OBJECTIVEThe objective of this study was to compare the duration of analgesia, need for analgesic medications, and pain-related nursing interventions in patients who did and did not receive ...ultrasound-guided femoral nerve blocks for femur fracture pain.
METHODSThis is a retrospective, preimplementation and postimplementation cohort study. An emergency department log of patients receiving femoral nerve blocks for femur fracture pain was compared with a similar cohort of patients with femur fractures who did not receive nerve blocks. The primary outcome is time from initial pain treatment until the next dose of analgesic. Data were analyzed using Kaplan-Meier methods. Secondary outcomes include number of doses of pain medication, total amount of morphine given, and number of pain-related nursing interventions. Data were analyzed with the Mann-Whitney U test.
RESULTSEighty-one patients met inclusion/exclusion criteria50 in the preimplementation cohort and 31 in the postimplementation group. The median times until next dose of analgesic medication were 2.2 hours (interquartile range IQR, 1.2–3.4 hours) in the preimplementation group and 6.1 hours (IQR, 3.8–9.5 hours) in the postimplementation group (P < 0.001). The median numbers of doses of pain medication were 0.3 per hour (IQR, 0.25–0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.07–0.3 per hour) in the postimplementation group. The median total doses of morphine were 14.8 µg/kg per hour (IQR, 9.4–19.2 µg/kg per hour) in the preimplementation group and 6.5 µg/kg per hour (IQR, 0–12.2 µg/kg per hour) in the postimplementation group (P = 0.01). The median numbers of nursing interventions were 0.4 per hour (IQR, 0.25–0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.1–0.2 per hour) in the postimplementation group (P < 0.001).
CONCLUSIONSPatients who received ultrasound-guided femoral nerve block for femur fracture pain had longer duration of analgesia, required fewer doses of analgesic medications, and needed fewer nursing interventions than those receiving systemic analgesic medication alone.
Studies have shown an increase in the use of antipsychotics to preschoolers for disruptive behavior and aggression. This study investigated the use of atypical antipsychotics in children ≤6 years of ...age in Kentucky who were on Medicaid.
Kentucky Medicaid prescription claims data between 2001 and 2010 were examined for all children ≤6 years of age who had received an atypical antipsychotic. Drug type, diagnosis codes, and geographic trends were analyzed using descriptive statistics.
A total of 70,777 prescriptions were written to 6915 distinct children ≤6 years of age. The use of atypical antipsychotics in this age group increased over the years 2001-2010 with a peak ∼ 1.0% in 2004, and averaged 0.75% in 2010. Older male children were more likely to receive atypical antipsychotics, and risperidone accounted for two thirds of the prescriptions written. Mood disorders, primarily bipolar disorder, accounted for almost 75% of the diagnoses provided. Only 32% of the prescriptions were written by child psychiatrists. Geographic analysis showed significantly higher use in the Western part of the state (more than three times the state mean in some counties).
The use of atypical antipsychotics in children ≤6 years of age has declined from its peak, but remains substantial. The prescription rates for atypical antipsychotics by providers other than child psychiatrists, and the marked geographic variation in use across the state of Kentucky suggest that improved systems of mental healthcare for this population are needed.
Training residents to be scholars is endorsed by leading medical education organizations. Our previous research suggests that the scholarly activity (SA) training experience is highly variable across ...pediatric residency programs, and residents and program directors (PDs) are generally dissatisfied. Understanding how PD and resident views align can help programs better guide resource allocation and improvement efforts.
We conducted cross-sectional surveys of second and third year pediatric residents and PDs at 22 diverse US categorical programs. We compared resident and PD responses to SA training beliefs, barriers, and satisfaction by 2-proportion z tests. We used descriptive statistics to describe resident responses in relation to same-institution PD responses.
About 464 of 771 residents (60.2%) and 22 PDs (100%) responded. Across programs, PDs more strongly agreed that all residents should participate in SA (59% of PDs n = 13 versus 27% of residents n = 127, P = .002). Residents more strongly believed all residents should have protected SA time (91% of residents n = 424 versus 68% of PDs n = 15, P = .001). PDs more strongly perceived gaps in other resources as barriers, including lack of funding to conduct or present SA (P < .001, P = .02), lack of statistical support (P = .03), and lack of faculty mentorship (P < .001). Within program concordance was low.
Discordance exists between PDs and residents with respect to SA participation and necessary resources, particularly, protected time. Programs must help residents identify when SA can be accomplished. Clearer national guidelines around SA training may also be necessary to reduce discordance and improve perceptions.
Abstract Objective To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis. Methods Patients with suspected ...appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8–18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with <10% missing data and kappa > 0.4 were entered into a multivariable model. Resultant β-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios. Results The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval CI, 20%–29%), specificity of 98% (95% CI, 96%–99%), and positive predictive value of 93% (95% CI, 86%–97%) for ruling in appendicitis. Conclusions We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging.
