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Scott HF, Lindberg DM, Brackman S, McGonagle E, Leonard JE, Adelgais K, Bajaj L, Dillon M, Kempe A. Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome. Ann Emerg Med 2024; 83:318-326. [PMID: 38069968 PMCID: PMC10960690 DOI: 10.1016/j.annemergmed.2023.10.011] [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: 05/20/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 02/29/2024]
Abstract
STUDY OBJECTIVE To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines. METHODS A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed. RESULTS We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in 2021. CONCLUSION Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.
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Affiliation(s)
- Halden F Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO.
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Savannah Brackman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Erin McGonagle
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Jan E Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Kathleen Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Lalit Bajaj
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Mairead Dillon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
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Abrams A, Kaufman E, Bajaj L. Not a crime scene: The need to examine the impact of police in the pediatric emergency department. Acad Emerg Med 2024. [PMID: 38528778 DOI: 10.1111/acem.14901] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/12/2024] [Accepted: 02/27/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Anna Abrams
- Children's Hospital Colorado, Aurora, Colorado, USA
- University of Colorado, Aurora, Colorado, USA
| | | | - Lalit Bajaj
- Children's Hospital Colorado, Aurora, Colorado, USA
- University of Colorado, Aurora, Colorado, USA
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McGonagle EA, Karavite DJ, Grundmeier RW, Schmidt SK, May LS, Cohen DM, Cruz AT, Tu SP, Bajaj L, Dayan PS, Mistry RD. Evaluation of an Antimicrobial Stewardship Decision Support for Pediatric Infections. Appl Clin Inform 2023; 14:108-118. [PMID: 36754066 PMCID: PMC9908419 DOI: 10.1055/s-0042-1760082] [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: 05/07/2022] [Accepted: 11/16/2022] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVES Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI). METHODS We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow. RESULTS Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices (p < 0.001) and provision of additional resources on antibiotic prescription (p < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system (p = 0.117). CONCLUSION Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.
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Affiliation(s)
- Erin A. McGonagle
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Dean J. Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Robert W. Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Sarah K. Schmidt
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Larissa S. May
- Department of Emergency Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Daniel M. Cohen
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, Ohio, United States
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Shin-Ping Tu
- Department of Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Lalit Bajaj
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Peter S. Dayan
- Department of Emergency Medicine and Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
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Scott HF, Kempe A, Bajaj L, Lindberg DM, Dafoe A, Dorsey Holliman B. "These Are Our Kids": Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care. Ann Emerg Med 2022; 80:347-357. [PMID: 35840434 PMCID: PMC9529081 DOI: 10.1016/j.annemergmed.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. METHODS In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. RESULTS Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. CONCLUSION Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO.
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO
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Freeman JF, Bajaj L. Is Home Oxygen Therapy an Alternative to Hospitalization for Bronchiolitis? Pediatrics 2022; 150:189384. [PMID: 36065736 DOI: 10.1542/peds.2022-058042] [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] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Julia F Freeman
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Lalit Bajaj
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Wang GS, Bajaj L, Poppy C, Valuck R. Integrated Prescription Drug Monitoring Program for Opioid Prescribing at a Children's Hospital. Clin Pediatr (Phila) 2022; 61:465-468. [PMID: 35442096 DOI: 10.1177/00099228221085344] [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] [Indexed: 11/15/2022]
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Lalit Bajaj
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA.,Department of Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher Poppy
- Clinical Application Services, Children's Hospital Colorado, Aurora, CO, USA
| | - Robert Valuck
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Balamuth F, Scott HF, Weiss SL, Webb M, Chamberlain JM, Bajaj L, Depinet H, Grundmeier RW, Campos D, Deakyne Davies SJ, Simon NJ, Cook LJ, Alpern ER. Validation of the Pediatric Sequential Organ Failure Assessment Score and Evaluation of Third International Consensus Definitions for Sepsis and Septic Shock Definitions in the Pediatric Emergency Department. JAMA Pediatr 2022; 176:672-678. [PMID: 35575803 PMCID: PMC9112137 DOI: 10.1001/jamapediatrics.2022.1301] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Pediatric sepsis definitions have evolved, and some have proposed using the measure used in adults to quantify organ dysfunction, a Sequential Organ Failure Assessment (SOFA) score of 2 or more in the setting of suspected infection. A pediatric adaptation of SOFA (pSOFA) showed excellent discrimination for mortality in critically ill children but has not been evaluated in an emergency department (ED) population. OBJECTIVE To delineate test characteristics of the pSOFA score for predicting in-hospital mortality among (1) all patients and (2) patients with suspected infection treated in pediatric EDs. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study took place from January 1, 2012, to January 31, 2020 in 9 US children's hospitals included in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The data was analyzed from February 1, 2020, to April 18, 2022. All ED visits for patients younger than 18 years were included. EXPOSURES ED pSOFA score was assigned by summing maximum pSOFA organ dysfunction components during ED stay (each 0-4 points). In the subset with suspected infection, visit meeting criteria for sepsis (suspected infection with a pSOFA score of 2 or more) and septic shock (suspected infection with vasoactive infusion and serum lactate level >18.0 mg/dL) were identified. MAIN OUTCOMES AND MEASURES Test characteristics of pSOFA scores of 2 or more during the ED stay for hospital mortality. RESULTS A total of 3 999 528 (female, 47.3%) ED visits were included. pSOFA scores ranged from 0 to 16, with 126 250 visits (3.2%) having a pSOFA score of 2 or more. pSOFA scores of 2 or more had sensitivity of 0.65 (95% CI, 0.62-0.67) and specificity of 0.97 (95% CI, 0.97-0.97), with negative predictive value of 1.0 (95% CI, 1.00-1.00) in predicting hospital mortality. Of 642 868 patients with suspected infection (16.1%), 42 992 (6.7%) met criteria for sepsis, and 374 (0.1%) met criteria for septic shock. Hospital mortality rates for suspected infection (599 502), sepsis (42 992), and septic shock (374) were 0.0%, 0.9%, and 8.0%, respectively. The pSOFA score had similar discrimination for hospital mortality in all ED visits (area under receiver operating characteristic curve, 0.81; 95% CI, 0.79-0.82) and the subset with suspected infection (area under receiver operating characteristic curve, 0.82; 95% CI, 0.80-0.84). CONCLUSIONS AND RELEVANCE In a large, multicenter study of pediatric ED visits, a pSOFA score of 2 or more was uncommon and associated with increased hospital mortality yet had poor sensitivity as a screening tool for hospital mortality. Conversely, children with a pSOFA score of 2 or less were at very low risk of death, with high specificity and negative predictive value. Among patients with suspected infection, patients with pSOFA-defined septic shock demonstrated the highest mortality.
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Affiliation(s)
- Fran Balamuth
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Scott L. Weiss
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | - Holly Depinet
- Cincinnnati Children’s Hospital and Medical Center, Cincinnati, Ohio
| | - Robert W. Grundmeier
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diego Campos
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Bakel LA, Richardson T, De Souza HG, Kaiser SV, Mahant S, Treasure JD, Waynik IY, Winer JC, Bajaj L. Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions. J Hosp Med 2022; 17:417-426. [PMID: 35535935 DOI: 10.1002/jhm.12811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.
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Affiliation(s)
- Leigh Anne Bakel
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ilana Y Waynik
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, Mansfield, Connecticut, USA
| | - Jeffrey C Winer
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lalit Bajaj
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Kaplan RL, Cruz AT, Freedman SB, Smith K, Freeman J, Lane RD, Michelson KA, Marble RD, Middelberg LK, Bergmann KR, McAneney C, Noorbakhsh KA, Pruitt C, Shah N, Badaki-Makun O, Schnadower D, Thompson AD, Blackstone MM, Abramo TJ, Srivastava G, Avva U, Samuels-Kalow M, Morientes O, Kannikeswaran N, Chaudhari PP, Strutt J, Vance C, Haines E, Khanna K, Gerard J, Bajaj L. Omphalitis and Concurrent Serious Bacterial Infection. Pediatrics 2022; 149:186812. [PMID: 35441224 DOI: 10.1542/peds.2021-054189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with omphalitis. METHODS Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants ≤90 days of age with omphalitis seen in the emergency department from January 1, 2008, to December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS Among 566 infants (median age 16 days), 537 (95%) were well-appearing, 64 (11%) had fever at home or in the emergency department, and 143 (25%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 472 (83%), 326 (58%), and 222 (39%) infants, respectively. Pathogens grew in 1.1% (95% confidence interval [CI], 0.3%-2.5%) of blood, 0.9% (95% CI, 0.2%-2.7%) of urine, and 0.9% (95% CI, 0.1%-3.2%) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 320 (57%) infants, with 85% (95% CI, 80%-88%) growing a pathogen, most commonly methicillin-sensitive Staphylococcus aureus (62%), followed by methicillin-resistant Staphylococcus aureus (11%) and Escherichia coli (10%). Four hundred ninety-eight (88%) were hospitalized, 81 (16%) to an ICU. Twelve (2.1% [95% CI, 1.1%-3.7%]) had sepsis or shock, and 2 (0.4% [95% CI, 0.0%-1.3%]) had severe cellulitis or necrotizing soft tissue infection. There was 1 death. Serious complications occurred only in infants aged <28 days. CONCLUSIONS In this multicenter cohort, mild, localized disease was typical of omphalitis. SBI and adverse outcomes were uncommon. Depending on age, routine testing for SBI is likely unnecessary in most afebrile, well-appearing infants with omphalitis.
