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Objective: Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification., Methods: We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models., Results: Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS ( P = 0.001) and nonaccidental trauma ( P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH., Conclusions: Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the diagnostic accuracy of a rapid host-protein test for differentiating bacterial from viral infections in patients who presented to the emergency department (ED) or urgent care center (UCC)., Methods: This was a prospective multicenter, blinded study. MeMed BV (MMBV), a test based on tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), interferon gamma-inducible protein-10 (IP-10), and C-reactive protein (CRP), was measured using a rapid measurement platform. Patients were enrolled from 9 EDs and 3 UCCs in the United States and Israel. Patients >3 months of age presenting with fever and clinical suspicion of acute infection were considered eligible. MMBV results were not provided to the treating clinician. MMBV results (bacterial/viral/equivocal) were compared against a reference standard method for classification of infection etiology determined by expert panel adjudication. Experts were blinded to MMBV results. They were provided with comprehensive patient data, including laboratory, microbiological, radiological and follow-up., Results: Of 563 adults and children enrolled, 476 comprised the study population (314 adults, 162 children). The predominant clinical syndrome was respiratory tract infection (60.5% upper, 11.3% lower). MMBV demonstrated sensitivity of 90.0% (95% confidence interval [CI]: 80.3-99.7), specificity of 92.8% (90.0%-95.5%), and negative predictive value of 98.8% (96.8%-99.6%) for bacterial infections. Only 7.2% of cases yielded equivocal MMBV scores. Area under the curve for MMBV was 0.95 (0.90-0.99)., Conclusions: MMBV had a high sensitivity and specificity relative to reference standard for differentiating bacterial from viral infections. Future implementation of MMBV for patients with suspected acute infections could potentially aid with appropriate antibiotic decision-making., Competing Interests: Cesar A. Arias, Natasha Ballard, Karen C. Carroll, Andrea T. Cruz, Richard Gordon, Salim Halabi, Jeffrey D. Harris, Kristina G. Hulten, Theresa Jacob, Mark D. Kellogg, Adi Klein, Pninit Shaked Mishan, Sergey M. Motov, Octavia M. Peck‐Palmer, Leticia M. Ryan, Ma'anit Shapira, George S. Suits, Henry E. Wang, Alexandra Weissman, and Richard E. Rothman have no relevant conflict of interests to declare. Richard G. Bachur and Sheldon L. Kaplan participated in a scientific advisory board on health economic modeling for MeMed and were compensated for their time. Richard E. Rothman participated in a scientific board on health care economic modeling (without compensation). Richard G. Bachur, Sheldon L. Kaplan, and Richard E. Rothman participated in discussions with the U.S. Food and Drug Administration clearance and were involved in study design, patient recruitment, data collection and analysis, and drafting and revising the manuscript., (© 2024 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Importance: Diagnostic delays are common in the emergency department (ED) and may predispose to worse outcomes., Objective: To evaluate the association of annual pediatric volume in the ED with delayed diagnosis., Design, Setting, and Participants: This retrospective cohort study included all children younger than 18 years treated at 954 EDs in 8 states with a first-time diagnosis of any of 23 acute, serious conditions: bacterial meningitis, compartment syndrome, complicated pneumonia, craniospinal abscess, deep neck infection, ectopic pregnancy, encephalitis, intussusception, Kawasaki disease, mastoiditis, myocarditis, necrotizing fasciitis, nontraumatic intracranial hemorrhage, orbital cellulitis, osteomyelitis, ovarian torsion, pulmonary embolism, pyloric stenosis, septic arthritis, sinus venous thrombosis, slipped capital femoral epiphysis, stroke, or testicular torsion. Patients were identified using the Healthcare Cost and Utilization Project State ED and Inpatient Databases. Data were collected from January 2015 to December 2019, and data were analyzed from July to December 2023., Exposure: Annual volume of children at the first ED visited., Main Outcomes and Measures: Possible delayed diagnosis, defined as a patient with an ED discharge within 7 days prior to diagnosis. A secondary outcome was condition-specific complications. Rates of possible delayed diagnosis and complications were determined. The association of volume with delayed diagnosis across conditions was evaluated using conditional logistic regression matching on condition, age, and medical complexity. Condition-specific volume-delay associations were tested using hierarchical logistic models with log volume as the exposure, adjusting for age, sex, payer, medical complexity, and hospital urbanicity. The association of delayed diagnosis with complications by condition was then examined using logistic regressions., Results: Of 58 998 included children, 37 211 (63.1%) were male, and the mean (SD) age was 7.1 (5.8) years. A total of 6709 (11.4%) had a complex chronic condition. Delayed diagnosis occurred in 9296 (15.8%; 95% CI, 15.5-16.1). Each 2-fold increase in annual pediatric volume was associated with a 26.7% (95% CI, 22.5-30.7) decrease in possible delayed diagnosis. For 21 of 23 conditions (all except ectopic pregnancy and sinus venous thrombosis), there were decreased rates of possible delayed diagnosis with increasing ED volume. Condition-specific complications were 11.2% (95% CI, 3.1-20.0) more likely among patients with a possible delayed diagnosis compared with those without., Conclusions and Relevance: EDs with fewer pediatric encounters had more possible delayed diagnoses across 23 serious conditions. Tools to support timely diagnosis in low-volume EDs are needed.

