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Objective: To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS., Data Sources: The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey., Data Collection/extraction Methods: Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown., Study Design: We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series., Principal Findings: There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95)., Conclusions: For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research., (© 2020 Health Research and Educational Trust.)

Objective: Providing meaningful evaluation to trainees rotating through the pediatric emergency medicine is important yet challenging. Information systems can be used to autopopulate an electronic case log, which can be leveraged to assist in the evaluation process. The objective of this study was to determine if a novel educational initiative using an automated case log improved faculty evaluation of trainees., Methods: This retrospective study examined faculty completion rate, as well as the content of medical student evaluations over a 3-academic-year study period. Three phases of evaluation were utilized: written, electronic, and electronic enhanced with individualized case reports created with the automated case log. The primary outcome was faculty response rate. Secondary outcomes included word count and the number of themes identified following qualitative analysis of narrative responses. Logistic regression was performed., Results: Forty-one faculty members completed evaluations of 43 students. The rates of completion for the written, electronic, and automated case log phases were 18%, 16%, and 62%, respectively. Faculty in the automated case log phase were significantly more likely to complete evaluations compared with those in the written evaluation phase (odds ratio, 7.6; 95% confidence interval, 4.5-13.0). The median word counts across the 3 phases were 19, 36, and 43, respectively. The median numbers of themes identified during the 3 phases were 3, 4, and 5, respectively. The differences in the word count and median number of themes between the written and automated case log phases were significantly different (P < 0.001)., Conclusions: The process of trainee evaluation can be improved by utilizing an automated case log to provide faculty members with individualized reports of shared patient encounters.

Simulation provides a means to educate, monitor, evaluate, and potentially document the competency of emergency physicians. The evolution of high-fidelity simulators has led to a surge of enhanced medical applications that fit nicely into the core of emergency medicine training. Simulation can facilitate training in resuscitation, procedures, CRM, and mass casualty management. Although improved outcomes from simulation are not well established, there is a general consensus regarding the added value over current training. And finally, simulation provides the ability to construct training to match the current educational efforts related to individual physicians or system-level improvements in communication and patient safety.

Background: Intussusception is the most common cause of intestinal obstruction in infants and children. To date, no study has evaluated the ability of physicians to predict the likelihood of intussusception., Objective: This study aimed to determine the ability of pediatric physicians to predict intussusception in patients being evaluated for intussusception and to investigate whether certain clinical findings correlate with physicians' risk assessment., Methods: A prospective cohort study of children aged 1 month to 6 years who presented with possible intussusception. The predicted likelihood of intussusception was recorded by physicians before knowledge of imaging results or final diagnosis. We defined a physician's prediction as high versus low risk based on a threshold prediction of 25% likelihood., Results: A total of 308 patients were studied including 38 (12.3%) with intussusception. Physicians' prediction was positively associated with the risk of intussusception (test for linear trend: odds ratio [OR], 2.1; 95% confidence interval [CI], 1.6-2.7; P < 0.001). Among patients considered high risk, the rate of intussusception was 36% (95% CI, 25%-49%) compared with 6% for those judged to be low risk (95% CI, 4%-10%). Using a threshold of 25% likelihood, successful prediction of high versus low risk occurred in 82% (95% CI, 77%-86%). Clinical predictors associated with assigning a designation of higher risk of intussusception included lethargy at home (OR, 2.7; 95% CI, 1.4-5.5) and bloody stool (OR, 2.5; 95% CI, 1.0-5.9)., Conclusions: Pediatric physicians can accurately predict the likelihood of intussusception. This ability to properly judge the risk of intussusception can be incorporated into management strategies.

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.

Objectives: The objectives of the study were (1) to determine the relative use of strategies for managing the well-appearing febrile infant and (2) to determine clinician adherence to protocol recommendations., Methods: Members of the American Academy of Pediatrics Section on Emergency Medicine were asked to complete an online, interactive, case-based questionnaire. Infants with a temperature of 38.6°C who were otherwise completely well were presented. Respondents ordered laboratory studies and received results. Treatment and disposition decisions based on those results were queried. Clinicians reported which published set of guidelines they followed. Major discriminating features of guidelines were used to assess adherence., Results: Two hundred ninety-nine (30%) clinicians completed the survey. The relative use of the 3 main guidelines was as follows: Philadelphia, 20%; Rochester, 15%; and Boston, 13%. Of respondents reporting that their practice is based on the Rochester criteria, 98% performed a lumbar puncture, 86% administered antibiotics, and 93% admitted the 25-day-old infant to the hospital, despite recommendations that a lumbar puncture was unnecessary and that the infant be managed as an outpatient without antibiotics. Similar deviations were seen among respondents who reported using the other criteria.Many respondents treated the infants with antibiotics, without obtaining cerebrospinal fluid for culture, despite recommendations against this practice., Conclusions: Although most physicians report following published guidelines for the management of the well-appearing febrile infant, compliance with recommendations is poor. The effect that deviating from the guidelines has on patient outcome is unknown. Despite recommendations to the contrary, many physicians administer antibiotics without obtaining cerebrospinal fluid for culture.

The Accreditation Council for Graduate Medical Education has mandated the assessment of medical training across 6 core competencies. The patient care competency is at the core of medical training. With the introduction of patient tracking systems used in emergency departments, patient-physician encounters can be systematically studied. The combination of tracking data with other clinical information systems can be used to create an electronic case log to quantify the experience of fellows, thereby offering a summative measure of the patient care competency. We used an automated case log to assess clinical exposure in our pediatric emergency medicine fellowship.