Daniel B. Fagbuyi

A Rapid Medical Screening Process Improves Emergency Department Patient Flow During Surge Associated With Novel H1N1 Influenza Virus

STUDY OBJECTIVE We compare emergency department (ED) patient flow during the fall 2009 novel H1N1-associated surge in patient volumes at an urban, tertiary care, pediatric medical center to that in the previous winter virus season. METHODS A rapid medical screening process was instituted to manage the surge in patient census. The process included the use of a new, separate clinical area converted from office space adjacent to the ED, the introduction of a new preprinted checklist for rapid documentation of medical history and physical examination of patients with influenza-like illness, the use of classroom-style parent discharge education, and the use of preprinted discharge prescription and instructions. We compared patient flow parameters, including waiting time, length of stay, and elopement rates, and returns within 48 hours and 7 days for a comparable period in winter 2008 to 2009. RESULTS During the first 30 days of the novel H1N1-associated surge in patient volumes (October 12 to November 10, 2009), overall ED daily volumes increased by a mean of 113 (51.8%) compared with baseline (daily increase range 49 to 118 patients). Of the 10,013 patients treated during this period, 4,287 (42.8%) had complaints consistent with influenza-like illness and 1,767 (17.6%) were treated with the rapid screening process. The mean wait time decreased from 92.9 to 81.2 minutes (difference 11.7 minutes; 95% confidence interval [CI] 10.2 to 13.2 minutes). Overall mean ED length of stay decreased from 241 to 212.3 minutes (difference 28.7 minutes; 95% CI 25.8 to 31.6 minutes). Rates of elopement were unchanged, and elopement rates as a function of daily patient volumes showed improved responsiveness to high volumes. Rates of return were unchanged within 48 hours (3.0% in 2009 versus 2.9% in 2008; odds ratio 1.03 [0.91 to 1.18]) and within 7 days (6.2% in 2009 versus 5.7% in 2008; odds ratio 1.09 [0.99 to 1.20]). The use of the rapid screening process required a mean of 23.5 (95% CI 16.4 to 30.6) additional hours per day of physician staffing and a mean of 26.3 (95% CI 18.5 to 34.1) additional hours of nursing staffing. CONCLUSION The implementation of a rapid screening process during the fall 2009 H1N1-associated surge in patient volumes was associated with improved patient flow without affecting rates of return to the ED within 48 hours or 7 days. This was accomplished with only a modest increase in staffing.

Comparison of pandemic and seasonal influenza A infections in pediatric patients: were they different?

Please cite this paper as: Song et al. (2012) Comparison of pandemic and seasonal influenza A infections in pediatric patients: were they different?. Influenza and Other Respiratory Viruses 6(1), 25–27.

Creation and Delphi-method Refinement of Pediatric Disaster Triage Simulations

Abstract Objective. There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. Methods. We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. Results. After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. Conclusions. The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Medical countermeasures for children in public health emergencies, disasters, or terrorism

Significant strides have been made over the past 10 to 15 years to develop medical countermeasures (MCMs) to address potential disaster hazards, including chemical, biological, radiologic, and nuclear threats. Significant and effective collaboration between the pediatric health community, including the American Academy of Pediatrics, and federal partners, such as the Office of the Assistant Secretary for Preparedness and Response, Centers for Disease Control and Prevention, Federal Emergency Management Agency, National Institutes of Health, Food and Drug Administration, and other federal agencies, over the past 5 years has resulted in substantial gains in addressing the needs of children related to disaster preparedness in general and MCMs in particular. Yet, major gaps still remain related to MCMs for children, a population highly vulnerable to the effects of exposure to such threats, because many vaccines and pharmaceuticals approved for use by adults as MCMs do not yet have pediatric formulations, dosing information, or safety information. As a result, the nation’s stockpiles and other caches (designated supply of MCMs) where pharmacotherapeutic and other MCMs are stored are less prepared to address the needs of children compared with those of adults in the event of a disaster. This policy statement provides recommendations to close the remaining gaps for the development and use of MCMs in children during public health emergencies or disasters. The progress made by federal agencies to date to address the needs of children and the shared commitment of collaboration that characterizes the current relationship between the pediatric health community and the federal agencies responsible for MCMs should encourage all child advocates to invest the necessary energy and resources now to complete the process of remedying the remaining significant gaps in preparedness.

Resource-Poor Settings: Infrastructure and Capacity Building: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

BACKGROUND Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. METHODS The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. CONCLUSIONS Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

Engagement and Education: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

BACKGROUND Engagement and education of ICU clinicians in disaster preparedness is fragmented by time constraints and institutional barriers and frequently occurs during a disaster. We reviewed the existing literature from 2007 to April 2013 and expert opinions about clinician engagement and education for critical care during a pandemic or disaster and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this article are important for all of those involved in a pandemic or large-scale disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS A systematic literature review was performed and suggestions formulated according to the American College of Chest Physicians (CHEST) Consensus Statement development methodology. We assessed articles, documents, reports, and gray literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: (1) situational awareness, (2) clinician roles and responsibilities, (3) education, and (4) community engagement. Together, these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care. CONCLUSIONS The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals. An effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians.