Objective: To determine the association of emergency department (ED) volume of children and delayed diagnosis of appendicitis., Background: Delayed diagnosis of appendicitis is common in children. The association between ED volume and delayed diagnosis is uncertain, but diagnosis-specific experience might improve diagnostic timeliness., Methods: Using Healthcare Cost and Utilization Project 8-state data from 2014 to 2019, we studied all children with appendicitis <18 years old in all EDs. The main outcome was probable delayed diagnosis: >75% likelihood that a delay occurred based on a previously validated measure. Hierarchical models tested associations between ED volumes and delay, adjusting for age, sex, and chronic conditions. We compared complication rates by delayed diagnosis occurrence., Results: Among 93,136 children with appendicitis, 3,293 (3.5%) had delayed diagnosis. Each 2-fold increase in ED volume was associated with a 6.9% (95% CI: 2.2, 11.3) decreased odds of delayed diagnosis. Each 2-fold increase in appendicitis volume was associated with a 24.1% (95% CI: 21.0, 27.0) decreased odds of delay. Those with delayed diagnosis were more likely to receive intensive care [odds ratio (OR): 1.81, 95% CI: 1.48, 2.21], have perforated appendicitis (OR: 2.81, 95% CI: 2.62, 3.02), undergo abdominal abscess drainage (OR: 2.49, 95% CI: 2.16, 2.88), have multiple abdominal surgeries (OR: 2.56, 95% CI: 2.13, 3.07), or develop sepsis (OR: 2.02, 95% CI: 1.61, 2.54)., Conclusions: Higher ED volumes were associated with a lower risk of delayed diagnosis of pediatric appendicitis. Delay was associated with complications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Missed diagnosis can predispose to worse condition-specific outcomes., Objective: To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis., Methods: We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance., Results: We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis., Conclusions: Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Detection of delayed diagnosis using administrative databases may illuminate the healthcare settings at highest risk. A method for detection of delays in claims has been validated in children's hospitals. We sought to further validate the method in community emergency departments (EDs)., Methods: We studied patients <21 years old diagnosed with appendicitis from 2008 to 2019 in 8 eastern Massachusetts EDs. Eligible patients had 2 ED encounters within 7 days, the second with an appendicitis diagnosis. Delayed diagnosis was evaluated in medical records by trained reviewers. A previously validated trigger tool was applied to participants' electronic medical record data. The tool used data elements included in administrative data, including initial encounter diagnoses, time between encounters, presence of medical complexity, and ultimate length of stay. The tool assigned a probability of delayed diagnosis for each patient. Test characteristics at 4 confidence thresholds were determined, and the area under the receiver operating curve was calculated., Results: We analyzed 68 children with 2 encounters leading to a diagnosis of appendicitis (i.e., possible delay). When assigning a delayed diagnosis prediction to patients at 4 thresholds of confidence (>0%, >50%, >75%, and >90% confident), the positive predictive values were respectively 74%, 89%, 92%, and 89%; the negative predictive values were respectively 100%, 57%, 50%, and 33%. The area under the receiver operating curve was 0.837 (95% confidence interval 0.719-0.954)., Conclusions: A trigger tool that identifies delays in diagnosis using only administrative data in community EDs has a high positive predictive value for true delay. The tool may be applied in community EDs., (Copyright © 2023 by the American Academy of Pediatrics.)

Objectives: To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis., Methods: Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined., Results: Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2-89.9) and specificity of 61.3 % (95 % confidence interval 56.0-65.4)., Conclusions: Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: To derive and validate a tool that retrospectively identifies delayed diagnosis of appendicitis in administrative data with high accuracy., Design: Cross-sectional study., Setting: Five paediatric emergency departments (EDs)., Participants: 669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis., Outcome: Delayed diagnosis was defined as appendicitis being present but not diagnosed at the first ED encounter based on standardised record review. The cohort was split into derivation (2/3) and validation (1/3) groups. We derived a prediction rule using logistic regression, with covariates including variables obtainable only from administrative data. The resulting trigger tool was applied to the validation group to determine area under the curve (AUC). Test characteristics were determined at two predicted probability thresholds., Results: Delayed diagnosis occurred in 471 (70.4%) patients. The tool had an AUC of 0.892 (95% CI 0.858 to 0.925) in the derivation group and 0.859 (95% CI 0.806 to 0.912) in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% (95% CI 78.2% to 89.8%) and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% (95% CI 87.4% to 98.6%) and identified 46.8% of delayed cases., Conclusions: This tool accurately identified delayed diagnosis of appendicitis. It may be used to screen for potential missed diagnoses or to specifically identify a cohort of children with delayed diagnosis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Appendiceal diameter is a primary sonographic determinant of paediatric appendicitis. We sought to determine if the diagnostic performance of outer appendiceal diameter differs based on age or with the addition of secondary sonographic findings., Methods: We retrospectively reviewed patients aged less than 19 years who presented to the Boston Children's Hospital ED and had an ultrasound (US) for the evaluation of appendicitis between November 2015 and October 2018. Our primary outcome was the presence of appendicitis. We analysed the cases to evaluate the optimal outer appendiceal diameter as a predictor for appendicitis stratified by age (<6, 6 to <11, 11 to <19 years), and with the addition of one or more secondary sonographic findings., Results: Overall, 945 patients met criteria for inclusion, of which 43.9% had appendicitis. Overall, appendiceal diameter as a continuous measure demonstrated excellent test performance across all age groups (area under the curve (AUC) >0.95) but was most predictive of appendicitis in the youngest age group (AUC=0.99 (0.98-1.00)). Although there was no significant difference in optimal diameter threshold between age groups, both 7- and 8-mm thresholds were more predictive than 6 mm across all groups (p<0.001). The addition of individual (particularly appendicolith or echogenic fat) or combinations of secondary sonographic findings increased the diagnostic value for appendicitis above diameter alone., Conclusions: Appendiceal diameter as a continuous measure was more predictive of appendicitis in the youngest group. Across all age groups, the optimal diameter threshold was 7 mm for the diagnosis of paediatric appendicitis. The addition of individual or combination secondary sonographic findings increases diagnostic performance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Significant variation exists in the management of febrile infants, particularly those between 1 and 2 months of age. An established algorithm for well-appearing febrile infants 1-2 months of age guided clinical care for three decades in our emergency