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Background and Objectives: Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs)., Methods: Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization., Results: We identified 35,070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R(2) = 0.10, P = .06) or revisits resulting in hospitalization (R(2) = 0.08, P = .09)., Conclusions: Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed., (Copyright © 2014 by the American Academy of Pediatrics.)

Background and Objective: Nationally, frequent utilizers of emergency departments (EDs) are targeted for quality improvement initiatives. The objective was to compare the characteristics and ED health services of children by their ED visit frequency., Methods: A retrospective study in 1,896,547 children aged 0 to 18 years with 3,263,330 visits to 37 EDs in 2011. The number of ED visits per child within 365 days of their first visit was counted. Patient characteristics (age, chronic condition) and ED care (medications, testing [laboratory and radiographic], and hospital admission) were assessed. We evaluated the relationship between patient characteristics and ED health services received with multivariable regression., Results: Children with ≥4 ED visits (8%) accounted for 24% of all visits and 31% ($1.4 billion) of all costs. As visit frequency increased from 1 to ≥4, the percentage of children aged <1 year increased (12.1% to 33.2%) and the percentage of children without a chronic condition decreased (81.9% to 45.6%) (P < .001 for both). Children with ≥4 ED visits had a higher percentage of visits without medication administration (aside from acetaminophen or ibuprofen), testing, or hospital admission when compared with children with 1 visit (35.4% vs 29.0%; P < .001). Children with ≥4 ED visits who were aged <1 year (odds ratio: 3.8; 95% confidence interval: 3.7-3.9) and who were without a chronic condition (odds ratio: 3.1; 95% confidence interval: 3.0-3.1) had the highest likelihood of experiencing this type of visit., Conclusions: With a disproportionate share of pediatric ED cost and utilization, frequent utilizers, especially infants without a chronic condition, are the least likely to need medications, testing, and hospital admission., (Copyright © 2014 by the American Academy of Pediatrics.)

Anterior shoulder dislocation is the most common joint dislocation seen in the emergency department. Although emergency medicine providers use several techniques for reduction, each method is associated with potential discomfort for the patient. In addition, pain from the dislocated shoulder causes muscle spasm that impedes reduction. Therefore, both analgesia and procedural sedation are often used to reduce pain and enable reduction. Intra-articular injection of lidocaine has demonstrated efficacy in reduction of pain and facilitation of shoulder reduction compared with analgesia and sedation. Intra-articular lidocaine may also reduce time to successful reduction of shoulder dislocations.

Importance: Ondansetron hydrochloride use in children with gastroenteritis is increasing rapidly; however, little is known about its impact on outcomes., Objective: To determine whether increasing emergency department ondansetron use has resulted in a reduction in intravenous rehydration rates., Design, Setting, and Participants: Retrospective observational analysis of eligible visits included in the Pediatric Health Information System administrative database. Eligible institutions included 18 emergency departments geographically distributed across the United States, and participants included 804,000 patients aged 0 to 18 years who were diagnosed as having gastroenteritis in an emergency department at an eligible participating institution between January 1, 2002, and December 31, 2011., Interventions: The presence or absence of oral ondansetron administration was identified for each patient through database review. Visits were categorized based on institutional ondansetron use: low (<5% administered ondansetron), medium (5%-25%), or high (>25%)., Main Outcomes and Measures: We conducted hospital-level analyses of the associations between ondansetron use and 3 outcomes: intravenous rehydration (primary), hospitalization, and emergency department revisits within 3 days. Time-series regression models were used, adjusting for demographic characteristics, laboratory testing, diagnostic imaging, and rotavirus infection., Results: A total of 804,000 eligible patient visits were identified. Oral ondansetron use increased from a median institutional rate of 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001). Intravenous rehydration was administered to 43,413 of 232,706 children (18.7%) during the low ondansetron period compared with 59,450 of 334,264 (17.8%) during the high ondansetron period (adjusted percentage change = -0.33%; 95% CI, -1.86% to 1.20%). During the transition from low to high ondansetron use, we observed no change in the hospitalization rate (adjusted percentage change = -0.33%; 95% CI, -0.95% to 0.29%), but emergency department revisits decreased (adjusted percentage change = -0.31%; 95% CI, -0.49% to -0.13%). The change in all 3 outcomes varied widely between low and high ondansetron use categories at an institutional level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration., Conclusions and Relevance: Although ondansetron use increased during the study period, intravenous rehydration rates were unchanged. Most children administered intravenous fluids did not receive oral ondansetron. Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.

