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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.)

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.)

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.)

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.)

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.)

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.

Background: Although oral antibiotics are recommended for the management of most urinary tract infections (UTIs), the administration of parenteral antibiotics before emergency department (ED) discharge is common. We investigated the relationship between the administration of a single dose of parenteral antibiotics before ED discharge and revisits requiring admission among children with UTIs., Methods: A retrospective analysis of administrative data from 36 pediatric hospitals was performed. Patients aged 29 days to 2 years who were evaluated in the ED with a UTI between 2010 and 2016 were studied. Primary outcome was adjusted 3-day ED revisit rates resulting in admission. All revisits, regardless of disposition, served as a secondary outcome. Average treatment effects were estimated by using inverse probability weighted regression, with adjustment for demographic factors, diagnostic testing, ED medications, and hospital-level factors., Results: We studied 29 919 children with a median age of 8.6 (interquartile range: 5.1-13.8) months. Of those studied, 36% of the children received parenteral antibiotics before discharge. Patients who received parenteral antibiotics had similar adjusted rates of revisits leading to admission as those who did not receive parenteral antibiotics (1.3% vs 1.0%, respectively; risk difference: 0.3% [95% confidence interval: -0.01% to 0.6%]), although overall revisit rates were higher among patients who received parenteral antibiotics (4.8% vs 3.3%; risk difference 1.5% [95% confidence interval: 0.9% to 2.1%])., Conclusions: Among discharged patients, a parenteral dose of antibiotics did not reduce revisits leading to admission, supporting the goal of discharging patients with oral antibiotics alone for most children with UTIs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

: media-1vid110.1542/5804413949001PEDS-VA&#95;2018-0236 Video Abstract BACKGROUND AND OBJECTIVES: The ability of the chest radiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia., Methods: Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit., Results: There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4-5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%-99.6%)., Conclusions: A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background: Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED., Methods: We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location., Results: Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36)., Conclusions: Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background: Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated., Methods: We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type., Results: Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303-209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789-73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis., Conclusions: In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives: We sought to develop and validate a clinical calculator that can be used to quantify risk for appendicitis on a continuous scale for patients with acute abdominal pain., Methods: The pediatric appendicitis risk calculator (pARC) was developed and validated through secondary analyses of 3 distinct cohorts. The derivation sample included visits to 9 pediatric emergency departments between March 2009 and April 2010. The validation sample included visits to a single pediatric emergency department from 2003 to 2004 and 2013 to 2015. Variables evaluated were as follows: age, sex, temperature, nausea and/or vomiting, pain duration, pain location, pain with walking, pain migration, guarding, white blood cell count, and absolute neutrophil count. We used stepwise regression to develop and select the best model. Test performance of the pARC was compared with the Pediatric Appendicitis Score (PAS)., Results: The derivation sample included 2423 children, 40% of whom had appendicitis. The validation sample included 1426 children, 35% of whom had appendicitis. The final pARC model included the following variables: sex, age, duration of pain, guarding, pain migration, maximal tenderness in the right-lower quadrant, and absolute neutrophil count. In the validation sample, the pARC exhibited near perfect calibration and a high degree of discrimination (area under the curve: 0.85; 95% confidence interval: 0.83 to 0.87) and outperformed the PAS (area under the curve: 0.77; 95% confidence interval: 0.75 to 0.80). By using the pARC, almost half of patients in the validation cohort could be accurately classified as at <15% risk or ≥85% risk for appendicitis, whereas only 23% would be identified as having a comparable PAS of <3 or >8., Conclusions: In our validation cohort of patients with acute abdominal pain, the pARC accurately quantified risk for appendicitis., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. The funding agencies took no part in data analysis, interpretation, or manuscript preparation. No person received any honorarium or other payment to produce this manuscript. This article was written by Dr Anupam Kharbanda, and all authors take full responsibility for the integrity of the data and the accuracy of data analysis., (Copyright © 2018 by the American Academy of Pediatrics.)

