Ilene Claudius

Do all infants with apparent life-threatening events need to be admitted?

OBJECTIVE. The goal was to identify criteria that would allow low-risk infants presenting with an apparent life-threatening event to be discharged safely from the emergency department. METHODS. We completed data forms prospectively on all previously healthy patients <12 months of age presenting to the emergency department of an urban tertiary care childrens hospital with an apparent life-threatening event over a 3-year period. These patients were then observed for subsequent events, significant interventions, or final diagnoses that would have mandated their admission (eg, sepsis). RESULTS. In our population of 59 infants, all 8 children who met the aforementioned outcome measures, thus requiring admission, either had experienced multiple apparent life-threatening events before presentation or were in their first month of life. In our study group, the high-risk criteria of age of <1 month and multiple apparent life-threatening events yielded a negative predictive value of 100% to identify the need for hospital admission. CONCLUSIONS. Our study suggests that >30-day-old infants who have experienced a single apparent life-threatening event may be discharged safely from the hospital, which would decrease admissions by 38%.

Decrease in Emergency Department Length of Stay as a Result of Triage Pulse Oximetry

Objectives: Many emergency departments do not perform pulse oximetry in triage, in spite of its potential for altering management decisions. We attempted to quantify the decrease in patient throughput time in a pediatric emergency department following the introduction of triage pulse oximetry. Methods: One hundred fifty-nine bronchiolitis patients from 2004 served as the preintervention group, and were evaluated against 89 severity-matched postintervention bronchiolitis patients from 2005. Their mean lengths of ED stay were compared by a t test. Results: The preintervention group had a mean length of stay of 4 hours and 59 minutes, and the postintervention group had a mean length of stay of 4 hours and 9 minutes, which was significantly different (P = 0.03). The sensitivity of respiratory distress on the triage exam for predicting hypoxia was fair (74%). Conclusions: Institution of triage pulse oximetry significantly decreases ED throughput times. Clinical exam alone is not a replacement for measurement of oxygen saturation.

The Utility of Safety Counseling in a Pediatric Emergency Department

Objective. Pediatric injuries have a significant impact on the medical system, costing lives and disabling many survivors. Although injury-prevention measures do exist, they are underutilized. A majority of families do not consistently receive counseling by a primary care provider (PCP). We attempted to demonstrate the efficacy of counseling families who presented to a pediatric emergency department with unrelated medical complaints. Methods. A self-report questionnaire was administered to assess the home safety of patients 2 weeks to 12 years old presenting to the emergency department. Targeted counseling on areas noted to be unsafe was provided, and a 2-week follow-up telephone call was made to assess the effectiveness of the counseling. Information on previous counseling by a PCP was also collected and analyzed. Logistic regression was performed to determine significance and calculate odds ratios. Results. Thirty-seven percent of caregivers recalled receiving any counseling at a PCP visit. Caregivers who had received prior counseling by a PCP were significantly more likely to have a safe home environment. Patients who were English speaking were significantly more likely to have received safety counseling than their Spanish-speaking counterparts. One hundred fifty families received counseling in the emergency department, and 117 were eligible for follow-up. Of these families, 39% made a positive change in the safety of their childs environment at the 2-week telephone follow-up. Conclusions. Caregivers receiving counseling by a PCP are more likely to provide a safe home environment for their children. Spanish-speaking patients are at particularly high risk of not receiving counseling. Of caregivers reporting unsafe practices during an unrelated emergency-department encounter, targeted counseling made a positive impact on behavior after discharge.

Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital.

STUDY OBJECTIVE We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. METHODS Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. RESULTS A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). CONCLUSION We found 3 variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation.

Accuracy of Magnetic Resonance Imaging and Ultrasound for Appendicitis in Diagnostic and Nondiagnostic Studies

OBJECTIVES Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis. METHODS Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy. RESULTS Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (ρ = 0.573, p = 0.0001) when all studies were considered. CONCLUSIONS Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.

