Danica B. Liberman

Management of anaphylaxis in children.

Anaphylaxis is a severe, life-threatening immunoglobulin E (IgE)-mediated hypersensitivity reaction. The key to successful management of anaphylaxis involves rapid diagnosis, assessment, and early initiation of therapy. Epinephrine is the undisputed initial therapy for anaphylaxis, and its administration should never be delayed. In most cases, additional interventions such as oxygen therapy, fluid resuscitation, &bgr;-agonists, antihistamines, and corticosteroids should be strongly considered. Although hospital course must be individualized to meet each patients needs, a minimum of 4 to 6 hours of observation period after complete symptom resolution may be reasonable to monitor for recurrence of symptoms and biphasic reaction. Before discharge, every patient should receive patient education about anaphylaxis, a prescription for self-injectable epinephrine, and instructions for follow-up care.

Pediatric Advance Directives: Parents’ Knowledge, Experience, and Preferences

OBJECTIVES: To explore parents’ and caregivers’ experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. METHODS: We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child’s past and current health status, and family demographics. RESULTS: Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. CONCLUSIONS: The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.

Low rates of follow-up with primary care providers after pediatric emergency department visits for respiratory tract Illnesses.

Objectives We sought to determine diagnosis-specific rates of follow-up with primary care providers (PCPs) after emergency department (ED) visits for respiratory tract illnesses. We hypothesized that follow-up rates would be higher among patients with acute infectious illnesses than among those with asthma. Methods This was a retrospective cohort study of a random sample of patients aged 0 to 12 years discharged over a 12-month period from an urban, tertiary care pediatric ED with 4 different respiratory tract illnesses (asthma, bronchiolitis, croup, and pneumonia). Primary care provider follow-up was examined for associations with sociodemographic and clinical factors and with subsequent ED visits. Results Rates of follow-up in the overall cohort were low: 23.6% (95% confidence interval, 19.7–27.4) by 7 days and 40.5% (95% confidence interval, 36.0–44.9) by 30 days. Compared with patients with asthma, the relative risks (RRs) of follow-up within 7 and 30 days were significantly higher among patients with bronchiolitis and pneumonia, but not with croup. For the cohort as a whole, the RR of follow-up within 7 and 30 days significantly decreased for each 1-year increase in age, and the RR of follow-up within 7 days significantly increased with the provision of explicit ED discharge instructions recommending follow-up. Among patients with asthma, follow-up with PCPs within 30 days was not associated with decreased ED visits for asthma over the following year. Conclusions Rates of PCP follow-up were globally low but significantly higher for patients with acute infectious illnesses, for younger patients, and for those receiving explicit ED discharge instructions.

Cost-Effectiveness of Watchful Waiting in Acute Otitis Media

Through a decision-analytic model, this study evaluates the cost-effectiveness of AAP guidelines for watchful waiting in acute otitis media management compared with current practice. BACKGROUND: American Academy of Pediatrics guidelines for acute otitis media (AOM) allow for children meeting certain criteria to undergo watchful waiting (WW). The cost-effectiveness of this policy has not been evaluated in the United States. METHODS: A retrospective review of a random selection of 250 patients ≤18 years old with AOM in the emergency department of a tertiary care children’s hospital was used to characterize current practice of AOM management. These data were incorporated into a decision-analytic cost-utility model comparing the cost-effectiveness of implementing WW to current practice. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed in 2015 USD per disability-adjusted life year (DALY) averted from a societal perspective. Multiple sensitivity analyses were conducted. RESULTS: From this cohort, chart review confirmed 247 actually had AOM on physical examination. Of these, 231 (93.5%) were prescribed antibiotics, 7 (2.8%) underwent WW, and 9 (3.6%) were sent home without an antibiotic prescription. When American Academy of Pediatrics criteria for WW were applied to this population, 104 patients (42.1%) met conditions for immediate antibiotic prescription, and 143 patients (57.9%) qualified for WW. In our modeled scenario, for every 1000 patients with AOM, implementing WW yielded 514 fewer immediate antibiotic prescriptions and 205 fewer antibiotic prescriptions used, averting 14.3 DALYs, and saving

Parent activation in the pediatric emergency department: Theory vs. reality

5573. The preferability of WW over current practice proved highly robust to sensitivity analysis. CONCLUSIONS: WW for AOM management is cost-effective. Implementing WW may improve outcomes and reduce health care expenditures.

The Effect of Language on the Discharge Process in a Pediatric Emergency Department

OBJECTIVE To measure parent activation and test for its associations with sociodemographics, clinical factors, and short-term outcomes. METHODS By convenience sampling, 246 parents of children treated in an emergency department (ED) of a childrens hospital completed the Parent-Patient Activation Measure (P-PAM) and answered sociodemographic questions. Clinical information was abstracted from medical records. Phone calls to parents and primary care physician offices were conducted within one-month post-ED visit for information about short-term outcomes. RESULTS We discovered higher than expected activation among our sample (mean = 73), higher activation scores by Spanish language and child chronic illness status, and associations between activation scores and ED visit and discharge instruction comprehension and filling prescriptions (short-term outcomes). However, the theory of parent activation did not adequately fit the data. CONCLUSION Before the P-PAM in pediatric clinical care becomes widespread, further research is necessary to better understand parent activation and its associations with pediatric outcomes. PRACTICE IMPLICATIONS Although the PAM has shown promise in accurately measuring patient activation across various populations and disease processes, the same is not yet true of the P-PAM. To date, pediatric studies using the P-PAM have called its psychometric properties into question. Further research is needed to understand and measure parent activation.

