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Objectives: Patients with febrile neutropenia are at high risk of morbidity and mortality from infectious causes. Decreasing time to antibiotic (TTA) administration is associated with improved patient outcomes. We sought to reduce TTA for children presenting to the emergency department with fever and neutropenia., Methods: In a prospective cohort study with historical comparison, TTA administration was evaluated in patients with neutropenia presenting to the Children's of Alabama Emergency Department. A protocol was established to reduce delays in antibiotic administration and increase the percentage of patients who receive treatment within 60 minutes of presentation. One hundred pre-protocol patient visits between August 2010 and December 2011 were evaluated and 153 post-protocol visits were evaluated between August 2012 and September 2013. We reviewed individual cases to determine barriers to rapid antibiotic administration., Results: Antibiotics were administered in 96.9 ± 57.8 minutes in the pre-protocol patient group, and only 35% of patients received antibiotics within 60 minutes of presentation and 70% received antibiotics within 120 minutes. After implementation of the protocol, TTA for neutropenic patients was decreased to 64.3 ± 28.4 minutes (P < 0.0001) with 51.4% receiving antibiotics within 60 minutes and 93.2% within 120 minutes., Conclusions: Implementing a standard approach to patients at risk for neutropenia decreased TTA. There are numerous challenges in providing timely antibiotics to children with febrile neutropenia. Identified delays included venous access (time to effect of topical anesthetics, and difficulty obtaining access), physicians waiting on laboratory results, and antibiotic availability.

Objective: To 1) determine the prevalence of hypoglycemia in childhood in a pediatric emergency department (ED), 2) determine epidemiology of idiopathic ketotic hypoglycemia (IKH), 3) determine diagnostic yield of the workup of hypoglycemia, and 4) review a diagnostic approach to hypoglycemia., Setting: Urban pediatric ED of a tertiary level children's hospital., Methods: Retrospective review of all medical records with a primary or secondary diagnosis of hypoglycemia (ICD-9 code 251.2) seen at the ED between 1/92 and 8/95., Results: Thirty-one patients were identified. Mean blood glucose was 34.2 mg/dl. Prevalence of hypoglycemia among population seeking care in our ED was 6.54/100,000 visits. Eighteen patients were diagnosed with IKH for a prevalence of 3.9/100,000. IKH demographics were: mean age 27.7 months; 12 males, 6 females; 8 white, 9 black, and 1 not available. The weights of five patients were < 25th percentile. Fourteen of the 18 IKH patients had hormone studies done insulin [cost $40], growth hormone [$69], cortisol [$54]. All 14 had appropriately suppressed insulin levels (< 5microU/ml) and high cortisol levels > 22 microg/ml. Thirteen of the 14 had normal or high growth hormone (GH) levels (0.7-6 ng/ml). Four IKH patients had urine drug screens ($280); all were negative. Although no IKH patient was febrile, six had sepsis workups ($380); all were negative. Urine ketones were positive in 15 of the 18 tested (> 3+ in eight patients). Mean anion gap was 20 (range: 16-30). Eight of the 18 IKH patients were discharged from the ED after return to normal status., Conclusions: IKH is the most common cause of hypoglycemia in children beyond the infancy period. In its typical presentation (previously healthy one- to five-year-old, with normal growth and development, who presents with a first episode of symptomatic fasting hypoglycemia and appropriate degree of ketonuria, without hepatomegaly, and with resolution of symptoms on administration of glucose), an extensive and overzealous workup for endocrinopathy or inborn error of metabolism is not necessary.