Is medical clearance necessary for pediatric psychiatric patients

BACKGROUND Although most studies have found low rates of organic illness in patients with isolated psychiatric complaints, psychiatric patients are frequently brought to emergency departments (EDs) for medical clearance. STUDY OBJECTIVES To assess the utility of ED medical clearance before transfer of pediatric patients on psychiatric holds to inpatient psychiatric facilities, and to evaluate charges associated with ED medical clearance. METHODS Retrospective study of pediatric psychiatric patients in one urban pediatric ED with 22,000 annual patient visits over an 18-month period. Patients were included if transported to the ED for medical clearance after being placed on an involuntary psychiatric hold in the prehospital setting. Main outcome measures were charges for screening laboratory tests and secondary ambulance transfers and wages for sitters resulting from ED visits for medical screening examinations of patients on psychiatric holds. We also determined what percentage of patients truly warranted a medical screen and the percentage of psychiatric holds overturned, avoiding transfer to a psychiatric hospital. RESULTS There were 789 patients included; 72 (9.1%) were determined to require medical screening. Total charges for laboratory assessments and secondary ambulance transfers and wages for sitters were

Impact of an emergency department pharmacy on medication omission and delay.

1,241,295, or US

Ethanol Ingestion in Two Infants Under 2 Months Old: A Previously Unreported Cause of ALTE

17,240 per patient requiring a medical screen. Only 35 (4.4%) holds were overturned in the ED. CONCLUSION Few patients brought to the ED on an involuntary hold required a medical screen. Use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) could have led to significant savings.

Most Routine Laboratory Testing Of Pediatric Psychiatric Patients In The Emergency Department Is Not Medically Necessary

Objectives The objective of the study was to evaluate the impact of adding a clinical pharmacist within a pediatric emergency department (ED) on medication omissions and delays, as well as medication errors on patients with prolonged ED stays of 8 hours or greater. Methods This is a retrospective review of medication omissions and delays on all patients admitted to a large, tertiary-care children’s hospital through the ED during a month before the addition of a clinical pharmacist (April 2007), during a month immediately after the addition of a clinical pharmacist (April 2009), and 6 months after the addition of a clinical pharmacist (October 2009). The medication omissions and delays were separated for urgent and nonurgent medications. A subgroup was further analyzed to evaluate the rate of medication omissions and delays for admitted patients boarded within the ED for 8 hours or greater. Results Medication omissions and delays decreased immediately after the addition of a clinical pharmacist for urgent medications (P = 0.007) and nonurgent medications (P < 0.0001). This decrease persisted 6 months after the addition of a clinical pharmacist approaching significance for urgent medications (P = 0.06) and statistically significant for nonurgent medications (P < 0.0001). For the patients who were boarded within the ED for 8 hours or greater, 52.8% experienced a medication omission or delay before the addition of a clinical pharmacist, compared with 28.6% and 36.2% experiencing an omission or delay in medications administration immediately after or 6 months after the addition of a clinical pharmacist, respectively. Conclusions Medication omissions and delays are common within the ED. Admitted patients boarded within the ED for 8 hours or greater are at an increased risk for medications omissions and delays. The addition of a clinical pharmacist within an ED may reduce the number of medication omissions and delays occurring.

Comparison of Computerized Patients versus Live Moulaged Actors for a Mass-casualty Drill.

The differential diagnosis for the infant presenting with an apparent life-threatening event (ALTE) is broad. Toxic ingestions are a relatively uncommon cause of an ALTE, although several over-the-counter, prescription, and illicit drugs have been implicated. We present 2 cases of ethanol intoxication in infants as a previously unreported cause of an ALTE. Additionally, serial ethanol levels for these patients offer novel insight into the pharmacokinetics of ethanol metabolism in infants. Ethanol ingestion may be an underrecognized cause of an ALTE and should be considered if the history or physical examination is suggestive.