Background and Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) has a low rate of survival to hospital discharge. Understanding whether pediatric emergency departments (EDs) have higher survival than general EDs may help identify ways to improve care for all patients with OHCA. We sought to determine if OHCA survival differs between pediatric and general EDs., Methods: We used the 2009-2014 Nationwide Emergency Department Sample to study children under 18 with cardiac arrest. We compared pediatric EDs (those with >75% pediatric visits) to general EDs on the outcome of survival to hospital discharge or transfer. We determined unadjusted and adjusted survival, accounting for age, region, and injury severity. Analyses were stratified by nontraumatic versus traumatic cause., Results: The incidences of nontraumatic and traumatic OHCA were 7.91 (95% confidence interval [CI]: 7.52-8.30) and 2.67 (95% CI: 2.49-2.85) per 100 000 person years. In nontraumatic OHCA, unadjusted survival was higher in pediatric EDs than general EDs (33.8% vs 18.9%, P < .001). The adjusted odds ratio of survival in pediatric versus general EDs was 2.2 (95% CI: 1.7-2.8). Children with traumatic OHCA had similar survival in pediatric and general EDs (31.7% vs 26.1%, P = .14; adjusted odds ratio = 1.3 [95% CI: 0.8-2.1])., Conclusions: In a nationally representative sample, survival from nontraumatic OHCA was higher in pediatric EDs than general EDs. Survival did not differ in traumatic OHCA. Identifying the features of pediatric ED OHCA care leading to higher survival could be translated into improved survival for children nationally., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background and Objectives: Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization., Methods: Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up., Results: 99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy., Conclusions: A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Bachur holds a patent for biomarkers of appendicitis (US 8535891 B2) and has had research support from Astute Medical, Inc (San Diego, CA); and Drs Lipsett and Monuteaux have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background and Objectives: In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children., Methods: We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain (<96 hours). Time of initial physical examination and time of operation were recorded. The presence of AP was determined using operative reports. We analyzed whether duration of time from initial ED physician evaluation to operation impacted the odds of AP using multivariable logistic regression, adjusting for traditionally suggested risk factors that increase the risk of perforation. We also modeled the odds of perforation in a subpopulation of patients without perforation on computed tomography., Results: Of 955 children with appendicitis, 25.9% ( n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8-8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96-1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89-1.02)., Conclusions: Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objectives: Unlike community-acquired pneumonia (CAP), there is a paucity of data characterizing the patient demographics and hospitalization characteristics of children with aspiration pneumonia. We used a large national database of US children's hospitals to assess the patient and hospitalization characteristics associated with aspiration pneumonia and compared these characteristics to patients with CAP., Methods: We identified children hospitalized with a diagnosis of aspiration pneumonia or CAP at 47 hospitals included in the Pediatric Health Information System between 2009 and 2014. We evaluated whether differences exist in patient characteristics (median age and proportion of patients with a complex chronic condition), and hospital characteristics (length of stay, ICU admission, cost, and 30-day readmission rate) between children with aspiration pneumonia and CAP. Lastly, we assessed whether seasonal variability exists within these 2 conditions., Results: Over the 6-year study period, there were 12 097 children hospitalized with aspiration pneumonia, and 121 489 with CAP. Compared with children with CAP, children with aspiration pneumonia were slightly younger and more likely to have an associated complex chronic condition. Those with aspiration pneumonia had longer hospitalizations, higher rates of ICU admission, and higher 30-day readmission rates. Additionally, the median cost for hospitalization was 2.4 times higher for children with aspiration pneumonia than for children with CAP. More seasonal variation was observed for CAP compared with aspiration pneumonia hospitalizations., Conclusions: Aspiration pneumonia preferentially affects children with medical complexity and, as such, accounts for longer and more costly hospitalizations and higher rates of ICU admission and readmission rates., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: Varying urine white blood cell (WBC) thresholds have been recommended for the presumptive diagnosis of urinary tract infection (UTI) among young infants. These thresholds have not been studied with newer automated urinalysis systems that analyze uncentrifuged urine that might be influenced by urine concentration. Our objective was to determine the optimal urine WBC threshold for UTI in young infants by using an automated urinalysis system, stratified by urine concentration., Methods: Retrospective cross-sectional study of infants aged <3 months evaluated for UTI in the emergency department with paired urinalysis and urine culture. UTI was defined as ≥50 000 colony-forming units/mL from catheterized specimens. Test characteristics were calculated across a range of WBC and leukocyte esterase (LE) cut-points, dichotomized into specific gravity groups (dilute <1.015; concentrated ≥1.015)., Results: Twenty-seven thousand infants with a median age of 1.7 months were studied. UTI prevalence was 7.8%. Optimal WBC cut-points were 3 WBC/high-power field (HPF) in dilute urine (likelihood ratio positive [LR+] 9.9, likelihood ratio negative [LR‒] 0.15) and 6 WBC/HPF (LR+ 10.1, LR‒ 0.17) in concentrated urine. For dipstick analysis, positive LE has excellent test characteristics regardless of urine concentration (LR+ 22.1, LR‒ 0.12 in dilute urine; LR+ 31.6, LR‒ 0.22 in concentrated urine)., Conclusions: Urine concentration should be incorporated into the interpretation of automated microscopic urinalysis in young infants. Pyuria thresholds of 3 WBC/HPF in dilute urine and 6 WBC/HPF in concentrated urine are recommended for the presumptive diagnosis of UTI. Without correction of specific gravity, positive LE by automated dipstick is a reliably strong indicator of UTI., (Copyright © 2016 by the American Academy of Pediatrics.)

