Allen L. Hsiao

Incidence and Predictors of Serious Bacterial Infections Among 57- to 180-Day-Old Infants

BACKGROUND. Numerous researchers have investigated fever in infants <2 months of age. However, the etiology of fever and usefulness of screening tests in older (2–6 months) infants is not well studied. METHODS. This was a prospective study of febrile infants 57–180 days old. Evaluation included blood and urine tests and direct fluorescent antibody (DFA) of nasal swabs for respiratory viruses. Additional studies were performed at the discretion of managing clinicians. RESULTS. Serious bacterial illness (SBI) was diagnosed in 44 (10.3%) of 429 infants: 41 with bacteruria and 4 with bacteremia (1 infant had concurrent Escherichia coli bacteruria and bacteremia). Lumbar puncture, performed in 58 (13.5%) infants, revealed no cases of bacterial meningitis. DFAs were positive in 163 (38.0%) infants: the majority were respiratory syncytial virus or influenza A. SBI was noted in 4.9% of infants with positive DFA. Age and height of fever were not significant predictors of SBI. White blood cell count (17.1 K/mm3 vs 12.4 K/mm3) and CRP (2.6 mg/dL vs 0.9 mg/dL) were elevated in infants with SBI, as was the Yale Observation Score (9.4 vs 8.0). CONCLUSIONS. A substantial proportion (10.3%) of older febrile infants has SBI. In the postpneumococcal vaccine era, only 1 infant had pneumococcal disease; bacteremia was noted in 0.9%. Bacteruria is commonly associated with fever in this age range. Infants older than 8 weeks remain at risk for bacteremia and bacteruria, regardless of positive DFA or other apparent source of fever. CRP is a better indicator than white blood cell count, but no single ideal indicator of SBI was identified for this age group.

Fever in the new millennium: a review of recent studies of markers of serious bacterial infection in febrile children.

Purpose of review Evaluation of a febrile infant or child for serious bacterial infections (SBI) can be a challenging task; there is no single reliable predictor of SBI in infants. This review examines some of the recent work evaluating the usefulness of indicators for SBI, such as white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6). Recent findings While WBC is traditionally used as an indicator of serious infection, it appears to be the least specific and sensitive test in children. CRP and PCT are the most promising, but neither is an ideal single indicator by itself, especially in infants. There has been very limited experience with PCT in this country, however. IL-6 is more useful than WBC but less accurate than either CRP or PCT. Summary Much progress has been made in recent years in finding more accurate indicators of SBI than WBC. However, while recent developments have given clinicians some new tools in evaluating febrile infants and children, it remains a formidable undertaking. In the especially vulnerable infant population, the holy grail of a single ideal SBI indicator remains elusive.

Utility of bedside bladder ultrasound before urethral catheterization in young children.

Background. Urethral catheterization is the method of choice for obtaining samples for urine culture and urine analysis in infants. Before the procedure, there is little certainty of the presence or amount of urine in the bladder. Consequently, this relatively invasive and uncomfortable procedure often needs to be repeated. The newly available technology of portable ultrasound may be useful in reducing the number of unsuccessful procedures. Objective. To investigate the utility of bedside ultrasound of the bladder performed by pediatric emergency medicine physicians before catheterization in reducing the number of unsuccessful attempts. Methods. A prospective, 2-phase study was performed in the setting of an urban pediatric emergency department from August 2003 to February 2004. Children who were between the ages of 0 and 24 months were enrolled. During the observation phase, the amount of urine obtained during the first catheterization was recorded for each patient. During the intervention period, a rapid bedside ultrasound of the bladder was performed by a pediatric emergency medicine physician immediately before urethral catheterization. When a sufficient amount of urine was seen, catheterization was conducted as usual. Otherwise, catheterization was deferred and repeated ultrasound was performed at 30-minute intervals until sufficient urine was identified. The amount of urine obtained was recorded. Results. During the observation phase, 136 infants underwent urethral catheterization. Overall, the rate of success during the first attempt, defined as obtaining >2 mL of urine, sufficient for culture and other routine studies, was 72% (95% confidence interval: 66%–78%). A total of 112 subjects were enrolled during the intervention phase. Sufficient urine was identified on the first ultrasound in 76% (n = 85) of the patients. Among these, 98% (n = 83) underwent successful urethral catheterization during the first attempt. Among those in whom insufficient urine was identified initially (n = 27; 24%), subsequent ultrasound revealed sufficient amount in all patients within 90 minutes. Among these, 93% (n = 25) underwent successful urethral catheterization during the first attempt. Overall rate of success of initial urethral catheterization during the intervention phase was 96% (95% confidence interval: 93%–99%). Compared with the success rate during the observation phase, the differences were statistically significant. The results were consistent after being adjusted for gender. Conclusion. A rapid bedside ultrasound of the bladder performed by pediatric emergency physicians led to an increased success rate of urethral catheterization in children who were younger than 2 years. We were able to avoid repeated invasive testing with a simple noninvasive procedure.

