol 2024. [PMID: 38415980 DOI: 10.1002/ppul.26943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Sriram Ramgopal
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Kenneth A Michelson
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Todd A Florin
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Gorski JK, Chaudhari PP, Spurrier RG, Goldstein SD, Zeineddin S, Martin-Gill C, Sepanski RJ, Stey AM, Ramgopal S. Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA Netw Open 2024; 7:e2356472. [PMID: 38363566 PMCID: PMC10873773 DOI: 10.1001/jamanetworkopen.2023.56472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
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Affiliation(s)
- Jillian K. Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Seth D. Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Suhail Zeineddin
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert J. Sepanski
- Department of Quality and Safety, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Anne M. Stey
- Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Wnorowska JH, Naik V, Ramgopal S, Watkins K, Hoffmann JA. Characteristics of pediatric behavioral health emergencies in the prehospital setting. Acad Emerg Med 2024; 31:129-139. [PMID: 37947152 PMCID: PMC10922610 DOI: 10.1111/acem.14833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. METHODS We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. RESULTS Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). CONCLUSIONS Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.
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Affiliation(s)
- Julia H Wnorowska
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vishal Naik
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Sriram Ramgopal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Kenshata Watkins
- Divison of Pediatric Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jennifer A Hoffmann
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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16
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Gorski JK, Mithal DS, Mills MG, Ramgopal S. Factors Associated with Pathway-Concordant Neuroimaging for Pediatric Ischemic Stroke. J Pediatr 2024; 268:113905. [PMID: 38190937 DOI: 10.1016/j.jpeds.2024.113905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To determine factors associated with magnetic resonance imaging (MRI) and noninvasive diagnostic angiography among children presenting to the emergency department (ED) with acute ischemic stroke. STUDY DESIGN We performed a cross-sectional study using data from >50 US children's hospitals. We included children 29 days through 17 years old hospitalized from the ED with an International Classification of Diseases, Tenth Revision, Clinical Modification, diagnosis code for acute ischemic stroke between October 1, 2015, and November 30, 2022. We excluded children with a principal diagnosis code of trauma/external injury, without neuroimaging on day of presentation, and into-ED transfers. Our outcomes were defined as acquisition of MRI (vs computed tomography only) and angiography (vs no angiography) on day of presentation. We performed generalized linear mixed modeling with hospital as a random effect to determine the association of demographics, known comorbidities, and treatment factors with each outcome. RESULTS We included 1601 children. In multivariable analysis, younger age, mechanical ventilation, and Black race were associated with lower odds of MRI acquisition, whereas history of moyamoya disease and sickle cell disease were associated with greater odds. Younger age, mechanical ventilation, Hispanic ethnicity, Black race, other races, history of metabolic disease, and history of seizures were associated with lower odds of angiography. CONCLUSIONS Younger and non-White children experienced lower odds of MRI and angiography, which may be driven by health system limitations or provider implicit biases or both. Our results expose risk factors for underdiagnosis of ischemic stroke and provide opportunities to tailor institutional pathways reflective of underlying pathophysiology.
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Affiliation(s)
- Jillian K Gorski
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL.
| | - Divakar S Mithal
- Division of Neurology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - Michele G Mills
- Division of Neurology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
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Gorski JK, Smith CM, Ramgopal S. Injury patterns and mortality associated with near-hanging in children. Am J Emerg Med 2024; 75:83-86. [PMID: 37924732 DOI: 10.1016/j.ajem.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/06/2023] [Accepted: 10/25/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND The pathophysiology of near-hanging in children is different from that of adults due to anatomic, physiologic, and injury-related mechanisms, with evidence suggesting that blunt cerebrovascular injuries (BCVI) and cervical spine injuries (CSI) are uncommon. We sought to estimate the incidence of secondary injuries and their association with mortality in pediatric near-hanging victims. METHODS We performed a retrospective observational study of children (≤17 years) with a diagnosis code for hanging between October 1, 2015 and February 28, 2023 who presented to one of 47 geographically diverse US children's hospitals. We evaluated the incidence of the following secondary injuries: cerebral edema, pneumothorax, pulmonary edema, BCVI, and CSI. We performed Fisher's exact test with Bonferroni correction to identify associations between intentionality, sex, age, and secondary injuries with mortality. RESULTS We included 1929 children, of whom 33.8% underwent neuroimaging, 45.9% underwent neck imaging, and 38.7% underwent neck angiography. The most common injury was cerebral edema (24.0%), followed by pulmonary edema (3.2%) and pneumothorax (2.8%). CSI (2.1%) and BCVI (0.9%) occurred infrequently. Cerebral edema, pneumothorax, pulmonary edema, and younger age (≤12 years) were associated with mortality. CONCLUSIONS In this multi-center study of pediatric near-hanging victims, BCVI and CSI occurred rarely and were not associated with mortality. While children in our study underwent neck imaging more frequently than head imaging, cerebral edema occurred more often than other injury types and imparted the highest mortality risk. Given the rarity of BCVI and CSI, a selective approach to neck imaging may be warranted in pediatric near-hanging events.
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Affiliation(s)
- Jillian K Gorski
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL 60611, USA.
| | - Craig M Smith
- Division of Critical Care, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL 60611, USA
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Smith AG, Kshetrapal A, Boles L, Simon NJE, Kurs-Lasky M, Shope TR, Shaikh N, Ramgopal S. External Validation of the UTICalc with and Without Race for Pediatric Urinary Tract Infection. J Pediatr 2023; 263:113681. [PMID: 37607649 DOI: 10.1016/j.jpeds.2023.113681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/06/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To validate externally the UTICalc, a popular clinical decision support tool used to determine the risk of urinary tract infections (UTIs) in febrile children, and compare its performance with and without the inclusion of race and at differing risk thresholds. METHODS We performed a retrospective, singlecenter case-control study of febrile children (2-24 months) in an emergency department. Cases with culture-confirmed UTI were matched 1:1 to controls. We compared the performance of the original model which included race (version 1.0) to a revised model which did not consider race (version 3.0). We evaluated model performance at risk thresholds between 2% and 5%. RESULTS We included 185 cases and 197 controls (median age 8.4 months; IQR, 4.4-13.0 months; 60.5% girls). When using UTICalc version 1.0, the model area under the receiver operator characteristic curve (AUROC) was 73.4% (95% CI 68.4%-78.5%), which was similar to the version 3.0 model (73.8%; 95% CI 68.7%-78.8%). When using a 2% risk threshold, the version 3.0 model demonstrated a sensitivity of 96.7% and a specificity of 25.0%, with declines in sensitivity and gains in specificity at higher risk thresholds. Version 1.0 of the UTICalc had 12 false negatives, of whom 10 were Black (83%); whereas version 3.0 had 6 false negatives, of whom 2 were Black (33%). CONCLUSIONS Versions of the UTICalc with and without race had similar performance to each other with a slight decline from the original derivation sample. The removal of race did not adversely affect the accuracy of the UTICalc.
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Affiliation(s)
- Anna G Smith
- Department of Emergency Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL; Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - Anisha Kshetrapal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - Lindsay Boles
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL; Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Norma-Jean E Simon
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - Marcia Kurs-Lasky
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Timothy R Shope
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL.
