Jennifer Thull-Freedman

Pediatric Myocarditis: Emergency Department Clinical Findings and Diagnostic Evaluation

OBJECTIVE. The goal was to determine, in children with myocarditis, the frequency of various presenting symptoms and the sensitivity of clinical and laboratory investigations routinely available in the emergency department. METHODS. We performed a retrospective review of all patients <18 years of age who were diagnosed as having myocarditis at our institution between May 2000 and May 2006 and who initially presented to an emergency department. Patients were categorized as having definite myocarditis (positive endomyocardial biopsy results) or probable myocarditis(diagnosis assigned by a pediatric cardiologist on the basis of history, physical examination, and investigation results in the absence of an endomyocardial biopsy or in the presence of negative biopsy results). All patients were assigned a predominant category of symptoms at presentation on the basis of criteria defined a priori. RESULTS. There were 16 cases of definite myocarditis and 15 cases of probable myocarditis. The age distribution was nonnormal, with peaks among children ≤3 years and ≥16 years of age. Of 14 patients who were seen by a physician before being diagnosed with myocarditis, 57% were originally diagnosed as having pneumonia or asthma. Thirty-two percent of patients presented with predominantly respiratory symptoms, 29% had cardiac symptoms, and 6% had gastrointestinal symptoms. Although evidence of cardiac dysfunction was frequently present in the form of respiratory distress, only a minority of children had evidence of hepatomegaly or abnormal cardiac examination results. The sensitivities of electrocardiograms and chest radiographs as screening tests were 93% and 55%, respectively. Among laboratory tests studied, aspartate aminotransferase measurement was the most sensitive (sensitivity: 85%). CONCLUSIONS. Children with myocarditis present with symptoms that can be mistaken for other types of illnesses; respiratory presentations were most common. When clinical suspicion of myocarditis exists, chest radiography alone is an insufficient screening test. All children should undergo electrocardiography. Aspartate aminotransferase testing may be a useful adjunctive investigation.

The Crying Infant: Diagnostic Testing and Frequency of Serious Underlying Disease

OBJECTIVE. To determine the proportion of children evaluated in an emergency department because of crying who have a serious underlying etiology. Secondary outcomes included the individual contributions of history, physical examination, and laboratory investigations in determining a diagnosis. PATIENTS AND METHODS. We performed a retrospective review of all afebrile patients <1 year of age who presented with a chief complaint of crying, irritability, screaming, colic, or fussiness. All children with a serious underlying illness were identified by using a priori defined criteria. Chart review was conducted to determine if history, physical examination, or investigation data contributed to establishing the childs diagnosis. RESULTS. Enrollment criteria were met by 237 patients, representing 0.6% of all visits. A total of 12 (5.1%) children had serious underlying etiologies with urinary tract infections being most prevalent (n = 3). Two (16.7%) of the serious diagnoses were only made on revisit. Of the 574 tests performed, 81 (14.1%) were positive. However, only 8 (1.4%) diagnoses were assigned on the basis of a positive investigation. History and/or examination suggested an etiology in 66.3% of cases. Unwell appearance was associated with serious etiologies. In only 2 (0.8%) children did investigations in the absence of a suggestive clinical picture contribute to the diagnosis. Both of these children were <4 months of age and had urinary tract infections. Among children <1 month of age, the positive rate of urine cultures performed was 10%. Ocular fluorescein staining and rectal examination with occult blood testing were performed infrequently, and results were negative in all cases. Successful follow-up was completed with 60% of caregivers, and no missed diagnoses were found. CONCLUSIONS. History and physical examination remains the cornerstone of the evaluation of the crying infant and should drive investigation selection. Afebrile infants in the first few months of life should undergo urine evaluation. Other investigations should be performed on the basis of clinical findings.

Emergency department revisits in children with gastroenteritis.