Use of Bedside Ultrasound to Assess Degree of Dehydration in Children With Gastroenteritis

OBJECTIVES Prospectively identifying children with significant dehydration from gastroenteritis is difficult in acute care settings. Previous work by our group has shown that bedside ultrasound (US) measurement of the inferior vena cava (IVC) and the aorta (Ao) diameter ratio is correlated with intravascular volume. This study was designed to validate the use of this method in the prospective identification of children with dehydration by investigating whether the IVC/Ao ratio correlated with dehydration in children with acute gastroenteritis. Another objective was to investigate the interrater reliability of the IVC/Ao measurements. METHODS A prospective observational study was carried out in a pediatric emergency department (PED) between November 2007 and June 2009. Children with acute gastroenteritis were enrolled as subjects. A pair of investigators obtained transverse images of the IVC and Ao using bedside US. The ratio of IVC and Ao diameters (IVC/Ao) was calculated. Subjects were asked to return after resolution of symptoms. The difference between the convalescent weight and ill weight was used to calculate the degree of dehydration. Greater than or equal to 5% difference was judged to be significant. Linear regression was performed with dehydration as the dependent variable and the IVC/Ao as the independent variable. Pearsons correlation coefficient was calculated to assess the degree of agreement between observers. RESULTS A total of 112 subjects were enrolled. Seventy-one subjects (63%) completed follow-up. Twenty-eight subjects (39%) had significant dehydration. The linear regression model resulted in an R² value of 0.21 (p < 0.001) and a slope (B) of 0.11 (95% confidence interval [CI] = 0.08 to 0.14). An IVC/Ao cutoff of 0.8 produced a sensitivity of 86% and a specificity of 56% for the diagnosis of significant dehydration. Forty-eight paired measurements of IVC/Ao ratios were made. The Pearson correlation coefficient was 0.76. CONCLUSIONS   In this pilot study the ratio of IVC to Ao diameters, as measured by bedside US, was a marginally accurate measurement of acute weight loss in children with dehydration from gastroenteritis. The technique demonstrated good interrater reliability.

Randomized Trial of Endotracheal Tube Versus Laryngeal Mask Airway in Simulated Prehospital Pediatric Arrest

