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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

WHAT'S NEW

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

Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care

OBJECTIVES

More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians.

METHODS

We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ2 to compare subgroups.

RESULTS

Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%).

CONCLUSIONS

Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Research Priorities for Pediatric Emergency Care to Address Disparities by Race, Ethnicity, and Language

Importance

Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking.

Objective

To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations.

Design, Setting, and Participants

In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks.

Outcome

Consensus agenda of research priorities to identify and address health care disparities in PEC.

Results

PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation.

Conclusions and Relevance

These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Variability in firearm injury among major pediatric trauma centers across the USA

Objectives

In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA.

Methods

We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ² test or Fisher's exact test was conducted for categorical comparisons.

Results

Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (β=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (β=-0.15 (SE 0.04), p=0.002; β=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site.

Conclusion

The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study.

Gaps in the Identification of Child Race and Ethnicity in a Pediatric Emergency Department

INTRODUCTION

Race and ethnicity are social constructs that are associated with meaningful health inequities. To address health disparities, it is essential to have valid, reliable race and ethnicity data. We compared child race and ethnicity as identified by the parent with that reported in the electronic health record (EHR).

METHODS

A convenience sample of parents of pediatric emergency department (PED) patients completed a tablet-based questionnaire (February-May 2021). Parents identified their child's race and ethnicity from options within a single category. We used chi-square to compare concordance between child race and ethnicity reported by the parent with that recorded in the EHR.

RESULTS

Of 219 approached parents, 206 (94%) completed questionnaires. Race and/or ethnicity were misidentified in the EHR for 56 children (27%). Misidentifications were most common among children whose parents identified them as multiracial (100% vs 15% of children identified as a single race, P < 0.001) or Hispanic (84% vs 17% of non-Hispanic children, P < 0.001), and children whose race and/or ethnicity differed from that of their parent (79% vs 18% of children with the same race and ethnicity as their parent, P < 0.001).

CONCLUSION

In this PED, misidentification of race and ethnicity was common. This study provides the basis for a multifaceted quality improvement effort at our institution. The quality of child race and ethnicity data in the emergency setting warrants further consideration across health equity efforts.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Acute Visual Disturbances and Ataxia Secondary to Attempted COVID-19 Prophylaxis With Ivermectin in a Nine-Year-Old

Ivermectin is an antiparasitic agent listed as an essential medication by the World Health Organization. Ivermectin utilization has increased due to the popular, though inaccurate, perception of its use in COVID-19 management. Poison Control Central calls regarding ivermectin toxicity have increased 245% since pre-pandemic baselines. This case study illustrates the clinical presentation of ivermectin toxicity in a nine-year-old child with acute vision changes and ataxia. The child was given 60 mg (1 mg/kg) of veterinary-grade ivermectin by a parent, 10 times the clinically recommended dose of 0.1 mg/kg, as prophylaxis after household exposure to COVID-19. Ten hours later, the child developed new-onset blurry vision, a perception of red dots in the peripheral vision, dizziness, and balance issues. Physical examination was notable for pulsating pupils, ataxia, and dysmetria. Symptoms resolved completely after 10 hours. Ivermectin ingestion is an important diagnostic consideration in children presenting with similar symptoms. We hope our case aids in the identification of ivermectin toxicity and hastens necessary supportive measures.

Comparison of Targeted and Routine Adolescent HIV Screening in a Pediatric Emergency Department

OBJECTIVES

The aims of the study were (1) to compare targeted and routine HIV screening in a pediatric emergency department (PED) and (2) to compare provider documented HIV risk assessment with adolescent perception of HIV risk assessment conducted during the PED visit.

METHODS

This prospective study ran concurrent to a PED routine HIV screening pilot. Adolescents could be tested for HIV by the PED provider per usual care (targeted testing); if not tested, they were approached for the routine screening pilot. A subset of adolescents completed a questionnaire on HIV risk. χ 2 analysis compared adolescents with targeted testing and routine screening. HIV-tested patients were asked if HIV risk was assessed; κ analysis compared this with documentation in the provider note.