Radiologic discrepancies in children with special healthcare needs in a pediatric emergency department

Health disparities linked to language have been clearly described in the literature. However, little is known about potential disparities in care related to language in the Pediatric Emergency Department (PED). This was a cross-sectional observational study using convenience sampling of English and Spanish PED discharges before and after electronic medical record (EMR) implementation. There were minimal differences between English and Spanish-speaking families in interactional elements and basic dialogue during discharge. Yet Spanish-speaking families had longer wait times to discharge once the decision to discharge was made. Interestingly, implementation of EMR added efficiency in terms of seeing a physician after arrival and equalizing the discharge instruction process between both groups. Contrary to literature on language-related health disparities, our study revealed minimal differences between English and Spanish-speaking families specifically in the PED discharge process.

Introducing Teamwork Challenges in Simulation Using Game Cards.

Background: After‐hours radiologic interpretation by nonradiology attendings or resident radiologists introduces the risk of discrepancies. Clinical outcomes following radiologic discrepancies among pediatric emergency department (ED) patients are poorly described. In particular, children with special healthcare needs (CSHCN), have more opportunities for discrepancies and potential consequences than non‐ CSHCN. Our objective was to determine the rates and types of radiologic discrepancies, and to compare CSHCN to non‐CSHCN. Methods: From July 2014 to February 2015, all children who underwent a diagnostic imaging study at a free‐standing childrens ED were included. Data collected included radiologic studies ‐ type and location – and clinical details ‐ chief complaint and CSHCN type. Differences between preliminary reads and final pediatric radiology attending reads were defined as discrepancies, and categorized by clinical significance. Descriptive statistics, z‐tests, and chi‐square were used. Results: Over 8 months, 8310 visits (7462 unique patients) had radiologic studies (2620 CSHCN, 5690 non‐CSHCN). A total of 198 (2.4%) radiologic discrepancies [56 (28.3%) CSHCN, 142 (71.7%) non‐CSHCN] were found. Chief complaints for CSCHN were more often within the cardiac, pulmonary and neurologic systems (p < 0.001 for each), whereas non‐CSHCN presented with more trauma (p < 0.001). The rates of discrepancies (CSHCN 2.1%, non‐ CSHCN 2.5%, p = 0.3) and severity of clinical consequences (p = 0.6) were not significantly different between CSHCN and non‐CSHCN. Conclusion: Though the frequency and type of radiologic studies performed between CSHCN and non‐CSHCN were different, we found no significant difference in the rate of radiologic discrepancies or the rate of clinically significant radiologic discrepancies.

Give and Take

Summary Statement Poor teamwork and communication during resuscitations are linked to patient safety problems and poorer outcomes. We present a novel simulation-based educational intervention using game cards to introduce challenges in teamwork. This intervention uses sets of game cards that designate roles, limitations, or communication challenges designed to introduce common communication or teamwork problems. Game cards are designed to be applicable for any simulation-based scenario and are independent from patient physiology. In our example, participants were pediatric emergency medicine fellows undergoing simulation training for orientation. We describe the use of card sets in different scenarios with increasing teamwork challenge and difficulty. Both postscenario and summative debriefings were facilitated to allow participants to reflect on their performance and discover ways to apply their strategies to real resuscitations. In this article, we present our experience with the novel use of game cards to modify simulation scenarios to improve communication and teamwork skills.

Rehab rounds: Involving families in rehabilitation through behavioral family management.

The nursing triage note said “safe surrender.” It was a little after 6 AM on a weekday, and I was just getting settled into a shift when this patient popped up on our tracking board. Minutes later our emergency department (ED) social worker came over to find me and let me know about a mother in triage who had brought in her baby to surrender. This would be my first safe surrender baby. The fair-skinned, perfectly healthy, beautiful, little baby boy looked just like my son did at that age. And his mom was in so many ways like every other mother I had ever met or known. She loved her son; she knew how he liked to be held, and the cry that meant he was hungry. She wanted what was best for him, but, in her own words, she felt that “I can’t give him the kind of life he deserves.” Her decision had come after weeks of internal debate and struggle, and over the course of 3,000 miles as she moved from Florida to Las Vegas, and ultimately to Los Angeles. I can’t even imagine the process she must have gone through to get to this point. She had several other children, she told me, all living out of state with her mother. Her life had been difficult, to say the least, with unstable living situations and even more unstable relationships. She wanted something better for her son. California’s Safely Surrendered Baby Law, first created in 2001, was officially signed into state law in 2006. From 2001 to the present, over 670 newborns have been safely surrendered. As I watched her change his diaper and feed him a bottle, I felt myself gradually losing grip on my role as the objective and collected physician and being overcome by my feelings as a mother, and simply as a fellow human being. I was witnessing this most intimate and profound moment between mother and son—the last time she would hold him, feed him, and admire him. I looked down, shielded my eyes, and quietly left, walking directly to the solitude of the clean utility closet to allow myself just a minute to process what I was experiencing before I had to move on to the next patient. My immediate reaction shifted between utter disbelief that any mother could give her child away to someone else and complete sympathy for this woman who