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Boles LH, Noorbakhsh KA, Smith T, Ramgopal S. Hospitalization and evaluation of brief resolved unexplained events (BRUEs) from a statewide sample. Am J Emerg Med 2023; 74:90-94. [PMID: 37802000 DOI: 10.1016/j.ajem.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE The 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown. The purpose of this study is to examine changes in the diagnosis and management of BRUE in a statewide sample of non-pediatric hospitals following publication of the CPG. METHODS This is a retrospective study of encounters of infants (<1 year) presenting to 178 non-pediatric Illinois Emergency Departments (EDs) between 2013 and 2019 with an International Classification of Disease (ICD) 9th and 10th revision billing code of ALTE or BRUE (799.82, ICD-9; R68.13, ICD-10). Our primary outcomes were counts of ALTE/BRUE and the percent of patients with ALTE/BRUE admitted and/or transferred to another facility. Our secondary outcome was clinical testing. We used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes. Results were stratified into academic and community EDs. RESULTS This study included 4639 ED encounters for infants with BRUE that presented to academic EDs (2229; 48.0%) or community EDs (2410; 52.0%). At academic EDs, ALTE/BRUE diagnoses were increasing by 2.3 per quarter prior to the CPG publication and decreased by 0.5 per quarter after the CPG publication, representing a change in slope of -2.8 per quarter (p < 0.01). The percent of ALTE/BRUE patients admitted/transferred was decreasing by 0.1% per quarter in the pre-intervention period and decreased by 0.3% per quarter in the post-intervention period, representing a change in slope of 0.7% (p = 0.03). At community EDs, ALTE/BRUE diagnoses were increasing by 2.9 per quarter prior to the CPG publication and increased by 1.4 per quarter after the CPG publication, a non-significant change in slope. The percent of ALTE/BRUE patients admitted/transferred was decreasing by 1.6% in the pre-intervention period and decreased by 0.9% in the post-intervention period, a non-significant change in slope. At academic EDs, there was no significant change in clinical testing. At community EDs, a lower proportion of patients in the post-intervention period had chest radiographs, blood cultures, metabolic panels, blood counts, and urine testing, while a higher proportion had pertussis testing and respiratory pathogen testing. CONCLUSIONS Counts of BRUE diagnoses and the overall proportion of children admitted or transferred showed a consistent decrease at academic EDs but had a nonsignificant change in trend at community EDs following the CPG publication in 2016. There was no significant change in clinical testing at academic EDs while community EDs had a significant decrease in some testing and an increase in other types of testing. Our findings suggest the need for greater implementation efforts in non-pediatric settings, specifically community EDs, where pediatric patients with BRUE present infrequently in order to optimize care for these children.
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Affiliation(s)
- Lindsay H Boles
- Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States of America.
| | - Kathleen A Noorbakhsh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
| | - Tracie Smith
- Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
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Ramgopal S, Graves C, Aronson PL, Cruz AT, Rogers A. Clinician Management Practices for Infants With Hypothermia in the Emergency Department. Pediatrics 2023; 152:e2023063000. [PMID: 38009075 DOI: 10.1542/peds.2023-063000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 11/28/2023] Open
Abstract
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.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher Graves
- Pediatric Emergency Medicine Associates (PEMA), LLC
- Division of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Andrea T Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Alexander Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan
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Owusu-Ansah S, Crowe RP, Ramgopal S. Racial, Ethnic, and Socioeconomic Disparities in Prehospital Encounters for Children with Asthma. PREHOSP EMERG CARE 2023; 27:1107-1114. [PMID: 37748188 DOI: 10.1080/10903127.2023.2260471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Asthma represents one of the most common medical conditions among children encountered by emergency medical services (EMS). While care disparities for children with asthma have been observed in other healthcare settings, limited data exist characterizing disparities in prehospital care. We sought to characterize differences in prehospital treatment and transport of children with suspected asthma exacerbations by race and ethnicity, within the context of community socioeconomic status. METHODS We conducted a multi-agency retrospective study of EMS encounters in 2019 for children (2-17 years) with asthma and wheezing using a national prehospital database. Our primary outcomes included EMS transport and prehospital bronchodilator or systemic corticosteroid administration. Scene socioeconomic status was evaluated using the social vulnerability index. We used generalized estimating equations to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for prehospital bronchodilator use or steroid use by race and ethnicity, adjusting for age, presence of abnormal vital signs, community size, bronchodilator use prior to EMS arrival, and transport disposition. RESULTS We analyzed 5,266 EMS encounters (median age 8 years). Approximately half (53%) were Black non-Hispanic and 34% were White non-Hispanic. Overall, 77% were transported by EMS. In an adjusted model, Black non-Hispanic children were 25% less likely to be transported compared to White non-Hispanic children (aOR: 0.75, 95%CI: 0.58-0.96). EMS administered at least one bronchodilator to 81% of Black non-Hispanic patients, 73% of Hispanic patients, and 68% of White, non-Hispanic patients. Relative to White non-Hispanic children, EMS bronchodilator administration was greater for Black non-Hispanic children, (aOR: 1.55, 95%CI: 1.25-1.93), after controlling for scene socioeconomic status and potential confounding variables. Systemic corticosteroids were administered in 3% of all encounters. Odds of prehospital systemic corticosteroid administration did not differ significantly by race and ethnicity. CONCLUSION Black non-Hispanic children comprised a larger proportion of EMS encounters for asthma and were more likely to receive a bronchodilator in adjusted analyses accounting for community socioeconomic status. However, these children were less likely to be transported by EMS. These findings may reflect disease severity not manifested by abnormal vital signs, management, and other social factors that warrant further investigation.
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Affiliation(s)
- Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Ramgopal S, Kapes J, Alpern ER, Carroll MS, Heffernan M, Simon NJE, Florin TA, Macy ML. Perceptions of Artificial Intelligence-Assisted Care for Children With a Respiratory Complaint. Hosp Pediatr 2023; 13:802-810. [PMID: 37593809 DOI: 10.1542/hpeds.2022-007066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVES To evaluate caregiver opinions on the use of artificial intelligence (AI)-assisted medical decision-making for children with a respiratory complaint in the emergency department (ED). METHODS We surveyed a sample of caregivers of children presenting to a pediatric ED with a respiratory complaint. We assessed caregiver opinions with respect to AI, defined as "specialized computer programs" that "help make decisions about the best way to care for children." We performed multivariable logistic regression to identify factors associated with discomfort with AI-assisted decision-making. RESULTS Of 279 caregivers who were approached, 254 (91.0%) participated. Most indicated they would want to know if AI was being used for their child's health care (93.5%) and were extremely or somewhat comfortable with the use of AI in deciding the need for blood (87.9%) and viral testing (87.6%), interpreting chest radiography (84.6%), and determining need for hospitalization (78.9%). In multivariable analysis, caregiver age of 30 to 37 years (adjusted odds ratio [aOR] 3.67, 95% confidence interval [CI] 1.43-9.38; relative to 18-29 years) and a diagnosis of bronchospasm (aOR 5.77, 95% CI 1.24-30.28 relative to asthma) were associated with greater discomfort with AI. Caregivers with children being admitted to the hospital (aOR 0.23, 95% CI 0.09-0.50) had less discomfort with AI. CONCLUSIONS Caregivers were receptive toward the use of AI-assisted decision-making. Some subgroups (caregivers aged 30-37 years with children discharged from the ED) demonstrated greater discomfort with AI. Engaging with these subgroups should be considered when developing AI applications for acute care.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jack Kapes
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael S Carroll
- Data Analytics and Reporting
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marie Heffernan
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Norma-Jean E Simon