OBJECTIVETo determine outpatient pediatricians’ self-reported experience with and preparation for patient emergencies, and their awareness of the American Academy of Pediatrics (AAP) policy statement ...on outpatient emergency preparedness.
METHODSA 34-question cross-sectional survey of outpatient pediatric faculty and gratis faculty from the sole medical school in a metropolitan area was used to assess demographic information, training, and equipment for patient emergencies and familiarity with the AAP policy.
RESULTSOf the 57 responses from 123 surveyed physicians (46% response rate), 23% worked in academics and 70% in private practice. At least 1 emergency per month was reported by 39%; 75% referred a patient to the emergency department or hospital at least monthly. Current Pediatric Advanced Life Support (PALS) certification was maintained by 21%, and 42% had current Basic Life Support (BLS). The majority (79%) agreed that respiratory emergencies were most common. Almost all had bag-valve mask (96%) in the office; however, only 65% had oropharyngeal airways. All reported feeling comfortable performing bag-valve mask ventilation, but only 68% reported the same comfort level with oropharyngeal airways. About half (44%) had intubation equipment, and about half (47%) had automated external defibrillators. Only 25% performed mock emergencies. About half of pediatricians (53%) reported awareness of the 2007 AAP policy guideline, and one quarter (23%) thought their office met guideline recommendations.
CONCLUSIONSAlthough emergencies occur frequently in general pediatric offices, pediatricians may not have adequate emergency equipment and training. Variable preparedness reflects the need for greater awareness of and compliance with the AAP policy.
OBJECTIVESkin and soft tissue infections are a major public health issue. Previous literature suggests a recurrence rate of 4% in children. The purpose of this study was to examine the epidemiology, ...body location, and history of previous infections among children in the emergency department setting.
METHODSA retrospective study was performed using electronic medical records from all subjects treated in a large pediatric emergency department with attending physician diagnosis and billing codes indicative of a cutaneous abscess from July 1, 2007, to December 31, 2007. Descriptive statistics were used to evaluate abscess location, prior history of infection, bacterial etiology, and patient disposition.
RESULTSThree hundred eighteen abscess visits occurred in 308 individual subjects; 79% were due to methicillin-resistant Staphylococcus aureus. Approximately 14% of subjects presented with more than 1 abscess. Those 2 years or younger were more likely to have buttock abscesses (P < 0.001). Of the 192 subjects for whom responses were documented, 82 (43%) had a history of a prior abscess. Children 2 years or younger were significantly more likely to be hospitalized or go to the operating room49% versus 15% (P < 0.001).
CONCLUSIONSMany children with a cutaneous abscess have a prior history of infection. Multiple abscesses are common. Young children are more likely to have abscesses in the diaper area or be hospitalized. Studies of effective hygiene practices and interventions to reduce recurrence are urgently needed.
Objective
The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the ...cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals.
Methods
This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours’ duration.
Results
Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (–0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites.
Conclusions
Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.
Objective
White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical ...pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age‐adjusted.
Methods
This is a multicenter prospective observational study of patients aged 3–18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5–11, and 12–18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut‐points.
Results
A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0–13.9 years) were studied. Forty‐one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval CI = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5–11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12–18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut‐point of 10,000/mm3, the sensitivity decreased with increasing age: 95% (<5 years), 91% (5–11 years), and 89% (12–18 years) whereas specificity increased by age: 36% (<5 years), 49% (5–12 years), and 64% (12–18 years).
Conclusion
WBC count and ANC had better diagnostic performance with increasing age. Age‐adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.
Little is known about how parents utilize medical information on the Internet prior to an emergency department (ED) visit.
The objective of the study was to determine the proportion of parents who ...accessed the Internet for medical information related to their child's illness in the 24 hours prior to an ED visit (IPED), to identify the websites used, and to understand how the content contributed to the decision to visit the ED.
A 40-question interview was conducted with parents presenting to an ED within a freestanding children's hospital. If parents reported IPED, the number and names of websites were documented. Parents indicated the helpfulness of Web-based content using a 100-mm visual analog scale and the degree to which it contributed to the decision to visit the ED using 5-point Likert-type responses.
About 11.8 % (31/262) reported IPED (95% CI 7.3-5.3). Parents who reported IPED were more likely to have at least some college education (P=.04), higher annual household income (P=.001), and older children (P=.04) than those who did not report IPED. About 35% (11/31) could not name any websites used. Mean level of helpfulness of Web-based content was 62 mm (standard deviation, SD=25 mm). After Internet use, some parents (29%, 9/31) were more certain they needed to visit the ED, whereas 19% (6/31) were less certain. A majority (87%, 195/224) of parents who used the Internet stated that they would be somewhat likely or very likely to visit a website recommended by a physician.
Nearly 1 out of 8 parents presenting to an urban pediatric ED reported using the Internet in the 24 hours prior to the ED visit. Among privately insured, at least one in 5 parents reported using the Internet prior to visiting the ED. Web-based medical information often influences decision making regarding ED utilization. Pediatric providers should provide parents with recommendations for high-quality sources of health information available on the Internet.
PDF