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Affiliation(s)
- Ron L Kaplan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathleen Smith
- Department of Pediatrics, Rady Children's Hospital San Diego, San Diego, California
| | - Julia Freeman
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado
| | - Roni D Lane
- Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard D Marble
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah K Middelberg
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Constance McAneney
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kathleen A Noorbakhsh
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Pruitt
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nipam Shah
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - David Schnadower
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Amy D Thompson
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Mercedes M Blackstone
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas J Abramo
- Pediatric Emergency Medicine Associates, Children's Hospital of Atlanta, Atlanta, Georgia
| | | | - Usha Avva
- Department of Pediatrics, Joseph M Sanzari Children's Hospital, Hackensack Meridian Health, Hackensack, New Jersey
| | | | - Oihane Morientes
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - Nirupama Kannikeswaran
- Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
| | - Pradip P Chaudhari
- Department of Pediatrics, University of Southern California, Children's Hospital Los Angeles, Los Angeles, California
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California
| | - Elizabeth Haines
- Ronald O. Perelman Department of Emergency Medicine/NYU Langone Health, New York, New York
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - James Gerard
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louise, Missouri
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado
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Staab S, Black T, Leonard J, Bruny J, Bajaj L, Grubenhoff JA. Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children. Pediatr Emerg Care 2022; 38:e690-e696. [PMID: 34170096 DOI: 10.1097/pec.0000000000002323] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/26/2022]
Abstract
OBJECTIVE When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. METHODS Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. RESULTS There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. CONCLUSIONS Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.
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Affiliation(s)
| | | | - Jan Leonard
- From the Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine
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11
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Johnson TJ, Goyal MK, Lorch SA, Chamberlain JM, Bajaj L, Alessandrini EA, Simmons T, Casper TC, Olsen CS, Grundmeier RW, Alpern ER. Racial/Ethnic Differences in Pediatric Emergency Department Wait Times. Pediatr Emerg Care 2022; 38:e929-e935. [PMID: 34140453 PMCID: PMC8671570 DOI: 10.1097/pec.0000000000002483] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. METHODS We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. RESULTS Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. CONCLUSIONS In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.
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Affiliation(s)
- Tiffani J Johnson
- From the University of California, Davis Medical Center, Sacramento, CA
| | - Monika K Goyal
- Children's National Health System, The George Washington University, Washington, DC
| | - Scott A Lorch
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - James M Chamberlain
- Children's National Health System, The George Washington University, Washington, DC
| | - Lalit Bajaj
- University of Colorado, Children's Hospital, Aurora, CO
| | | | | | | | | | - Robert W Grundmeier
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth R Alpern
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
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12
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Linakis JG, Thomas SA, Bromberg JR, Casper TC, Chun TH, Mello MJ, Richards R, Ahmad F, Bajaj L, Brown KM, Chernick LS, Cohen DM, Dean JM, Fein J, Horeczko T, Levas MN, McAninch B, Monuteaux MC, Mull CC, Grupp-Phelan J, Powell EC, Rogers A, Shenoi RP, Suffoletto B, Vance C, Spirito A. Adolescent alcohol use predicts cannabis use over a three year follow-up period. Subst Abus 2022; 43:514-519. [PMID: 34236277 PMCID: PMC8759759 DOI: 10.1080/08897077.2021.1949665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.
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Affiliation(s)
| | | | - Julie R. Bromberg
- The Warren Alpert Medical School of Brown University;,Rhode Island Hospital
| | | | - Thomas H. Chun
- The Warren Alpert Medical School of Brown University;,Rhode Island Hospital
| | - Michael J. Mello
- The Warren Alpert Medical School of Brown University;,Rhode Island Hospital
| | | | - Fahd Ahmad
- St. Louis Children’s Hospital/ Washington University
| | | | | | | | | | | | - Joel Fein
- The Children’s Hospital of Philadelphia
| | - Timothy Horeczko
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
| | | | - B McAninch
- University of Pittsburgh/ Children’s Hospital of Pittsburgh of UPMC
| | | | - Colette C. Mull
- Sidney Kimmel Medical College at Jefferson University/ Nemours Alfred I. duPont Hospital for Children
| | | | | | | | | | - Brian Suffoletto
- University of Pittsburgh/ Children’s Hospital of Pittsburgh of UPMC
| | | | - Anthony Spirito
- The Warren Alpert Medical School of Brown University;,Address correspondence to: Anthony Spirito, PhD, Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Box G-BH, Providence, RI 02912, United States,
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13
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Wang GS, Reese J, Bakel LA, Leonard J, Bos T, Bielsky A, Nickels S, Bajaj L. Prescribing Patterns of Oral Opioid Analgesic for Long Bone Fracture at Tertiary Care Children's Hospital Emergency Departments and Urgent Cares. Pediatr Emerg Care 2021; 37:e1524-e1527. [PMID: 32384393 DOI: 10.1097/pec.0000000000002105] [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: 11/25/2022]
Abstract
OBJECTIVES Disparities in opioid prescribing in children can lead to underprescribing and poorly controlled pain. On the contrary, unnecessary overprescribing can increase the risk for misuse, abuse, and diversion. The primary objective of this study was to compare the demographics and clinical characteristics of children with an extremity fracture who did and did not receive an opioid prescription from a tertiary care children's hospital. METHODS This was a retrospective cohort study of children younger than 22 years with extremity fracture evaluated at a tertiary care children's hospital emergency department (ED) and surrounding satellite locations (3 EDs and 4 urgent cares), from January 1, 2017, to December 31, 2017. RESULTS There were 3325 patients younger than 22 years who were seen for evaluation of an extremity fracture. The overall median age of patients was 8 years (interquartile range [IQR], 4-11), and 1976 (59.4%) were male. Patients with extremity fractures who received opioid analgesics were older than those who did not receive opioids (median age of 10 years [IQR, 6-13 years] vs 7 years [IQR, 4-11 years], P < 0.001). There was a significant difference found between insurance types, specifically those patients receiving Medicaid and private insurance. Patients who received opioid analgesics had a higher initial pain score (7 [IQR, 4-9] vs 5 [IQR, 2-7], P < 0.001), were more likely to have an physician (MD/DO) provider (P < 0.001), and were more likely to present to the ED (P < 0.001). CONCLUSIONS Younger patients, patients with Medicaid insurance, patients treated by an advanced care provider, and patients who presented to an urgent care were less likely to receive opioid analgesics upon discharge. These findings demonstrate that more standardization and guidance on opioid prescribing are needed in pediatrics, to both adequately treat pain and reduce harms from overprescribing of opioid analgesics.
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Affiliation(s)
| | - Jennifer Reese
- Division of Hospitalist Medicine, University of Colorado Anschutz Medical Campus
| | | | - Jan Leonard
- Division of Emergency Medicine, University of Colorado Anschutz Medical Campus
| | - Tod Bos
- Department of Clinical Effectiveness, Children's Hospital Colorado
| | - Alan Bielsky
- Department of Anesthesia, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Nickels
- Department of Clinical Effectiveness, Children's Hospital Colorado
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14
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Wang GS, Reese J, Bakel LA, Leonard J, Bielsky A, Reid A, Bos T, Nickels S, Bajaj L. Prescribing Patterns of Oral Opioid Analgesic for Acute Pain at a Tertiary Care Children's Hospital Emergency Departments and Urgent Cares. Pediatr Emerg Care 2021; 37:e841-e845. [PMID: 31688834 DOI: 10.1097/pec.0000000000001909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/25/2022]
Abstract
OBJECTIVES Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days. METHODS A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded. RESULTS Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4-3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for >7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received >3 days of opioids were younger (P < 0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications. CONCLUSIONS Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.
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15
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Goyal MK, Drendel AL, Chamberlain JM, Wheeler J, Olsen C, Grundmeier RW, Cook L, Bajaj L, Babcock L, Zorc JJ, Johnson T, Alpern ER. Racial/Ethnic Differences in ED Opioid Prescriptions for Long Bone Fractures: Trends Over Time. Pediatrics 2021; 148:peds.2021-052481. [PMID: 34645690 DOI: 10.1542/peds.2021-052481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Monika K Goyal
- Department of Pediatric Emergency Medicine, Children's National Hospital and The School of Medicine & Health Sciences, The George Washington University, Washington, District of Columbia
| | - Amy L Drendel
- Department of Pediatrics, Medical College of Wisconsin, University of Wisconsin, Madison, Wisconsin
| | - James M Chamberlain
- Department of Pediatric Emergency Medicine, Children's National Hospital and The School of Medicine & Health Sciences, The George Washington University, Washington, District of Columbia
| | - Justin Wheeler
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Cody Olsen
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Robert W Grundmeier
- Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Larry Cook
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Lalit Bajaj
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Lynn Babcock
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center
| | - Joeseph J Zorc
- Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tiffani Johnson
- Department of Emergency Medicine, University of California Davis, Sacramento, California
| | - Elizabeth R Alpern
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital
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16
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Goyal MK, Chamberlain JM, Webb M, Grundmeier RW, Johnson TJ, Lorch SA, Zorc JJ, Alessandrini E, Bajaj L, Cook L, Alpern ER. Racial and ethnic disparities in the delayed diagnosis of appendicitis among children. Acad Emerg Med 2021; 28:949-956. [PMID: 32991770 DOI: 10.1111/acem.14142] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/11/2020] [Accepted: 09/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). METHODS This was a 3-year multicenter (seven EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7 days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, other) with 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). RESULTS Of 7,298 patients with appendicitis and documented race/ethnicity, 2,567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; adjusted odds ratio [aOR] = 1.21 [95% confidence interval {CI} = 1.01 to 1.45]). A total of 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR = 1.81 [95% CI = 1.09 to 2.98]). Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR = 0.41 [95% CI = 0.18 to 0.96]) or definitive imaging (e.g., ultrasound/computed tomography/magnetic resonance imaging; 10.3% vs. 35.9%; aOR = 0.15 [95% CI = 0.05 to 0.50]) during prior visits. CONCLUSIONS In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis and, thus, may contribute to higher perforation rates demonstrated among minority children.
