A National Patient Safety Curriculum in Pediatric Emergency Medicine Background Patient safety has become an important and required topic in medical education. A needs assessment showed that pediatric emergency medicine program directors were interested in a common pediatric emergency-specific safety curriculum. Objective The objective of this study was to describe the development and performance of a web-based patient safety curriculum in pediatric emergency medicine. Methods A web-based curriculum was created by the Committee on Quality Transformation of the Section of Emergency Medicine for the American Academy of Pediatrics. The curriculum consisted of emergency-specific safety topic didactic sessions with a pretest and posttest assessment. Vignette-based scenarios were also included and were discussed locally by the program directors. Results Fifty-two percent (37/71) of US Pediatric Emergency Medicine fellowship programs enrolled their fellows in the patient safety curriculum. Overall, 183 Pediatric Emergency Medicine fellows participated in the curriculum. Only 22% (40/183) of fellow participants completed the entire curriculum. The curriculum showed significant improved safety knowledge based upon the pretest and posttest results. Sixty-five percent of responders thought more about safety topics after the curriculum was completed, and 85% witnessed a safety event in the past month, whereas only 48% reported them. Conclusions An online centralized curriculum is an effective platform for teaching content in quality and safety to a national group of physicians. Local oversight by program directors may improve compliance with curriculum completion.

Presumed Systemic Inflammatory Response Syndrome in the Pediatric Emergency Department Objective The aim of this study was to examine the incidence and outcomes of patients presenting with systemic inflammatory response syndrome (SIRS) in the pediatric emergency department (PED). Methods This was a descriptive, retrospective cohort study of all patients from birth to 18 years presenting to the PED of a single center on 16 days distributed over 1 year. The presence of presumed SIRS (pSIRS, defined as noncore temperature measurement and cell count when clinically indicated) and sepsis was determined for all study patients. Patients were followed up for 1 week. Results The incidence of pSIRS was 15.3% (216/1416). Suspected or proven infection was present in 37.1% (n = 525) of the study population and 76.4% (n = 165) with pSIRS, with no cases of severe sepsis or septic shock. Sensitivity and specificity of pSIRS for predicting infection were 31.4% (95% confidence interval [CI], 27.5%–35.6%) and 94.3% (95% CI, 92.5%–95.7%), respectively. Although patients with pSIRS had a relative risk of 2.4 (95% CI, 1.6–3.5; P < 0.0001) for admission, 74% were discharged home with no subsequent PED visits. Of defined sepsis cases, 75% were discharged home without return. Conclusions Presumed SIRS and sepsis are relatively common in the PED. Use of pSIRS to screen for sepsis risks missing infection, whereas using pSIRS in the current sepsis definition results in overinclusion of nonsevere illness.

Pediatric Emergency Department and Primary Care Provider Attitudes on Assessing Childhood Adversity Objective The purpose of this study was to understand pediatric emergency department (ED) and primary care (PC) health care provider attitudes and beliefs regarding the intersection between childhood adversities and health care. Methods We conducted in-depth, semistructured interviews in 2 settings (ED and PC) within an urban health care system. Purposive sampling was used to balance the sample among 3 health care provider roles. Interview questions were based on a modified health beliefs model exploring the “readiness to act” among providers. Interviews were recorded, transcribed, and coded. Interviews continued until theme saturation was reached. Results Saturation was achieved after 26 ED and 19 PC interviews. Emergency department/primary care providers were similar in their perception of patient susceptibility to childhood adversity. Childhood mental health problems were the most frequently referenced adverse outcome, followed by poor childhood physical health. Adult health outcomes because of childhood adversity were rarely mentioned. Many providers felt that knowing about childhood adversity in the medical setting was important because it relates to provision of tangible resources. There were mixed opinions about whether or not pediatric health care providers should be identifying childhood adversities at all. Conclusions Although providers exhibited knowledge about childhood adversity, the perceived effect on health was only immediate and tangible. The effect of childhood adversity on lifelong health and the responsibility and potential accountability health systems have in addressing these important health determinants was not recognized by many respondents in our study. Addressing these provider perspectives will be a critical component of successful transformation toward more accountable health care delivery systems.

