Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States

Utility of Serum Amylase in Children With Abdominal Pain in the Pediatric Emergency Department

OBJECTIVES

Abdominal pain is among the most common chief complaints seen in pediatric emergency departments (PEDs). This study aims to evaluate the diagnostic utility of amylase and lipase in the evaluation of abdominal pain in the PED.

METHODS

Retrospective, cross-sectional study of patients aged 0 to 18 years with amylase and/or lipase while in the PED in 2019. Diagnostic utility of amylase and lipase was analyzed with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR). The χ 2 or Fisher exact test was used when appropriate.

RESULTS

We identified 496 PED visits with tests for amylase (0.2%), lipase (53%), or both (46.8%). Abnormal levels for amylase and lipase were 4.6% and 5.6%, respectively. Amylase use in abdominal pain evaluation showed sensitivity of 30%, specificity of 92%, PPV of 26%, NPV of 93%, and LR of 7.1 ( P = 0.008). Lipase use in abdominal pain evaluation showed sensitivity of 7.5%, specificity of 94.5%, PPV of 10.7%, NPV of 92%, and LR of 0.251 ( P = 0.616). Amylase at 3 times its normal level showed sensitivity of 10%, specificity of 99.5%, PPV of 66.7%, NPV of 92.2%, and LR of 6.35 ( P = 0.012), whereas lipase showed a sensitivity of 5%, specificity of 99.3%, PPV of 40%, NPV of 92.2%, and LR of 3.9 ( P = 0.048). Identification of a clinically significant diagnosis via coordering of amylase and lipase versus lipase alone was not significant.

CONCLUSIONS

Although serum amylase and lipase testing may be suitable for abdominal pain screening, the concurrent use of both does not seem to add any clinically significant value to diagnosis.

Antibiotic Stewardship and Treatment of Uncomplicated Urinary Tract Infection (UTI) in Children and Adolescents in the Emergency Department of a Community Hospital

A retrospective, cross-sectional study of children with suspected urinary tract infections (UTIs) 3 months to 18 years of age who had a urinalysis and urine culture (UC) during an emergency department (ED) visit between 2019 and 2020 was performed. Chi-square, Fisher exact, and independent samples T tests were used as appropriate. Median age was 6.6 years (interquartile range = 3.3-12.4). Urinalysis positivity was 92.8%, of which 81.9% of children were prescribed a first-line antibiotic. First-line antibiotic use was 82.7%. Positive UC rate was 84.7%, with 84% receiving a first-line antibiotic (P = .025). The correlation between a positive urinalysis and a positive UC was 80.8% (P < .001). Change of antibiotics based on the uropathogen of positive UCs was 6.3% (P < .001). The urinalysis and UC guided the diagnosis and treatment of UTIs. First-line antibiotics can be safely administered in the ED and prescribed for positive urinalyses. Studies are needed to evaluate the discontinuation of antibiotics with negative UCs as part of antibiotic stewardship initiatives.

Changes in Bronchiolitis Characteristics During the COVID-19 Pandemic: A Description of Pediatric Emergency Department Visits in a Community Hospital, 2019-2021

A retrospective, cross-sectional study of children with bronchiolitis aged 1 to 24 months during an ED visit between 2019 and 2021 was performed. Chi-square or Kruskal-Wallis was used to compare groups. The gamma coefficient was used to measure the association of variables through time. Bronchiolitis cases decreased by 75% from 2019 to 2020 and rose back to prepandemic levels by 2021. Radiographs (gamma -0.443), steroids (gamma -0.298), and bronchodilators (gamma -0.414) decreased during the study period (P < .001). Laboratory studies (gamma 0.032), viral testing (gamma 0.097), antibiotic use (gamma -0.069), and respiratory support (gamma 0.166) were unchanged. The decrease in steroids and bronchodilators was related to a clinical pathway that discouraged their use. Respiratory support remained unchanged. The COVID-19 pandemic (2019-2021) seems to have had little effect on the severity or resource utilization associated with bronchiolitis but may have unraveled a potential bronchiolitis phenotype that may have been more prominent during the pandemic.

Diagnostic Yield of Abdominal Radiographs in the Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Abdominal radiographs (ARs) are commonly used in the pediatric emergency department (PED). Their low diagnostic accuracy leads to overuse, excess radiation exposure, and increased resource usage. This study aims to assess the diagnostic yield of ARs in the evaluation of intraabdominal pathology in the PED.