Objectives: The aim of the study was to determine whether intravenous fluid administration is independently associated with a reduction in unscheduled emergency department (ED) revisits within 7 days. Methods: We conducted a single-center, retrospective observational cohort study in a pediatric ED in Toronto, Canada. Participants were younger than 18 years, diagnosed as having gastroenteritis, and discharged home between July 2003 and June 2008. Multivariable regression models were used to determine the associations between the exposures (intravenous rehydration, triage severity score, age) and ED revisits and revisits with intravenous rehydration. Accuracy was assessed using bootstrap analysis. Results: There were 22,125 potentially eligible visits; 3346 were included in our final cohort. A total of 497 children (15%) received intravenous rehydration and 543 (16%) had an unscheduled revisit. Regression analysis included 2874 children with complete data, and identified 5 independent predictors of an ED revisit: intravenous rehydration (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.36–2.26); number of vomiting episodes (1.20; 95% CI 1.04–1.28/5 episode increase); days of diarrhea (OR 0.92; 95% CI 0.88–0.97/day increase); frequency of diarrhea (1.19; 95% CI 1.03–1.38/5 episode increase); and age (OR 0.94; 95% CI 0.91–0.98/year). Bootstrap methodology identified intravenous rehydration, age, number of vomiting episodes, days of diarrhea, and number of diarrheal stools a minimum of 500 of 1000 iterations. Conclusions: Intravenous rehydration is associated with unscheduled ED revisits after adjustment for clinical findings. Although children experiencing revisits were likely more unwell, our data do not support the provision of intravenous fluids to prevent unscheduled ED revisits in children with mild-to-moderate dehydration.

Quasi-Experimental designs for quality improvement research

Presentation Quality Improvement (QI) research may be defined as “the design, development and evaluation of complex interventions aimed at the re-design of health care systems to produce improved outcomes”. The challenge of QI lies in bridging the gap between knowing what needs to happen at an individual patient level and implementing this at a systems level. The inherent complexity of systems poses challenges in terms of implementation, but also presents the researcher with circumstances for which conventional research methods may not prove useful. Explanatory trials are designed to answer the question “does this intervention work under ideal circumstances?” Patient and system variability are typically rigorously controlled. Pragmatic trials seek to answer how well an intervention works in usual practice [1]. It is important to contend with variation (e.g., in patient volume or complexity) and not control for it. Consider the analogy of water sampled from a pond versus a river [2]. If one takes random samples of water from a still pool of water one can draw inference about the pond as aw hole, as it is relatively static and unchanging. This is the principle we are using in attempting to extrapolate the findings of a randomized controlled trial to a population. The real world however, behaves far more like a river where the water changes from second to second, influenced by innumerable complex interacting factors such as the season, rain, construction. In QI research it is important to understand the changing nature of the river (i.e. causes of system variation) in order to be able to predict how to make an intervention work under all the conditions in which it will be expected to perform. QI research should focus therefore on robust, sequential experimentation. Too often, quality improvement investigators seek to proceed to clinical trials before sufficient exploration, investigation, and understanding of the complex system and its interactions have been achieved. Campbell et al present a trajectory for QI research required to build requisite knowledge [3]. The design and testing of complex interventions in care delivery proceeds through a series of planned stages. One begins by developing a concept or theory and then progresses to designing a prototype. Next, an intervention is piloted on a small scale before performing a detailed test and finally disseminating the ideas generated. A variety of study designs may be used as learning proceeds across this trajectory of understanding. Research methods that address issues of internal validity without randomization of individuals are referred to as “quasi-experimental” designs and include time-series, equivalent time series, multiple baseline and factorial design.

Pediatric constipation in the emergency department: evaluation, treatment, and outcomes.

Objectives: Limited knowledge exists surrounding the pharmacologic management of pediatric constipation in the emergency department (ED) setting and the success of interventions. Our primary objective was to determine whether enema administration is associated with 7-day ED revisits for persistent symptoms. Secondary objectives focused on assessing other predictors of ED revisits. Methods: We conducted a retrospective cohort study of children <18 years old, diagnosed as having constipation (International Classification of Diseases-10 codes F98.1 nonorganic encopresis, K59.0 constipation) in a pediatric ED in Toronto, Canada, between November 2008 and October 2010. Results: A total of 3592 visits were included; 6% (n = 225) were associated with a revisit. Children with revisits more frequently had vomiting (28% vs 17%, P = 0.001), more pain (5.7 ± 3.6 vs 4.6–3.6 of 10, P = 0.01), and underwent more blood tests (19% 05, 11%, 95% confidence interval [CI] of the difference 3%–14%] and diagnostic imaging (62% vs 47%, 95% CI of the difference 9%–22%). Children administered an enema were 1.54 times more likely to revisit the ED than those who did not receive an enema (8.6% vs 5.5%, 95% CI of the difference 1.1%–5.2%, P = 0.001). Type of enema administered varied by age (P < 0.001). Regression analysis identified the following independent predictors of revisits: diagnostic imaging (odds ratio [OR] 1.54, 95% CI 1.15–2.06), vomiting (OR 1.45, 95% CI 1.07–1.98), enema administration (OR 1.40, 95% CI 1.05–1.88), and significant medical history (OR 1.26, 95% CI 1.04–1.53). Conclusions: Enema administration and diagnostic imaging are associated with revisits in children diagnosed with constipation. Their role in the ED management of pediatric constipation requires further evaluation.