A Practice Guideline for Postreduction Management of Intussusception of Children in the Emergency Department Objectives The aim of this study was to evaluate the effects of a practice guideline of postreduction management of intussusception in children on the length of stay (LOS) from reduction in the pediatric emergency department (PED) and on the incidence of recurrence. Methods We developed a practice guideline of postreduction management of intussusception in the PED. The practice guideline involved feeding 2 hours after reduction and discharge 2 hours after successful feeding. The guideline was implemented on October 1, 2012. Retrospective quasi-experimental study was conducted for evaluation of the difference in LOS in the PED after reduction of intussusceptions, and the recurrence rate of intussusceptions between the preimplementation and postimplementation periods. Piecewise regression was performed to determine the differences between groups. Results In total, 45 and 52 patients were included in the preimplementation and postimplementation periods, respectively. The median LOS in the postimplementation period was significantly shorter than that in the preimplementation period (289 vs 532 minutes, respectively; P = 0.001). The slope of the LOS changed from 0.68 to −0.29. The slope decreased by 0.97 after practice guideline implementation. This difference was not statistically significant (P = 0.123), but it changed from a positive to negative gradient. The recurrence rate was not significantly different between the 2 periods (P = 0.605). Conclusions Implementation of a practice guideline involving early feeding and discharge after reduction of intussusception resulted in a reduced LOS from reduction of intussusception in the PED and was not associated with recurrence of intussusception.

Efficacy of Rapid Fluid Administration Using Various Setups and Devices Objectives In clinical practice, there are various methods that can be used for the rapid administration of fluid in infants and children. The current study prospectively evaluates gravity, pressure-assisted, and hand-pump methods for the rapid administration of fluid using an in vitro model. Methods Thirty participants were asked to deliver 500 mL of fluid using 1 of 6 setups: (1) standard blood tubing with gravity administration, (2) standard blood tubing with pressure bag maintained at 300 mm Hg, (3) standard blood tubing with pressure bag inflated to 300 mm Hg and left to flow, (4) blood tubing with in-line bulb pump, (5) blood tubing with in-line bulb pump and pressure bag, and (6) standard blood tubing with 20-mL syringe attached to the stopcock for a push-and-pull technique using a 20-mL syringe. Results The blood tubing with an in-line bulb pump to allow manual acceleration of the administration of fluid along with a pressure bag on the intravenous fluid bag achieved the fastest flow rate, requiring an average of 98 seconds to deliver 500 mL of fluid. Conclusions When considering factors that affect fluid administration, Poiseuille’s law dictates that the most important variable is the radius of the intravenous cannula, whereas the length of the cannula and the viscosity of the fluid administered are of secondary importance. With these limitations in mind, other factors may be used to speed fluid administration. Our study demonstrates the advantage of using blood tubing with the in-line bulb pump combined with a pressure bag.

Management of Pediatric Acute Mastoiditis in Israel: Nationwide Survey Among Otorhinolaryngologists and Emergency Pediatricians Introduction Acute mastoiditis (AM) is a medical emergency that mandates prompt diagnosis and treatment. Nevertheless, its management often differs between otorhinolaryngologists (ORLs) and pediatricians (PEDs) working in emergency departments. We sought to characterize the similarities and differences between management protocols of these 2 disciplines. Methods A voluntary electronic questionnaire, including 17 items pertaining to pediatric AM management, was sent to all the 20 otorhinolaryngology and their corresponding pediatric emergency departments nationwide. Each department sent 1 filled out questionnaire. The response rate was 100%. Results Eighteen (90%) ORLs are notified when a child with suspected AM arrives. Medical history collected by both disciplines was similar—previous otologic history (100%), previous antibiotic use (100%), and pneumococcal conjugate vaccination status (60%)—whereas acute otitis media risk factors were more important to PEDs (13 [65%] PEDs, 10 [50%] ORLs). According to 85% to 90% of ORLs and PEDs, imaging was not mandatory upon admission. According to 14 (70%) PEDs and 16 (80%) ORLs, imaging was overall performed in less than 50% of patients during hospitalization. Intravenous ceftriaxone and cefuroxime were the most common first-line antibiotic treatments (8 [40%] ORLs, 10 [50%] PEDs), with a mean treatment duration of 7 to 10 days. Eighteen (90%) of the ORLs, compared with 15 (75%) PEDs, reported that myringotomy (with or without ventilating tube insertion) was performed upon diagnosis (P = 0.05). Conclusions The management of pediatric AM is generally similar by both disciplines. The use of imaging studies is mild-moderate. We call for a national registry and encourage the publication of guidelines.