department. With mounting evidence for procalcitonin (PCT) to detect invasive bacterial infection (IBI), we revised our algorithm intending to decrease lumbar punctures (LPs) and antibiotic administration without increasing hospitalizations, revisits, or missed IBI., Methods: The algorithm's risk stratification was revised based on the expert review of evidence regarding test performance of PCT for IBI in febrile infants. With the revision, routine LP and empiric antibiotics were not recommended for low-risk infants. We used quality improvement strategies to disseminate the revised algorithm and reinforce uptake. The primary outcomes were the proportion of infants undergoing lumbar punctures or receiving antibiotics. Admission rates, 72-hour revisits requiring admission, and missed IBI were monitored as balancing measures., Results: We studied 616 infants including 326 (52.9%), after the implementation of the revised algorithm. LP was performed in 66.2% prerevision and 31.9% postrevision (34.3% absolute reduction, P < 0.001). Antibiotic administration decreased by 26.2% (pre 62.4% to post 36.2%, P < 0.001) and hospitalization rates decreased by 8.1% ( P = 0.03). There have been no missed IBIs. Adherence to the pathway led to a sustained reduction in LPs and antibiotic administration for 24 months., Conclusion: A revised pathway with the addition of PCT resulted in a safe, sustained reduction in LPs and reduced antibiotic administration in febrile infants 1-2 months of age., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives: Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking., Methods: We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis., Results: We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period., Conclusions: NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound., Study Design: We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural consolidations, stratified by the presence of larger (>1 cm) sonographic consolidations. The children were followed prospectively for 2 weeks to identify a delayed diagnosis of pneumonia., Results: A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these patients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger (>1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated subcentimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations (59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consolidations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up period., Conclusions: Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; however, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolidations should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these cases., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We aimed to characterize recent trends in bronchiolitis at US children's hospitals and to compare severity of illness in bronchiolitis in the most recent year to the previous seasonal epidemics., Methods: This is a cross-sectional study of visits for bronchiolitis in infants <24 months old from October 2016 to September 2021 at 46 US children's hospitals participating in the Pediatric Health Information Systems database. Study years were defined by 12-month periods beginning in October to account for typical winter epidemics that crossover calendar years. We used logistic and Fourier Poisson regression models to examine trends in outcomes and compare seasonality, respectively., Results: The study included 389 411 emergency visits for bronchiolitis. Median age of infants with bronchiolitis was higher in October 2020 to September 2021 compared to previous epidemics (8 and 6 months, respectively, P < .001) The odds of hospitalization, ICU admission, invasive mechanical ventilation, and noninvasive ventilation did not differ in October 2020 to September 2021 compared to previous epidemics from October 2016 to September 2020 (all P > .05 for unadjusted models and models adjusted for age). Seasonality varied significantly among these 2 periods (P < .001)., Conclusions: Although the seasonality of bronchiolitis differed in October 2020 to September 2021, severity of illness in infants with bronchiolitis was consistent with previous epidemics., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia., Methods: We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia., Results: Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73)., Conclusions: In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia., Competing Interests: This project was funded by the William F. Milton fund from Harvard University (awarded to Mark Neuman). The other authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest., Design: Multicenter retrospective cross-sectional study., Setting: Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database., Patients: Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018., Measurements and Main Results: Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0)., Conclusions: In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objectives: We examined trends in resource use for infants undergoing emergency department evaluation for serious bacterial infection, including lumbar puncture (LP), antibiotic administration, hospitalization, and procalcitonin testing, as well as the association between procalcitonin testing and LP, administration of parenteral antibiotics, and hospitalization., Methods: We performed a cross-sectional study of infants aged 0 to 60 days who underwent emergency department evaluation for serious bacterial infection with blood and urine cultures from 2010 to 2019 in 27 hospitals in the Pediatric Health Information System. We examined temporal trends in LP, antibiotic administration, hospitalization, and procalcitonin testing from 2010 to 2019. We also estimated multivariable logistic regression models for 2017-2019, adjusted for demographic factors and stratified by age (<28 and 29-60 days), with LP, antibiotic administration, and hospitalization as dependent variables and hospital-level procalcitonin testing as the independent variable., Results: We studied 106 547 index visits. From 2010 to 2019, rates of LP, antibiotic administration, and hospitalization decreased more for infants aged 29 to 60 days compared with infants aged 0 to 28 days (annual decrease in odds of LP, antibiotics administration, and hospitalization: 0 to 28 days: 5%, 5%, and 3%, respectively; 29-60 days: 15%, 12%, and 7%, respectively). Procalcitonin testing increased significantly each calendar year (odds ratio per calendar year 2.19; 95% confidence interval 1.82-2.62), with the majority (91.1%) performed during 2017-2019. From 2017 to 2019, there was no association between hospital-level procalcitonin testing and any outcome studied (all P values > .05)., Conclusions: Rates of LP, antibiotic administration, and hospitalization decreased significantly for infants 29 to 60 days during 2010-2019. Although procalcitonin testing increased during 2017-2019, we found no association with hospital-level procalcitonin testing and patterns of resource use., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objective: Diabetic ketoacidosis (DKA) is a common emergency department presentation of both new-onset and established diabetes mellitus (DM). β-Hydroxybutyrate (BOHB) provides a direct measure of the pathophysiologic derangement in DKA as compared with the nonspecific measurements of blood pH and bicarbonate. Our objective was to characterize the relationship between BOHB and DKA., Methods: This is a cross-sectional retrospective study of pediatric patients with DM presenting to an urban pediatric emergency department between January 1, 2016, and September 30, 2018. Analyses were performed on each patient's initial, simultaneous