Objectives: The objectives of this study were to determine agreement of abdominal radiography (AXR) interpretation and to compare test characteristics, between pediatric emergency medicine (PEM) physicians and pediatric radiologists for evaluation of intussusception., Methods: This was a retrospective cohort study of children aged 3 months to 3 years presenting to a pediatric emergency department (ED) between 2007 and 2009. For inclusion, subjects required an ED presentation for suspected intussusception, performance of a 2-view AXR (supine and upright/lateral decubitus views) and abdominal ultrasound performed during the ED visit, and a subsequent criterion-standard measure for intussusception available (contrast enema, operative report, or clinical follow-up). All AXRs were reviewed by 2 blinded PEM physicians and 2 pediatric radiologists. Interrater agreement (κ) for AXR interpretation and diagnostic test characteristics were calculated for comparison., Results: A total of 286 children were included; intussusception was present in 61 patients (21.3%). Moderate agreement was present between the PEM physicians and radiologists for AXR assessment, with κ = 0.57 (95% confidence interval [CI], 0.47-0.66). Radiologist AXR interpretation had specificity of 86.7% (95% CI, 81.6-90.5), sensitivity of 62.3% (95% CI, 49.8-73.4), positive predictive value of 55.9% (95% CI, 43.3-67.9), and negative predictive value of 89.4% (95% CI, 84.6-93.2). Pediatric emergency medicine physician AXR interpretation had specificity of 68.9% (95% CI, 62.6-74.6), sensitivity of 78.7% (95% CI, 66.9-87.1), positive predictive value of 40.7% (95% CI, 32.2-49.7), and negative predictive value of 92.3% (95% CI, 87.1-95.5)., Conclusions: Agreement between PEM physicians and pediatric radiologists for evaluation of AXR in suspected intussusception is moderate. Sensitivity and negative predictive value of AXR alone are not sufficiently high overall to exclude intussusception; however, PEM physician interpretation of AXR may possess utility in determining need for abdominal ultrasound in low-risk patients given the high negative predictive value.

Although patients with eczema herpeticum often receive antibiotics for presumed bacterial coinfection, the effect of empiric antibiotic therapy is unknown. Our objective therefore was to determine the association between empiric antibiotics and outcomes in children hospitalized with eczema herpeticum. We conducted a multicenter retrospective cohort study of 1,150 children ages 2 months to 17 years admitted with eczema herpeticum between January 1, 2001, and March 31, 2010, to 42 tertiary care children's hospitals in the Pediatric Health Information System. All patients received antibiotics during the hospitalization. Multivariable linear regression models determined the association between empiric antibiotic therapy and the main outcome measure: hospital length of stay (LOS). There were no deaths during the study period. Receipt of empiric antibiotics was not associated with a change in the LOS on unadjusted or multivariable analysis. The class of empiric antibiotic was not associated with the LOS except for receipt of vancomycin, which was associated with a longer LOS (21% adjusted longer LOS, 95% confidence interval (CI) = 8-35%; p = 0.001). When restricted to patients with a bloodstream infection, receipt of empiric antibiotics was associated with a 51% adjusted shorter LOS (95% CI = -24 to -68%; p = 0.002). In children hospitalized with eczema herpeticum, empiric antibiotic therapy was not associated with a shorter LOS overall, but was associated with a shorter LOS in patients with a bloodstream infection. These findings highlight the importance of early recognition of systemic bacterial illness in children with eczema herpeticum. Empiric antibiotics did not affect mortality, which is low., (© 2012 Wiley Periodicals, Inc.)

There is concern that the use of topical corticosteroids in patients with eczema herpeticum may facilitate dissemination of herpes simplex virus and worsen disease. Our primary aim therefore was to determine whether topical corticosteroid use in children hospitalized with eczema herpeticum is associated with longer hospital length of stay (LOS). We performed a multicenter retrospective cohort study of 1,331 children ages 2 months to 17 years admitted with a diagnosis of eczema herpeticum between January 1, 2001, and March 31, 2010, to 42 tertiary care children's hospitals in the Pediatric Health Information System database. Multivariable linear regression models determined the association between receipt of topical corticosteroid therapy on the first day of hospitalization and the main outcome measure: LOS. Receipt of topical corticosteroid therapy on day 1 of hospitalization was not associated with a longer LOS on unadjusted or multivariable analysis (p = 0.75). Receipt of topical calcineurin inhibitors during the hospitalization was also not associated with a longer LOS (p = 0.12). Receipt of systemic corticosteroids was associated with an 18% adjusted longer LOS (95% confidence interval 2%-36%; p = 0.03). Further study is needed to identify which children with eczema herpeticum may benefit from topical corticosteroids, but their use during active infection is not associated with poorer outcomes, although the use of systemic corticosteroids was associated with a longer LOS and should be avoided in patients with eczema herpeticum pending future prospective study., (© 2012 Wiley Periodicals, Inc.)