METHODS

Retrospective, cross-sectional study of patients aged 0 to 18 years with an AR who visited the PED between 2017 and 2019. Diagnostic yield was analyzed with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and likelihood ratio.

RESULTS

A total of 4288 ARs were identified, with a rate of 6%. The overall abnormal AR rate was 31%. The incidences of an abnormal AR in abdominal pain, vomiting, and constipation were 26%, 37%, and 50%, respectively. There was a 13% rate of clinically significant diagnoses. The AR diagnostic yield showed 44% sensitivity, 70% specificity, 17% positive predictive value, and 90% NPV ( P < 0.05). Unadjusted odds ratio analysis of positive AR and abdominal pain, vomiting, and constipation revealed an odds ratio of 0.68 (95% confidence interval [CI], 0.63-0.75), 1.22 (95% CI, 1.06-1.39), and 1.72 (95% CI, 1.54-1.91), respectively.

CONCLUSIONS

There is a low rate of intraabdominal pathologic processes that an AR can identify. A normal AR does not change patient management, nor does it reduce the need for further radiologic imaging. Despite a good NPV, the AR is not a useful diagnostic tool in the PED because of its limited ability to rule in or rule out clinically significant diagnoses.

Effect of the COVID-19 Pandemic on the Pediatric Emergency Department Flow

OBJECTIVE

The aim of this study was to determine how the early stages of the coronavirus disease 2019 (COVID-19) pandemic affected the use of the pediatric emergency department (PED).

METHODS

Cross-sectional study of PED visits during January through April, 2016-2020. Data included: total PED visits, emergency severity index (ESI), disposition, chief complaint, age (months), time from first provider to disposition (PTD), and PED length of stay (PED-LOS). P-value <0.01 was statistically significant.

RESULTS

In total, 67,499 visits were reported. There was a significant decrease in PED visits of 24-71% from March to April 2020. Chief complaints for fever and cough were highest in March 2020; while April 2020 had a shorter mean PED-LOS (from 158 to 123 min), an increase of admissions (from 8% to 14%), a decrease in ESI 4 (10%), and an increase in ESI 3 (8%) (P < 0.001). There was no difference in mean monthly PTD time.

CONCLUSIONS

Patient flow in the PED was negatively affected by a decrease in PED visits and increase in admission rate that may be related to higher acuity. By understanding the interaction between hospital processes on PEDs and patient factors during a pandemic, we are able to anticipate and better allocate future resources.

Developments in Surge Research Priorities: A Systematic Review of the Literature Following the Academic Emergency Medicine Consensus Conference, 2007-2015

OBJECTIVES

In 2006, Academic Emergency Medicine (AEM) published a special issue summarizing the proceedings of the AEM consensus conference on the "Science of Surge." One major goal of the conference was to establish research priorities in the field of "disasters" surge. For this review, we wished to determine the progress toward the conference's identified research priorities: 1) defining criteria and methods for allocation of scarce resources, 2) identifying effective triage protocols, 3) determining decision-makers and means to evaluate response efficacy, 4) developing communication and information sharing strategies, and 5) identifying methods for evaluating workforce needs.

METHODS

Specific criteria were developed in conjunction with library search experts. PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases were queried for peer-reviewed articles from 2007 to 2015 addressing scientific advances related to the above five research priorities identified by AEM consensus conference. Abstracts and foreign language articles were excluded. Only articles with quantitative data on predefined outcomes were included; consensus panel recommendations on the above priorities were also included for the purposes of this review. Included study designs were randomized controlled trials, prospective, retrospective, qualitative (consensus panel), observational, cohort, case-control, or controlled before-and-after studies. Quality assessment was performed using a standardized tool for quantitative studies.

RESULTS

Of the 2,484 unique articles identified by the search strategy, 313 articles appeared to be related to disaster surge. Following detailed text review, 50 articles with quantitative data and 11 concept papers (consensus conference recommendations) addressed at least one AEM consensus conference surge research priority. Outcomes included validation of the benchmark of 500 beds/million of population for disaster surge capacity, effectiveness of simulation- and Internet-based tools for forecasting of hospital and regional demand during disasters, effectiveness of reverse triage approaches, development of new disaster surge metrics, validation of mass critical care approaches (altered standards of care), use of telemedicine, and predictions of optimal hospital staffing levels for disaster surge events. Simulation tools appeared to provide some of the highest quality research.