BOHB and pH. Diagnostic test characteristics of BOHB were calculated, and logistic regression was performed to investigate the effects of age and other key clinical factors., Results: Among 594 patients with DM, with median age of 12.3 years (interquartile range, 8.7-15.9 years), 176 (29.6%) presented with DKA. The inclusion of age, transfer status, and new-onset in the statistical model did not improve the prediction of DKA beyond BOHB alone. β-Hydroxybutyrate demonstrated strong discrimination for DKA, with an area under the curve of 0.95 (95% confidence interval, 0.93-0.97). A BOHB value of 5.3 mmol/L predicted DKA with optimal accuracy (90.6% of patients were correctly classified). The sensitivity, specificity, and positive and negative predictive values of this cut point were 76.7% (95% confidence interval, 69.8%-82.7%), 96.4% (94.2%-98.0%), 90.0% (84.0%-94.3%), and 90.8% (87.7%-93.3%), respectively., Conclusions: β-Hydroxybutyrate accurately predicts DKA in children and adolescents. More importantly, because plasma BOHB is the ideal biochemical marker of DKA, BOHB may provide a more optimal definition of DKA for management decisions and treatment targets., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Secondary sonographic findings of appendicitis can aid image analysis and support diagnosis with and without visualization of an appendix., Objective: We sought to determine if age affected the test performance of secondary findings for pediatric appendicitis., Materials and Methods: We performed a medical record review of emergency department patients younger than 19 years of age who had a sonogram for suspected appendicitis. Our primary patient outcome was appendicitis, as determined by pathology or by image-confirmed perforation/abscess. Our primary analysis was test performance of secondary sonographic findings as recorded by sonographers on the final diagnosis of appendicitis stratified by age (<6 years, 6 to <11 years, 11 to <19 years)., Results: A total of 1,219 patients with suspected appendicitis were evaluated by ultrasound, and 1,147 patients met the criteria for analysis. Of the 1,147 patients, 431 (37.6%) had a final diagnosis of appendicitis. Across all age groups, echogenic fat was the most accurate secondary finding (92.5% [95% confidence interval (CI): 91.0, 94.0]) and free fluid was the least accurate secondary finding (54.7% [95% CI: 51.8, 57.5]). There was no significant difference in the age-stratified test performance of secondary sonographic findings except that (1) appendicolith was a more accurate predictor in patients <6 years old than in the middle group (P<0.001) or the oldest group (P<0.001), and (2) free fluid was a more accurate predictor in the middle group than in the oldest group (P=0.02)., Conclusion: There are no significant differences in the age-stratified test performance of secondary sonographic findings in the prediction of pediatric appendicitis except that appendicolith is more predictive in younger patients., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Importance: Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear., Objective: To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes., Design, Setting, and Participants: This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis., Exposures: Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC)., Main Outcomes and Measures: Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures., Results: A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4)., Conclusions and Relevance: In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.

Background: Illness complications are condition-specific adverse outcomes. Detecting complications of pediatric illness in administrative data would facilitate widespread quality measurement, however the accuracy of such detection is unclear., Methods: We conducted a cross-sectional study of patients visiting a large pediatric emergency department. We analyzed those <22 years old from 2012 to 2019 with 1 of 14 serious conditions: appendicitis, bacterial meningitis, diabetic ketoacidosis (DKA), empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. We applied a method using disposition, diagnosis codes, and procedure codes to identify complications. The automated determination was compared with the criterion standard of manual health record review by using positive predictive values (PPVs) and negative predictive values (NPVs). Interrater reliability of manual reviews used a κ., Results: We analyzed 1534 encounters. PPVs and NPVs for complications were >80% for 8 of 14 conditions: appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. Lower PPVs for complications were observed for DKA (57%), empyema (53%), encephalitis (78%), ovarian torsion (21%), and septic arthritis (64%). A lower NPV was observed in stroke (68%). The κ between reviewers was 0.88., Conclusions: An automated method to measure complications by using administrative data can detect complications in appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. For DKA, empyema, encephalitis, ovarian torsion, septic arthritis, and stroke, the tool may be used to screen for complicated cases that may subsequently undergo manual review., Competing Interests: POTENTIAL CONFLICT OF INTEREST The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background and Objectives: There are no effective interventions to prevent hospital admissions in infants with bronchiolitis. The American Academy of Pediatrics recommends against routine bronchodilator use for bronchiolitis. The objective of this study was to characterize trends in and outcomes associated with the use of bronchodilators for bronchiolitis., Methods: This is a multicenter retrospective study of infants <12 months of age with bronchiolitis from 49 children's hospitals from 2010 to 2018. The primary outcomes were rates of hospital admissions, ICU admissions, emergency department (ED) return visits after initial ED discharge, noninvasive ventilation, and invasive ventilation. Multivariable logistic regression was used to evaluate the rates of outcomes among hospitals with high and low early use of bronchodilators (on day of presentation)., Results: A total of 446 696 ED visits of infants with bronchiolitis were included. Bronchodilator use, hospital admissions, and ED return visits decreased between 2010 and 2018 (all P < .001). ICU admissions and invasive and noninvasive ventilation increased over the study period (all P < .001). Hospital-level early bronchodilator use (hospitals with high versus low use) was not associated with differences in patient-level hospital admissions, ICU admissions, ED return visits, noninvasive ventilation, or invasive ventilation (all P > .05)., Conclusions: In a large study of infants at children's hospitals, bronchodilator therapy decreased significantly from 2010 to 2018. Hospital-level early bronchodilator use was not associated with a reduction in any outcomes. This study supports the current American Academy of Pediatrics recommendation to limit routine use of bronchodilators in infants with bronchiolitis., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objective: To estimate rates of critical medical and neurosurgical interventions and resource utilization for children with traumatic intracranial hemorrhage (ICH)., Methods: This was a retrospective study of children younger than 18 years hospitalized in 1 of 35 hospitals in the Pediatric Health Information System from 2009 to 2019 for ICH. We defined critical intervention as a critical medical (hyperosmotic agents and intubation) or neurosurgical intervention. We determined rates of critical interventions, intensive care unit (ICU) admission, and repeat neuroimaging. We