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O'Neill LB, Bhansali P, Bost JE, Chamberlain JM, Ottolini MC. "Sick or not sick?" A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department. Diagnosis (Berl) 2021; 9:207-215. [PMID: 34890171 DOI: 10.1515/dx-2021-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Experienced physicians must rapidly identify ill pediatric patients. We evaluated the ability of an illness rating score (IRS) to predict admission to a pediatric hospital and explored the underlying clinical reasoning of the gestalt assessment of illness. METHODS We used mixed-methods to study pediatric emergency medicine physicians at an academic children's hospital emergency department (ED). Physicians rated patients' illness severity with the IRS, anchored by 0 (totally well) and 10 (critically ill), and shared their rationale with concurrent think-aloud responses. The association between IRS and need for hospitalization, respiratory support, parenteral antibiotics, and resuscitative intravenous (IV) fluids were analyzed with mixed effects linear regression. Area under the curve (AUC) receiver operator characteristic (ROC) curve and test characteristics at different cut-points were calculated for IRS as a predictor of admission. Think-aloud responses were qualitatively analyzed via inductive process. RESULTS A total of 141 IRS were analyzed (mean 3.56, SD 2.30, range 0-9). Mean IRS were significantly higher for patients requiring admission (4.32 vs. 3.13, p<0.001), respiratory support (6.15 vs. 3.98, p = 0.033), IV fluids (4.53 vs. 3.14, p < 0.001), and parenteral antibiotics (4.68 vs. 3.32, p = 0.009). AUC for IRS as a predictor of admission was 0.635 (95% CI: 0.534-0.737). Analysis of 95 think-aloud responses yielded eight categories that describe the underlying clinical reasoning. CONCLUSIONS Rapid assessments as captured by the IRS differentiated pediatric patients who required admission and medical interventions. Think-aloud responses for the rationale for rapid assessments may form the basis for teaching the skill of identifying ill pediatric patients.
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Affiliation(s)
- Laura B O'Neill
- Division of Hospital Medicine at Children's National Hospital, and George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - Priti Bhansali
- Division of Hospital Medicine at Children's National Hospital, and George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - James E Bost
- Department of Biostatistics and Study Methodology at Children's National Hospital, and George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - James M Chamberlain
- Division of Emergency Medicine at Children's National Hospital, and George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Mary C Ottolini
- Tufts University School of Medicine and the George W. Hallett MD Chair of Pediatrics at the Barbara Bush Children's Hospital, Portland, ME, USA
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Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest. Resuscitation 2021; 159:117-125. [PMID: 33400929 DOI: 10.1016/j.resuscitation.2020.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/13/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown. METHODS Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge. RESULTS Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85). CONCLUSIONS In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.
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Pollack MM, Holubkov R, Berg RA, Newth CJL, Meert KL, Harrison RE, Carcillo J, Dalton H, Wessel DL, Dean JM. Predicting cardiac arrests in pediatric intensive care units. Resuscitation 2018; 133:25-32. [PMID: 30261219 PMCID: PMC6258339 DOI: 10.1016/j.resuscitation.2018.09.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/22/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Early identification of children at risk for cardiac arrest would allow for skill training associated with improved outcomes and provides a prevention opportunity. OBJECTIVE Develop and assess a predictive model for cardiopulmonary arrest using data available in the first 4 h. METHODS Data from PICU patients from 8 institutions included descriptive, severity of illness, cardiac arrest, and outcomes. RESULTS Of the 10074 patients, 120 satisfying inclusion criteria sustained a cardiac arrest and 67 (55.9%) died. In univariate analysis, patients with cardiac arrest prior to admission were over 6 times and those with cardiac arrests during the first 4 h were over 50 times more likely to have a subsequent arrest. The multivariate logistic regression model performance was excellent (area under the ROC curve = 0.85 and Hosmer-Lemeshow statistic, p = 0.35). The variables with the highest odds ratio's for sustaining a cardiac arrest in the multivariable model were admission from an inpatient unit (8.23 (CI: 4.35-15.54)), and cardiac arrest in the first 4 h (6.48 (CI: 2.07-20.36). The average risk predicted by the model was highest (11.6%) among children sustaining an arrest during hours >4-12 and continued to be high even for days after the risk assessment period; the average predicted risk was 9.5% for arrests that occurred after 8 PICU days. CONCLUSIONS Patients at high risk of cardiac arrest can be identified with routinely available data after 4 h. The cardiac arrest may occur relatively close to the risk assessment period or days later.
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Affiliation(s)
- Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington DC, United States.
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States
| | - Rick E Harrison
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Heidi Dalton
- Department of Child Health, Phoenix Children's Hospital and University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States(1)
| | - David L Wessel
- Department of Pediatrics, Children's National Medical Center, Washington DC, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
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Mokhateb-Rafii T, Bialer M, Rodgers S, Moore C, Sweberg T. A Cryptic Cause of Cardiac Arrest. J Emerg Med 2018; 56:e1-e4. [PMID: 30420309 DOI: 10.1016/j.jemermed.2018.09.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/20/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND RIPPLY2-associated spondylocostal dysostosis is a rare disorder that leads to segmentation defects of the vertebrae. These vertebral defects can result in severe instability of the cervical spine, leading to cardiac arrest after only minor whiplash injury. CASE REPORT We present the case of a healthy 7-year-old child who experienced an out-of-hospital cardiac arrest. He was reported to have profound respiratory distress and collapsed after going down a slide, without trauma. He was resuscitated in the field, and presented to the emergency department, where return of spontaneous circulation was achieved. Imaging of his cervical spine revealed multiple abnormalities. It was determined that a whiplash injury led to hypoxia and bradycardia due to the anatomic abnormalities of his cervical spine, resulting in cardiovascular collapse. He recovered fully and was later diagnosed with SCDO6, an autosomal recessive inherited disorder caused by a mutation in the RIPPLY2 gene. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Unfamiliarity of providers with this mechanism of cardiac arrest, and the rarity of the syndrome itself, make early recognition very difficult. Late diagnosis and lack of preventative measures, including immediate cervical spine stabilization, can lead to catastrophic outcomes. In patients with cardiac arrest of unclear etiology, early consideration of cervical spine immobilization and evaluation can be lifesaving.