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Affiliation(s)
- Monika K. Goyal
- Departments of Pediatrics & Emergency Medicine Children's National HospitalThe George Washington University Washington DC USA
| | - James M. Chamberlain
- Departments of Pediatrics & Emergency Medicine Children's National HospitalThe George Washington University Washington DC USA
| | - Michael Webb
- Department of Pediatrics University of Utah Salt Lake City UT USA
| | - Robert W. Grundmeier
- Department of Pediatrics Children's Hospital of PhiladelphiaUniversity of Pennsylvania Philadelphia PA USA
| | | | - Scott A. Lorch
- Department of Pediatrics Children's Hospital of PhiladelphiaUniversity of Pennsylvania Philadelphia PA USA
| | - Joseph J. Zorc
- Department of Pediatrics Children's Hospital of PhiladelphiaUniversity of Pennsylvania Philadelphia PA USA
| | - Evaline Alessandrini
- James M. Anderson Center for Health Systems Excellence Cincinnati Children's Hospital Medical Center Cincinnati OH USA
| | - Lalit Bajaj
- Department of Pediatrics University of ColoradoChildren's Hospital Colorado Aurora CO USA
| | - Lawrence Cook
- Department of Pediatrics University of Utah Salt Lake City UT USA
| | - Elizabeth R. Alpern
- Department of Pediatrics Ann & Robert H. Lurie Children's HospitalNorthwestern University Feinberg School of Medicine Chicago IL USA
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17
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Lockwood JM, Scott HF, Wathen B, Rolison E, Smith C, Bundy J, Swanson A, Nickels S, Bakel LA, Bajaj L. An Acute Care Sepsis Response System Targeting Improved Antibiotic Administration. Hosp Pediatr 2021; 11:944-955. [PMID: 34404744 DOI: 10.1542/hpeds.2021-006011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020. METHODS Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement. RESULTS We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died. CONCLUSIONS We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.
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Affiliation(s)
| | - Halden F Scott
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Elise Rolison
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Carter Smith
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Jane Bundy
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Angela Swanson
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah Nickels
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Leigh Anne Bakel
- Sections of Hospital Medicine.,Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Lalit Bajaj
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado.,Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
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18
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Kaplan RL, Cruz AT, Michelson KA, McAneney C, Blackstone MM, Pruitt CM, Shah N, Noorbakhsh KA, Abramo TJ, Marble RD, Middelberg L, Smith K, Kannikeswaran N, Schnadower D, Srivastava G, Thompson AD, Lane RD, Freeman JF, Bergmann KR, Morientes O, Gerard J, Badaki-Makun O, Avva U, Chaudhari PP, Freedman SB, Samuels-Kalow M, Haines E, Strutt J, Khanna K, Vance C, Bajaj L. Neonatal Mastitis and Concurrent Serious Bacterial Infection. Pediatrics 2021; 148:peds.2021-051322. [PMID: 34187909 DOI: 10.1542/peds.2021-051322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Accepted: 04/19/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis. METHODS Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths. CONCLUSIONS In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.
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Affiliation(s)
- Ron L Kaplan
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Constance McAneney
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mercedes M Blackstone
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M Pruitt
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Nipam Shah
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, Alabama
| | - Kathleen A Noorbakhsh
- Department of Pediatrics, School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas J Abramo
- Pediatric Emergency Medicine Associates, Children's Hospital of Atlanta, Atlanta, Georgia
| | - Richard D Marble
- Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Leah Middelberg
- Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kathleen Smith
- Department of Pediatrics, School of Medicine, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Nirupama Kannikeswaran
- Department of Pediatrics, College of Medicine, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Schnadower
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Amy D Thompson
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Roni D Lane
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Julia F Freeman
- Children's Hospital Colorado and Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Oihane Morientes
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - James Gerard
- Department of Pediatrics, School of Medicine, Saint Louis University and SSM Health Cardinal Glennon Children's Hospital, St Louis, Missouri
| | | | - Usha Avva
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, New Jersey
| | - Pradip P Chaudhari
- Department of Pediatrics, Kerk School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary and Alberta Children's Hospital, Alberta, Canada
| | | | - Elizabeth Haines
- Ronald O. Perelman Department of Emergency Medicine, Grossman School of Medicine, New York University and New York University Langone Health, New York, New York
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Kajal Khanna
- Department of Emergency Medicine, School of Medicine, Stanford University, Stanford, California
| | - Cheryl Vance
- Department of Pediatrics and Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, California
| | - Lalit Bajaj
- Children's Hospital Colorado and Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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19
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Drendel AL, Brousseau DC, Casper TC, Bajaj L, Alessandrini EA, Grundmeier RW, Chamberlain JM, Goyal MK, Olsen CS, Alpern ER. Opioid Prescription Patterns at Emergency Department Discharge for Children with Fractures. Pain Med 2021; 21:1947-1954. [PMID: 32022894 DOI: 10.1093/pm/pnz348] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. DESIGN A retrospective cohort study of pediatric ED visits in 2015. SETTING Four pediatric EDs. SUBJECTS Children aged four to 18 years with a long-bone fracture discharged from the ED. METHODS A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. RESULTS There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9-9.7%), B = 12.1% (95% CI = 10.5-14.0%), C = 16.9% (95% CI = 15.2-18.8%), D = 23.8% (95% CI = 21.7-26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12-18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. CONCLUSIONS For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.
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Affiliation(s)
| | | | | | - Lalit Bajaj
- University of Colorado, Children's Hospital Colorado, Colorado
| | | | - Robert W Grundmeier
- University of Pennsylvania, Children's Hospital of Philadelphia, Pennsylvania
| | - James M Chamberlain
- Children's National Medical Center, The George Washington University, Washington, DC
| | - Monika K Goyal
- Children's National Medical Center, The George Washington University, Washington, DC
| | | | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago for The Pediatric Emergency Care Applied Research Network (PECARN), Chicago, Illinois, USA
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20
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Bauer ME, MacBrayne C, Stein A, Searns J, Hicks A, Sarin T, Lin T, Duffey H, Rannie M, Wickstrom K, Yang C, Bajaj L, Carel K. A Multidisciplinary Quality Improvement Initiative to Facilitate Penicillin Allergy Delabeling Among Hospitalized Pediatric Patients. Hosp Pediatr 2021; 11:427-434. [PMID: 33849960 DOI: 10.1542/hpeds.2020-001636] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 06/12/2023]
Abstract
BACKGROUND Penicillin allergy is reported in up to 10% of the general population; however, >90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction. METHODS Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution's quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre- and postpathway implementation. RESULTS After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation. CONCLUSIONS Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.
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Affiliation(s)
| | - Christine MacBrayne
- Section of Infectious Disease and Antimicrobial Stewardship, Children's Hospital Colorado, Aurora, Colorado; and
| | - Amy Stein
- Department of Pediatrics, Sections of Allergy and Immunology
| | | | - Allison Hicks
- Department of Pediatrics, Sections of Allergy and Immunology
| | - Tara Sarin
- Department of Pediatrics, Sections of Allergy and Immunology
| | - Taylor Lin
- Department of Pediatrics, Sections of Allergy and Immunology
| | - Hannah Duffey
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | | | - Cheryl Yang
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Lalit Bajaj
- Pediatric Emergency Medicine, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Kirstin Carel
- Department of Pediatrics, Sections of Allergy and Immunology
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21
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Rao S, Kwan BM, Curtis DJ, Swanson A, Bakel LA, Bajaj L, Boguniewicz J, Lockwood JM, Ogawa K, Pemberton K, Fuhlbrigge RC, Brumbaugh D, Givens P, Nozik ES, Sills MR. Implementation of a Rapid Evidence Assessment Infrastructure during the Coronavirus Disease 2019 (COVID-19) Pandemic to Develop Policies, Clinical Pathways, Stimulate Academic Research, and Create Educational Opportunities. J Pediatr 2021; 230:4-8.e2. [PMID: 33091418 PMCID: PMC7572277 DOI: 10.1016/j.jpeds.2020.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Suchitra Rao
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Epidemiology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Bethany M Kwan
- Department of Family Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO
| | - Donna J Curtis
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Angela Swanson
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | - Leigh Anne Bakel
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Lalit Bajaj
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Juri Boguniewicz
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Justin M Lockwood
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kaleigh Ogawa
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | | | - Robert C Fuhlbrigge
- Department of Pediatrics (Rheumatology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - David Brumbaugh
- Department of Pediatrics (Gastroenterology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Patricia Givens
- Department of Nursing, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Eva S Nozik
- Department of Pediatrics (Critical Care), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Marion R Sills
- Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
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22
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Scott HF, Colborn KL, Sevick CJ, Bajaj L, Deakyne Davies SJ, Fairclough D, Kissoon N, Kempe A. Development and Validation of a Model to Predict Pediatric Septic Shock Using Data Known 2 Hours After Hospital Arrival. Pediatr Crit Care Med 2021; 22:16-26. [PMID: 33060422 PMCID: PMC7790844 DOI: 10.1097/pcc.0000000000002589] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To use Electronic Health Record (EHR) data from the first two hours of care to derive and validate a model to predict hypotensive septic shock in children with infection. Design: Derivation-validation study using an existing registry Setting: Six emergency care sites within a regional pediatric healthcare system. Three datasets of unique visits were designated: Patients: Patients in whom clinicians were concerned about serious infection from 60 days-17 years were included; those with septic shock in the first two hours were excluded. There were 2318 included visits; 197 developed septic shock (8.5%). Interventions: Lasso with tenfold cross-validation was used for variable selection; logistic regression was then used to construct a model from those variables in the training set. Variables were derived from EHR data known in the first two hours, including vital signs, medical history, demographics, laboratory information. Test characteristics at two thresholds were evaluated: 1) optimizing sensitivity and specificity, 2) set to 90% sensitivity. Measurements and Main Results: Septic shock was defined as systolic hypotension and vasoactive use or ≥30 ml/kg isotonic crystalloid administration in the first 24 hours. A model was created using twenty predictors, with an area under the receiver operating curve in the training set of 0.85 (0.82-0.88); 0.83 [0.78-0.89] in the temporal test set; 0.83 [0.60-1.00] in the geographic test set. Sensitivity and specificity varied based on cutpoint; when sensitivity in the training set was set to 90% (83%, 94%), specificity was 62% (60%, 65%). Conclusions: This model predicted risk of septic shock in children with suspected infection 2 hours after arrival, a critical timepoint for emergent treatment and transfer decisions. Varied cutpoints could be used to customize sensitivity to clinical context.
