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Background: Children with ventricular shunts undergo frequent neuroimaging in the emergency department (ED) to evaluate for possible shunt malfunctions. Historically, the primary imaging modality has been computed tomography (CT), which exposes patients to ionizing radiation and an increase in the lifetime risk of malignancy. “Rapid” magnetic resonance imaging (rMRI) is an accurate and feasible alternative to CT for shunt evaluations. Therefore, we sought to reduce use of CT and increase use of rMRI as the primary neuroimaging study for the evaluation of suspected shunt malfunction. Specifically, we aimed to reduce the proportion of head CTs among …

BACKGROUND: Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. METHODS: We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. RESULTS: Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8–15.4), 608 (0.5%, 95% confidence interval: 0.5%–0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%–0.1%) (P < .001 for each). CONCLUSIONS: A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.

Background. Headache is a common complaint among children in the emergency department (ED). Although usually benign in nature, some headaches are secondary to serious neurologic diagnoses (SND). We seek to characterize the proportion of patients discharged from the ED with a diagnosis of headache and found to have SNDs during subsequent visits. Methods. We performed a multicenter retrospective cohort study using data from forty-eight pediatric hospitals in the Pediatric Health Information System between October 1, 2015 and March 31, 2019. We included patients ≤18 years discharged from the ED with an ICD-10 primary diagnosis code for headache. …

BACKGROUND: Emergency departments (EDs) vary in their level of readiness to care for pediatric emergencies. We evaluated the effect of ED pediatric readiness on the mortality of critically ill children. METHODS: We conducted a retrospective cohort study in Florida, Iowa, Massachusetts, Nebraska, and New York, focusing on patients aged 0 to 18 years with critical illness, defined as requiring intensive care admission or experiencing death during the encounter. We used ED and inpatient administrative data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project linked to hospital-specific data from the 2013 National Pediatric Readiness Project. The relationship between hospital-specific pediatric readiness and encounter mortality in the entire cohort and in condition-specific subgroups was evaluated by using multivariable logistic regression and fractional polynomials. RESULTS: We studied 20 483 critically ill children presenting to 426 hospitals. The median weighted pediatric readiness score was 74.8 (interquartile range: 59.3–88.0; range: 29.6–100). Unadjusted in-hospital mortality decreased with increasing readiness score (mortality by lowest to highest readiness quartile: 11.1%, 5.4%, 4.9%, and 3.4%; P < .001 for trend). Adjusting for age, chronic complex conditions, and severity of illness, presentation to a hospital in the highest readiness quartile was associated with decreased odds of in-hospital mortality (adjusted odds ratio compared with the lowest quartile: 0.25; 95% confidence interval: 0.18–0.37; P < .001). Similar results were seen in specific subgroups. CONCLUSIONS: Presentation to hospitals with a high pediatric readiness score is associated with decreased mortality. Efforts to increase ED readiness for pediatric emergencies may improve patient outcomes.

The authors of this study evaluate the effect of the 2013 New York State sepsis regulations on pediatric sepsis outcomes using a comparative interrupted time-series analytic approach. BACKGROUND: In 2013, New York introduced regulations mandating that hospitals develop pediatric-specific protocols for sepsis recognition and treatment. METHODS: We used hospital discharge data from 2011 to 2015 to compare changes in pediatric sepsis outcomes in New York and 4 control states: Florida, Massachusetts, Maryland, and New Jersey. We examined the effect of the New York regulations on 30-day in-hospital mortality using a comparative interrupted time-series approach, controlling for patient and hospital characteristics and preregulation temporal trends. RESULTS: We studied 9436 children admitted to 237 hospitals. Unadjusted pediatric sepsis mortality decreased in both New York (14.0% to 11.5%) and control states (14.4% to 11.2%). In the primary analysis, there was no significant effect of the regulations on mortality trends (differential quarterly change in mortality in New York compared with control states: −0.96%; 95% confidence interval [CI]: −1.95% to 0.02%; P = .06). However, in a prespecified sensitivity analysis excluding metropolitan New York hospitals that participated in earlier sepsis quality improvement, the regulations were associated with improved mortality trends (differential change: −2.08%; 95% CI: −3.79% to −0.37%; P = .02). The regulations were also associated with improved mortality trends in several prespecified subgroups, including previously healthy children (differential change: −1.36%; 95% CI: −2.62% to −0.09%; P = .04) and children not admitted through the emergency department (differential change: −2.42%; 95% CI: −4.24% to −0.61%; P = .01). CONCLUSIONS: Implementation of statewide sepsis regulations was generally associated with improved mortality trends in New York State, particularly in prespecified subpopulations of patients, suggesting that the regulations were successful in affecting sepsis outcomes.

OBJECTIVE: To determine the interrater reliability of clinical examination by pediatric emergency medicine physicians for the diagnosis of skin and soft-tissue infections (SSTIs). METHODS: A cross-sectional study of patients presenting to a pediatric emergency department with SSTIs was performed. Each lesion was examined by a treating physician and a study physician (from a pool of 62 physicians) at the bedside during the emergency department visit. The primary outcome was reliability, as measured with the weighted κ statistic, for determining whether the lesion was an abscess and whether the lesion required a drainage procedure. RESULTS: A total of 371 lesions were analyzed for interrater reliability. The weighted κ value for diagnosis of the lesion as an abscess was 0.39 (95% confidence interval: 0.32–0.47), and that for assessment of the need for drainage was 0.43 (95% confidence interval: 0.36–0.51). Agreement was statistically more likely for lesions in children ≥4 years of age but was not more likely for lesions in nonblack patients, lesions in patients with a history of or exposure to a close contact with a SSTI, or lesions examined by 2 experienced pediatric emergency medicine physicians. CONCLUSIONS: Among the 62 participating physicians at our site, the reliability of the clinical examination was poor. This may indicate that improved education and/or more-objective means for diagnosing these infections in the acute care setting are warranted. Additional studies are needed to determine whether these results are generalizable to other settings.