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Ramgopal S, Martin-Gill C. Deviation From National Dosing Recommendations for Children Having Out-of-hospital Emergencies. Pediatrics 2023:e2023061223. [PMID: 37424429 DOI: 10.1542/peds.2023-061223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Previous evaluations of medication dosing variance for children in the prehospital setting have been limited regionally or to specific conditions. We sought to describe pediatric dosing deviations from nationally recommended guidelines for commonly administered medications from a registry of prehospital encounters. METHODS We evaluated prehospital patient care records for children (<18 years) from approximately 2000 emergency medical services agencies from 2020 to 2021. We investigated dosing deviations (defined as being ≥20% of the weight-appropriate dose from national guidelines) for the following: lorazepam, diazepam, and midazolam for seizures; fentanyl, hydromorphone, morphine, and ketorolac; intramuscular epinephrine and diphenhydramine for children with allergy or anaphylaxis; intravenous epinephrine; and methylprednisolone. RESULTS Of 990 497 pediatric encounters, 63 963 (6.4%) received at least 1 nonnebulized medication. Among nonnebulized doses, 53.9% were for the studied drugs. Among encounters who received a study drug and which had a documented weight (80.3%), the overall consistency with national guidelines was 42.6 per 100 administrations. Appropriate dosing was most common with methylprednisolone (75.1%), intramuscular epinephrine (67.9%), and ketorolac (56.4%). Medications with the lowest consistency with national guidelines were diazepam (19.5%) and lorazepam (21.2%). Most deviations represented an underdose, which was greatest with lorazepam (74.7%) and morphine (73.8%). Results were similar when estimating dosages from weights calculated by age. CONCLUSIONS We identified variance in weight-based dosing from national guidelines for common pediatric medications in the prehospital setting, which may be attributable to protocol differences or dosing errors. Addressing these should be a target for future educational, quality improvement, and research activities.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Attridge MM, Heneghan JA, Akande M, Ramgopal S. Association of Pediatric Mortality With the Child Opportunity Index Among Children Presenting to the Emergency Department. Acad Pediatr 2023; 23:980-987. [PMID: 36682452 DOI: 10.1016/j.acap.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/10/2023] [Accepted: 01/14/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Child health and development is influenced by neighborhood context. The Child Opportunity Index (COI) is a multidimensional measure of neighborhood conditions. We sought to evaluate the association of COI with mortality among children presenting to the emergency department (ED). METHODS We performed a multicenter cross-sectional study of pediatric (<18 years) ED encounters from a statewide dataset from 2016 to 2020. We constructed a multivariable logistic regression model to evaluate the association between COI and in-hospital mortality after adjusting for sociodemographic characteristics and medical complexity. RESULTS Among 4,653,070 included encounters, in-hospital mortality occurred in 1855 (0.04%). There was a higher proportion of encounters with mortality in the lower COI categories relative to the higher COI categories (0.053%, 0.038%, 0.031%, 0.034%, 0.034% ranging from Very Low to Very High, respectively). In adjusted models, child residence in Low (adjusted odds ratio 1.26; 95% confidence interval [CI], 1.04-1.53) and Very Low (adjusted odds ratio 1.58; 95% CI, 1.31-1.90) COI neighborhoods was associated with mortality relative to residence in Very High COI neighborhoods. This association was noted across all domains of COI (education, health and environment, and social and economic), using an expanded definition of mortality, using nationally normed COI, and excluding patients with complex chronic conditions. Other factors associated with increased odds of mortality included age, medical complexity, payor status, age, and race and ethnicity. CONCLUSIONS Understanding the association of neighborhood context on child mortality can inform public health interventions to improve child mortality rates and reduce disparities.
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Affiliation(s)
- Megan M Attridge
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (MM Attridge and S Ramgopal), Chicago, Ill.
| | - Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital; University of Minnesota (JA Heneghan), Minneapolis, Minn
| | - Manzilat Akande
- Section of Pediatric Critical Care, Oklahoma University Health Sciences Center (M Akande), Oklahoma City, Okla
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (MM Attridge and S Ramgopal), Chicago, Ill
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Navanandan N, Florin TA, Leonard J, Ramgopal S, Cotter JM, Shah SS, Ruddy RM, Ambroggio L. Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia. Pediatr Emerg Care 2023; 39:482-487. [PMID: 37306694 PMCID: PMC10351650 DOI: 10.1097/pec.0000000000002984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). METHODS Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. RESULTS Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). CONCLUSIONS In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Todd A. Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Leonard
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S. Shah
- Division of Hospital Medicine and Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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Ramgopal S, Rodean J, Alpern ER, Hall M, Chaudhari PP, Marin JR, Shah SS, Freedman SB, Eltorki M, Badaki-Makun O, Shapiro DJ, Rhine T, Morse RB, Neuman MI. Ambulatory follow-up among publicly insured children discharged from the emergency department. Acad Emerg Med 2023; 30:721-730. [PMID: 36809681 DOI: 10.1111/acem.14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization. METHODS We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling. RESULTS We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03). CONCLUSIONS One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tara Rhine
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rustin B Morse
- Department of Pediatrics, Center for Clinical Excellence, Nationwide Children's Hospital, The Ohio State University College of Medicine, Ohio, Columbus, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Ramgopal S, Cotter JM, Navanandan N, Shah SS, Ruddy RM, Ambroggio L, Florin TA. Viral Detection Is Associated With Severe Disease in Children With Suspected Community-Acquired Pneumonia. Pediatr Emerg Care 2023; 39:465-469. [PMID: 37308159 DOI: 10.1097/pec.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the role of virus detection on disease severity among children presenting to the emergency department (ED) with suspected community-acquired pneumonia (CAP). METHODS We performed a single-center prospective study of children presenting to a pediatric ED with signs and symptoms of a lower respiratory tract infection and who had a chest radiograph performed for suspected CAP. We included patients who had virus testing, with results classified as negative for virus, human rhinovirus, respiratory syncytial virus (RSV), influenza, and other viruses. We evaluated the association between virus detection and disease severity using a 4-tiered measure of disease severity based on clinical outcomes, ranging from mild ( discharged from the ED) to severe (receipt of positive-pressure ventilation, vasopressors, thoracostomy tube placement, or extracorporeal membrane oxygenation, intensive care unit admission, diagnosis of severe sepsis or septic shock, or death) in models adjusted for age, procalcitonin, C-reactive protein, radiologist interpretation of the chest radiograph, presence of wheeze, fever, and provision of antibiotics. RESULTS Five hundred seventy-three patients were enrolled in the parent study, of whom viruses were detected in 344 (60%), including 159 (28%) human rhinovirus, 114 (20%) RSV, and 34 (6%) with influenza. In multivariable models, viral infections were associated with increasing disease severity, with the greatest effect noted with RSV (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.30-4.81) followed by rhinovirus (aOR, 2.18; 95% CI, 1.27-3.76). Viral detection was not associated with increased severity among patients with radiographic pneumonia (n = 223; OR, 1.82; 95% CI, 0.87-3.87) but was associated with severity among patients without radiographic pneumonia (n = 141; OR, 2.51; 95% CI, 1.40-4.59). CONCLUSIONS The detection of a virus in the nasopharynx was associated with more severe disease compared with no virus; this finding persisted after adjustment for age, biomarkers, and radiographic findings. Viral testing may assist with risk stratification of patients with lower respiratory tract infections.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M Cotter
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Nidhya Navanandan
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M Ruddy
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Todd A Florin
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Kusma JD, Macy ML, Kociolek LK, Davis MM, Ramgopal S. Seasonality in Respiratory Syncytial Virus Hospitalizations and Immunoprophylaxis. JAMA Health Forum 2023; 4:e231582. [PMID: 37389862 DOI: 10.1001/jamahealthforum.2023.1582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Affiliation(s)
- Jennifer D Kusma
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michelle L Macy
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Larry K Kociolek
- Division of Infectious Disease, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Matthew M Davis
