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Caring for critically ill patients requires non-technical skills such as teamwork, communication, and task management. The Behaviorally Anchored Rating Scale (BARS) is a brief tool used to assess non-technical skills. The investigators determined inter- and intra-rater reliability of the BARS when used to assess medical students in simulated scenarios.The investigators created simulation scenarios for medical students during their pediatric clerkship. Content experts reviewed video recordings of the simulations and assigned BARS scores for four performance components (Situational Awareness, Decision-Making, Communication, and Teamwork) for the leader and for the team as a whole. Krippendorff's alpha with ordinal difference was calculated to measure inter- and intra-rater reliability.Thirty medical students had recordings available for review. Inter- and intra-rater reliability for performance components were, respectively, Individual Situational Awareness (0.488, 0.638), Individual Decision-Making (0.529, 0.691), Individual Communication (0.347, 0.473), Individual Teamwork (0.414, 0.466), Team Situational Awareness (0.450, 0.593), Team Decision Making (0.423, 0.703), Team Communication (0.256, 0.517), and Team Teamwork (0.415, 0.490).The BARS demonstrated limited reliability when assessing medical students during their pediatric clerkship. Given the unique needs of this population, a modified or new objective scoring system for assessing non-technical skills may be needed for medical students.

OBJECTIVES:To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).METHODS:We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.RESULTS:Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%–1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%–3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%–1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.CONCLUSION:Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Background Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted. Objective Determine association between AO and hypoxemia in pediatric patients undergoing ETI. Methods Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011–June 2011) and with (August 2014–March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO2) Results 149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus Conclusions Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia.

To define those children who develop acute kidney injury (AKI) within 48 h of admission from the emergency department (ED) and ascertain patient-related factors in the ED associated with AKI. Retrospective, cohort study of children, birth to 19 years, admitted to a tertiary pediatric hospital from the ED between January 2010 and December 2013 who had serum creatinine (SCr) drawn as part of clinical care. AKI was defined as a 50% increase in SCr above baseline, as measured within 48 h of hospital presentation. Multivariable logistic regression was performed to determine factors associated with AKI by comparing those with and without kidney injury on hospital presentation. Of all ED admissions, 13,827 subjects (27%) were included; 10% developed AKI. Of kids with AKI, 75% had a measured SCr consistent with AKI while in the ED, 36% were admitted to the intensive care unit, and 2% died (all significantly more than children without AKI). Young age, history of AKI or solid organ transplant, receipt of intravenous fluids or central venous access in the ED, and admission to intensive care were factors independently associated with AKI (AUC = 0.793, 95% CI 0.78–0.81). One in 10 children who had SCr measured and were admitted to a tertiary pediatric hospital had AKI on or within 48 h of presentation. Inherent characteristics, identifiable in the ED, are associated with an increased risk of AKI. Future research should focus on improving AKI recognition in the ED by the development of a risk stratification tool.

Background Identifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children. Objective To derive and test performance of an “acute” RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers. Methods Study of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24–72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed. Results 118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86–0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69–99) and a negative predictive value of 99% (92–100) (versus sensitivity 59% (33–82) and NPV 93% (89–96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker. Conclusions This pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.

BACKGROUND: Emergency department (ED) visits for sports-related traumatic brain injuries (TBIs) have risen. This study evaluated how the number and severity of admissions have changed as ED visits for sports-related TBIs have increased. METHODS: A retrospective study of children aged 0 to 19 years at a level 1 trauma center was performed. Patients from 2002 to 2011 with a primary or secondary diagnosis of TBI were identified from the hospital’s inpatient and outpatient trauma registries. Frequencies were used to characterize the population, χ2 analysis was performed to determine differences between groups, and regression analysis looked at relationship between year and injury severity score or length of stay. RESULTS: Sport was responsible for injury in 3878 (15.4%) cases during the study period; 3506 (90.4%) were discharged from the hospital, and 372 (9.6%) were admitted. Seventy-three percent were male patients and 78% Caucasian; mean age was 13 ± 3.5 years. ED visits for sports-related TBIs increased 92% over the study period, yet there was no significant change (χ2 = 9.8, df = 9, P = .37) in the percentage of children admitted. Mean injury severity score for those admitted decreased from 7.8 to 4.8 (β = –0.46; P = .006); length of stay trended downward (β = –0.05; P = .05). CONCLUSIONS: The percentage of children being admitted from the ED with sports-related TBI has not changed over the past 10 years. The severity of admitted sports-related TBI is decreasing. Additional research is needed to correlate these trends with other TBI mechanisms.

Fever of unknown origin can be challenging to the emergency medicine physician and the array of both benign and potentially life-threatening diagnoses on the differential can lead to a costly, time-consuming work-up. In this article, we present a case of potentially fatal tick-borne illness with a focus on history, physical exam, and laboratory findings that would differentiate this diagnosis from other causes of fever of unknown origin and aid in early and efficient initiation of treatment for patients.