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Affiliation(s)
- Halden F. Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Kathryn L. Colborn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Carter J. Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
- Center for Clinical Effectiveness, Children’s Hospital Colorado, Aurora CO, United States
| | | | - Diane Fairclough
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Niranjan Kissoon
- British Columbia Children’s Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
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Searns JB, Stein A, MacBrayne C, Sarin T, Lin T, Duffey H, Hicks A, Wickstrom K, Bajaj L, Bauer M, Carel K. 1332. Single Dose Oral Amoxicillin Challenge is a Safe and Effective Strategy to Delabel Penicillin Allergies among Low Risk Hospitalized Children. Open Forum Infect Dis 2020. [PMCID: PMC7776632 DOI: 10.1093/ofid/ofaa439.1514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Over 90% of children with reported penicillin allergy can tolerate penicillin without incident. Developing effective and safe strategies to remove inappropriate penicillin allergies has the potential to improve care; however, guidance on how to identify, test, and delabel patients is limited. Methods In April 2019, Children’s Hospital Colorado (CHCO) implemented a penicillin allergy clinical pathway (CP) alongside a risk assessment tool to stratify patients based on allergic history (Figure 1). Patients at “no increased risk” were educated and delabeled without testing. Low risk patients were offered an oral amoxicillin drug challenge with close observation. A single, non-graded, treatment dose of amoxicillin (45 mg/kg, max dose 1000mg) was used for low risk patients, and no preceding allergic skin testing was performed. Patients with no signs or symptoms of allergic response 60 minutes after amoxicillin administration were delabeled. Children delabeled of penicillin allergies on the CHCO hospital medicine service were compared between the pre-CP (1/1/17-3/31/19) and post-CP (4/1/19-3/31/20) cohorts. Figure 1. Penicillin Allergy Risk Assessment ![]()
Results Pre-CP, 683/10624 (6.4%) patients reported a penicillin allergy and 18/683 (2.6%) were delabeled by discharge. Post-CP, 345/6559 (5.3%) patients reported a penicillin allergy and 47/345 (13.6%) were delabeled by discharge (P-value < 0.0001, Figure 2). Among the 47 post-CP patients, 11 were delabeled by history alone, 19 underwent oral amoxicillin drug challenge per CP, and 17 received a different treatment dose penicillin per treatment team. Only one penicillin-exposed patients had a reaction. This patient developed a delayed, non-progressive rash and had penicillin allergy restored to their chart. No patient required emergency medical intervention, and none were “relabeled” penicillin allergic in the 6 months following discharge. Figure 2. Monthly Rate of Penicillin Allergic Patients Delabeled by Discharge ![]()
Conclusion A drug challenge using a single non-graded dose of oral amoxicillin is a safe and effective strategy to delabel low risk children of inappropriate penicillin allergies when implemented alongside a risk assessment tool. Further studies are needed to evaluate the long-term benefits of delabeling inappropriate penicillin allergies and to continue monitoring for adverse events. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Justin B Searns
- Children’s Hospital Colorado, University of Colorado, Aurora, CO
| | - Amy Stein
- Children’s Hospital Colorado, Aurora, Colorado
| | | | - Tara Sarin
- University of Colorado, Children’s Hospital Colorado, Aurora, Colorado
| | - Taylor Lin
- University of Colorado, Children’s Hospital Colorado, Aurora, Colorado
| | | | - Allison Hicks
- University of Colorado, Children’s Hospital Colorado, Aurora, Colorado
| | | | - Lalit Bajaj
- University of Colorado School of Medicine, Aurora, Colorado
| | - Maureen Bauer
- University of Colorado, Children’s Hospital Colorado, Aurora, Colorado
| | - Kirstin Carel
- University of Colorado, Children’s Hospital Colorado, Aurora, Colorado
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24
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Rao S, Ambroggio L, Asturias EJ, Bajaj L, Corrado M, Inge T, Jung S, Morrissey T, Osborne CM, Searns JB, Whitney G, Dominguez S. 408. Evaluation of the negative predictive value of the SARS-CoV-2 PCR respiratory assays in asymptomatic children undergoing surgery. Open Forum Infect Dis 2020. [PMCID: PMC7777618 DOI: 10.1093/ofid/ofaa439.603] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Universal pre-operative screening with SARS-CoV-2 PCR has been adopted by institutions to mitigate risk to healthcare workers (HCW) during aerosol-generating procedures such as intubation. However, there remains uncertainty regarding rates of false negative results and optimal sampling type. The objective was to determine the reliability of single, pre-operative SARS-CoV-2 testing from the nasopharynx in children undergoing general anesthesia. Methods Children < 18 years of age who underwent intubation for a procedure received pre-operative testing 24–48 hours prior with a nasopharyngeal (NP) swab or wash, in conjunction with intra-operative nasal wash (NW) and tracheal aspirate (TA) sampling. All paired samples underwent testing using the Simplexa DiaSorin platform or a modified Centers for Disease Control assay. Cohen’s Kappa was used for interrater reliability of each sample result. McNemar’s Test was used to compare result proportions by sample type. Positive and negative predictive values (PPV, NPV) were calculated based on the intraoperative NW as the reference standard. Analyses were conducted using SAS (v 9.4). Results We collected full sample sets from 364 children from April 14 to May 15; 66% of pre-operative samples were NP swabs. The median age was 6 years (IQR 2,13), 55% were male, 68% were white and 41% of children had a high-risk comorbidity. Most surgeries were conducted by general surgery (23%), followed by orthopedics (19%). Only 2.5% of children had respiratory symptoms, and 4.8% had a documented fever within a week of the procedure. SARS-CoV-2 positive samples occurred in 4/364 (1%) of pre-operative samples, 8/363 (2.2%) of intra-operative samples, and 8/348 (2.3%) of TA samples. The pre-operative test had 100% PPV and 99% NPV, and the TA had 100% PPV and 98.6% NPV (Table 1). There was very good agreement (Figure) between pre- and intraoperative upper respiratory sampling, with a Kappa of 0.66, (95% CI 0.35–0.97). There was no statistical difference in results by sample type. Table 1. Comparison of intra-operative and pre-operative nasopharyngeal sample results, test characteristics and test concordance ![]()
Table 2. Comparison of intra-operative nasopharyngeal and tracheal aspirate sample results, test characteristics and test concordance ![]()
Figure 1 Percent agreement between pre-operative and intra-operative samples ![]()
Conclusion There is a high PPV and NPV of pre-operative SARS-CoV-2 PCR testing among children undergoing anesthesia. These data can help inform guidelines regarding appropriate precautions for HCW performing high risk procedures in asymptomatic pediatric patients. Disclosures Suchitra Rao, MD, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)
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Affiliation(s)
| | | | | | - Lalit Bajaj
- University of Colorado School of Medicine, Aurora, Colorado
| | | | - Thomas Inge
- University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah Jung
- Children’s Hospital Colorado, Aurora, Colorado
| | | | - Christina M Osborne
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Justin B Searns
- Children’s Hospital Colorado, University of Colorado, Aurora, CO
| | - Gina Whitney
- University of Colorado School of Medicine, Aurora, Colorado
| | - Samuel Dominguez
- University of Colorado, School of Medicine, San Francisco, California
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25
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Brousseau DC, Alpern ER, Chamberlain JM, Ellison AM, Bajaj L, Cohen DM, Hariharan S, Cook LJ, Harding M, Panepinto J. A Multiyear Cross-sectional Study of Guideline Adherence for the Timeliness of Opioid Administration in Children With Sickle Cell Pain Crisis. Ann Emerg Med 2020; 76:S6-S11. [PMID: 32928464 DOI: 10.1016/j.annemergmed.2020.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. METHODS We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. RESULTS A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both). CONCLUSION Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.