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Ramgopal S, Heneghan JA. Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample. J Am Coll Emerg Physicians Open 2023; 4:e12950. [PMID: 37124473 PMCID: PMC10132184 DOI: 10.1002/emp2.12950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Objective The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs. Methods We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes. Results Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%). Conclusions and Relevance The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Julia A. Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's HospitalUniversity of MinnesotaMinneapolisMinnesotaUSA
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Ramgopal S, Sepanski RJ, Crowe RP, Martin-Gill C. External Validation of Empirically Derived Vital Signs in Children and Comparison to Other Vital Signs Classification Criteria. PREHOSP EMERG CARE 2023; 28:253-261. [PMID: 37105575 DOI: 10.1080/10903127.2023.2206473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Various vital sign ranges for pediatric patients have differing utility in identifying children with serious illness or injury requiring immediate intervention. While commonly used ranges are derived from samples of healthy children, limited research has explored the utility of those derived from real-world encounters by emergency medical services (EMS). We first sought to externally validate pediatric vital sign ranges empirically derived from the prehospital setting. Second, we compared the proportion of children who received prehospital interventions using current common classification systems versus empirically derived vital sign ranges. METHODS We retrospectively reviewed pediatric (<18 years) prehospital records from the 2021 ESO Collaborative dataset. We compared the proportions of encounters having vital signs (heart rate, respiratory rate, and systolic blood pressure) at the cutoffs of >99th, >95th, >90th, <10th, <5th and <1st centiles to previously reported centiles derived from EMS encounters in 2019-2020. We compared the deviation of mean Z-score by age between data sources. We identified the proportion of encounters with extreme (defined as <10th or >90th centile) vital signs who received prehospital interventions for the empirically derived criteria to six other classification criteria. RESULTS 510,414 encounters were included, of which 66.9% were for medical indications and 70.7% resulted in hospital transport. The study sample had similar proportions of encounters identified at studied cutoffs compared to the previously published derivation sample, with all differences in proportions ≤1.1% between samples. All mean Z-scores were within 0.2 standard deviations of those from the derivation sample for each vital sign. Using empirically derived criteria, 34.2% had at least one extreme vital sign, compared to 69.1% with Pediatric Advanced Life Support criteria. Empirically derived extreme vital signs identified a higher proportion of children requiring most prehospital interventions compared to other vital signs criteria. CONCLUSION Previously published empirically derived centiles for pediatric prehospital vital signs were replicated in this large multi-agency dataset. Compared to commonly used vital sign ranges, empirically derived criteria identified a higher proportion of children who received key prehospital interventions. Future steps include evaluating the role of these criteria in predictive models for in-hospital outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert J Sepanski
- Department of Quality Improvement, Children's Hospital of The King's Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia
| | | | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ramgopal S. Nonspecific Diagnoses and Return Visits Among Children Discharged From the Emergency Department. Hosp Pediatr 2023:191234. [PMID: 37132336 DOI: 10.1542/hpeds.2022-007081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Previous work has suggested an association between diagnostic uncertainty and the use of nonspecific diagnostic billing codes. We sought to evaluate differences in emergency department (ED) return visits among children discharged from the ED with specific and nonspecific discharge diagnosis codes. METHODS We performed a retrospective study including children (aged <18 years) discharged from 40 pediatric EDs between July 2021 and June 2022. Our primary and secondary outcomes were 7-day and 30-day ED return visits, respectively. Our predictor of interest was diagnosis, classified as nonspecific (only signs/symptoms diagnoses, e.g., "cough") or specific (≥1 specific diagnosis, e.g., "pneumonia"). We evaluated for associations using Cox proportional hazard models adjusted for race/ethnicity, payer status, age, medical complexity, and neighborhood opportunity. RESULTS Among 1870100 discharged children, 7-day return visits occurred in 73956 (4.0%); of these, 15.8% had nonspecific discharge diagnoses. The adjusted hazard ratio (aHR) of a return visit among children with a nonspecific diagnosis on their index visit was 1.08 (95% confidence interval, 1.06-1.10). Nonspecific diagnoses with the highest aHR of return visits were for fever, convulsions, digestive system, abdominal signs/symptoms, and headache. Respiratory and emotional/behavior signs or symptoms had a lower aHR of 7-day return visits. The aHR of nonspecific diagnosis on 30-day return visits was 1.01 (95% confidence interval 1.01-1.03). CONCLUSIONS Children with nonspecific diagnoses discharged from the ED had distinct patterns of health care utilization compared with those having specific diagnoses. Further research is required to evaluate the role of diagnostic uncertainty with diagnosis code application in the ED.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Akande MY, Ramgopal S, Graham RJ, Goodman DM, Heneghan JA. Child Opportunity Index and Emergent PICU Readmissions: A Retrospective, Cross-Sectional Study of 43 U.S. Hospitals. Pediatr Crit Care Med 2023; 24:e213-e223. [PMID: 36897092 DOI: 10.1097/pcc.0000000000003191] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVES To examine the association between a validated composite measure of neighborhood factors, the Child Opportunity Index (COI), and emergent PICU readmission during the year following discharge for survivors of pediatric critical illness. DESIGN Retrospective cross-sectional study. SETTING Forty-three U.S. children's hospitals contributing to the Pediatric Health Information System administrative dataset. PATIENTS Children (< 18 yr) with at least one emergent PICU admission in 2018-2019 who survived an index admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 78,839 patients, 26% resided in very low COI neighborhoods, 21% in low COI, 19% in moderate COI, 17% in high COI, and 17% in very high COI neighborhoods, and 12.6% had an emergent PICU readmission within 1 year. After adjusting for patient-level demographic and clinical factors, residence in neighborhoods with moderate, low, and very low COI was associated with increased odds of emergent 1-year PICU readmission relative to patients in very high COI neighborhoods. Lower COI levels were associated with readmission in diabetic ketoacidosis and asthma. We failed to find an association between COI and emergent PICU readmission in patients with an index PICU admission diagnosis of respiratory conditions, sepsis, or trauma. CONCLUSIONS Children living in neighborhoods with lower child opportunity had an increased risk of emergent 1-year readmission to the PICU, particularly children with chronic conditions such as asthma and diabetes. Assessing the neighborhood context to which children return following critical illness may inform community-level initiatives to foster recovery and reduce the risk of adverse outcomes.
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Affiliation(s)
- Manzilat Y Akande
- Section of Critical Care, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert J Graham
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Denise M Goodman
- Division of Pediatric Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital; University of Minnesota, Minneapolis, MN
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Fant C, Marin JR, Ramgopal S, Simon NJE, Richards R, Olsen CS, Alessandrini EA, Alpern ER. Updated Diagnosis Grouping System for Pediatric Emergency Department Visits. Pediatr Emerg Care 2023; 39:299-303. [PMID: 35881008 DOI: 10.1097/pec.0000000000002692] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aims to update the Diagnosis Grouping System (DGS) for International Classification of Disease, Tenth Revision ( ICD-10 ) codes for ongoing use. The DGS was developed in 2010 using ICD-9 codes with 21 major groups and 27 subgroups to facilitate research on pediatric patients presenting to emergency departments and required updated classification for more recent ICD codes. METHODS All emergency department discharges available in the Pediatric Emergency Care Applied Research Network (PECARN) database for 2016 were included to identify ICD-10 codes. These codes were then mapped onto the DGS codes originally derived from ICD-9 . We used ICD-10 codes from the PECARN database from 2017 to 2019 to confirm validity. RESULTS The DGS was updated with ICD-10 codes based on 2016 PECARN data, and this updated DGS was successfully applied to 6,853,479 (97.3%) of all codes from 2017 to 2019. DISCUSSION Using ICD-10 codes from the PECARN Registry, the DGS was updated to reflect ICD-10 codes to facilitate ongoing research.