The febrile young infant is commonly encountered in the emergency department, and the incidence of serious bacterial infection in these patients is as high as 15%. Undiagnosed bacterial infections such as meningitis and bacteremia can lead to overwhelming sepsis and death or neurologic sequelae. Undetected urinary tract infection can lead to pyelonephritis and renal scarring. These outcomes necessitate the evaluation for a bacterial source of fever; therefore, performance of a full sepsis workup is recommended to rule out bacteremia, urinary tract infection, and bacterial meningitis in addition to other invasive bacterial diseases including pneumonia, bacterial enteritis, cellulitis, and osteomyelitis. Parents and emergency clinicians often question the necessity of this approach in the well-appearing febrile young infant, and it is important to understand and communicate the evidence that guides the approach to these patients. Recent studies examining the risk of serious bacterial infection in young infants with bronchiolitis and the role of viral testing in the febrile young infant will also be discussed in this review.

Objective: The objective of this study was to identify if family characteristics or opinions affected participation in family centered rounds., Design: Observational study of 431 patient encounters on daily work rounds, followed by 100 questionnaires completed by family members of patients in the unit during observation., Setting: PICU at a tertiary care, academic, free-standing children's hospital., Subjects: Patients and families admitted to the PICU during the observation period., Intervention: None., Measurements and Main Results: The most frequent family members present for rounds were mothers (40%). Race, educational level, age of the family member, age of the child, whether the admission was expected, and whether the family member was a medical professional had no association with whether the family member attended rounds. Both family members who were present and those who were not present felt being at rounds would improve the care of their child (87% vs. 100%, p = 0.57). A family's response that they preferred to attend rounds was the only factor associated with a higher likelihood of attending rounds (odds ratio 3.4, 95% confidence interval 1.1-10.8, p = 0.03)., Conclusion: Families feel that participating in family centered rounds improves the care of their children. Those that like attending rounds are more likely to participate in family centered rounds, but family demographic characteristics were not associated with rounds attendance. Future studies are needed to identify barriers to family participation in family centered rounds.

Background: The clinical presentation of intussusception is variable; therefore, screening with either abdominal radiography (AXR) or abdominal ultrasound (US) is often used, although the optimal method is not known., Purpose: This study aimed to compare the utility of AXR with that of the US in children with suspected intussusception., Methods: Retrospective cohort of children age 3 months to 3 years presenting to a pediatric emergency department (ED) between 2007 and 2009. Inclusion criteria were as follows: (1) presentation to the ED for suspected intussusception and (2) both 2-view AXR and US performed during the ED visit. An AXR was deemed negative for intussusception if air was visualized in the ascending colon on 2 views and transverse colon on the supine view; US results were obtained from the radiologist report at the time of presentation. Criterion standard measures for intussusception were contrast enema, operative report, or follow-up., Results: A total of 286 children were included, with mean (SD) age 16.1 (9.1) months; 62.2% were male, and 43.7% were African American. Intussusception was present in 61 subjects (21.3%). Abdominal radiography had sensitivity of 62.3% (95% confidence interval [CI], 50.1%-74.5%) and specificity of 86.7% (95% CI, 82.2%-91.1%), whereas US had a sensitivity of 98.4% (95% CI, 95.2%-100.0%) and specificity of 96.4% (95% CI, 94.0%-98.9%). Ultrasound had a greater negative predictive value (99.5%; 95% CI, 98.6%-100.4%) compared with AXR (89.4%; 95% CI, 85.4%-93.5%). Abdominal radiography had a greater false-positive rate (13.3% vs 3.6%) and greater false-negative rate (37.8% vs 1.6%), compared with US., Conclusions: Ultrasound is superior to AXR as a screening method for establishing and excluding the diagnosis of intussusception. The poor test characteristics of 2-view AXR suggest that it should not be used as a primary screening method in cases of suspected intussusception.