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Affiliation(s)
- David C Brousseau
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Elizabeth R Alpern
- Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Angela M Ellison
- Department of Pediatrics/Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Denver, CO
| | | | - Selena Hariharan
- Cincinnati Children's Hospital and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lawrence J Cook
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Monica Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Julie Panepinto
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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26
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Goyal MK, Johnson TJ, Chamberlain JM, Cook L, Webb M, Drendel AL, Alessandrini E, Bajaj L, Lorch S, Grundmeier RW, Alpern ER. Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures. Pediatrics 2020; 145:peds.2019-3370. [PMID: 32312910 PMCID: PMC7193974 DOI: 10.1542/peds.2019-3370] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [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] [Accepted: 12/26/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS We performed a 3-year retrospective cross-sectional study of children <18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≥2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain). RESULTS In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51-1.95]; Hispanic: 1.32 [1.16-1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14-1.76]; Hispanic: 1.38 [1.04-1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77-0.95]; Hispanic: aOR 0.86 [0.76-0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67-0.90]; Hispanic: aOR 0.80 [0.67-0.95]). CONCLUSIONS There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.
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Affiliation(s)
- Monika K. Goyal
- Division of Emergency Medicine and Trauma Services, Department of Pediatrics, Children’s National Health System and The George Washington University, Washington, District of Columbia
| | - Tiffani J. Johnson
- Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M. Chamberlain
- Division of Emergency Medicine and Trauma Services, Department of Pediatrics, Children’s National Health System and The George Washington University, Washington, District of Columbia
| | - Lawrence Cook
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Michael Webb
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Amy L. Drendel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Evaline Alessandrini
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lalit Bajaj
- Department of Pediatrics, School of Medicine, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado; and
| | - Scott Lorch
- Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert W. Grundmeier
- Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R. Alpern
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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27
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Stein A, MacBrayne C, Yang C, Sarin T, Hicks A, Searns J, Bajaj L, Bauer ME, Carel K. Clinical Pathway to Increase Rates of Penicillin Allergy De-labeling. J Allergy Clin Immunol 2020. [DOI: 10.1016/j.jaci.2019.12.664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Scott HF, Colborn KL, Sevick CJ, Bajaj L, Kissoon N, Deakyne Davies SJ, Kempe A. Development and Validation of a Predictive Model of the Risk of Pediatric Septic Shock Using Data Known at the Time of Hospital Arrival. J Pediatr 2020; 217:145-151.e6. [PMID: 31733815 PMCID: PMC6980682 DOI: 10.1016/j.jpeds.2019.09.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival. STUDY DESIGN This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set. RESULTS Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set. CONCLUSIONS This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO.
| | - Kathryn L Colborn
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Carter J Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO; Center for Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | - Niranjan Kissoon
- Division of Critical Care, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Allison Kempe
- Department of Pediatrics, University of Colorado, Aurora, CO; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
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29
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Affiliation(s)
- Joseph J Zorc
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC.,Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Lalit Bajaj
- Division of Emergency Medicine, Children's Hospital Colorado, Denver.,Department of Pediatrics, University of Colorado School of Medicine, Denver
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30
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Wang GS, Bourne DWA, Klawitter J, Sempio C, Chapman K, Knupp K, Wempe MF, Borgelt L, Christians U, Heard K, Bajaj L. Disposition of oral delta-9 tetrahydrocannabinol (THC) in children receiving cannabis extracts for epilepsy. Clin Toxicol (Phila) 2019; 58:124-128. [DOI: 10.1080/15563650.2019.1616093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - David W A Bourne
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Center for Translational Pharmacokinetics and Pharmacogenomics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jost Klawitter
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Cristina Sempio
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kevin Chapman
- Department of Neurology and Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Kelly Knupp
- Department of Neurology and Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Michael F. Wempe
- Departments of Clinical Pharmacy and Family Medicine, Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura Borgelt
- Departments of Clinical Pharmacy and Family Medicine, Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Uwe Christians
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, CO, USA
| | - Lalit Bajaj
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
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Ballard DW, Kuppermann N, Vinson DR, Tham E, Hoffman JM, Swietlik M, Deakyne Davies SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Richards R, Casper TC, Goldberg HS, Grundmeier RW, Dayan PS. Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries. Ann Emerg Med 2019; 73:440-451. [DOI: 10.1016/j.annemergmed.2018.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 11/26/2022]
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Linakis JG, Bromberg JR, Casper TC, Chun TH, Mello MJ, Richards R, Mull CC, Shenoi RP, Vance C, Ahmad F, Bajaj L, Brown KM, Chernick LS, Cohen DM, Fein J, Horeczko T, Levas MN, McAninch B, Monuteaux MC, Grupp-Phelan J, Powell EC, Rogers A, Suffoletto B, Dean JM, Spirito A. Predictive Validity of a 2-Question Alcohol Screen at 1-, 2-, and 3-Year Follow-up. Pediatrics 2019; 143:e20182001. [PMID: 30783022 PMCID: PMC6398369 DOI: 10.1542/peds.2018-2001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Accepted: 12/13/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool's predictive validity for alcohol misuse and alcohol use disorders (AUDs). METHODS Participants (N = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up. RESULTS Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year (P = .0002), 2 years (P <.0001), and 3 years (P = .0005), as were the differences between moderate- and highest-risk drinkers at 1 and 2 years (P < .0001 and P = .0088, respectively) but not at 3 years (P = .0758). The best combined score for sensitivity (86.2% at 1 year, 75.6% at 2 years, and 60.0% at 3 years) and specificity (78.1% at 1 year, 79.2% at 2 years, and 80.0% at 3 years) was achieved by using "lower risk" and higher as a cutoff for the prediction of a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis. CONCLUSIONS The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen.
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Affiliation(s)
- James G. Linakis
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
| | - Julie R. Bromberg
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
| | | | - Thomas H. Chun
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
| | - Michael J. Mello
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
| | | | - Colette C. Mull
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Rohit P. Shenoi
- Texas Children’s Hospital and College of Medicine, Baylor University, Houston, Texas
| | - Cheryl Vance
- University of California, Davis, Davis, California
| | - Fahd Ahmad
- St Louis Children’s Hospital and School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Lalit Bajaj
- Children’s Hospital Colorado, Aurora, Colorado
| | - Kathleen M. Brown
- Children’s National Medical Center, Washington, District of Columbia
| | | | | | - Joel Fein
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Brett McAninch
- University of Pittsburg Medical Center Children’s Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Elizabeth C. Powell
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | | | - Brian Suffoletto
- University of Pittsburg Medical Center Children’s Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Anthony Spirito
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - for the Pediatric Emergency Care Applied Research Network
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
- University of Utah, Salt Lake City, Utah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
- Texas Children’s Hospital and College of Medicine, Baylor University, Houston, Texas
- University of California, Davis, Davis, California
- St Louis Children’s Hospital and School of Medicine, Washington University in St Louis, St Louis, Missouri
- Children’s Hospital Colorado, Aurora, Colorado
- Children’s National Medical Center, Washington, District of Columbia
- Columbia University Irving Medical Center, New York City, New York
- Nationwide Children’s Hospital, Columbus, Ohio
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Los Angeles Biomedical Research Institute, Torrance, California
- Medical College of Wisconsin, Milwaukee, Wisconsin
- University of Pittsburg Medical Center Children’s Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Boston Children’s Hospital, Boston, Massachusetts
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
- University of Michigan, Ann Arbor, Michigan
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Grubenhoff JA, Ziniel SI, Bajaj L, Hyman D. Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program. Diagnosis (Berl) 2019; 6:101-107. [DOI: 10.1515/dx-2018-0056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/21/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Improving Diagnosis in Healthcare calls for improved training in diagnostic reasoning and establishing non-judgmental forums to learn from diagnostic errors arising from heuristic-driven reasoning. Little is known about pediatric providers’ familiarity with heuristics or the culture surrounding forums where diagnostic errors are discussed. This study aimed to describe pediatric providers’ familiarity with common heuristics and perceptions surrounding public discussions of diagnostic errors.
Methods
We surveyed pediatric providers at a university-affiliated children’s hospital. The survey asked participants to identify common heuristics used during clinical reasoning (five definitions; four exemplar clinical vignettes). Participants answered questions regarding comfort publicly discussing their own diagnostic errors and barriers to sharing them.
Results
Seventy (30.6% response rate) faculty completed the survey. The mean number of correctly selected heuristics was 1.60/5 [standard deviation (SD)=1.13] and 1.01/4 (SD=1.06) for the definitions and vignettes, respectively. A low but significant correlation existed between correctly identifying a definition and selecting the correct heuristic in vignettes (Spearman’s ρ=0.27, p=0.02). Clinicians were significantly less likely to be “pretty” or “very” comfortable discussing diagnostic errors in public vs. private conversations (28.3% vs. 74.3%, p<0.01). The most frequently cited barriers to discussing errors were loss of reputation (62.9%) and fear of knowledge-base (58.6%) or decision-making (57.1%) being judged.
Conclusions
Pediatric providers demonstrated limited familiarity with common heuristics leading to diagnostic error. Greater years in practice is associated with more comfort discussing diagnostic errors, but negative peer and personal perceptions of diagnostic performance are common barriers to discussing errors publicly.