used hierarchical logistic regression to identify high-level factors associated with undergoing critical interventions, controlling for hospital-level effects., Results: There were 12,714 children with ICH included in the study. Median (interquartile range) age was 4.3 (0.7-11.0) years. Twelve percent (n = 1470) of children underwent a critical clinical intervention. Critical medical interventions occurred in 10% (n = 1219), and neurosurgical interventions occurred in 3% (n = 419). Intensive care unit admission occurred in 44% (n = 5565), whereas repeat neuroimaging occurred in 40% (n = 5072). Among ICU patients, 79% (n = 4366) did not undergo a critical intervention. Of the 11,244 children with no critical interventions, 39% (n = 4366) underwent ICU admission, and 37% (n = 4099) repeat neuroimaging. After controlling for hospital, children with isolated subdural (P = 0.013) and isolated subarachnoid (P < 0.001) hemorrhage were less likely to receive critical interventions., Conclusions: Critical medical interventions occurred in 10% of children with ICH, and neurosurgical interventions occurred in 3%. Intensive care unit admission and repeat neuroimaging are common, even among those who did not undergo critical interventions. Selective utilization of ICU admission and repeat neuroimaging in children who are at low risk of requiring critical interventions could improve overall quality of care and decrease unnecessary resource utilization., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS., Data Sources: The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey., Data Collection/extraction Methods: Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown., Study Design: We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series., Principal Findings: There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95)., Conclusions: For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research., (© 2020 Health Research and Educational Trust.)

Objectives: We aimed to determine trends and institutional variation in repeat neuroimaging in children with traumatic intracranial hemorrhage and to identify factors associated with neuroimaging modality (subsequent magnetic resonance imaging [MRI] vs computed tomography [CT])., Methods: We conducted a retrospective cross-sectional study of 35 hospitals in the Pediatric Health Information System database. We included children <18 years of age hospitalized from 2010-2019 with intracranial hemorrhage and who underwent a brain CT. We calculated repeat neuroimaging rates by modality and used regression analyses to examine temporal trends. We used hierarchical logistic regression to identify factors associated with subsequent MRI versus repeat CT, controlling for hospital., Results: We identified 12,714 children with intracranial hemorrhage, of which 5072 with repeat neuroimaging were studied. Of the 5072 children with repeat neuroimaging, repeat CT was performed in 67.6% (n = 3429) and subsequent MRI in 32.4% (n = 1643). Overall repeat neuroimaging with either a CT or MRI remained similar from 2010-2019 ( P  = 0.431); however, repeat CT scans significantly decreased ( P  = 0.001); whereas, MRIs significantly increased ( P  < 0.001). Repeat neuroimaging by hospital ranged from 20%-80%. After controlling for institution, subsequent MRI was more likely to be used in younger children and children who did not receive hyperosmotic agents, neurosurgical interventions, or intensive care unit admission (all P -values <0.001)., Conclusions: We found that repeat neuroimaging rates for children with intracranial hemorrhage vary substantially by institution. We also found that although MRI was increasingly used to re-image these children, overall repeat neuroimaging rates (CT or MRI) have not decreased over the past decade. Future work to implement optimal utilization of neuroimaging in these children is needed., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization., Methods: Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate., Results: Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P < 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P < 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Vascular endothelial growth factor (VEGF) and its receptor, soluble fms-like tyrosine kinase (sFLT), are biomarkers of endothelial activation. Vascular endothelial growth factor and sFLT have been associated with sepsis severity among adults, but pediatric data are lacking. The goal of this study was to assess VEGF and sFLT as predictors of outcome for children with sepsis., Methods: Biomarkers measured for each patient at time of presentation to the emergency department were compared in children with septic shock versus children with sepsis without shock. For children with septic shock, the associations between biomarker levels and clinical outcome measures, including intensive care unit and hospital length of stay, vasoactive inotrope score, and measures of organ dysfunction, were assessed., Results: Soluble fms-like tyrosine kinase and VEGF were elevated in children with septic shock (n = 73) compared with those with sepsis (n = 93). Elevated sFLT but not VEGF was associated with longer intensive care unit length of stay (P = 0.003), longer time requiring vasoactive agents (P < 0.001), higher maximum vasoactive inotrope score (P < 0.001), and higher maximum pediatric logistic organ dysfunction score (P < 0.001)., Conclusions: Vascular endothelial growth factor and sFLT measured in the emergency department are elevated in children with septic shock, and elevated sFLT but not VEGF is associated with worse clinical outcomes.

Objective: The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions., Methods: We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model., Results: The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years., Conclusions: The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

Objectives: Screening for urinary tract infection (UTI) includes urinary nitrite testing by dipstick urinalysis. Gram-negative enteric organisms produce urinary nitrite and represent the most common uropathogens. Enterococcus, a less common uropathogen, does not produce nitrite and has a unique antibiotic resistance pattern. Whether to adjust empiric antibiotics in the absence of urinary nitrite has not been established. Our primary objective was to determine prevalence of enterococcal UTI among young children with a nitrite negative urinalysis., Methods: A retrospective study of children aged less than 2 years evaluated in the emergency department for possible UTI and had a paired urinalysis and urine culture was performed. Urinary tract infection was defined by catheterized culture yielding greater than or equal to 50,000 colony-forming units per milliliter of a single uropathogen. Prevalence of uropathogens among nitrite negative samples was studied., Results: A total of 7599 children were studied. Median (interquartile range) age was 5.6 (2.3-11.2) months, and 57% were female. Prevalence of UTI was 8.1%. Enterococcus was the uropathogen in 2.1% of UTIs, and all cases had negative dipstick nitrite. Among nitrite negative UTIs, 95.6% of uropathogens were gram-negative and only 3.2% (confidence interval, 1.8%-5.3%) were enterococcus. None of the 200 UTIs with positive nitrite yielded enterococcus (upper confidence interval, 1.4%). Among children with positive leukocyte esterase and negative nitrite, only 0.7% of cases had enterococcal UTI., Conclusions: Only 3% of nitrite negative UTIs were caused by enterococcus. Given the low prevalence of enterococcal UTI, the absence of dipstick nitrite should not affect routine empiric antibiotic choice for presumptive UTI in young children.