RESULTS

Over 4 months, 107 adolescents received targeted testing and 344 received routine screening. One 14-year-old patient tested positive by routine screening; this adolescent had 2 PED visits without targeted testing within 60 days. Compared with routine screening, adolescents with targeted testing were more likely female (82% vs 57%, P < 0.001), 16 years or older (71% vs 44%, P < 0.001), or had genitourinary/gynecologic concerns (48% vs 6%, P < 0.001). Adolescents with HIV risk factors were missed by targeted testing but received routine screening. Adolescents with documented HIV risk assessment were more likely to receive targeted testing. There was moderate agreement (κ = 0.61) between provider documentation and adolescent perception of HIV risk assessment.

CONCLUSIONS

There are gaps in PED HIV risk assessment and testing, which may miss opportunities to diagnose adolescent HIV. Routine HIV screening addresses these gaps and expands adolescent HIV testing in the PED.

Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol

INTRODUCTION

The management of low-risk febrile infants presents a model population for exploring how implicit racial bias promotes inequitable emergency care for children who belong to racial, ethnic and language minority groups. Although widely used clinical standards guide the clinical care of febrile infants, there remains substantial variability in management strategies. Deviations from recommended care may be informed by the physician's assessment of the family's values, risk tolerance and access to supportive resources. However, in the fast-paced emergency setting, such assessments may be influenced by implicit racial bias. Despite significant research to inform the clinical care of febrile infants, there is a dearth of knowledge regarding health disparities and clinical guideline implementation. The proposed mixed methods approach will (1) quantify the extent of disparities by race, ethnicity and language proficiency and (2) explore the role of implicit bias in physician-patient communication when caring for this population.

METHODS AND ANALYSIS

With 42 participating sites from the Pediatric Emergency Medicine Collaborative Research Committee, we will conduct a multicenter, cross-sectional study of low-risk febrile infants treated in the emergency department (ED) and apply multivariable logistic regression to assess the association between (1) race and ethnicity and (2) limited English proficiency with the primary outcome, discharge to home without lumbar puncture or antibiotics. We will concurrently perform an interpretive study using purposive sampling to conduct individual semistructured interviews with (1) minority parents of febrile infants and (2) paediatric ED physicians. We will triangulate or compare perspectives to better elucidate disparities and bias in communication and medical decision-making.

ETHICS AND DISSEMINATION

This study has been approved by the University of Florida Institutional Review Board. All participating sites in the multicenter analysis will obtain local institutional review board approval. The results of this study will be presented at academic conferences and in peer-reviewed publications.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

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

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

Research environment and resources to support pediatric emergency medicine fellow research

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Unique Needs for the Implementation of Emergency Department Human Immunodeficiency Virus Screening in Adolescents

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommend universal human immunodeficiency virus (HIV) screening starting at 13 years, which has been implemented in many general U.S. emergency departments (EDs) but infrequently in pediatric EDs. We aimed to 1) implement a pilot of routine adolescent HIV screening in a pediatric ED and 2) determine the unique barriers to CDC-recommended screening in this region of high HIV prevalence.

METHODS

This was a prospective 4-month implementation of a routine HIV screening pilot in a convenience sample of adolescents 13 to 18 years at a single pediatric ED, based on study personnel availability. Serum-based fourth-generation HIV testing was run through a central laboratory. Parents were allowed to remain in the room for HIV counseling and testing. Data were collected regarding patient characteristics and HIV testing quality metrics. Comparisons were made using chi-square and Fisher's exact tests. Regression analysis was performed to assess for an association between parent presence at the time of enrollment and adolescent decision to participate in HIV screening.

RESULTS

Over 4 months, 344 of 806 adolescents approached consented to HIV screening (57% female, mean ± SD = 15.1 ± 1.6 years). Adolescents with HIV screening were more likely to be older than those who declined (p = 0.025). Other blood tests were collected with the HIV sample for 21% of adolescents; mean time to result was 105 minutes (interquartile range = 69 to 123) and 79% were discharged before the result was available. Having a parent present for enrollment was not associated with adolescent participation (adjusted odds ratio = 1.07, 95% CI = 0.67 to 1.70). Barriers to testing included: fear of needlestick, time to results, cost, and staff availability. One of 344 tests was positive in a young adolescent with Stage 1 HIV.

CONCLUSIONS

Routine HIV screening in adolescents was able to be implemented in this pediatric ED and led to the identification of early infection in a young adolescent who would have otherwise been undetected at this stage of disease. Addressing the unique barriers to adolescent HIV screening is critical in high-prevalence regions and may lead to earlier diagnosis and treatment in this vulnerable population.

