Search

Pediatric mental health presentations continue to increase across the US. These patients often board for significant periods of time and may require more resources than other acute non-mental health patients. This has important implications for the overall function of the emergency department (ED) as well as care of all ED patients. This study evaluated a policy developed to allow for inpatient hospital admission when 30% of the ED was occupied by boarding patients at a tertiary care children's hospital. We found an increase in the number of patients for whom this policy applied, and increased days/month this policy was executed over time. There was an increase in the average ED LOS and left without being seen rate during this time which we hypothesize would have been higher without this policy. A hospital policy allowing mental health patients to be admitted to the inpatient hospital once stabilized has the potential to improve ED flow and functionality. [ABSTRACT FROM AUTHOR]

Background: Migraine headaches are a common reason for pediatric emergency department (ED) visits. Small studies suggest the potential efficacy of sub-anesthetic doses of propofol for migraine with a favorable side effect profile and potentially decreased length of stay (LOS).Objective: The objective of this study was to compare the efficacy of low-dose propofol (LDP) to standard therapy (ST) in pediatric migraine treatment.Methods: We conducted a prospective, pragmatic randomized controlled trial from April 2014 through June 2016 in the ED at two pediatric hospitals. Patients aged 7-19 years were eligible if they were diagnosed with migraine by the emergency physician and had a presenting visual analog pain score (VAS) of 6-10. Primary outcome was the percent of pain reduction. Secondary outcomes were ED LOS, 24-h rebound headache, return visits to the ED, and adverse reactions.Results: Seventy-four patients were enrolled, but 8 were excluded, leaving 66 patients in the final analysis (36 ST, 30 LDP). Pain reduction was 59% for ST and 51% for LDP (p = 0.34) with 72.2% vs. 73.3% achieving a VAS ≤ 4 with initial therapy (p = 0.92). There was a nonsignificant trend toward shorter median LOS from drug administration to final disposition favoring propofol (79 min vs. 111 min; p = 0.09). Rebound headache was significantly more common in the ST vs. LDP group (66.7% vs. 25.0%; p = 0.01).Conclusions: LDP did not achieve better pain reduction than ST, however, LDP was associated with significantly fewer rebound headaches and a nonsignificant trend toward shorter median LOS from drug administration to disposition. [ABSTRACT FROM AUTHOR]

Adolescent ingestions are common reasons for calls to poison centers in United States. As opposed to younger children who mostly have unintentional exposures, adolescent ingestions often result from intentional use. This manuscript reviews recent reports on adolescent ingestions related to intentional abuse, self-harm, and use of opioid medications. [ABSTRACT FROM AUTHOR]

Purpose Suicide attempts by adolescents most commonly involve the overdose of medications. To date, there has been little information on the over-the-counter or prescription medicines that adolescents ingest for self-harm. Identification of medications chosen in suicide attempts may help guide anticipatory guidance to parents by primary care providers and Poison Centers in prevention programs. Methods This was a retrospective observational study using the American Association of Poison Control Center's National Poison Data System. Data were collected on patients aged 13–19 years old at the time of their substance ingestion, between the years 2004 and 2013 and that were coded as reason for ingestion of “intentional-suspected suicide.” Results During the 10-year study period, there were 390,560 poison center calls for intentional-suspected suicide in the United States between 2004 and 2013, accounting for 80.3% of all “intentional” ingestion calls in the adolescent population. Over the entire age range, the most common substance ingested included acetaminophen (10.9%), ibuprofen (9%), selective serotonin reuptake inhibitors (7.7%), atypical antipsychotic (6%), and antihistamines (5%). The most common medications coded as resulting in major clinical effects or death were antidepressants and atypical antipsychotics. Conclusions Adolescent ingestion choices for suicide attempts have remained relatively consistent over the past 10 years. However, there was a recent decrease in selective serotonin reuptake inhibitor ingestions. The most common medications used in an overdose attempt were ibuprofen and acetaminophen. Further preventative efforts are needed in this at-risk population from multiple providers at various levels. [ABSTRACT FROM AUTHOR]

Objective: To describe the inpatient management of pediatric migraine and the association between specific medications and hospital length of stay (LOS).Study Design: Historical cohort study review of patients age <19 years of age admitted to a single tertiary care children's hospital between 2010 and 2015 for treatment of migraine headache.Results: The cohort consisted of 58 encounters with an average patient age of 14.3 years (SD 3.2 years) with a female predominance (62%). The mean number of inpatient medications received by patients was 3 (range 1-7), with dopamine antagonists and dihydroergotamine used most commonly (67% and 59% of encounters, respectively). The average LOS was 56 hours (95% CI 48.2-63.2) and did not vary by medication received, although patients who received an opioid had a significantly longer LOS (79.2 vs 47.9 hours respectively; P < .001).Conclusions: Children admitted to the hospital for treatment of migraine headache frequently require a large number of medications over an average hospital LOS of more than 2 days without apparent differences based on medication received other than prolonged stays for subjects who received opioids. [ABSTRACT FROM AUTHOR]