Background: Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described., Objective: The objective was to characterize the critically ill pediatric EM case exposure among EM residents., Methods: This is a secondary analysis of a multicenter retrospective review of pediatric patients (aged < 18 years) seen by the 2015 graduating resident physicians at four U.S. EM training programs. The per-resident exposure to Emergency Severity Index (ESI) Level 1 pediatric patients was measured. Resident-level counts of pediatric patients were measured; specific counts were classified by age and Pediatric Emergency Care Applied Network diagnostic categories., Results: There were 31,552 children seen by 51 residents across all programs; 434 children (1.3%) had an ESI of 1. The median patient age was 8 years (interquartile range [IQR] 3-12 years). The median overall pediatric critical case exposure per resident was 6 (IQR 3-12 cases). The median trauma and medical exposure was 2 (IQR 0-3) and 3 (IQR 2-10), respectively. For 13 out of 20 diagnostic categories, at least 50% of residents did not see any critical care case in that category. Sixty-eight percent of residents saw 10 or fewer critically ill cases by the end of training., Conclusion: Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To compare the clinical presentation of intussusception among children younger and older than 24 months of age., Design/methods: We performed a retrospective cross-sectional cohort study of children treated in the emergency department, aged 1 month to 6 years, who had an abdominal ultrasound to evaluate for intussusception over a 5-year period. After stratifying by an age cut-point of 24 months, univariate and multivariate analyses were performed., Results: One thousand two hundred fifty-eight cases of suspected intussusception were studied; median age was 1.7 years (interquartile range, 0.8, 2.9 years), and 37% were female. Intussusception was identified in 176 children (14%); 153 (87%) were ileocolic, and 23 were ileoileal. Abdominal pain (odds ratio, 4.0; 95% confidence interval [CI], 1.5-10.5), emesis (OR, 3.5; 95% CI, 1.8-6.7), bilious emesis (OR, 2.9; 95% CI, 1.5-5.7), lethargy (OR, 2.3; 95% CI, 1.3-5.7), rectal bleeding (OR, 2.8; 95% CI, 1.4-5.7), and irritability (OR, 0.4; 95% CI, 0.2-0.8) were found to be predictors in those younger than 24 months. In children older than 24 months, male sex was the only predictor identified (OR, 2.0; 95% CI, 1.1-3.7). In cases where abdominal radiographs were obtained (n = 1212), any abnormality on abdominal radiograph was found to be predictive in both age groups (OR, 7.8; 95% CI, 3.8-25.7; and OR, 3.1; 95% CI, 1.8-5.2, respectively)., Conclusions: Intussusception presents differently in children younger than 24 months compared with older children. "Traditional" clinical predictors of intussusception should be interpreted with caution when assessing children older than 2 years.

Objectives: Using case review to determine whether a patient experienced a delayed diagnosis is challenging. Measurement would be more accurate if case reviewers had access to multi-expert consensus on grading the likelihood of delayed diagnosis. Our objective was to use expert consensus to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis., Methods: Case vignettes were constructed for each condition. In each vignette, a patient has the condition and had a previous emergency department (ED) visit within 7 days. Condition-specific multi-specialty expert Delphi panels reviewed the case vignettes and graded the likelihood of a delayed diagnosis on a five-point scale. Delayed diagnosis was defined as the condition being present during the previous ED visit. Consensus was defined as ≥75% agreement. In each Delphi round, panelists were given the scores from the previous round and asked to rescore. A case scoring guide was created from the consensus scores., Results: Eighteen expert panelists participated. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes. We reached consensus on 23/30 (77%) DKA vignettes. A case review guide was created from the consensus scores., Conclusions: Multi-specialty expert reviewers can agree on the likelihood of a delayed diagnosis for cases of appendicitis and sepsis, and for most cases of DKA. We created a guide that can be used by researchers and quality improvement specialists to allow for objective case review to determine when delayed diagnoses have occurred for appendicitis, DKA, and sepsis., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Isolated amnesia is an uncommon presenting complaint in the pediatric age group. We report the case of an 18-year-old woman who presented with the acute onset of memory difficulty and an otherwise normal neurologic examination. Brain magnetic resonance imaging demonstrated inflammation in the bilateral temporal lobes. Serum and cerebrospinal fluid testing ultimately revealed a diagnosis of autoimmune encephalitis. Although rare, the acute onset of isolated amnesia deserves a prompt, comprehensive evaluation.