OBJECTIVE. Proficiency in airway management in children is difficult to acquire and maintain for prehospital providers. The laryngeal mask airway is a relatively new airway device. Its ease of use makes it an attractive potential alternative to endotracheal tubes in pediatrics. The objective of this study was to investigate whether, in simulated cardiopulmonary arrests in children, the use of laryngeal mask airway, compared with endotracheal tubes, results in shorter time to effective ventilation when performed by prehospital providers. METHODS. A randomized, crossover study was conducted in a local paramedic training program. Fifty-two emergency medical technicians agreed to participate. After a 2-hour training session, an arrest scenario was presented to each participant by using an infant-sized human patient simulator. The participants were randomly assigned first to use 1 of the 2 devices. Time to successful ventilation was recorded. Number of attempts and results were recorded. After the airway was secured successfully, the scenario was repeated with the alternative device. RESULTS. The mean ± SD length of time to effective ventilation was 46 seconds when using endotracheal tubes and 23 seconds when using laryngeal mask airway, with a mean difference of 23 seconds. The mean number of attempts to achieve effective ventilation was 1.27 when using endotracheal tubes and 1.1 when using laryngeal mask airway. There were 9 (17%) episodes of esophageal intubations and 14 (27%) episodes of right main-stem intubations in the endotracheal tube group, and there were 5 (9.5%) episodes of malposition in the laryngeal mask airway group. CONCLUSIONS. In simulated pediatric arrests, the use of laryngeal mask airway, compared with endotracheal tubes, led to more rapid establishment of effective ventilation and fewer complications when performed by prehospital providers.

Diagnosis of Intussusception by Physician Novice Sonographers in the Emergency Department

STUDY OBJECTIVE We investigate the performance characteristics of bedside emergency department (ED) ultrasonography by nonradiologist physician sonographers in the diagnosis of ileocolic intussusception in children. METHODS This was a prospective, observational study conducted in a pediatric ED of an urban tertiary care childrens hospital. Pediatric emergency physicians with no experience in bowel ultrasonography underwent a focused 1-hour training session conducted by a pediatric radiologist. The session included a didactic component on sonographic appearances of ileocolic intussusception, review of images with positive and negative results for intussusceptions, and a hands-on component with a live child model. On completion of the training, a prospective convenience sample study was performed. Children were enrolled if they were to undergo diagnostic radiology ultrasonography for suspected intussusception. Bedside ultrasonography by trained pediatric emergency physicians was performed and interpreted as either positive or negative for ileocolic intussusception. Ultrasonographic studies were then performed by diagnostic radiologists, and their results were used as the reference standard. Test characteristics (sensitivity, specificity, positive and negative predictive values) and likelihood ratios were calculated. RESULTS Six pediatric emergency physicians completed the training and performed the bedside studies. Eighty-two patients were enrolled. The median age was 25 months (range 3 to 127 months). Thirteen patients (16%) received a diagnosis of ileocolic intussusception by diagnostic radiology. Bedside ultrasonography had a sensitivity of 85% (95% confidence interval [CI] 54% to 97%), specificity of 97% (95% CI 89% to 99%), positive predictive value of 85% (95% CI 54% to 97%), and negative predictive value of 97% (95% CI 89% to 99%). A positive bedside ultrasonographic result had a likelihood ratio of 29 (95% CI 7.3 to 117), and a negative bedside ultrasonographic result had a likelihood ratio of 0.16 (95% CI 0.04 to 0.57). CONCLUSION With limited and focused training, pediatric emergency physicians can accurately diagnose ileocolic intussusception in children by using bedside ultrasonography.

Pediatric Fatality Following Ingestion of Dinitrophenol: Postmortem Identification of a “Dietary Supplement”

Dinitrophenol, a chemical currently used as an insecticide, is known to uncouple mitochondrial oxidative phosphorylation. A component of explosives, it has also been used in the past as a food coloring and clothing dye. In the 1930s, physicians prescribed it for weight loss, but this practice was discontinued when reports of cataracts, deaths, and other adverse outcomes came to light. We describe in our report the overdose and fatality of a teenager who purchased the product as a weight loss dietary supplement by mail order. We also describe a laboratory method that allowed postmortem determination of the dinitrophenol concentration in the victims serum. Her death, despite prompt medical treatment, underscores the danger of dinitrophenol. The easy accessibility and apparent resurgent interest in dinitrophenol as a weight loss agent is extremely timely and troubling.

A randomized trial to assess the efficacy of point-of-care testing in decreasing length of stay in a pediatric emergency department.