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Affiliation(s)
- Colleen Fant
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jennifer R Marin
- Department of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sriram Ramgopal
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Norma-Jean E Simon
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | | | - Elizabeth R Alpern
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Ramgopal S, Sepanski RJ, Crowe RP, Martin-Gill C. Age-based centiles for diastolic blood pressure among children in the out-of-hospital emergency setting. J Am Coll Emerg Physicians Open 2023; 4:e12915. [PMID: 36852188 PMCID: PMC9958513 DOI: 10.1002/emp2.12915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/11/2023] [Accepted: 02/03/2023] [Indexed: 02/27/2023] Open
Abstract
Objective To compare Pediatric Advanced Life Support (PALS) diastolic blood pressure (DBP) criteria to empirically derived DBP criteria for the prediction of out-of-hospital interventions in children. Methods We performed a retrospective study of pediatric (<18 years) encounters from the ESO Data Collaborative, which includes approximately 2000 Emergency Medical Services agencies in the United States. We developed age-based centile curves for DBP using generalized additive models for location, scale, and shape. We compared the proportion of encounters with a low DBP when using empirically derived and PALS criteria and calculated their associations with the delivery of out-of-hospital interventions (advanced airway management, cardiopulmonary resuscitation, cardiac epinephrine, any systemic epinephrine, defibrillation, and bolus intravenous fluids). Results We included 343,129 encounters. When using PALS criteria, 155,564 (45.3%) were classified as having abnormal DBP, including 120,624 (35.2%) with high DBP and 34,940 (10.2%) with low DBP. When using empirically-derived criteria, 18.6% had an abnormal DBP (ie, a DBP <10th or >90th centile). The accuracy of low DBP for out-of-hospital interventions between the two criteria was similar. Conclusion PALS criteria for DBP classified a high proportion of children as having abnormal vital signs, particularly with diastolic hypertension. Empirically derived DBP thresholds more accurately predict the delivery of key out-of-hospital interventions. If externally validated, correlated to in-hospital outcomes, and combined with thresholds for other vital signs, these may better predict the need for out-of-hospital interventions.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Robert J Sepanski
- Department of Quality Improvement Children's Hospital of The King's Daughters Norfolk Virginia USA.,Department of Pediatrics Eastern Virginia Medical School Norfolk Virginia USA
| | | | - Christian Martin-Gill
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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Ramgopal S, Sepanski RJ, Martin-Gill C. Empirically Derived Age-Based Vital Signs for Children in the Out-of-Hospital Setting. Ann Emerg Med 2023; 81:402-412. [PMID: 36402633 DOI: 10.1016/j.annemergmed.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/15/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To compare Pediatric Advanced Life Support (PALS) vital signs criteria to empirically derived vital signs cut-points for predicting out-of-hospital interventions in children. METHODS We performed a cross-sectional study of pediatric encounters (<18 years) using the 2019 to 2020 datasets of the National Emergency Medical Services Information System, which we randomly divided into equal size derivation and validation samples. We developed age-based centile curves for initial heart rate, respiratory rate, and systolic blood pressure using generalized additive models for location, scale, and shape, which we evaluated in the validation sample. In addition, we compared the proportion of encounters with at least 1 abnormal vital sign when using empirically derived and PALS criteria and calculated their associations with the delivery of out-of-hospital medical interventions (eg, vascular access, medication delivery, or airway maneuvers). RESULTS We included 3,704,398 encounters. Among encounters with all 3 vital signs recorded (n=2,595,217), 45.9% had at least 1 abnormal vital sign using empirically derived criteria and 75.6% with PALS derived criteria. A higher proportion of encounters with a heart rate, respiratory rate, or systolic blood pressure less than 10th or more than 90th age-based empirically derived percentile had medical interventions than those with abnormal vital signs using PALS criteria. CONCLUSION PALS criteria classified a high proportion of children as having abnormal vital signs. Empirically derived vital signs developed from out-of-hospital encounters more accurately predict the delivery of the out-of-hospital medical interventions. If externally validated and correlated to inhospital outcomes, these cut-points may provide a useful assessment tool for children in the out-of-hospital setting.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Robert J Sepanski
- Department of Quality Improvement, Children's Hospital of The King's Daughters and Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Ramgopal S, Martin-Gill C. Prehospital Seizure Management in Children: An Evaluation of a Nationally Representative Sample. J Pediatr 2023:113379. [PMID: 36889629 DOI: 10.1016/j.jpeds.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/10/2023] [Accepted: 02/19/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVE To describe the characteristics and emergency medical services (EMS) interventions, appropriateness of medication dosing, and factors associated with use of any or multiple doses of benzodiazepines for children with seizures in the prehospital setting from a nationally representative dataset. METHODS We performed a retrospective study of EMS encounters within the National Emergency Medical Services Information System between 2019-2021, including children (<18 years) with an impression of seizures. We identified (1) factors associated with the use of benzodiazepines in a logistic regression model and (2) factors associated with multiple doses of benzodiazepines in an ordinal regression model. RESULTS We included 361,177 encounters for seizure. Among transports with an Advanced Life Support clinician, 89.9% were given no benzodiazepines, and 7.7%, 1.9%, and 0.4% were given 1, 2 and ≥3 doses of benzodiazepines, respectively. Encounters given more doses of benzodiazepines had increased use of supplemental oxygen. A high proportion (43.4%) of EMS-provided initial benzodiazepine doses were inappropriately low. EMS-provided benzodiazepine use was associated with use of benzodiazepine prior to EMS arrival. Provision of multiple doses of EMS-provided benzodiazepines was associated with use of a low initial dose of benzodiazepine and use of lorazepam or diazepam compared with midazolam. CONCLUSION A large proportion of prehospital pediatric patients with seizure are given inappropriately low dose of benzodiazepines. Use of a low dose of benzodiazepine and use of benzodiazepines other than midazolam are associated with additional benzodiazepine usage. Our findings have implications for future research and quality improvement needs in pediatric prehospital seizure management.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Cercone A, Ramgopal S, Martin-Gill C. Completeness of Pediatric Versus Adult Patient Assessment Documentation in the National Emergency Medical Services Information System. PREHOSP EMERG CARE 2023; 28:243-252. [PMID: 36758201 DOI: 10.1080/10903127.2023.2178563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Pediatric prehospital encounters are proportionally low-frequency events. National pediatric readiness initiatives have targeted gaps in prehospital pediatric assessment and management. Regional studies suggest that pediatric vital signs are inconsistently obtained and documented. We aimed to assess national emergency medical services (EMS) data to evaluate completeness of assessment documentation for pediatric versus adult patients and to identify the documentation of condition-specific assessments. METHODS We performed a retrospective cross-sectional analysis of EMS encounters from the National Emergency Medical Services Information System for 2019, including all 9-1-1 encounters resulting in transport. Our primary outcome was the proportion of encounters with complete vital signs (heart rate, respiratory rate, and systolic blood pressure) documented by pediatric age category relative to adult encounters. Pediatric patients were considered as those less than 18 years old. Our secondary outcome was condition-specific assessments for encounters with respiratory emergencies, cardiac complaints, and trauma. We performed multivariable logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for vital signs documentation by age after adjusting for sex, injury status, transport type (advanced vs basic life support), census region, urbanicity, organization nonprofit status, and organization type. RESULTS Of 18,918,914 EMS encounters, 6.4% involved pediatric patients. Documentation of complete vital signs was lowest in those <1 month old (30.8%) and rose with increasing age (highest in adults; 91.8%). Relative to adults, the adjusted odds of documented complete vital signs in patients <1 month old was 0.03 (95% CI 0.03-0.03) and increased with age to 0.76 (95% CI 0.75-0.77) in those 12-17 years old. Among those patients with respiratory, cardiac, and traumatic complaints, children had lower proportions of documented pulse oximetry, monitor use, and pain scores, respectively, compared to adults. CONCLUSION Documentation of complete vital signs and condition-specific assessments occurs less frequently in children, especially in younger age groups, as compared to adults, which is a finding that exists across urbanicity, region, and level of response. These findings provide a benchmark for clinical care, quality improvement, and research in the prehospital setting.