Objective: Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries., Methods: We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time., Results: We included 6851 ED visits of which 4242 (62%) occurred in the post-guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation., Conclusions: An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries., (Copyright © 2015 by the American Academy of Pediatrics.)

Background and Objectives: Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits., Methods: Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit., Results: The study identified 32,124 children with migraine; 27,317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists., Conclusions: The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return., (Copyright © 2015 by the American Academy of Pediatrics.)

Objectives: We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours., Methods: We conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours., Results: Overall, 24,905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions., Conclusions: A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

Background and Objectives: Diagnostic imaging is often used in the evaluation of children with possible appendicitis. The utility of imaging may vary according to a patient's age and gender. The objectives of this study were (1) to examine the use of computed tomography (CT) and ultrasound for age and gender subgroups of children undergoing an appendectomy; and (2) to study the association between imaging and negative appendectomy rates (NARs) among these subgroups., Methods: Retrospective review of children presenting to 40 US pediatric emergency departments from 2005 to 2009 (Pediatric Health Information Systems database). Children undergoing an appendectomy were stratified by age and gender for measuring the association between ultrasound and CT use and the outcome of negative appendectomy., Results: A total of 8 959 155 visits at 40 pediatric emergency departments were investigated; 55 227 children had appendicitis. The NAR was 3.6%. NARs were highest for children younger than 5 years (boys 16.8%, girls 14.6%) and girls older than 10 years (4.8%). At the institutional level, increased rates of diagnostic imaging (ultrasound and/or CT) were associated with lower NARs for all age and gender subgroups other than children younger than 5 years, The NAR was 1.2% for boys older than 5 years without any diagnostic imaging., Conclusions: The impact of diagnostic imaging on negative appendectomy rate varies by age and gender. Diagnostic imaging for boys older than 5 years with suspected appendicitis has no meaningful impact on NAR. Diagnostic strategies for possible appendicitis should incorporate the risk of negative appendectomy by age and gender.

Objective: Our objective was to determine the interrater reliability of clinical history and physical examination findings in children undergoing evaluation for possible appendicitis in a large, multicenter cohort., Methods: We conducted a prospective, multicenter, cross-sectional study of children aged 3-18 years with possible appendicitis. Two clinicians independently evaluated patients and completed structured case report forms within 60 minutes of each other and without knowing the results of diagnostic imaging. We calculated raw agreement and assessed reliability by using the unweighted Cohen κ statistic with 2-sided 95% confidence intervals., Results: A total of 811 patients had 2 assessments completed, and 599 (74%) had 2 assessments completed within 60 minutes. Seventy-five percent of paired assessments were completed by pediatric emergency physicians. Raw agreement ranged from 64.9% to 92.3% for history variables and 4 of 6 variables had moderate interrater reliability (κ > .4). The highest κ values were noted for duration of pain (κ = .56 [95% confidence intervals .51-.61]) and history of emesis (.84 [.80-.89]). For physical examination variables, raw agreement ranged from 60.9% to 98.7%, with 4 of 8 variables exhibiting moderate reliability. Among physical examination variables, the highest κ values were noted for abdominal pain with walking, jumping, or coughing (.54 [.45-.63]) and presence of any abdominal tenderness on examination (.49 [.19-.80])., Conclusions: Interrater reliability of patient history and physical examination variables was generally fair to moderate. Those variables with higher interrater reliability are more appropriate for inclusion in clinical prediction rules in children with possible appendicitis.

