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Objectives Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits. Methods We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1–18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI. Results Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74. Conclusions Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.

BACKGROUND AND OBJECTIVES: Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years. METHODS: Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1–16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013–2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use. RESULTS: A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3–1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1–1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9–2.3]) experienced the highest likelihood for sustaining high ED use. CONCLUSIONS: One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.

The use of abdominal radiographs contributes to increased healthcare costs, radiation exposure, and potentially to misdiagnoses. We evaluated the association between abdominal radiograph performance and emergency department (ED) revisits with important alternate diagnosis among children with constipation.Retrospective cohort study of children aged18 years diagnosed with constipation at one of 23 EDs from 2004 to 2015. The primary exposure was abdominal radiograph performance. The primary outcome was a 3-day ED revisit with a clinically important alternate diagnosis. RAND/University of California, Los Angeles methodology was used to define whether the revisit was related to the index visit and due to a clinically important condition other than constipation. Regression analysis was performed to identify exposures independently related to the primary outcome.A total of 65.7% (185 439/282 225) of children with constipation had an index ED visit abdominal radiograph performed. Three-day revisits occurred in 3.7% (10 566/282 225) of children, and 0.28% (784/282 225) returned with a clinically important alternate related diagnosis. Appendicitis was the most common such revisit, accounting for 34.1% of all 3-day clinically important related revisits. Children who had an abdominal radiograph performed were more likely to have a 3-day revisit with a clinically important alternate related diagnosis (0.33% vs 0.17%; difference 0.17%; 95% CI 0.13-0.20). Following adjustment for covariates, abdominal radiograph performance was associated with a 3-day revisit with a clinically important alternate diagnosis (aOR: 1.39; 95% CI 1.15-1.67). Additional characteristics associated with the primary outcome included narcotic (aOR: 2.63) and antiemetic (aOR: 2.35) administration and underlying comorbidities (aOR: 2.52).Among children diagnosed with constipation, abdominal radiograph performance is associated with an increased risk of a revisit with a clinically important alternate related diagnosis.

OBJECTIVE. We evaluated the diagnostic utility of the presence and number of cerebrospinal fluid (CSF) bands in distinguishing bacterial from aseptic meningitis among children with CSF pleocytosis.METHODS. We identified retrospectively a cohort of children 29 days to 19 years of age with CSF pleocytosis (≥10 × 106 leukocytes per L) who were treated in the emergency departments of 8 pediatric centers between January 2001 and June 2004 and whose CSF was evaluated for the presence of bands. We performed bivariate and multivariate analyses to determine the ability of CSF bands to distinguish bacterial from aseptic meningitis.RESULTS. Among 1116 children whose CSF was evaluated for the presence of bands, 48 children (4% of study patients) had bacterial meningitis. Bacterial meningitis, compared with aseptic meningitis, was associated with a greater CSF band proportion (0.03 vs 0.01; difference: 0.02; 95% confidence interval: 0.00–0.04) and CSF absolute band count (392 × 106 cells per L vs 3 × 106 cells per L; difference: 389 × 106 cells per L; 95% confidence interval: −77 × 106 cells per L to 855 × 106 cells per L). In addition, 29% of patients with bacterial meningitis, compared with 18% of patients with aseptic meningitis, had any bands detected in the CSF. After adjustment for other factors associated with bacterial meningitis, however, CSF band presence, CSF absolute band count, and CSF band proportion were not independently associated with bacterial meningitis.CONCLUSION. In this multicenter study, neither the presence nor quantity of CSF bands independently predicted bacterial meningitis among children with CSF pleocytosis.

We hypothesized that transillumination would increase peripheral intravenous (IV) insertion success rates in pediatric emergency department patients. Primary outcome was success in first attempt, and secondary outcome was success within 2 attempts.We evaluated IV insertion by pediatric emergency department physicians and nurses using the Veinlite (TransLite, Sugar Land, Tex). Patients who required nonemergent IV insertion were enrolled if younger than 3 years or aged 3 to 21 years with a history of difficult access. Participants were randomly assigned to transillumination or nontransillumination. Analyses were performed using a mixed-effects logistic regression model adjusting for provider effect.We evaluated 240 patients. After adjusting for significant covariates (safety catheter [P = 0.008], visibility [P = 0.01], and palpability [P = 0.03]) and controlling for provider effect, IV placement was more likely successful in first attempt in transilluminated patients (P = 0.03; odds ratio, 2.1 [95% confidence interval, 1.1-3.9]). After adjusting for significant covariates (safety catheter [P0.001], location [P = 0.005], and palpability [P = 0.05]) and controlling for provider effect, IV placement was more likely successful within 2 attempts in transilluminated patients (P = 0.01; odds ratio, 3.5 [95% confidence interval, 1.4-8.9]). Intracluster correlation for random effect of provider was 10% in first attempt and 16% within 2 attempts.After adjusting for multiple significant covariates and controlling for random effect of provider, our results indicated a benefit in the use of Veinlite transillumination for IV insertion in first attempt and within 2 attempts. This technique seemed to facilitate nonemergent IV placement in pediatric patients compared with standard practice.

Objectives To determine abdominal radiograph use and frequency of digital rectal examinations in children presenting to the emergency department (ED) with abdominal pain and suspected constipation and to determine the impact of an educational module on their use. Study design Retrospective chart review of patients evaluated at a pediatric ED because of the complaint of abdominal pain who had the discharge diagnosis of constipation over two 2-month periods, one before and one after an educational module. Results Comparing pre- and posteducational module periods, there was a significant decrease in abdominal radiograph utilization (69.5% vs 26.4%, respectively, P ≤ .001) and significant increase in performance of digital rectal examination (22.9% vs 47.3%, respectively, P ≤ .001). We demonstrated a 33.6% reduction in abdominal radiograph in children who had a digital rectal examination as part of their examination. Overall, we demonstrated a 43.1% decrease in patients receiving an abdominal radiograph. When time and costs of an abdominal radiograph are considered, this results in significant cost savings. Conclusions An educational module reviewing the established criteria for the diagnosis of constipation and presented to ED providers results in increased use of digital rectal examination and decreased use of abdominal radiograph in patients evaluated for abdominal pain and ultimately diagnosed with constipation. The change also was associated with reduction in cost and time and radiation exposure in the ED for these patients.

OBJECTIVE. The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis.METHODS. We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture.RESULTS. We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with ≥12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for CONCLUSIONS. In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

ContextChildren with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/μL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10 000 cells/μL, and a history of seizure before or at the time of presentation.ObjectiveTo validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination.Design, Setting, and PatientsA multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells ≥10 cells/μL) and who had not received antibiotic treatment before lumbar puncture.Main Outcome MeasureThe sensitivity and negative predictive value of the Bacterial Meningitis Score.ResultsAmong 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized.ConclusionsThis large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.