Hospital Readmissions Among Children With H1N1 Influenza Infection.

OBJECTIVES To describe readmissions among children hospitalized with H1N1 (influenza subtype, hemagglutinin1, neuraminidase 1) pandemic influenza and secondarily to determine the association of oseltamivir during index hospitalization with readmission. METHODS We reviewed data from 42 freestanding childrens hospitals contributing to the Pediatric Health Information System from May through December 2009 when H1N1 was the predominant influenza strain. Children were divided into 2 groups by whether they experienced complications of influenza during index hospitalization. Primary outcome was readmission at 3, 7, and 30 days among both patient groups. Secondary outcome was the association of oseltamivir treatment with readmission. RESULTS The study included 8899 children; 6162 patients had uncomplicated index hospitalization, of whom 3808 (61.8%) received oseltamivir during hospitalization, and 2737 children had complicated influenza, of whom 1055 (38.5%) received oseltamivir. Median 3-, 7-, and 30-day readmission rates were 1.6%, 2.5%, and 4.7% for patients with uncomplicated index hospitalizations and 4.3%, 5.8%, and 10.3% among patients with complicated influenza. The 30-day readmission rates did not differ by treatment group among patients with uncomplicated influenza; however, patients with complicated index hospitalizations who received oseltamivir had lower all-cause 30-day readmissions than untreated patients. The most common causes of readmission were pneumonia and asthma exacerbations. CONCLUSIONS Oseltamivir use for hospitalized children did not decrease 30-day readmission rates in children after uncomplicated index hospitalization but was associated with a lower 30-day readmission rate among children with complicated infections during the 2009 H1N1 pandemic. Readmission rates for children who had complicated influenza infection during index hospitalizations are high.

Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States

Quantifying how close hospitals came to exhausting capacity during the outbreak of pandemic influenza A (H1N1) 2009 can help the health care system plan for more virulent pandemics. This ecologic analysis used emergency department (ED) and inpatient data from 34 US childrens hospitals. For the 11-week pandemic (H1N1) 2009 period during fall 2009, inpatient occupancy reached 95%, which was lower than the 101% occupancy during the 2008-09 seasonal influenza period. Fewer than 1 additional admission per 10 inpatient beds would have caused hospitals to reach 100% occupancy. Using parameters based on historical precedent, we built 5 models projecting inpatient occupancy, varying the ED visit numbers and admission rate for influenza-related ED visits. The 5 scenarios projected median occupancy as high as 132% of capacity. The pandemic did not exhaust inpatient bed capacity, but a more virulent pandemic has the potential to push childrens hospitals past their maximum inpatient capacity.

Diastolic Hypotension, Troponin Elevation, and Electrocardiographic Changes Associated With the Management of Moderate to Severe Asthma in Children

OBJECTIVE The objective was to determine the occurrence of, and the factors associated with, diastolic hypotension and troponin elevation or electrocardiogram (ECG) ST-segment changes in a convenience sample of children with moderate to severe asthma receiving continuous albuterol nebulization. METHODS This was a prospective, descriptive study in a pediatric emergency department and an intensive care unit of a tertiary academic center. Fifty children with moderate to severe asthma (clinical asthma score > 8) who received 10 to 15 mg/hour continuous albuterol for >2 hours between June 5, 2007, and February 4, 2008, were approached. Hourly diastolic blood pressures were recorded. Cardiac troponin I (cTnI) and ECG tracings were obtained following the first 2 hours of albuterol and then subsequently every 12 hours while receiving continuous albuterol. Main outcome measures were: 1) incidence of diastolic hypotension, 2) incidence of troponin elevation, and 3) incidence of ECG ST-depression. RESULTS Fifty patients were enrolled. Thirty-three (66%) patients developed diastolic hypotension during the first 6 hours of continuous albuterol. Diastolic blood pressure declined from baseline at 1-6 hours (p < 0.01 vs. baseline). Twelve patients (24%) had elevated cTnI, 15 patients (30%) had ST-segment change, four patients (8%) had both, and 23 patients (46%, 95% confidence interval [CI] = 32 to 60) had either a cTnI elevation or an ECG ST-segment change. Troponin elevation and diastolic hypotension were not associated (RR = 1.2, 95% CI = 0.6 to 2.3). CONCLUSIONS In a subset of children with moderate to severe asthma, diastolic hypotension, troponin elevation, and ECG ST-segment change occur during administration of continuous albuterol. Future studies are necessary to determine the clinical significance of these findings.

Going viral: adapting to pediatric surge during the H1N1 pandemic.

Objectives The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. Methods Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant’s hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. Results The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. Conclusions Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.