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Affiliation(s)
- Joseph A. Grubenhoff
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Sonja I. Ziniel
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Lalit Bajaj
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Daniel Hyman
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
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Spirito A, Bromberg JR, Casper TC, Chun T, Mello MJ, Mull CC, Shenoi RP, Vance C, Ahmad F, Bajaj L, Brown KM, Chernick LS, Cohen DM, Fein J, Horeczko T, Levas MN, McAninch B, Monuteaux MC, Grupp-Phelan J, Powell EC, Rogers A, Suffoletto B, Linakis JG. Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use? Subst Use Misuse 2019; 54:1007-1016. [PMID: 30727811 PMCID: PMC6476662 DOI: 10.1080/10826084.2018.1558251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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] [Indexed: 10/27/2022]
Abstract
BACKGROUND The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse. OBJECTIVE A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs. METHODS Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer. RESULTS A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.
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Affiliation(s)
- Anthony Spirito
- a The Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Pediatrics, Emergency Medicine, Providence, Rhode Island, USA
| | - Julie R Bromberg
- a The Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Pediatrics, Emergency Medicine, Providence, Rhode Island, USA.,b Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island, USA
| | - T Charles Casper
- c University of Utah, Department of Pediatrics, Salt Lake City, Utah, USA
| | - Thomas Chun
- a The Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Pediatrics, Emergency Medicine, Providence, Rhode Island, USA.,b Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island, USA
| | - Michael J Mello
- a The Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Pediatrics, Emergency Medicine, Providence, Rhode Island, USA.,b Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island, USA
| | - Colette C Mull
- d Nemours/Alfred I. duPont Hospital for Children, Department of Pediatrics, Wilmington, Delaware, USA
| | - Rohit P Shenoi
- e Baylor College of Medicine/Texas Children's Hospital, Departments of Emergency Medicine and Pediatrics, Houston, Texas, USA
| | - Cheryl Vance
- f University of California , Davis, Department of Pediatrics, Davis , California, USA
| | - Fahd Ahmad
- g St. Louis Children's Hospital/Washington University, Department of Emergency Medicine, St. Louis, Washington, USA
| | - Lalit Bajaj
- h Children's Hospital - Colorado, Departments of Pediatric Emergency Medicine and Pediatrics, Aurora, Colorado, USA
| | - Kathleen M Brown
- i Children's National Medical Center, Department of Emergency Medicine and Trauma Services, Washington, DC, USA
| | - Lauren S Chernick
- j Columbia University Medical Center, Department of Pediatric Emergency Medicine, New York, New York, USA
| | - Daniel M Cohen
- k Nationwide Children's Hospital, Departments of Pediatrics and Emergency Medicine, Columbus, Ohio, USA
| | - Joel Fein
- l The Children's Hospital of Philadelphia, Departments of Pediatrics and Emergency Medicine, Philadelphia, Pennsylvania, USA
| | - Timothy Horeczko
- m Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Department of Emergency and Pediatric Emergency Medicine, Los Angeles, California, USA
| | - Michael N Levas
- n Medical College of Wisconsin, Department of Pediatric Emergency Medicine, Milwaukee, Wisconsin, USA
| | - B McAninch
- o University of Pittsburgh/Children's Hospital of Pittsburgh of UPMC, Division of Pediatric Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael C Monuteaux
- p Boston Children's Hospital, Department of Pediatrics, Boston, Massachusetts, USA
| | - Jackie Grupp-Phelan
- q University of California , San Francisco, Department of Pediatric Emergency Medicine, San Francisco , California, USA
| | - Elizabeth C Powell
- r Lurie Children's Hospital of Chicago, Department of Pediatric Emergency Medicine, Chicago, Illinois, USA
| | - Alexander Rogers
- s University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan, USA
| | - Brian Suffoletto
- o University of Pittsburgh/Children's Hospital of Pittsburgh of UPMC, Division of Pediatric Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - James G Linakis
- a The Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Pediatrics, Emergency Medicine, Providence, Rhode Island, USA.,b Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island, USA
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Bajaj L. The Impact of the Evolving Health Care System on Pediatric Emergency Care. Pediatr Clin North Am 2018; 65:1247-1256. [PMID: 30446060 DOI: 10.1016/j.pcl.2018.07.007] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article discusses the implications of health care reform on the pediatric emergency department (ED). The author briefly discusses the health care costs and outcomes in the United States in comparison to other developed nations. The article discusses the impact of the Affordable Care Act and insurance expansion on the pediatric ED. Then the article addresses the impacts of the growing patient financial responsibility on ED use. There will be a discussion of the development of pediatric accountable care organizations and how payment mechanisms are evolving, and the challenges the pediatric ED may face in these new payment strategies.
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Affiliation(s)
- Lalit Bajaj
- Clinical Effectiveness, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue B400, Aurora, CO 80045, USA.
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Bennett CV, Maguire S, Nuttall D, Lindberg DM, Moulton S, Bajaj L, Kemp AM, Mullen S. First aid for children's burns in the US and UK: An urgent call to establish and promote international standards. Burns 2018; 45:440-449. [PMID: 30266196 DOI: 10.1016/j.burns.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 07/10/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn. METHODS A prospective cross-sectional study of 500 children (0-16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015-2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities. RESULTS Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver. CONCLUSION A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.
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Affiliation(s)
- C Verity Bennett
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, United Kingdom.
| | - Sabine Maguire
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, United Kingdom
| | - Diane Nuttall
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, United Kingdom
| | - Daniel M Lindberg
- Department of Emergency Medicine, Children's Hospital Colorado, United States
| | - Steven Moulton
- Division of Paediatric Surgery, Children's Hospital Colorado, United States; Department of Surgery, University of Colorado School of Medicine, United States
| | - Lalit Bajaj
- Department of Emergency Medicine, Children's Hospital Colorado, United States
| | - Alison M Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, United Kingdom
| | - Stephen Mullen
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, United Kingdom; Paediatric Emergency Department, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, BT12 6BA, United Kingdom
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Kharbanda AB, Christensen EW, Dudley NC, Bajaj L, Stevenson MD, Macias CG, Mittal MK, Bachur RG, Bennett JE, Sinclair K, McMichael B, Dayan PS. Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis. Acad Emerg Med 2018; 25:785-794. [PMID: 29427374 DOI: 10.1111/acem.13387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 11/06/2017] [Revised: 02/01/2018] [Accepted: 02/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.
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Affiliation(s)
- Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Eric W Christensen
- Health Services Management, College of Continuing and Professional Studies, University of Minnesota, Minneapolis, MN
| | - Nanette C Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO
| | | | - Charles G Macias
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Manoj K Mittal
- Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jonathan E Bennett
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Jefferson Medical College, Wilmington, DE
| | - Kelly Sinclair
- Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Brianna McMichael
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, MN
| | - Peter S Dayan
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
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Tyler A, Krack P, Bakel LA, O'Hara K, Scudamore D, Topoz I, Freeman J, Moss A, Allen R, Swanson A, Bajaj L. Interventions to Reduce Over-Utilized Tests and Treatments in Bronchiolitis. Pediatrics 2018; 141:peds.2017-0485. [PMID: 29752289 DOI: 10.1542/peds.2017-0485] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The American Academy of Pediatrics published bronchiolitis clinical practice guidelines in 2014 recommending against the routine use of bronchodilators, chest radiographs, or respiratory viral testing in children with a clinical diagnosis of bronchiolitis. Our aim in this project was to align care with the American Academy of Pediatrics clinical practice guidelines by decreasing the overuse of these interventions. METHODS This study included patients who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. The team used a multidisciplinary kickoff event to understand the problem and develop interventions, including sharing provider-specific data and asking providers to sign a pledge to reduce use. We used a novel, real-time data dashboard to collect and analyze data. RESULTS Special cause variation on control charts indicated improvement for all outcomes for inpatients during the intervention season. Pre- and postanalyses in which we compared baseline to intervention values for all admitted patients and patients who were discharged from the emergency department or urgent care revealed a significant reduction in the ordering of chest radiographs (from 22.7% to 13.6%; P ≤ .001), respiratory viral testing (from 12.5% to 9.8%; P = .001), and bronchodilators (from 17.5% to 10.3%; P = .001) without changes in balancing measures (eg, hospital readmission within 7 days [1.7% (preanalysis) and 1.0% (postanalysis); P = .21]) for bronchiolitis. CONCLUSIONS This multidisciplinary improvement initiative resulted in a significant reduction in use for bronchiolitis care at our institution. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases.