Objectives: The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility., Methods: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer., Results: Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission., Conclusions: Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

Objective: We sought to assess interrater reliability (IRR) of lung point-of-care ultrasound (POCUS) findings among pediatric patients with suspected pneumonia., Methods: A convenience sample of patients between the ages of 6 months and 18 years with a clinical suspicion of pneumonia had a lung ultrasound performed by a POCUS-credentialed emergency medicine physician with subsequent expert review. Each lung zone was assessed as either normal or abnormal, and specific ultrasound findings were recorded. IRR was assessed by intraclass correlation coefficient (ICC) and kappa statistics., Results: Seventy-one patients, with a total of 852 lung zones imaged, were included. The sonographer assessment of normal versus abnormal, across each of the zones, demonstrated moderate agreement with ICC 0.46 (95% CI: 0.41, 0.52) and kappa 0.56. Right-sided zones demonstrated moderate agreement [0.43 (CI 0.35, 0.51)] while left-sided zones, specifically left-sided anterior zones, showed only fair agreement [0.36 (0.28, 0.44)]. IRR varied between specific findings: ICC for B-lines 0.52 (95% CI: 0.46, 0.57), pleural effusion 0.40 (0.34, 0.45), consolidation 0.39 (0.33, 0.44), subpleural consolidation 0.31 (0.25, 0.37), and pleural line irregularity 0.16 (0.10, 0.23). A composite indicator of typical pneumonia findings (consolidation, B-lines, and pleural effusion) demonstrated moderate [ICC 0.52 (0.46, 0.57)] reliability., Conclusions: We found moderate interrater reliability of lung POCUS findings for the assessment of pediatric patients with suspected pneumonia. B-lines had the highest reliability. Further assessment of lung POCUS is necessary to guide proper training and optimal scanning techniques to ensure adequate reliability of ultrasound findings in the assessment of pediatric pneumonia., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care., Methods: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability., Results: The national median HCI was 0.06 (interquartile range: 0.01-0.17) in 2008 and 0.02 (interquartile range: 0.00-0.09) in 2016 ( P < .001). Definitive care became less common regardless of annual pediatric volume, urban or rural designation, or condition frequency. In 2016, 2171 EDs (49.0%) had HCIs <0.013, which represented the lowest 25% of ED HCIs in 2008. Pediatric visits to EDs categorized in the bottom 2008 capability quartile more than doubled from 2.5 million in 2008 to 5.3 million in 2016. Despite decreasing capability, centers with higher annual pediatric volume and urban centers provided more definitive inpatient care and had fewer inter-ED transfers than lower-volume and rural centers., Conclusions: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Objective: To investigate the risk of critical illness by age group among young children without a chronic condition presenting to the emergency department (ED) with suspected influenza., Study Design: Retrospective study of patients aged <2 years presenting to the ED with suspected influenza (defined by diagnostic codes for influenza or influenza-like illness) from 2009 to 2017 in 49 hospitals in the Pediatric Health Information System. Patients with chronic conditions were excluded. The main clinical outcomes were intensive care unit (ICU) admission, ventilatory support, vasopressor administration, and mortality, which were compared independently by age group (<3 months, 3 to <6 months, 6 to <12 months, and 12 to <24 months). To compare outcomes by age, we estimated the prevalence of each outcome by age group after fitting logistic regression models to control for demographic differences between groups., Results: A total of 55 986 children were studied. Overall admission and ICU admission rates were 20% and 2%, respectively. After adjustment for demographic variables, infants aged <3 months had higher rates of ICU admission (2.7%; 95% CI, 2.0%-3.3%; P < .001 compared with other age groups) and ventilatory support (2.5%; 95% CI, 1.9%-3.2%; P < .001 compared with other age groups); however, there were no differences in vasopressor administration. The overall case fatality rate was low (0.007%) and thus could not be compared across age groups., Conclusions: Infants aged <3 months with suspected influenza are at greatest risk for critical illness. Although critical illness is uncommon, these findings should be incorporated into acute management decisions, including the need for specified outpatient follow-up or hospitalization, and public health efforts should focus on prevention and disease-modifying interventions in this high-risk population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Delayed diagnoses of serious emergency conditions can lead to morbidity in children, but are challenging to identify and measure. We developed and piloted an automated tool for identifying delayed diagnosis of two serious conditions commonly seen in the ED using administrative data., Methods: We identified cases with a final diagnosis of appendicitis or sepsis in a freestanding children's hospital from 2008 to 2018, with any hospital ED encounter within the preceding 7 days. Two investigators reviewed a subset of these cases using the electronic health records (EHR) to determine if there was a delayed diagnosis and interrater reliability was assessed using the intraclass correlation coefficient (ICC). An automated tool was applied to the same cases to assess its positive predictive value (PPV) to identify those with a delayed diagnosis, using the manual chart review as the gold standard. The tool used number of days since visit, presence of a related diagnosis on the initial visit, and whether or not the patient was discharged., Results: Previous ED encounters preceded 91/3703 (2.5%) appendicitis cases and 159/1754 (9.1%) sepsis cases; 78 cases of each were sampled for review. In manual review, 73.4% and 22.8% were thought to have delayed diagnoses; reviewer agreement was excellent (appendicitis ICC 0.77, 95% CI 0.62 to 0.86 and sepsis ICC 0.77, 95% CI 0.43 to 0.89). The PPVs of the automated tool for determination of delayed diagnosis for appendicitis within 1, 3 or 7 days were 96.2%, 95.1% and 93.6%, respectively. For sepsis, the PPVs were 71.4%, 63.6% and 41.2% within 1, 3 or 7 days, respectively., Conclusions: This automated tool performed well compared with expert EHR review. Performance was stronger for appendicitis. Further tool refinement could improve performance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications., Study Design: Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges., Results: We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke)., Conclusions: Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: As both fever and pneumonia can be associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia., Methods: In this retrospective cross-sectional analysis of 91,429 children < 5 years of age presenting to