Background: Opioid abuse is a public health epidemic in the United States. Much literature has focused on the prescribing practices of physicians and opioid misuse by adults. However, there are limited data on the effect of opioid prescriptions on adolescent recreational ingestion of these medications.Objectives: The objective of this study was to assess for a relationship between opioid prescribing practices across the United States and adolescent opioid ingestion calls to poison centers.Methods: This was an observational study using the National Poison Data System. The study population consisted of poison center calls regarding adolescents between 2005 and 2010 in the database with a coding of "intentional abuse" and an opioid ingestion. National opioid prescription estimates were generated using nationally representative outpatient and inpatient databases.Results: There were 4186 adolescent opioid ingestion calls during the study period. There was a general increase between 2005 and 2010 in both teen opioid abuse calls (617 in 2005 to 782 in 2010) and national opioid prescriptions (approximately 78 million in 2005 to 108 million in 2010). For each opioid prescription increase per 100 persons per year, the annual teen opioid abuse calls increased by 1.8% (95% confidence interval 0.9-2.8%), equivalent to an absolute increase of about 0.04 to 0.05 calls per 100,000 teens annually.Conclusions: There appears to be an association between opioid prescriptions nationally and poison center calls for adolescent opioid ingestions. This is particularly important in this patient population because of impulsivity and early exposure to substance abuse. Providers should be aware of the nonmedical use of opioids by adolescents and educate patients accordingly. [ABSTRACT FROM AUTHOR]

Objective: To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample. Study design: This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine. Results: Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non–evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning. Conclusions: There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED. [Copyright &y& Elsevier]

Background: Anomalous aortic origin of a coronary artery from the opposite sinus with an intramural course between the great arteries (AAOCA) is associated with ischemia and sudden cardiac death in children, and surgical unroofing has been used to alleviate that risk. Methods: The cardiology database was reviewed to identify all patients with AAOCA who underwent surgical unroofing 10 years. Results: From March 1999 to September 2009, 27 patients with a mean age of 12.6 ± 3.5 years (range, 4–20 years) had surgical unroofing of AAOCA of the left coronary from the right sinus (left AAOCA, 7/27, 26%) or of the right coronary from the left sinus (right AAOCA, 20/27, 74%). Of these, 26 had diagnoses made by transthoracic echocardiography. Symptoms included resuscitated sudden cardiac death in 3, syncope in 8, and chest pain in 4. No symptoms were present in 12 cases of serendipitous diagnosis. Unroofing of the intramural portion was successfully performed in all cases. A slitlike coronary orifice was described at surgical inspection in 12 patients, 7 of whom had right AAOCA and no symptoms. All patients after unroofing have patent coronary flow by Doppler and normal echocardiography and exercise treadmill testing at mean follow-up of 1.8 years. None have activity restrictions. Conclusions: AAOCA is frequently characterized by an intramural course, which can be reliably identified by echocardiography. This form can be safely repaired by unroofing the intramural segment without early morbidity. Symptoms of possible ischemia are common but not always correlated with coronary ostial findings at surgery. [Copyright &y& Elsevier]

Objectives: To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type.Study Design: A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7-17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit.Results: A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P < .001). Pediatricians were less likely to prescribe opioids in both ED (-2.70 percentage point; 95% CI, -3.53 to -1.88) and ambulatory settings (-0.31 percentage point; 95% CI, -0.54 to -0.08; P < .001).Conclusions: Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts. [ABSTRACT FROM AUTHOR]

Background: The assessment of capillary refill time (CRT) is a common physical examination technique. However, despite its importance and its widespread use, there is little standardization, which can lead to inaccurate assessments.Objective: In this article, we assessed how different physicians estimate CRT. We hypothesized that when different physicians are presented with the same recordings of CRT, clinicians will, on average, provide different CRT estimates.Methods: Using recordings of different fingertip compressions, physicians assessed and documented when capillary refill had returned to normal. Videos were recorded of the fingertips only, with no other identifying markers or subject characteristics provided. Videos were shown at one-quarter speed to allow time for recognition and response to the capillary refill. The primary outcome was physician estimates of CRT for each video recording.Results: An analysis of variance regression revealed significant differences in physician estimates of CRT when examining the same CRT videos from 34 subjects. Further regression analyses reveal the importance of controlling for the physician that is examining the patient when predicting a patient's CRT.Conclusions: Results indicate that some physicians gave, on average, slower CRT estimates, whereas others gave, on average, faster CRT estimates. Objective approaches and innovations in assessment of capillary refill have the potential to increase the diagnostic accuracy of this important clinical examination finding. [ABSTRACT FROM AUTHOR]

Background: Pediatric emergency department (PED) visits among children and adolescents with acute mental health needs have increased over the past decade with long wait times in the PED awaiting disposition.Objective: The objective of this study was to evaluate the effect of a new pediatric mental health liaison program with the hypothesis that this model reduces length of stay (LOS) and hospitalization rates among pediatric mental health patients.Methods: This was a pre- and postintervention retrospective study of the year prior to (June 2012-June 2013) and the year after (October 2013-October 2014) implementation of a new PED psychiatric team. All patients aged 1-18 years with a mental health International Classification of Diseases-9(th) Revision code were included. Patients who did not receive a Psychiatry consult in the PED were excluded.Results: There were 83 encounters in the year prior to and 129 encounters in the year after the implementation of the liaison program. There was an increase in the suicidality of mental health patients during this time. There was a significant decrease in mean PED LOS of 27% (95% confidence interval [CI] 0-46%; p = 0.05) from pre- to postintervention period. The decrease in the proportion of patients admitted/transferred to an inpatient psychiatric facility in the postintervention year was statistically significant (odds ratio 0.35; 95% CI 0.17-0.71; p < 0.01).Conclusions: The use of a dedicated child psychiatrist and mental health social worker to the PED results in significantly decreased LOS and need for admission without any change in return visit rate. Larger, multicenter studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]