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Affiliation(s)
- Angelica Cercone
- Division of Emergency Medicine, UPMC Children's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Lo YHJ, Graves C, Holland JL, Rogers AJ, Money N, Hashikawa AN, Ramgopal S. Temperature threshold in the screening of bacterial infections in young infants with hypothermia. Emerg Med J 2023; 40:189-194. [PMID: 36396347 DOI: 10.1136/emermed-2022-212575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Young infants with hypothermia presenting to the emergency department (ED) are at risk for serious bacterial infections (SBI), however there is no consensus temperature to prompt evaluation for SBI among these children. We sought to statistically derive a temperature threshold to guide detection of SBI in young infants with hypothermia presenting to the ED. METHODS We performed a cross-sectional study of infants ≤90 days old presenting to four academic paediatric EDs in the United States of America from January 2015 through December 2019 with a rectal temperature of ≤36.4°C. Our primary outcomes were SBI, defined as urinary tract infection (UTI), bacteraemia and/or bacterial meningitis, and invasive bacterial infections (IBI, limited to bacteraemia and/or bacterial meningitis). We constructed receiver operating characteristic (ROC) curves to evaluate an optimally derived cutpoint for minimum ED temperature and presence of SBI or IBI. RESULTS We included 3376 infants, of whom SBI were found in 62 (1.8%) and IBI in 16 (0.5%). The most common infection identified was Escherichia coli UTI. Overall, cohort minimum median temperature was 36.2°C (IQR 36.0°C-36.4°C). Patients with SBI and IBI had lower median temperatures, 35.8°C (IQR 35.8°C-36.3°C) and 35.4°C (IQR 35.7°C-36.3°C), respectively, compared with those without corresponding infections (both p<0.05). Using an outcome of SBI, the area under the ROC curve (AUROC) was 61.0% (95% CI 54.1% to 67.9%). At a cutpoint of 36.2°C, sensitivity was 59.7% and specificity was 59.2%. When using an outcome of IBI, the AUROC was 65.9% (95% CI 51.1% to 80.6%). Using a cutpoint of 36.1°C in this model resulted in a sensitivity of 68.8% and specificity of 60.1%. CONCLUSION Young infants with SBI and IBI presented with lower temperatures than infants without infections. However, there was no temperature threshold to reliably identify SBI or IBI. Further research incorporating clinical and laboratory parameters, in addition to temperature, may help to improve risk stratification for these vulnerable patients.
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Affiliation(s)
- Yu Hsiang Johnny Lo
- Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Christopher Graves
- Emergency Medicine, Pediatric Emergency Medicine Associates (PEMA), Atlanta, Georgia, USA
| | | | - Alexander Joseph Rogers
- Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nathan Money
- Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Andrew Nobuhide Hashikawa
- Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sriram Ramgopal
- Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. Incorporation of biomarkers into a prediction model for paediatric radiographic pneumonia. ERJ Open Res 2023; 9:00339-2022. [PMID: 36891073 PMCID: PMC9986752 DOI: 10.1183/23120541.00339-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Objective The aim of this study was to evaluate biomarkers to predict radiographic pneumonia among children with suspected lower respiratory tract infections (LRTI). Methods We performed a single-centre prospective cohort study of children 3 months to 18 years evaluated in the emergency department with signs and symptoms of LRTI. We evaluated the incorporation of four biomarkers (white blood cell count, absolute neutrophil count, C-reactive protein (CRP) and procalcitonin), in isolation and in combination, with a previously developed clinical model (which included focal decreased breath sounds, age and fever duration) for an outcome of radiographic pneumonia using multivariable logistic regression. We evaluated the improvement in performance of each model with the concordance (c-) index. Results Of 580 included children, 213 (36.7%) had radiographic pneumonia. In multivariable analysis, all biomarkers were statistically associated with radiographic pneumonia, with CRP having the greatest adjusted odds ratio of 1.79 (95% CI 1.47-2.18). As an isolated predictor, CRP at a cut-off of 3.72 mg·dL-1 demonstrated a sensitivity of 60% and a specificity of 75%. The model incorporating CRP demonstrated improved sensitivity (70.0% versus 57.7%) and similar specificity (85.3% versus 88.3%) compared to the clinical model when using a statistically derived cutpoint. In addition, the multivariable CRP model demonstrated the greatest improvement in concordance index (0.780 to 0.812) compared with a model including only clinical variables. Conclusion A model consisting of three clinical variables and CRP demonstrated improved performance for the identification of paediatric radiographic pneumonia compared with a model with clinical variables alone.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado and Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard M Ruddy
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ramgopal S, Cotter JM, Navanandan N, Ambroggio L, Florin TA. Disease severity of community-acquired pneumonia among children with medical complexity. Pediatr Pulmonol 2023; 58:967-970. [PMID: 36471562 DOI: 10.1002/ppul.26269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/02/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Gorski JK, Alpern ER, Lorenz DJ, Ramgopal S. Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample. Acad Pediatr 2023; 23:381-386. [PMID: 36280036 DOI: 10.1016/j.acap.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED). METHODS We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity. RESULTS We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races. CONCLUSIONS Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.
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Affiliation(s)
- Jillian K Gorski
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital (JK Gorski, ER Alpern, and S Ramgopal), Chicago, Ill.