an urban pediatric emergency department, the relationship between triage RR and temperature was analyzed using regression analysis. We assessed the predictive value of temperature-adjusted RR for the diagnosis of pneumonia; diagnostic performance was evaluated for continuous RR as well as World Health Organization (WHO) age-based RR thresholds., Results: The mean RR increased 2.6 breaths/minute for each 1°C increase in temperature. Interpatient variability was comparatively large; at any temperature, the interquartile range (75th percentile minus 25th percentile) varied from 4 to 16 breaths/minute. For predicting pneumonia, temperature- and age-adjusted RR was superior to age-adjusted RR: area under the curve (AUC) = 0.76 (95% confidence interval [CI], 0.75-0.78) versus AUC = 0.73 (95% CI, 0.72-0.75), respectively. Using WHO RR criteria, temperature-adjusted RR improved diagnostic discrimination, as the AUC increased from 0.58 (95% CI, 0.57-0.59) to 0.72 (95% CI, 0.70-0.73)., Conclusions: The effects of temperature on respiratory rate are modest, with a mean increase of 2.6 breaths/minute for each 1°C rise in temperature. Despite considerable interpatient variability in respiratory rates by temperature, temperature adjustment improves the diagnostic value of respiratory rate for pneumonia., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Oral antibiotics effectively treat most pediatric urinary tract infections (UTIs); however, children with UTIs are frequently admitted. We examined variation and trends in admission for children with UTIs plus investigated the relationship between admission and emergency department (ED) revisits for those initially managed on an outpatient basis. We hypothesized that hospitals would have similar 3-day revisit rates regardless of the admission rate at the index visit., Methods: This was a retrospective analysis of 36 hospitals in the Pediatric Health Information System. ED visits for children aged <2 years presenting with UTI between 2010 and 2016 were studied. Main outcomes were age-stratified and included admission and 3-day ED revisit rates. Regression analyses were used to test hospital-level associations between outcomes and linear temporal trends., Results: A total of 41,792 visits were studied. The overall admission rate was 27%. The admission rate was 89% for children aged <2 months and 15% for those aged 2 to 24 months. Interhospital admission rates varied from 6% to 64%. Admission and revisit rates were inversely related (mean change, -0.07; 95% confidence interval [CI], -0.13 to -0.02 per 1% increase in admission rate); however, lower admission rates were not associated with increased revisits leading to admission (mean change, -0.02; 95% CI, -0.07 to 0.03). Over the study period, admission rates were stable (test for linear trend: adjusted odds ratio [aOR], 0.99; 95% CI, 0.95-1.02); however, among infants aged <2 months, admissions decreased (aOR, 0.92; 95% CI, 0.88-0.97)., Conclusions: A substantial variation in admission rates exists for children with UTI. Although hospitals with lower admission rates had higher revisit rates, those hospitals did not have an increase in revisits with subsequent admission, supporting the goal of outpatient management., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Biomarkers that can measure illness severity and predict the risk of delayed recovery may be useful in guiding pediatric septic shock. Amino-terminal pro-B-type natriuretic peptide has not been assessed in pediatric septic patients at the time of presentation to the emergency department prior to any interventions. The primary aim was to assess if emergency department amino-terminal pro-B-type natriuretic peptide is associated with worse outcomes and severity of illness., Design: Prospective observational pilot study., Settings: Tertiary free-standing children's hospital., Patients: Children 0-17 years old with a diagnosis of septic shock were enrolled. Patients with preexisting cardiac and renal dysfunction were excluded., Interventions: None., Measurements and Main Results: Amino-terminal pro-B-type natriuretic peptide analysis was performed on samples obtained in the emergency department prior to any intervention. The association between biomarkers and clinical outcomes and illness severity using Pediatric RISk of Mortality 3 were assessed. Eighty-two patients with septic shock underwent analysis. The median (interquartile range) amino-terminal pro-B-type natriuretic peptide levels was 394 pg/mL (102-1,392 pg/mL). Each decile change increase in amino-terminal pro-B-type natriuretic peptide was associated with a change in ICU length of stay by 8.7%, (95% CI, 2.4-15.5), hospital length of stay by 5.7% (95% CI, 0.4-11.2), organ dysfunction by 5.1% (95% CI, 1.8-8.5), a higher inotropic score at 12, 24, and 36 hours, and longer time requiring vasoactive agents. There was a significant correlation between baseline amino-terminal pro-B-type natriuretic peptide and the Pediatric RISk of Mortality 3 score (Spearman rho = 0.247; p = 0.029)., Conclusions: This pilot study shows an association between emergency department amino-terminal pro-B-type natriuretic peptide on presentation and worse septic shock outcomes and amino-terminal pro-B-type natriuretic peptide levels correlates with an ICU severity score.

Objectives: The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers., Methods: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training., Results: The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest., Conclusions: Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Objective: To improve the prediction of pediatric pneumonia by developing a series of models based on clinically distinct subgroups. We hypothesized that these subgroup models would provide superior estimates of pneumonia risk compared with a single pediatric model., Study Design: We conducted a secondary analysis of a prospective cohort being evaluated for radiographic pneumonia in an urban pediatric emergency department (ED). Using multivariate modeling, we created 4 models across subgroups stratified by age and presence of wheezing to predict the risk of pneumonia., Results: A total of 2351 patients were included in the study. In this series, the prevalence of pneumonia was 8.5%, and 21.6% were hospitalized. The highest prevalence of pneumonia was in children aged >2 years without wheezing (13.3%). Children aged <2 years with wheezing had the lowest prevalence of pneumonia (4.0%). The most accurate model was for children aged <2 years with wheezing (area under the curve [AUC], 0.80), and the poorest performing model was for those aged <2 years without wheezing (AUC, 0.64). The AUC of a combination of the 4 subgroup models was 0.76 (95% CI, 0.72-0.80). The precision of the models' estimates (expected vs observed) was ± 3.7%., Conclusions: Using 4 complementary prediction models for pediatric pneumonia, an accurate risk of pneumonia can be calculated. These models can provide the basis for clinical decision making support to guide the use of chest radiographs and promote antibiotic stewardship., (Copyright © 2018 Elsevier Inc. All rights reserved.)