Objectives: To compare the effect of point-of-care (POC) testing versus traditional laboratory methods on length of stay in a pediatric emergency department (ED). Methods: This study was a prospective, randomized, controlled trial of patients solely requiring blood work that a POC device was capable of performing. Two hundred twenty-five patients presenting to a tertiary hospital ED in an urban setting enrolled after informed consent. Of all patients studied, 114 were randomized to the POC group, 111 to routine laboratory analysis. Exact times of critical phases of management and patient flow were recorded by dedicated research assistants. Medical management decisions were made at the discretion of the supervising physicians. Results: Similar waiting periods were noted in both groups for time spent in the waiting room, time waiting for first physician contact, and time waiting for blood draw. Significantly less time was required for results to become available to physicians when POC testing was used (65.0 minutes; P < 0.001). Significant decrease in overall length of stay was also noted, with patients randomized to the POC group spending an average of 38.5 minutes (P < 0.001) less time in the ED. Conclusions: Point-of-care testing can significantly decrease the length of stay in select pediatric patients in an ED setting. Point-of-care devices may prove to facilitate patient flow during busiest periods of service demand.

Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record

Methods A 2-arm randomized clinical trial of 250 physicians and patients treated by those physicians. The physician is the unit of randomization. A BPA and order set were developed and embedded in the Epic (Madison, WI) EMR used at 2 hospitals. When an adult patient is admitted to a medical service, a BPA fires if the patient is coded in the EMR as a smoker. For physicians randomized to the intervention, the BPA offers to take the physician to an order set to prescribe tobacco treatment medications and refer the patient to the state smoker’s quitline. Additionally, tobacco use disorder” is added to the patient’s problem list, and an email is sent to the patient’s primary care provider (PCP). In the control arm, a BPA silently fires with no additional actions for the physician. Results Since August 2013, the BPA fired for 4187 patients (1887 intervention, 2300 control). Compared to control arm physicians, intervention physicians were more likely to order tobacco treatment medication (24% v. 9%, P = 0.0001, Fisher’s exact test), populate the problem list with tobacco use disorder (46% v. 4%, P < 0.0001), and make a referral to the state smokers’ quitline (19% v. 0%, P < 0.0001). In addition, intervention physicians sent an email to the patient’s PCP 1876 (99%) times.

Emergency Department Information System Adoption in the United States

OBJECTIVES The American Recovery and Reinvestment Act of 2009 incentivizes adoption of health care information technology (HIT) based on support for specific standards, policies, and features. Limited data have been published on national emergency department information systems (EDIS) adoption, and to our knowledge, no prior studies have considered functionality measures. This study determined current national estimates of EDIS adoption using both single-response rates of EDIS adoption and a novel feature-based definition and also identified emergency department (ED) characteristics associated with EDIS use. METHODS The 2006 National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits that also surveyed participating EDs on EDIS, was used to estimate EDIS adoption. EDIS adoption rates were calculated using two definitions: 1) single-response-response to a single survey question as to whether the EDIS was complete, partial, or none; and 2) feature-based-based on the reported features supported by the EDIS, systems were categorized as fully functional, basic, other, or none. The relationship of EDIS adoption to specific ED characteristics such as facility type and location was also examined. RESULTS Using the single-response classification, 16.1% of EDs had a complete EDIS, while 30.4% had a partial EDIS, and 53.5% had none. In contrast, using a feature-based categorization, 1.7% EDs had a fully functional EDIS, 12.3% had basic, 32.1% had other, and 53.9% had none. In multivariable analysis, urban EDs were significantly more likely to have a fully functional or basic EDIS than were rural EDs. Pediatric EDs were significantly more likely than general EDs to have other EDIS. CONCLUSIONS Despite more optimistic single-response estimates, fewer than 2% of our nations EDs have a fully functional EDIS. EDs in urban areas and those specializing in the care of pediatric patients are more likely to support EDIS. Accurate and consistent EDIS adoption estimates are dependent on whether there are standardized EDIS definitions and classifications of features. To realize the potential value of EDIS for improved emergency care, we need to better understand the extent and correlates of the diffusion of this technology and increase emergency medicine engagement in national HIT policy-making.