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital (JK Gorski, ER Alpern, and S Ramgopal), Chicago, Ill
| | - Douglas J Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville (DJ Lorenz), Louisville, Ky
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital (JK Gorski, ER Alpern, and S Ramgopal), Chicago, Ill
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Ramgopal S, Jaeger L, Cercone A, Martin-Gill C, Fishe J. The Child Opportunity Index and Pediatric Emergency Medical Services Utilization. PREHOSP EMERG CARE 2023; 27:238-245. [PMID: 35536226 DOI: 10.1080/10903127.2022.2076268] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The delivery of emergency medical services (EMS) is a resource-intensive process, and prior studies suggest that EMS utilization in children may vary by socioeconomic status. The Child Opportunity Index (COI) provides a multidimensional measure of neighborhood-level resources and conditions that affect the health of children. We evaluated EMS utilization and measures of acuity among children by COI.Methods: We performed a cross-sectional study using encounters for patients less than 18 years of age from 10,067 EMS agencies in 47 US states and territories contributing to the National Emergency Medical Services Information System 2019 dataset. We compared patient demographics, EMS encounter characteristics, and care provided to children stratified by ZIP code using the COI 2.0.Results: We included 1,293,038 EMS encounters (median age 10 years, IQR 3-15 years). The distributions of encounters in the five tiers of COI were 30.6%, 20.1%, 18.0%, 16.3% and 15.1%, (from Very Low to Very High, respectively). The distribution of diagnoses between groups was similar. Most measures of EMS acuity/resource use were similar between groups, including non-transport status, cardiac arrest, vital sign abnormalities, and EMS-administered procedures and medications. Among children with respiratory-related encounters, children in the Very Low group had a greater need for nebulized medications (26.4% vs 18.3% in Very High COI children). Among children with trauma, a lower proportion in the Very Low group were given analgesia (4.0% vs 7.4% in the Very High group), though pain scores were similar in all groups.Conclusion: Pediatric EMS encounters from lower COI neighborhoods occur more frequently relative to encounters from higher COI neighborhoods. Despite these differences, children from lower COI strata generally have similar encounter characteristics to those in other COI strata, suggestive of a greater number of true out-of-hospital emergencies among children from these areas. Notable differences in care included use of respiratory medication to children with respiratory diagnoses, and administration of pain medication to children with trauma.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lindsay Jaeger
- Department of Pediatrics, Section of Emergency Medicine, University of Chicago School of Medicine, Chicago, Illinois
| | - Angelica Cercone
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Fishe
- Division of Pediatric Emergency Medicine, Dept of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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Holland JL, Ramgopal S, Money N, Graves C, Lo YH, Hashikawa A, Rogers A. Biomarkers and their association with bacterial illnesses in hypothermic infants. Am J Emerg Med 2023; 64:137-141. [PMID: 36528001 PMCID: PMC10368072 DOI: 10.1016/j.ajem.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To describe the association of biomarkers with serious bacterial infection (SBI; urinary tract infection [UTI], bacteremia and/or bacterial meningitis) in hypothermic infants presenting to the emergency department (ED). METHODS We performed a cross sectional study in four academic pediatric EDs from January 2015 through December 2019, including infants ≤90 days old presenting with a rectal temperature of ≤36.4 °C. We constructed receiver operating characteristic (ROC) curves to evaluate the accuracy of blood biomarkers including white blood cell count (WBC), absolute neutrophil count (ANC) and platelets for identifying SBI, with exploratory analyses evaluating procalcitonin and band counts. RESULTS Among 850 included infants (53.5% males; median days of age 13 [IQR 5-58 days]), SBI were found in 55 (6.5%). For infants with SBI, the area under the curve (AUC; 95% confidence interval) for WBC was 0.70 (0.61-0.78) with sensitivity 0.64 (0.50-0.74) and specificity 0.77 (0.74-0.80). The AUC for ANC was 0.77 (0.70-0.84) with sensitivity 0.69 (0.55-0.81) and specificity 0.77 (0.74-0.8). For platelets, the AUC was 0.6 (0.52-0.67) with sensitivity 0.73 (0.59-0.84) and specificity 0.5 (0.46-0.53). Both the WBC and ANC were minimally accurate for identifying hypothermic infants with SBI. When looking at the accuracy of these biomarkers for identifying invasive bacterial infection (IBI; bacteremia and/or bacterial meningitis), ANC again showed minimal accuracy with an AUC of 0.70 (0.55-0.85). CONCLUSIONS Biomarkers commonly used as part of an infectious workup are generally poor at identifying SBI in hypothermic infants. Our findings from this cohort of hypothermic infants are similar to those reported from febrile infants, suggesting similarities in the bioresponse to infection between hypothermic and febrile infants. Additional research is required to improve risk stratification for hypothermic infants, and to better guide evaluation and management.
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Affiliation(s)
- Jamie L Holland
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan Money
- Division of Pediatric Hospital Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christopher Graves
- Division of Pediatric Emergency Medicine, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Yu Hsiang Lo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Andrew Hashikawa
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Heneghan JA, Raval MV, Ramgopal S. Neighborhood opportunity and pediatric trauma. J Pediatr Surg 2023; 58:182-184. [PMID: 35934525 DOI: 10.1016/j.jpedsurg.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital; University of Minnesota, 2450 Riverside Ave S AO-301, Minneapolis, MN 55454, USA.
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Rixe N, Frisch A, Wang Z, Martin JM, Suresh S, Florin TA, Ramgopal S. The development of a novel natural language processing tool to identify pediatric chest radiograph reports with pneumonia. Front Digit Health 2023; 5:1104604. [PMID: 36910570 PMCID: PMC9992200 DOI: 10.3389/fdgth.2023.1104604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Chest radiographs are frequently used to diagnose community-acquired pneumonia (CAP) for children in the acute care setting. Natural language processing (NLP)-based tools may be incorporated into the electronic health record and combined with other clinical data to develop meaningful clinical decision support tools for this common pediatric infection. We sought to develop and internally validate NLP algorithms to identify pediatric chest radiograph (CXR) reports with pneumonia. Materials and methods We performed a retrospective study of encounters for patients from six pediatric hospitals over a 3-year period. We utilized six NLP techniques: word embedding, support vector machines, extreme gradient boosting (XGBoost), light gradient boosting machines Naïve Bayes and logistic regression. We evaluated their performance of each model from a validation sample of 1,350 chest radiographs developed as a stratified random sample of 35% admitted and 65% discharged patients when both using expert consensus and diagnosis codes. Results Of 172,662 encounters in the derivation sample, 15.6% had a discharge diagnosis of pneumonia in a primary or secondary position. The median patient age in the derivation sample was 3.7 years (interquartile range, 1.4-9.5 years). In the validation sample, 185/1350 (13.8%) and 205/1350 (15.3%) were classified as pneumonia by content experts and by diagnosis codes, respectively. Compared to content experts, Naïve Bayes had the highest sensitivity (93.5%) and XGBoost had the highest F1 score (72.4). Compared to a diagnosis code of pneumonia, the highest sensitivity was again with the Naïve Bayes (80.1%), and the highest F1 score was with the support vector machine (53.0%). Conclusion NLP algorithms can accurately identify pediatric pneumonia from radiography reports. Following external validation and implementation into the electronic health record, these algorithms can facilitate clinical decision support and inform large database research.