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Affiliation(s)
- Amy Tyler
- Children's Hospital Colorado, Aurora, Colorado; .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Paige Krack
- Children's Hospital Colorado, Aurora, Colorado
| | - Leigh Anne Bakel
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Kimberly O'Hara
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Douglas Scudamore
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Irina Topoz
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Julia Freeman
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Renee Allen
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Lalit Bajaj
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
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Deakyne Davies SJ, Grundmeier RW, Campos DA, Hayes KL, Bell J, Alessandrini EA, Bajaj L, Chamberlain JM, Gorelick MH, Enriquez R, Casper TC, Scheid B, Kittick M, Dean JM, Alpern ER. The Pediatric Emergency Care Applied Research Network Registry: A Multicenter Electronic Health Record Registry of Pediatric Emergency Care. Appl Clin Inform 2018; 9:366-376. [PMID: 29791930 DOI: 10.1055/s-0038-1651496] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes. METHODS A data dictionary, and subsequent data model, were developed describing EHR data sources to include all processes of care within the emergency department (ED). ED visit data were deidentified and XML files were created and submitted to a central data coordinating center for inclusion in the registry. Automated data quality control occurred prior to submission through an application created for this project. Data quality reports were created for manual data quality review. RESULTS The Pediatric Emergency Care Applied Research Network (PECARN) Registry, representing four hospital systems and seven EDs, demonstrates that ED data from disparate health systems and EHR vendors can be harmonized for use in a single registry with a common data model. The current PECARN Registry represents data from 2,019,461 pediatric ED visits, 894,503 distinct patients, more than 12.5 million narrative reports, and 12,469,754 laboratory tests and continues to accrue data monthly. CONCLUSION The Registry is a robust harmonized clinical registry that includes data from diverse patients, sites, and EHR vendors derived via data extraction, deidentification, and secure submission to a central data coordinating center. The data provided may be used for benchmarking, clinical quality improvement, and comparative effectiveness research.
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Affiliation(s)
- Sara J Deakyne Davies
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Robert W Grundmeier
- Department of Pediatrics and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Diego A Campos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Katie L Hayes
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, United States
| | - Jamie Bell
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Evaline A Alessandrini
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, United States
| | - James M Chamberlain
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee Wisconsin, United States
| | - Rene Enriquez
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Beth Scheid
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Marlena Kittick
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
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Scott HF, Greenwald EE, Bajaj L, Deakyne Davies SJ, Brou L, Kempe A. The Sensitivity of Clinician Diagnosis of Sepsis in Tertiary and Community-Based Emergency Settings. J Pediatr 2018; 195:220-227.e1. [PMID: 29395173 DOI: 10.1016/j.jpeds.2017.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 07/20/2017] [Revised: 10/02/2017] [Accepted: 11/15/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess whether the risk of missed clinician diagnosis of pediatric sepsis requiring care in the intensive care unit (ICU) was greater in community vs tertiary pediatric emergency care settings with sepsis pathways. STUDY DESIGN An observational cohort study in a tertiary pediatric emergency department (ED) staffed by pediatric emergency physicians and 4 affiliated community pediatric ED/urgent care sites staffed by general pediatricians. Use of an institutional sepsis order set or pathway was considered clinician diagnosis of sepsis. Risk of missed diagnosis was compared for 2 outcomes: suspected infection plus ICU admission (sepsis-ICU) and suspected infection plus vasoactive agent/positive-pressure ventilation (sepsis-VV). RESULTS From January 1, 2014 to December 31, 2015, there were 141 552 tertiary and 139 332 community emergency visits. Clinicians diagnosed sepsis in 1136 visits; median age was 5.7 (2.4, 12.0) years. In the tertiary ED, there were 306 sepsis-ICU visits (0.2%) and 112 sepsis-VV visits (0.08%). In community sites, there were 46 sepsis-ICU visits (0.03%) and 20 sepsis-VV visits (0.01%). The risk of missed diagnosis in community vs tertiary sites was significantly greater for sepsis-ICU (relative risk 4.30, CI 2.15-8.60) and sepsis-VV (relative risk 14.0, CI 2.91-67.24). Sensitivity for sepsis-ICU was 94.4% (91.3%-96.5%) at the tertiary site and 76.1% (62.1%-86.1%) at community sites. CONCLUSIONS The risk of missed diagnosis of sepsis-ICU was greater in community vs tertiary emergency care settings despite shared pathways and education, but with differences in resources, providers, and sepsis incidence. More research is needed to optimize diagnostic approaches in all settings.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, CO.
| | - Emily E Greenwald
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, CO; Center for Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO; Research Informatics, Children's Hospital Colorado, Aurora, CO
| | | | - Lina Brou
- Department of Pediatrics, University of Colorado, Aurora, CO
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
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Schuh S, Babl FE, Dalziel SR, Freedman SB, Macias CG, Stephens D, Steele DW, Fernandes RM, Zemek R, Plint AC, Florin TA, Lyttle MD, Johnson DW, Gouin S, Schnadower D, Klassen TP, Bajaj L, Benito J, Kharbanda A, Kuppermann N. Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study. Pediatrics 2017; 140:peds.2017-0842. [PMID: 29184035 DOI: 10.1542/peds.2017-0842] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [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] [Accepted: 09/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. METHODS Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). RESULTS Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7). CONCLUSIONS More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.
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Affiliation(s)
- Suzanne Schuh
- Division of Paediatric Emergency Medicine and.,The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, and University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, and University of Auckland, Auckland, New Zealand
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Derek Stephens
- The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dale W Steele
- Section of Pediatric Emergency Medicine, Hasbro Children's Hospital and Section of Pediatric Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark D Lyttle
- Pediatric Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine.,Emergency Medicine, and.,Physiology and Pharmacology, Department of Pediatrics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Serge Gouin
- Centre hospitalier universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - David Schnadower
- Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Terry P Klassen
- Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Anupam Kharbanda
- Emergency Department, Children's Hospital of Minnesota, Minneapolis, Minnesota; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, Davis School of Medicine, University of California, Sacramento, California
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Goyal MK, Johnson TJ, Chamberlain JM, Casper TC, Simmons T, Alessandrini EA, Bajaj L, Grundmeier RW, Gerber JS, Lorch SA, Alpern ER. Racial and Ethnic Differences in Antibiotic Use for Viral Illness in Emergency Departments. Pediatrics 2017; 140:e20170203. [PMID: 28872046 PMCID: PMC5613999 DOI: 10.1542/peds.2017-0203] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [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] [Accepted: 05/02/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED. METHODS This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site. RESULTS Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [CI] 2.4%-2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; CI 0.36-0.53), Hispanic (aOR 0.65; CI 0.53-0.81), and other NH (aOR 0.68; CI 0.52-0.87) children remained less likely to receive antibiotics for viral ARTIs. CONCLUSIONS Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias.
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Affiliation(s)
- Monika K Goyal
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC;
| | - Tiffani J Johnson
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Timothy Simmons
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Evaline A Alessandrini
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Children's Hospital, Boulder, Colorado; and
| | - Robert W Grundmeier
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A Lorch
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R Alpern
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora.,Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora.,Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora.,Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora
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Freeman JF, Deakyne S, Bajaj L. Emergency Department-initiated Home Oxygen for Bronchiolitis: A Prospective Study of Community Follow-up, Caregiver Satisfaction, and Outcomes. Acad Emerg Med 2017; 24:920-929. [PMID: 28207971 DOI: 10.1111/acem.13179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/07/2017] [Accepted: 02/11/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Retrospective studies have shown home oxygen to be a safe alternative to hospitalization for some patients with bronchiolitis living at high altitudes. We aimed to prospectively describe adverse events, follow-up, duration of home oxygen, factors associated with failure, and caregiver preferences. METHODS This was a prospective observational study of hypoxemic bronchiolitis patients ages 3 to 18 months who were discharged from a tertiary care pediatric emergency department on home oxygen over three winters (2011-2014). Caregivers were contacted on postdischarge days ~3, 7, 14, and 28 while on oxygen. Caregivers not reached by phone were sent a survey and their primary care physicians were contacted. Records of admitted subjects were reviewed. Outcome measures included hospital readmission, positive pressure ventilation (noninvasive or intubation), outpatient follow-up, duration of home oxygen therapy, and caregiver satisfaction. RESULTS A total of 274 patients were enrolled. Forty-eight (17.5%) were admitted and 225 (82.1%) were discharged on oxygen. The median age was 8 months. Eighteen subjects were lost to follow-up. A total of 196 (87.1%) were successfully treated with outpatient oxygen, and 11 (4.9%) failed outpatient therapy and were hospitalized. Only one hospitalized patient required invasive ventilation. The median duration of home oxygen was 7 days. Child noncompliance was the most common problem (reported by 14%). The median caregiver comfort level with home oxygen was 9 of 10. Eighty-eight percent of caregivers would again choose home oxygen over admission. CONCLUSIONS This study confirms that outpatient oxygen therapy can reduce hospitalizations due to bronchiolitis in a relatively high-altitude setting, with low failure and complication rates. Caregivers are comfortable with home oxygen and prefer it to hospitalization.
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Affiliation(s)
- Julia Fuzak Freeman
- Department of Pediatrics; Section of Emergency Medicine; University of Colorado Denver; Aurora CO
| | - Sara Deakyne
- Research Institute; Children's Hospital Colorado; Aurora CO
| | - Lalit Bajaj
- Department of Pediatrics; Section of Emergency Medicine; University of Colorado Denver; Aurora CO
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Weisz K, Bajaj L, Deakyne SJ, Brou L, Brent A, Wathen J, Roosevelt GE. Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department. J Emerg Med 2017; 53:1-9. [DOI: 10.1016/j.jemermed.2017.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/20/2017] [Accepted: 03/11/2017] [Indexed: 11/30/2022]
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Stevenson MD, Dayan PS, Dudley NC, Bajaj L, Macias CG, Bachur RG, Sinclair K, Bennett J, Mittal MK, Donneyong MM, Kharbanda AB. Time From Emergency Department Evaluation to Operation and Appendiceal Perforation. Pediatrics 2017; 139:peds.2016-0742. [PMID: 28562252 DOI: 10.1542/peds.2016-0742] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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] [Accepted: 03/07/2017] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children. METHODS We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain (<96 hours). Time of initial physical examination and time of operation were recorded. The presence of AP was determined using operative reports. We analyzed whether duration of time from initial ED physician evaluation to operation impacted the odds of AP using multivariable logistic regression, adjusting for traditionally suggested risk factors that increase the risk of perforation. We also modeled the odds of perforation in a subpopulation of patients without perforation on computed tomography. RESULTS Of 955 children with appendicitis, 25.9% (n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8-8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96-1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89-1.02). CONCLUSIONS Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.