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Affiliation(s)
- Tanya Mokhateb-Rafii
- Department of Pediatric Critical Care, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
| | - Martin Bialer
- Department of Medical Genetics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
| | - Shaun Rodgers
- Department of Neurosurgery, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
| | - Christine Moore
- Department of Medical Genetics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
| | - Todd Sweberg
- Department of Pediatric Critical Care, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
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Kirschen MP, Walter JK. Ethical Issues in Neuroprognostication after Severe Pediatric Brain Injury. Semin Pediatr Neurol 2015; 22:187-95. [PMID: 26358429 DOI: 10.1016/j.spen.2015.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurologic outcome prediction, or neuroprognostication, after severe brain injury in children is a challenging task and has many ethical dimensions. Neurologists and intensivists are frequently asked by families to predict functional recovery after brain injury to help guide medical decision making despite limited outcome data. Using two clinical cases of children with severe brain injury from different mechanisms: hypoxic-ischemic injury secondary to cardiac arrest and traumatic brain injury, this article first addresses the importance of making a correct diagnosis in a child with a disorder of consciousness and then discusses some of the clinical challenges with deducing an accurate and timely outcome prediction. We further explore the ethical obligations of physicians when supporting parental decision making. We highlight the need to focus on how to elicit family values for a brain injured child, how to manage prognostic uncertainty, and how to effectively communicate with families in these challenging situations. We offer guidance for physicians when they have diverging views from families on aggressiveness of care or feel pressured to prognosticate with in a "window of opportunity" for limiting or withdrawing life sustaining therapies. We conclude with a discussion of the potential influence of emerging technologies, specifically advanced functional neuroimaging, on neurologic outcome prediction after severe brain injury.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia and Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, PA; Department of Neurology, Children's Hospital of Philadelphia and Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, PA.
| | - Jennifer K Walter
- Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Medical Ethics, Children's Hospital of Philadelphia and Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Kirschen MP, Topjian AA, Hammond R, Illes J, Abend NS. Neuroprognostication after pediatric cardiac arrest. Pediatr Neurol 2014; 51:663-668.e2. [PMID: 25193413 PMCID: PMC4254345 DOI: 10.1016/j.pediatrneurol.2014.07.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/16/2014] [Accepted: 07/18/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Management decisions and parental counseling after pediatric cardiac arrest depend on the ability of physicians to make accurate and timely predictions regarding neurological recovery. We evaluated neurologists and intensivists performing neuroprognostication after cardiac arrest to determine prediction agreement, accuracy, and confidence. METHODS Pediatric neurologists (n = 10) and intensivists (n = 9) reviewed 18 cases of children successfully resuscitated from a cardiac arrest and managed in the pediatric intensive care unit. Cases were sequentially presented (after arrest day 1, days 2-4, and days 5-7), with updated examinations, neurophysiologic data, and neuroimaging data. At each time period, physicians predicted outcome by Pediatric Cerebral Performance Category and specified prediction confidence. RESULTS Predicted discharge Pediatric Cerebral Performance Category versus actual hospital discharge Pediatric Cerebral Performance Category outcomes were compared. Exact (Predicted Pediatric Cerebral Performance Category - Actual Pediatric Cerebral Performance Category = 0) and close (Predicted Pediatric Cerebral Performance Category - Actual Pediatric Cerebral Performance Category = ±1) outcome prediction accuracies for all physicians improved over successive periods (P < 0.05). Prediction accuracy did not differ significantly between physician groups at any period or overall. Agreement improved over time among neurologists (day 1 Kappa [κ], 0.28; days 2-4 κ, 0.43; days 5-7 κ, 0.68) and among intensivists (day 1 κ, 0.30; days 2-4 κ, 0.44; days 5-7 κ, 0.57). Prediction confidence increased over time (P < 0.001) and did not differ between physician groups. CONCLUSIONS Inter-rater agreement among neurologists and among intensivists improved over time and reached moderate levels. For all physicians, prediction accuracy and confidence improved over time. Further prospective research is needed to better characterize how physicians objectively and subjectively estimate neurological recovery after acute brain injury.
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Affiliation(s)
- Matthew P. Kirschen
- Division of Neurology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Communications should be addressed to: Dr. Kirschen; Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia; 3400 Civic Center Boulevard, Suite 7C26; Philadelphia, Pennsylvania 19104.
| | - Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel Hammond
- Westat Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia
| | - Judy Illes
- National Core for Neuroethics, Division of Neurology, Department of Medicine, The University of British Columbia
| | - Nicholas S. Abend
- Division of Neurology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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