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Affiliation(s)
- Nancy Rixe
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Zhendong Wang
- School of Computing and Information, University of Pittsburgh, Pittsburgh, PA, United States
| | - Judith M Martin
- Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Srinivasan Suresh
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Ramgopal S, Sanchez-Pinto LN, Horvat CM, Carroll MS, Luo Y, Florin TA. Artificial intelligence-based clinical decision support in pediatrics. Pediatr Res 2023; 93:334-341. [PMID: 35906317 PMCID: PMC9668209 DOI: 10.1038/s41390-022-02226-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/29/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
Machine learning models may be integrated into clinical decision support (CDS) systems to identify children at risk of specific diagnoses or clinical deterioration to provide evidence-based recommendations. This use of artificial intelligence models in clinical decision support (AI-CDS) may have several advantages over traditional "rule-based" CDS models in pediatric care through increased model accuracy, with fewer false alerts and missed patients. AI-CDS tools must be appropriately developed, provide insight into the rationale behind decisions, be seamlessly integrated into care pathways, be intuitive to use, answer clinically relevant questions, respect the content expertise of the healthcare provider, and be scientifically sound. While numerous machine learning models have been reported in pediatric care, their integration into AI-CDS remains incompletely realized to date. Important challenges in the application of AI models in pediatric care include the relatively lower rates of clinically significant outcomes compared to adults, and the lack of sufficiently large datasets available necessary for the development of machine learning models. In this review article, we summarize key concepts related to AI-CDS, its current application to pediatric care, and its potential benefits and risks. IMPACT: The performance of clinical decision support may be enhanced by the utilization of machine learning-based algorithms to improve the predictive performance of underlying models. Artificial intelligence-based clinical decision support (AI-CDS) uses models that are experientially improved through training and are particularly well suited toward high-dimensional data. The application of AI-CDS toward pediatric care remains limited currently but represents an important area of future research.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - L. Nelson Sanchez-Pinto
- grid.16753.360000 0001 2299 3507Division of Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Health and Biomedical Informatics), Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Christopher M. Horvat
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Michael S. Carroll
- grid.16753.360000 0001 2299 3507Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Yuan Luo
- grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Health and Biomedical Informatics), Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Todd A. Florin
- grid.16753.360000 0001 2299 3507Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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Ramgopal S, Heffernan ME, Bendelow A, Davis MM, Carroll MS, Florin TA, Alpern ER, Macy ML. Parental Perceptions on Use of Artificial Intelligence in Pediatric Acute Care. Acad Pediatr 2023; 23:140-147. [PMID: 35577283 DOI: 10.1016/j.acap.2022.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/26/2022] [Accepted: 05/07/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Family engagement is critical in the implementation of artificial intelligence (AI)-based clinical decision support tools, which will play an increasing role in health care in the future. We sought to understand parental perceptions of computer-assisted health care of children in the emergency department (ED). METHODS We conducted a population-weighted household panel survey of parents with minor children in their home in a large US city to evaluate perceptions of the use of computer programs for the care of children with respiratory illness. We identified demographics associated with discomfort with AI using survey-weighted logistic regression. RESULTS Surveys were completed by 1620 parents (panel response rate = 49.7%). Most respondents were comfortable with the use of computer programs to determine the need for antibiotics (77.6%) or bloodwork (76.5%), and to interpret radiographs (77.5%). In multivariable analysis, Black non-Hispanic parents reported greater discomfort with AI relative to White non-Hispanic parents (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.03-2.70) as did younger parents (18-25 years) relative to parents ≥46 years (OR 2.48, 95% CI 1.31-4.67). The greatest perceived benefits of computer programs were finding something a human would miss (64.2%, 95% CI 60.9%-67.4%) and obtaining a more rapid diagnosis (59.6%; 56.2%-62.9%). Areas of greatest concern were diagnostic errors (63.0%, 95% CI 59.6%-66.4%), and recommending incorrect treatment (58.9%, 95% CI 55.5%-62.3%). CONCLUSIONS Parents were generally receptive to computer-assisted management of children with respiratory illnesses in the ED, though reservations emerged. Black non-Hispanic and younger parents were more likely to express discomfort about AI.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, TA Florin, ER Alpern, and ML Macy), Chicago, Ill.
| | - Marie E Heffernan
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (ME Heffernan, MM Davis, M Carroll, and ML Macy), Chicago, Ill; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (ME Heffernan and MM Davis), Chicago, Ill
| | - Anne Bendelow
- Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (A Bendelow and M Carroll), Chicago, Ill
| | - Matthew M Davis
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (ME Heffernan, MM Davis, M Carroll, and ML Macy), Chicago, Ill; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (ME Heffernan and MM Davis), Chicago, Ill
| | - Michael S Carroll
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (ME Heffernan, MM Davis, M Carroll, and ML Macy), Chicago, Ill; Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (A Bendelow and M Carroll), Chicago, Ill
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, TA Florin, ER Alpern, and ML Macy), Chicago, Ill
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, TA Florin, ER Alpern, and ML Macy), Chicago, Ill
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, TA Florin, ER Alpern, and ML Macy), Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (ME Heffernan, MM Davis, M Carroll, and ML Macy), Chicago, Ill
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Ramgopal S, Goodman DM, Kan K, Smith T, Foster CC. Children With Medical Complexity and Mental and Behavioral Disorders in the Emergency Department. Hosp Pediatr 2023; 13:9-16. [PMID: 36472088 PMCID: PMC10719868 DOI: 10.1542/hpeds.2022-006835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND To assess the overlap and admission or transfer rate of children with chronic complex conditions (CCC) and with mental or behavioral health (MBH) disorders among children presenting to the emergency department (ED). METHODS We performed a cross-sectional analysis from 2 data sources: hospitals in the Pediatric Health Information System (PHIS) and from a statewide sample (Illinois COMPdata). We included ED encounters 2 to 21 years and compared differences in admission and/or transfer between subgroups. Among patients with both a CCC and MBH, we evaluated if a primary MBH diagnosis was associated with admission or transfer. RESULTS There were 11 880 930 encounters in the PHIS dataset; 0.7% had an MBH and CCC, 2.2% had an MBH, and 8.0% had a CCC. Patients with an MBH and CCC had a greater need for admission or transfer (86.5%) compared with patients with an MBH alone (57.7%) or CCC alone (52.0%). Among 5 362 701 patients in the COMPdata set, 0.2% had an MBH and CCC, 2.1% had an MBH, and 3.2% had a CCC, with similar admission or transfer needs between groups (61.8% admission or transfer with CCC and MBH; 42.8% MBH alone, and 27.3% with CCC alone). Within both datasets, patients with both a MBH and CCC had a higher odds of admission or transfer when their primary diagnosis was an MBH disorder. CONCLUSIONS While accounting for a small proportion of ED patients, CCC with concomitant MBH have a higher need for admission or transfer relative to other patients.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Denise M. Goodman
- Division of Pediatric Critical Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center
| | - Tracie Smith
- Population Health Analytics, Division of Data Analytics and Reporting, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Carolyn C. Foster
- Division of Advanced General Pediatrics and Primary Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center
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Abstract
OBJECTIVES Children with medical complexity are at increased risk for critical illness and adverse outcomes. However, there is currently no consensus definition of medical complexity in pediatric critical care research. DESIGN Retrospective, cross-sectional cohort study. SETTING One hundred thirty-one U.S. PICUs participating in the Virtual Pediatric Systems Database. SUBJECTS Children less than 21 years old admitted from 2017 to 2019. Multisystem complexity was identified on the basis of two common definitions of medical complexity, Pediatric Complex Chronic Conditions (CCC), greater than or equal to 2 qualifying diagnoses, and Pediatric Medical Complexity Algorithm (PMCA), complex chronic disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 291,583 index PICU admissions, 226,430 (77.7%) met at least one definition of multisystem complexity, including 168,332 patients identified by CCC and 201,537 by PMCA. Of these, 143,439 (63.3%) were identified by both definitions. Cohen kappa was 0.39, indicating only fair agreement between definitions. Children identified by CCC were younger and were less frequently scheduled admissions and discharged home from the ICU than PMCA. The most common reason for admission was respiratory in both groups, although this represented a larger proportion of CCC patients. ICU and hospital length of stay were longer for patients identified by CCC. No difference in median severity of illness scoring was identified between definitions, but CCC patients had higher inhospital mortality. Readmission to the ICU in the subsequent year was seen in approximately one-fifth of patients in either group. CONCLUSIONS Commonly used definitions of medical complexity identified distinct populations of children with multisystem complexity in the PICU with only fair agreement.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN
| | - Denise M Goodman
- Division of Pediatric Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Cotter JM, Florin TA, Moss A, Suresh K, Navanandan N, Ramgopal S, Shah SS, Ruddy R, Kempe A, Ambroggio L. Antibiotic use and outcomes among children hospitalized with suspected pneumonia. J Hosp Med 2022; 17:975-983. [PMID: 36380654 PMCID: PMC9722550 DOI: 10.1002/jhm.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP). OBJECTIVE We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP. DESIGNS, SETTINGS AND PARTICIPANTS We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP. INTERVENTION The exposure was the receipt of antibiotics in the emergency department (ED). MAIN OUTCOME AND MEASURES Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses. RESULTS Among 523 children, 66% were <5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Todd A Florin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Sriram Ramgopal
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Richard Ruddy
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
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