Objective: To determine the association of delayed acyclovir therapy with death among neonates with herpes simplex virus (HSV) infection., Methods: A multicenter, retrospective, cohort study was conducted between January 1, 2003, and December 31, 2009, with 1086 neonates (age: ≤28 days) with HSV infection from 41 tertiary care children's hospitals. Early acyclovir therapy was defined as initiation of intravenous acyclovir treatment within 1 day after hospital admission, and delayed acyclovir therapy was defined as initiation of treatment >1 and ≤7 days after hospital admission. Multivariate logistic regression models determined the association between delayed acyclovir therapy and death, with the use of propensity scores for each neonate's likelihood of receiving delayed acyclovir treatment to control for differences in illness severity between groups., Results: The median age was 10 days. Delayed acyclovir therapy was administered to 262 neonates (24.1%). In most cases (86.2%) of delayed receipt, acyclovir administration occurred on the second or third day of hospitalization. The overall mortality rate was 7.3% (95% confidence interval: 5.8%-9.0%); 9.5% of those who received delayed acyclovir treatment and 6.6% of those who received early acyclovir treatment died. In a multivariate analysis, delayed acyclovir therapy was associated with significantly greater odds of death (adjusted odds ratio: 2.63 [95% confidence interval: 1.36-5.08]) compared with early acyclovir therapy., Conclusions: In this multicenter observational study of neonates with HSV infection, delayed initiation of acyclovir therapy was associated with in-hospital death. Our data support the use of empiric acyclovir therapy for neonates undergoing testing for HSV infection.

Objective: To describe the epidemiology and outcomes of children hospitalized with eczema herpeticum and to determine the association with delayed acyclovir on outcomes., Patients and Methods: This was a multicenter retrospective cohort study conducted between January 1, 2001, and March 31, 2010, of 1331 children aged 2 months to 17 years with eczema herpeticum from 42 tertiary care children's hospitals in the Pediatric Health Information System database. Multivariable linear regression models determined the association between delayed acyclovir therapy and the main outcome measure: hospital length of stay (LOS)., Results: There were no deaths during the study period. Staphylococcus aureus infection was diagnosed in 30.3% of the patients; 3.9% of the patients had a bloodstream infection. Fifty-one patients (3.8%) required ICU admission. There were 893 patients (67.1%) who received acyclovir on the first day of admission. The median LOS increased with each day delay in acyclovir initiation. In multivariable analysis, delay of acyclovir initiation by 1 day was associated with an 11% increased LOS (95% confidence interval [CI]: 3%-20%; P = .008), and LOS increased by 41% when acyclovir was started on day 3 (95% CI: 19%-67%; P < .001) and by 98% when started on day 4 to 7 (95% CI: 60%-145%; P < .001). Use of topical corticosteroids on day 1 of hospitalization was not associated with LOS., Conclusions: Delay of acyclovir initiation is associated with increased LOS in hospitalized children with eczema herpeticum. Use of topical corticosteroids on admission is not associated with increased LOS. The mortality rate of hospitalized children with eczema herpeticum is low.

Infective endocarditis due to Neisseria sicca, a normal inhabitant of the upper respiratory tract, is rarely reported but associated with embolic phenomena and large vegetations often requiring surgical intervention. We report a previously healthy 12-year-old girl who presented with prolonged fever and altered mental status. The patient developed rapidly progressive respiratory insufficiency and cardiovascular instability, and echocardiography demonstrated a large vegetation on the mitral valve. She developed worsening mitral regurgitation with resultant pulmonary hemorrhage and underwent mitral valve replacement. Her blood culture was positive for N. sicca. This infection should be considered in patients with prolonged high fever and multiorgan dysfunction. Despite a typically severe course, reported mortality is low.

Objectives: Our objectives were to determine the impact of family presence during PICU rounds on family satisfaction, resident teaching, and length of rounds and to assess factors associated with family satisfaction., Methods: This was an observational study of a convenience sample of morning work rounds in a PICU, followed by surveys of family members of patients in the unit and residents who had been present for rounds., Results: A total of 411 patient encounters were observed, 98 family questionnaires were fully completed, and 33 resident questionnaires were completed. Ninety-eight percent of family members liked to be present for rounds. On the first day of admission, family members were less likely to understand the plan (P=.03), to feel comfortable asking questions (P = .007), or to want bad news during rounds (P = .009). They were more likely to have privacy concerns (P = .02) and to want 1 individual to convey the plan after rounds (P=.01). Higher education level was associated with decreased privacy concerns (P = .002) but did not affect understanding of the plan. Fifty-two percent of residents perceived that teaching was decreased with families present. Time spent with individual patients was not increased by family member presence (P = .12)., Conclusions: Family satisfaction is high, but families of patients on the first day of admission may need special attention. The medical team should conduct rounds in a manner that addresses the privacy concerns of families. Residents often think that teaching is decreased when families are present.

Burkitt lymphoma (BL) is a rapidly dividing tumor that commonly presents itself in the jaw in its endemic form and the abdomen in the sporadic type. Central nervous system involvement at diagnosis is not uncommon, but there have been no previously published reports of BL involving the clivus. Increased tumor burden is associated with complications such as tumor lysis syndrome, and recognition of unusual presentations is important for timely management. We report 3 patients with BL involving the clivus at diagnosis.