Predictors of clinically significant upper gastrointestinal hemorrhage among children with hematemesis.

Objectives: The aim of the study was to determine the proportion of children with hematemesis who experience a clinically significant upper gastrointestinal hemorrhage (UGIH) and to identify variables predicting their occurrence. Methods: A retrospective cohort study was conducted. All of the emergency department visits by children ages 0 to 18 years who presented with hematemesis between 2000 and 2007 were reviewed. The primary aim of the study was to determine the proportion of children who developed a clinically significant UGIH; the secondary aim was to identify risk factors predictive of a clinically significant UGIH. A significant UGIH was defined by any of the following: hemoglobin drop >20 g/L, blood transfusion, or emergent endoscopy or surgical procedure. Results: Twenty-seven of 613 eligible children (4%; 95% confidence interval 3%–6%) had a clinically significant UGIH. Clinically significant hemorrhages were associated with older age (9.7 vs 2.9 years; P < 0.001), vomiting moderate to large amounts of fresh blood (58% vs 20%; P < 0.001), melena (37% vs 5%; P < 0.001), significant medical history (63% vs 24%; P < 0.001), unwell appearance (44% vs 6%; P < 0.001), and tachycardia (41% vs 10%; P < 0.001). The frequency of laboratory investigations increased with age (P < 0.001). The hemoglobin level was the only laboratory investigation whose results differed between those with and without significant bleeds. The presence of any one of the following characteristics identified all of the children with a clinically significant hemorrhage: melena, hematochezia, unwell appearance, or a moderate to large volume of fresh blood in the vomitus, sensitivity 100% (95% confidence interval 85%–100%). Conclusions: The occurrence of a clinically significant UGIH was uncommon among children with hematemesis, especially in well-appearing children without melena, hematochezia, or who had not vomited a moderate to large amount of fresh blood.

Province-Wide Review of Pediatric Shiga Toxin-Producing Escherichia coli Case Management

Objective To identify the gaps in the care of children infected with Shiga toxin‐producing Escherichia coli (STEC), we sought to quantitate care received and management timelines. Such knowledge is crucial to the design of interventions to prevent the development of hemolytic uremic syndrome (HUS). Study design We conducted a retrospective case‐series study of 78 children infected with STEC in Alberta, Canada, through the linkage of microbiology and laboratory results, telephone health advice records, hospital charts, physician billing submissions, and outpatient antimicrobial dispensing databases. Outcomes were the time intervals between initial presentation and reporting of positive culture result and symptom onset to HUS and to describe the proportions that had baseline blood work performed and received antibiotics. Results Seventy‐eight children infected with STEC were identified; 13% (10/78) developed HUS. Median time from initial presentation to laboratory stool sample receipt was 33 hours (IQR 18, 42); time to positive culture was 120 hours (IQR 86, 205). Time from symptom onset to HUS diagnosis was 188 ± 37 hours. Baseline blood tests were obtained in 74% (58/78) of infected children. Antibiotics were administered to 50% (5/10) of those who developed HUS and 22% (15/78) of those who did not; P = .11. The provincial telephone advice system received 31 calls regarding 24 children infected with STEC; 23% (7/31) of callers were recommended to seek emergency department care. Conclusions A significant proportion of children developed HUS following multiple interactions with the health care system. Delays in the confirmation of STEC infection occurred. There are numerous opportunities to improve the timing, monitoring, and interventions in children infected with STEC.

Treating and reducing anxiety and pain in the paediatric emergency department—TIME FOR ACTION—the TRAPPED quality improvement collaborative

Background/Objectives In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period. Methods A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described. Results All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites. Conclusion While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.