CONCLUSION

Disaster simulation studies have arguably revolutionized the study of disaster surge in the intervening years since the 2006 AEM Science of Surge conference, helping to validate some previously known disaster surge benchmarks and to generate new surge metrics. Use of reverse triage approaches and altered standards of care, as well as Internet-based tools such as Google Flu Trends, have also proven effective. However, there remains significant work to be done toward standardizing research methodologies and outcomes, as well as validating disaster surge metrics.

Hospital Readmissions Among Children With H1N1 Influenza Infection

OBJECTIVES

To describe readmissions among children hospitalized with H1N1 (influenza subtype, hemagglutinin1, neuraminidase 1) pandemic influenza and secondarily to determine the association of oseltamivir during index hospitalization with readmission.

METHODS

We reviewed data from 42 freestanding children's hospitals contributing to the Pediatric Health Information System from May through December 2009 when H1N1 was the predominant influenza strain. Children were divided into 2 groups by whether they experienced complications of influenza during index hospitalization. Primary outcome was readmission at 3, 7, and 30 days among both patient groups. Secondary outcome was the association of oseltamivir treatment with readmission.

RESULTS

The study included 8899 children; 6162 patients had uncomplicated index hospitalization, of whom 3808 (61.8%) received oseltamivir during hospitalization, and 2737 children had complicated influenza, of whom 1055 (38.5%) received oseltamivir. Median 3-, 7-, and 30-day readmission rates were 1.6%, 2.5%, and 4.7% for patients with uncomplicated index hospitalizations and 4.3%, 5.8%, and 10.3% among patients with complicated influenza. The 30-day readmission rates did not differ by treatment group among patients with uncomplicated influenza; however, patients with complicated index hospitalizations who received oseltamivir had lower all-cause 30-day readmissions than untreated patients. The most common causes of readmission were pneumonia and asthma exacerbations.

CONCLUSIONS

Oseltamivir use for hospitalized children did not decrease 30-day readmission rates in children after uncomplicated index hospitalization but was associated with a lower 30-day readmission rate among children with complicated infections during the 2009 H1N1 pandemic. Readmission rates for children who had complicated influenza infection during index hospitalizations are high.

Impact of the 2009 influenza (H1N1) pandemic on the United States military health care system

BACKGROUND

During public health emergencies, the Military Health System experiences challenges similar to those across the U.S. public and private health systems. This study explored how 1 such event, the 2009/2010 influenza (H1N1) pandemic, impacted health care utilization and associated costs in the Military Health System.

METHODS

Data from the Military Data Repository were used to examine diagnoses, claims data, and dates of services with respect to military or civilian care during 2004-2009/2010 influenza seasons. Comparison analysis was conducted through two-tailed t-tests and regression models.

RESULTS

There was a significant increase in inpatient and outpatient health care utilization during the 2009/2010 H1N1 pandemic year, most markedly for emergency department visits. The 2009/2010 H1N1 pandemic cost the Department of Defense $100 million compared to influenza-related health care costs incurred in previous influenza seasons. Highest health care utilization costs were found in children less than age 5. The greatest cost burden was attributed to immunizations for active duty personnel delivered at military facilities.

CONCLUSION

Annual trend analysis of costs and health care utilization would be helpful to plan and resource emerging influenza pandemics and to identify subgroups at greatest risk for contracting influenza.

Interventions to mitigate emergency department and hospital crowding during an infectious respiratory disease outbreak: results from an expert panel

OBJECTIVE

To identify and prioritize potential Emergency Department (ED) and hospital-based interventions which could mitigate the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential data sources that may be useful for triggering decisions to implement these high priority interventions.

DESIGN

Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine appropriate "triggers" for implementation of the high priority interventions in the context of four different infectious respiratory disease scenarios that vary by patient volumes (high versus low) and illness severity (high versus low).

SETTING

One day in-person conference held November, 2011.

PARTICIPANTS

Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED operations, and hospital operations.

MAIN OUTCOME MEASURE

Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, we created a prioritized list of potential data sources which could be useful to trigger interventions.

RESULTS

High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital utilization metrics.

CONCLUSIONS

We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various outbreak scenarios. The data sources identified to "trigger" the implementation of these high priority interventions consist mainly of sources available at the local, institutional level.