Deficiencies in Provider-Reported Interpreter Use in a Clinical Trial Comparing Telephonic and Video Interpretation in a Pediatric Emergency Department

BACKGROUND

Professional interpretation improves health care quality and outcomes for limited English proficient (LEP) patients, yet interpreter use remains low even when interpretation is available remotely. The researchers analyzed the effect of remote interpretation (telephone or video) on pediatric emergency provider attitudes and behaviors around professional interpretation.

METHODS

A cross-sectional questionnaire of pediatric emergency providers was conducted as part of a randomized trial of telephone vs. video interpretation with Spanish speaking LEP families. Providers recalled lapses of professional interpretation for medical communication (use of an ad hoc or no interpreter), if they had delayed or deferred communication due to the need for professional interpretation, and were asked about their satisfaction with the interpretation modality. Bivariate and multivariate analysis of professional interpreter use and communication behaviors were analyzed by self-report of study group assignment.

RESULTS

One third of providers reported lapses of professional interpretation and many reported less frequent (45.6%) and deferred (34.6%) communication due to the need for interpretation. There was no significant difference in these outcomes between telephone and video assignment. Interpreter skill and technical difficulties were similar between groups. Providers assigned to telephone, compared to video, were more likely to be dissatisfied (p < 0.001) and to report that interpretation was ineffective (p = 0.002).

CONCLUSION

Despite access to interpretation, providers caring for patients enrolled in a study of professional interpreter modalities reported frequent lapses in professional interpretation and deferring or delaying communication because an interpreter was needed. Addressing barriers to remote interpreter use will improve quality of care and health equity for LEP patients.

Asymptomatic Adolescent HIV: Identifying a Role for Universal HIV Screening in the Pediatric Emergency Department

Adolescents account for most undiagnosed HIV infections in the United States. Although the Centers for Disease Control and Prevention (CDC) recommends universal HIV screening for all patients ≥13 years, <10% of adolescents have been tested for HIV. To identify earlier opportunities for adolescent HIV prevention and diagnosis in a region of high HIV prevalence, we sought to describe pediatric emergency department (PED) visits made by a retrospective cohort of adolescents who were later diagnosed with HIV as young adults (<25 years) through an adult emergency department (ED) universal HIV screening program. CD4+ count was used to estimate the time of HIV infection before diagnosis and all PED visits in the 10 years before diagnosis were analyzed. Universal HIV screening in the adult ED diagnosed 193 young adults (median 22 years; 90% men; 29% stage 3); 70% had CD4+ at diagnosis that was used to estimate time of infection (mean 3.8 years). Thirty-eight HIV-infected young adults had a total of 109 PED visits in the 10 years before HIV diagnosis. Sexual history was documented in 12% of PED visits and a sexually transmitted infection test was sent in 6%. Ten HIV-infected young adults had 26 PED visits during the time in which they were likely already infected with HIV, each a potential missed opportunity for earlier diagnosis. HIV-infected and at-risk adolescents are underrecognized in PED visits. Implementation of CDC-recommended universal screening may lead to earlier diagnoses and improve outcomes; the PED may also be critical in identifying adolescents eligible for preexposure prophylaxis.

Identifying a Golden Opportunity: Adolescent Interest in Contraceptive Initiation in a Pediatric Emergency Department

Objectives: Contraception use reduces teen pregnancy, and long-acting reversible contraception is recommended as first-line treatment. Since many adolescents use the emergency department (ED) as a primary source of health care, it is a potential site of contraceptive counseling and provision. We surveyed female adolescents to assess desire for contraceptive counseling and initiation/change during an ED visit. Materials and Methods: This was a cross sectional study of a convenience sample of female ED patients aged 16-21 years in an urban pediatric ED. Participants completed an anonymous questionnaire about sexual health, contraceptive use, and interest in contraceptive counseling. The primary outcome was adolescent interest in starting/changing contraception during an ED visit. Results: Three hundred eighty-one patients (mean age 19.1 ± 1.6 years) completed the survey. Most (80.5%) had been sexually active with a male partner, and 110 (28.2%) had previously been pregnant. Two-thirds were interested in discussing contraception and 22.5% were likely to start or change contraception during the ED visit. Those who wanted to start or change contraception were more likely to be sexually active with a male partner (93% vs. 82%, p = 0.02) and to report that they were not satisfied with their current contraception (44% vs. 21%, p = 0.0003). Fifteen (17%) of the adolescents likely to start or change contraception were interested in progestin implant initiation in the ED. Conclusions: Adolescents were interested in initiating or changing contraception during the ED visit, providing an important opportunity to discuss and initiate effective contraception.