Adolescent Coping Strategies in the Emergency Department Objectives The objective of this study was to describe coping mechanisms used by adolescents during emergency treatment. Methods A convenience sample of adolescent patients (aged 12–18 years) was surveyed in our large (87,000 annual visits) urban academic pediatric emergency department (ED) with an adapted Adolescent Coping Orientation for Problem Experiences survey. Parents were surveyed about their perceptions of their child's coping mechanisms. Participants were excluded if they were non–English speaking, in police custody, had altered mental status, or were hemodynamically unstable. Results Of the 123 adolescents approached, 93 participated (response rate, 76%) and 80 completed the survey (completion rate, 86%). Sixty percent were female, and the mean (SD) age was 15 (2) years. Most respondents were non–Hispanic black (62%). Adolescents presented for acute complaints (48%); chronic worsening problems (33%); and injury from an accident or assault (19%). While in the ED, 62% felt safe, 56% reported boredom, and 94% felt supported by their parents. Adolescents reported that listening to music (82%), sleeping (76%), and focusing on getting better (75%) would minimize their stress in the ED. A total of 50 parents completed the survey. There was 79% agreement between parents and adolescents regarding adolescents listening to music to cope in the ED. There was 72% agreement between parents and adolescents in regard to parental support. Conclusions In this urban ED, parental involvement and listening to music were the most common coping strategies adolescents used during an ED visit. Attempts to improve patient-centered care should address opportunities for parental support and mechanisms for adolescents to listen to music.

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine Objective The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. Methods A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. Results Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children’s hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). Conclusions Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

Clinical Profile, Etiology, and Outcome of Infantile Ocular Trauma: A Developing Country Perspective Objective The aim of this article was to study the clinical profile, etiology, and outcome of infantile ocular trauma in a developing country setting. Methods A retrospective study on corneal trauma in infants (≤12 months old) was undertaken in a tertiary care hospital during a 2-year period. An analysis of clinical profile, etiology, microbiological profile, clinical course, and outcome was studied. Results Seventy-six infants were included. Approximately 69% presented within 24 hours of injury. The common presentations were inability to open the eyelids, redness of eyes, and watering. Self-infliction by child's hand (49%) was found to be the main cause of corneal trauma. Corneal abrasion was seen in 34 cases (45%), isolated epithelial defects were seen in 30%, and infective keratitis was seen in 25%. Infection was found in 14 cases (fungal filaments in 7 and gram-positive cocci in 7). Only 36 infants followed up regularly in the hospital. All the infants following up in the hospital recovered in due course. Conclusions Infantile ocular trauma is a common morbidity that is underreported. Self-infliction by child's hand was found to be the main cause of corneal trauma. Cases presenting early and following up regularly till recovery have a favorable clinical course with good outcome. A high loss to follow-up indicates that awareness needs to be created among the caregivers.

Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Outcomes After Pediatric Out-of-Hospital Cardiac Arrest Objectives A dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) is expected to influence the outcomes of pediatric out-of-hospital cardiac arrest (OHCA). Our objective was to measure the effect size of a DA-BCPR on survival outcomes according to location of the event. Methods All emergency medical service treated OHCA patients younger than 19 years in Korea from January 2012 through December 2013 were analyzed. Patients with OHCA witnessed by emergency medical service providers and those with missing outcome information were excluded. Patients were categorized into the following categories: No-BCPR, BCPR without dispatcher assistance (BCPR-NDA), and BCPR-DA. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for outcomes by exposure group (reference, No-BCPR group) with and without an interaction term between exposure and location of arrest. Results A total of 1013 eligible patients were analyzed. Among these patients, 16.6% received BCPR-NDA, 23.2% received BCPR-DA, and 60.2% received no BCPR. After adjusting for potential confounders, compared with N0-BCPR group, AORs for survival were 1.79 (95% CI, 1.03–3.12) in BCPR group, 1.71 (95% CI, 0.85–3.46) in BCPR-NDA group, and 1.39 (95% CI, 0.72–2.69) in BCPR-DA group. The AORs for survival of BCPR-NDA and BCPR-DA in public location were 3.30 (95% CI, 1.12–9.72) and 2.95 (95% CI, 1.00–8.67), whereas BCPR-NDA and BCPR-DA in private locations were 1.62 (95% CI, 0.68–3.88) and 1.15 (95% CI, 0.53–2.51). Conclusion The DA-CPR was associated with better outcomes in pediatric OHCA patients whose arrest occurred in public locations, but no improvement in outcomes was identified in patients whose arrest occurred at private locations.