Objective: To study the association between historical and physical examination findings and radiographic pneumonia in children who present with suspicion for pneumonia in the emergency department, and to develop a clinical decision rule for the use of chest radiography., Methods: We conducted a prospective cohort study in an urban pediatric emergency department of patients younger than 21 who had a chest radiograph performed for suspicion of pneumonia (n = 2574). Pneumonia was categorized into 2 groups on the basis of an attending radiologist interpretation of the chest radiograph: radiographic pneumonia (includes definite and equivocal cases of pneumonia) and definite pneumonia. We estimated a multivariate logistic regression model with pneumonia status as the dependent variable and the historical and physical examination findings as the independent variables. We also performed a recursive partitioning analysis., Results: Sixteen percent of patients had radiographic pneumonia. History of chest pain, focal rales, duration of fever, and oximetry levels at triage were significant predictors of pneumonia. The presence of tachypnea, retractions, and grunting were not associated with pneumonia. Hypoxia (oxygen saturation ≤92%) was the strongest predictor of pneumonia (odds ratio: 3.6 [95% confidence interval (CI): 2.0-6.8]). Recursive partitioning analysis revealed that among subjects with O₂ saturation >92%, no history of fever, no focal decreased breath sounds, and no focal rales, the rate of radiographic pneumonia was 7.6% (95% CI: 5.3-10.0) and definite pneumonia was 2.9% (95% CI: 1.4-4.4)., Conclusion: Historical and physical examination findings can be used to risk stratify children for risk of radiographic pneumonia.

Sport-related concussion is a common injury in children and adolescents. Athletes seldom report concussive symptoms, which makes the diagnosis a challenge. The management of sport-related concussion has changed significantly over the last several years. The previously used grading systems and return-to-play guidelines have been abandoned in favor of more individualized assessment and management. Neuropsychological testing is being used more frequently to assist in management. After recovery, it is recommended that an athlete's return-to-play progress in a gradual, stepwise fashion while being monitored by a health care provider. Proper assessment and management of a sport-related concussion is crucial, because repeat concussions can result in decreased neurocognitive functioning, increased symptomatology, and, at times, catastrophic outcomes.

Background: Some children who present with fever and erythroderma have rapid clinical deterioration or progress to toxic shock syndrome. Our primary objective was to determine whether specific clinical features of those who present with fever and erythroderma can predict who will develop hypotension or progress to toxic shock syndrome. Our secondary objective was to describe the clinical presentation, course, and outcome of children with fever and erythroderma., Methods: We conducted a medical chart review of children < or = 19 years of age with fever and erythroderma who presented to an urban pediatric emergency department over 60 months. Historical, clinical, and laboratory data were abstracted from the medical chart., Results: Fifty-six patients with fever and erythroderma were studied. Eighteen percent of patients presented with hypotension. Thirty-three percent of the remaining patients who were normotensive on arrival developed shock. Fifty-two percent of patients with hypotension required vasopressor support. The most important predictors of developing hypotension after presentation were: age > or = 3 years, ill appearance, vomiting, glucose > or = 110 mg/dL, calcium < or = 8.6 mg/dL, platelets < or = 300,000/microL, elevated creatinine, polymorphonuclear leukocytes > or = 80%, and presence of a focal infection. Among all patients studied, 4 variables were determined to be the most important predictors of developing toxic shock syndrome: age > or = 3 years, ill appearance, elevated creatinine, and hypotension on arrival., Conclusions: Overall, 45% of patients with fever and erythroderma developed shock, including 33% of those who were normotensive on presentation. Older age, presence of vomiting, identification of a focal bacterial source, as well as specific laboratory parameters can be used to help predict which patients are likely to have hemodynamic deterioration. Given the high rate of clinical decompensation, all of the patients with fever and erythroderma should be hospitalized, closely monitored, and managed aggressively.