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Affiliation(s)
| | - Peter S Dayan
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nanette C Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Charles G Macias
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kelly Sinclair
- Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Jonathan Bennett
- Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Manoj K Mittal
- Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennyslvania
| | - Macarius M Donneyong
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, Ohio; and
| | - Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota
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Conners GP, Kressly SJ, Perrin JM, Richerson JE, Sankrithi UM, Simon GR, Boudreau ADA, Baker C, Barden GA, Hackell J, Hardin A, Meade K, Moore S, Shook JE, Callahan JM, Chun TH, Conway EE, Dudley NC, Gross TK, Lane NE, Macias CG, Timm NL, Alexander JJ, Bell DM, Bunik M, Burke BL, Herendeen NE, Kahn JA, Macias CG, Mahajan PV, Gorelick MH, Bajaj L, Gonzalez del Rey JA, Herr S, Mull CC, Schnadower D, Sirbaugh PE, Lumba-Brown A, Dahl-Grove DL, Gross TK, McAneney CM, Remick KE, Sirbaugh PE, Kharbanda A, Nigrovic L, Mullan PC, Wolff MS, Schor JA, Edwards AR, Alexander JJ, Flanagan PJ, Hudak ML, Katkin JP, Kraft CA, Quinonez RA, Shenkin BN, Smith TK, Tieder JS. Nonemergency Acute Care: When It's Not the Medical Home. Pediatrics 2017; 139:peds.2017-0629. [PMID: 28557775 DOI: 10.1542/peds.2017-0629] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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] [Indexed: 11/24/2022] Open
Abstract
The American Academy of Pediatrics (AAP) affirms that the optimal location for children to receive care for acute, nonemergency health concerns is the medical home. The medical home is characterized by the AAP as a care model that "must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective." However, some children and families use acute care services outside the medical home because there is a perceived or real benefit related to accessibility, convenience, or cost of care. Examples of such acute care entities include urgent care facilities, retail-based clinics, and commercial telemedicine services. Children deserve high-quality, appropriate, and safe acute care services wherever they access the health care system, with timely and complete communication with the medical home, to ensure coordinated and continuous care. Treatment of children under established, new, and evolving practice arrangements in acute care entities should adhere to the core principles of continuity of care and communication, best practices within a defined scope of services, pediatric-trained staff, safe transitions of care, and continuous improvement. In support of the medical home, the AAP urges stakeholders, including payers, to avoid any incentives (eg, reduced copays) that encourage visits to external entities for acute issues as a preference over the medical home.
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Affiliation(s)
- Gregory P. Conners
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | | | - James M. Perrin
- Harvard Medical School and MassGeneral Hospital for Children, Boston, Massachusetts
| | | | - Usha M. Sankrithi
- Department of Emergency Medicine, Seattle Children’s Hospital, Seattle, Washington
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Dayan PS, Ballard DW, Tham E, Hoffman JM, Swietlik M, Deakyne SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Vinson DR, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Wang J, Casper TC, Goldberg HS, Grundmeier RW, Kuppermann N. Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support. Pediatrics 2017; 139:peds.2016-2709. [PMID: 28341799 DOI: 10.1542/peds.2016-2709] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [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] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma. METHODS Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend. RESULTS We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P < .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%). CONCLUSIONS The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.
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Affiliation(s)
- Peter S Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York;
| | - Dustin W Ballard
- Kaiser Permanente, San Rafael Medical Center, San Rafael, California.,Division of Research, Kaiser Permanente, Oakland, California
| | - Eric Tham
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | | | - Marguerite Swietlik
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Sara J Deakyne
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Evaline A Alessandrini
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leah Tzimenatos
- Departments of Emergency Medicine and.,Pediatrics, University of California Davis School of Medicine, Sacramento, California
| | - Lalit Bajaj
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - David R Vinson
- Division of Research, Kaiser Permanente, Oakland, California.,Kaiser Permanente, Roseville Medical Center, Roseville, California
| | - Dustin G Mark
- Kaiser Permanente, Oakland Medical Center, Oakland, California
| | - Steve R Offerman
- Kaiser Permanente, South Sacramento Medical Center, Sacramento, California,
| | - Uli K Chettipally
- Kaiser Permanente, South San Francisco Medical Center, San Francisco, California
| | - Marilyn D Paterno
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Molly H Schaeffer
- Information Systems, Partners HealthCare System, Boston, Massachusetts
| | - Jun Wang
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Howard S Goldberg
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Information Systems, Partners HealthCare System, Boston, Massachusetts
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, University of California Davis School of Medicine, Sacramento, California
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Kharbanda AB, Monuteaux MC, Bachur RG, Dudley NC, Bajaj L, Stevenson MD, Macias CG, Mittal MK, Bennett JE, Sinclair K, Dayan PS. A Clinical Score to Predict Appendicitis in Older Male Children. Acad Pediatr 2017; 17:261-266. [PMID: 27890780 PMCID: PMC5562406 DOI: 10.1016/j.acap.2016.11.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 07/11/2016] [Revised: 11/14/2016] [Accepted: 11/17/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis. METHODS Patients with suspected appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8-18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with <10% missing data and kappa > 0.4 were entered into a multivariable model. Resultant β-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios. RESULTS The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval [CI], 20%-29%), specificity of 98% (95% CI, 96%-99%), and positive predictive value of 93% (95% CI, 86%-97%) for ruling in appendicitis. CONCLUSIONS We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging.
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Affiliation(s)
- Anupam B. Kharbanda
- Department of Pediatrics Emergency Medicine, Children's Hospitals and Clinics of Minnesota
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nanette C. Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO
| | | | | | - Manoj K. Mittal
- Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University ofPennsylvania, Philadelphia, PA
| | - Jonathan E. Bennett
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Jefferson Medical College, Wilmington, DE
| | - Kelly Sinclair
- Department of Pediatrics, University of Missouri, Kansas City, MO
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Scott HF, Brou L, Deakyne SJ, Kempe A, Fairclough DL, Bajaj L. Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children. JAMA Pediatr 2017; 171:249-255. [PMID: 28068437 DOI: 10.1001/jamapediatrics.2016.3681] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Improving emergency care of pediatric sepsis is a public health priority, but optimal early diagnostic approaches are unclear. Measurement of lactate levels is associated with improved outcomes in adult septic shock, but pediatric guidelines do not endorse its use, in part because the association between early lactate levels and mortality is unknown in pediatric sepsis. OBJECTIVE To determine whether the initial serum lactate level is associated with 30-day mortality in children with suspected sepsis. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study of a clinical registry of pediatric patients with suspected sepsis in the emergency department of a tertiary children's hospital from April 1, 2012, to December 31, 2015, tested the hypothesis that a serum lactate level of greater than 36 mg/dL is associated with increased mortality compared with a serum lactate level of 36 mg/dL or less. Consecutive patients with sepsis were identified and included in the registry following consensus guidelines for clinical recognition (infection and decreased mental status or perfusion). Among 2520 registry visits, 1221 were excluded for transfer from another medical center, no measurement of lactate levels, and patients younger than 61 days or 18 years or older, leaving 1299 visits available for analysis. Lactate testing is prepopulated in the institutional sepsis order set but may be canceled at clinical discretion. EXPOSURES Venous lactate level of greater than 36 mg/dL on the first measurement within the first 8 hours after arrival. MAIN OUTCOMES AND MEASURES Thirty-day in-hospital mortality was the primary outcome. Odds ratios were calculated using logistic regression to account for potential confounders. RESULTS Of the 1299 patients included in the analysis (753 boys [58.0%] and 546 girls [42.0%]; mean [SD] age, 7.3 [5.3] years), 899 (69.2%) had chronic medical conditions and 367 (28.3%) had acute organ dysfunction. Thirty-day mortality occurred in 5 of 103 patients (4.8%) with lactate levels greater than 36 mg/dL and 20 of 1196 patients (1.7%) with lactate levels of 36 mg/dL or less. Initial lactate levels of greater than 36 mg/dL were significantly associated with 30-day mortality in unadjusted (odds ratio, 3.00; 95% CI, 1.10-8.17) and adjusted (odds ratio, 3.26; 95% CI, 1.16- 9.16) analyses. The sensitivity of lactate levels greater than 36 mg/dL for 30-day mortality was 20.0% (95% CI, 8.9%-39.1%), and specificity was 92.3% (90.7%-93.7%). CONCLUSIONS AND RELEVANCE In children treated for sepsis in the emergency department, lactate levels greater than 36 mg/dL were associated with mortality but had a low sensitivity. Measurement of lactate levels may have utility in early risk stratification of pediatric sepsis.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado, Aurora2Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Lina Brou
- Department of Pediatrics, University of Colorado, Aurora
| | - Sara J Deakyne
- Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Aurora3Department of Pediatrics, Children's Hospital Colorado, Aurora4Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora
| | - Diane L Fairclough
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora5Colorado School of Public Health, Aurora
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Aurora2Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
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