Resolution of Acute Priapism in Two Children With Sickle Cell Disease Who Received Nitrous Oxide

BACKGROUND

Nitrous oxide (N O) is an inhalational medication that has anxiolytic, amnestic, potent venodilatory and mild-to-moderate analgesic properties commonly used in the emergency department (ED) setting. N₂ O has a rapid onset of action (<5 minutes) and recovery (<5 minutes) and can be quickly titrated to effect without the need for IV access. It has few side effects, does not require renal or hepatic metabolism for excretion and has no reports of allergic reaction. Priapism is a serious complication of sickle cell disease (SCD) affecting approximately 35% of males, with an adverse impact on quality of life. Treatment options are limited and not evidence based, including hydration, alkalization, analgesia, oxygenation to prevent further sickling, and exchange transfusion. Patients who do not respond within 4 hours often require a painful invasive procedure that includes aspiration of blood from the corpus cavernosum and phenylephrine injections. Case reports have described a therapeutic benefit from oral pseudoephedrine, sildenafil, and intravenous (IV) arginine, however controlled clinical trials are lacking. Although a 50:50 nitrous oxide/oxygen mix is commonly used in France to enhance analgesia in patients with SCD and vasoocclusive pain events (VOE) not sufficiently responding to IV morphine, there are no reports of its use to treat priapism. We describe the effects of N₂ O for the treatment of acute priapism associated with SCD in a pediatric ED.

METHODS

This is a case series of two adolescent boys with Hb-SS who on 3 separate occasions presented to the ED with acute priapism that failed oral therapy (pseudoephedrine and opioids). N₂ O gas was utilized to help facilitate IV catheter placement.

RESULTS

In each presentation (at ages 8 and 10 years for patient 1; age 15 years for patient 2), the patient experienced complete resolution of the priapism within 4-15 min of receiving N₂ O (max 60%). The patients were discharged from the ED following each presentation and had no recurrence during the subsequent week.

CONCLUSIONS

Priapism is a challenging complication of SCD associated with long-term morbidity and a paucity of treatment options. Opioids are commonly used. Given the risks and inconsistent results of current recommended therapy, N₂ O may represent a potential opioid-sparing treatment option for priapism presenting to the ED that warrants further investigation. Although anecdotal, N₂ O inhalation is an intervention to consider during a time when a treating ED physician may have few alternatives.

Professional Interpreter Use and Discharge Communication in the Pediatric Emergency Department

OBJECTIVE

Families with limited English proficiency (LEP) experience communication barriers and are at risk for adverse events after discharge from the pediatric emergency department (ED). We sought to describe the characteristics of ED discharge communication for LEP families and to assess whether the use of a professional interpreter was associated with provider communication quality during ED discharge.

METHODS

Transcripts of video-recorded ED visits for Spanish-speaking LEP families were obtained from a larger study comparing professional interpretation modalities in a freestanding children's hospital. Caregiver-provider communication interactions that included discharge education were analyzed for content and for the techniques that providers used to assess caregiver comprehension. Regression analysis was used to assess for an association between professional interpreter use and discharge education content or assessment of caregiver comprehension.

RESULTS

We analyzed 101 discharge communication interactions from 47 LEP patient visits; 31% of communications did not use professional interpretation. Although most patients (70%) received complete discharge education content, only 65% received instructions on medication dosing, and only 55% were given return precautions. Thirteen percent of the patient visits included an open-ended question to assess caregiver comprehension, and none included teach-back. Professional interpreter use was associated with greater odds of complete discharge education content (odds ratio [OR], 7.1; 95% confidence interval [CI], 1.4-37.0) and high-quality provider assessment of caregiver comprehension (OR, 6.1; 95% CI, 2.3-15.9).

CONCLUSIONS

Professional interpreter use is associated with superior provider discharge communication behaviors. This study identifies clear areas for improving discharge communication, which may improve safety and outcomes for LEP children discharged from the ED.