Objective: Computed tomography (CT) has gained widespread acceptance in the evaluation of children with suspected appendicitis. Concern has been raised regarding the long-term effects of ionizing radiation. Other means of diagnosing appendicitis, such as clinical scores, are lacking in children. We sought to develop a clinical decision rule to predict which children with acute abdominal pain do not have appendicitis., Methods: Prospective cohort study was conducted of children and adolescents who aged 3 to 18 years, had signs and symptoms suspicious for appendicitis, and presented to the emergency department between April 2003 and July 2004. Standardized data-collection forms were completed on eligible patients. Two low-risk clinical decision rules were created and validated using logistic regression and recursive partitioning. The sensitivity, negative predictive value (NPV), and negative likelihood ratio of each clinical rule were compared., Results: A total of 601 patients were enrolled. Using logistic regression, we created a 6-part score that consisted of nausea (2 points), history of focal right lower quadrant pain (2 points), migration of pain (1 point), difficulty walking (1 point), rebound tenderness/pain with percussion (2 points), and absolute neutrophil count of >6.75 x 10(3)/microL (6 points). A score < or =5 had a sensitivity of 96.3% (95% confidence interval [CI]: 87.5-99.0), NPV of 95.6% (95% CI: 90.8-99.0), and negative likelihood ratio of .102 (95% CI: 0.026-0.405) in the validation set. Using recursive partitioning, a second low-risk decision rule was developed consisting of absolute neutrophil count of <6.75 x 10(3)/microL, absence of nausea, and absence of maximal tenderness in the right lower quadrant. This rule had a sensitivity of 98.1% (95% CI: 90.1-99.9), NPV of 97.5% (95% CI: 86.8-99.9), and negative likelihood ratio of 0.058 (95% CI: 0.008-0.411) in the validation set. Theoretical application of the low-risk rules would have resulted in a 20% reduction in CT., Conclusions: Our low-risk decision rules can predict accurately which children are at low risk for appendicitis and could be treated safely with careful observation rather than CT examination.

Objective: To develop a data-derived model for predicting serious bacterial infection (SBI) among febrile infants <3 months old., Methods: All infants /=38.0 degrees C seen in an urban emergency department (ED) were retrospectively identified. SBI was defined as a positive culture of urine, blood, or cerebrospinal fluid. Tree-structured analysis via recursive partitioning was used to develop the model. SBI or No-SBI was the dichotomous outcome variable, and age, temperature, urinalysis (UA), white blood cell (WBC) count, absolute neutrophil count, and cerebrospinal fluid WBC were entered as potential predictors. The model was tested by V-fold cross-validation., Results: Of 5279 febrile infants studied, SBI was diagnosed in 373 patients (7%): 316 urinary tract infections (UTIs), 17 meningitis, and 59 bacteremia (8 with meningitis, 11 with UTIs). The model sequentially used 4 clinical parameters to define high-risk patients: positive UA, WBC count >/=20 000/mm(3) or /=39.6 degrees C, and age <13 days. The sensitivity of the model for SBI is 82% (95% confidence interval [CI]: 78%-86%) and the negative predictive value is 98.3% (95% CI: 97.8%-98.7%). The negative predictive value for bacteremia or meningitis is 99.6% (95% CI: 99.4%-99.8%). The relative risk between high- and low-risk groups is 12.1 (95% CI: 9.3-15.6). Sixty-six SBI patients (18%) were misclassified into the lower risk group: 51 UTIs, 14 with bacteremia, and 1 with meningitis., Conclusions: Decision-tree analysis using common clinical variables can reasonably predict febrile infants at high-risk for SBI. Sequential use of UA, WBC count, temperature, and age can identify infants who are at high risk of SBI with a relative risk of 12.1 compared with lower-risk infants.