Psychotropic Medication Administration in Pediatric Emergency Departments

BACKGROUND AND OBJECTIVES

Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals.

METHODS

We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital.

RESULTS

Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001).

CONCLUSIONS

Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.

Exposure to potentially lethal weapons and drugs among U.S. adolescents with recent depressive symptoms or suicidality in the Adolescent Behaviors and Experiences Survey

The scope of lethal means exposure (i.e. guns, intravenous drugs, prescription drugs) relative to depressive symptoms and suicidality in adolescents is not well described. Using the Adolescent Behaviors and Experiences Survey (ABES), we found lethal means exposure increased in a dose dependent manner with increasing depressive symptoms, adjusting for age, sex, race, and ethnicity. Adolescent males were more than 6 times more likely to have exposure to guns and intravenous drugs compared to adolescent females.

Resource utilization among children presenting with cannabis poisonings in the emergency department

BACKGROUND

Exploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings.

METHODS

This is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0-10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named "ancillary testing" was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time.

RESULTS

A total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2-6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12]).

CONCLUSIONS

We found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation.

Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where

Objectives

Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions.

Methods

This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods.

Results

Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods.

Conclusions

Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.

Substance Use-related Emergency Department Visits and Resource Utilization

Introduction

Substance use-related visits to the emergency department (ED) have been linked to higher service delivery costs, although little is known about the specific services used. Our goal In this study was to describe the recent trends of substance use-related ED visits and assess the association between substance use and specific ED resource utilization.

Methods

We performed a retrospective, cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2013–2018. All ED visits in the United States for patients ≥18 years of age were included. The primary exposure was having substance use included as a chief complaint or diagnosis, which we identified using the International Classification of Diseases, 9th and 10th revisions, codes. The primary outcome was the use of diagnostic services (including laboratory studies and cardiac monitoring) or imaging studies in the ED.

Results

The study sample included 95,506 visits in the US, extrapolating to over 619 million ED visits nationwide. The total number of ED visits remained stable during the study period, but substance use-related visits increased by 45%, with these visits making up 2.93% of total ED visits in 2013 and 4.25% in 2018. This increase was primarily driven by stimulant-, sedative- (opioids and benzodiazepines), and hallucinogen-related visits. Mental health-related visits rose in parallel by 66% during the same period. Compared to non-substance use-related visits, substance use-related visits were more likely to undergo any diagnostic study (adjusted odds ratio [aOR] 1.28; 95% confidence interval (CI): 1.11–1.47; P = 0.001), toxicology screening (aOR 10.15; 95% CI: 8.84–11.66), but less likely to have imaging studies (aOR 0.62; 95% CI: 0.56–0.68; P <0.0001). In stratified analyses, substance use-related visits with concurrent mental health disorders were more likely to undergo imaging studies (aOR 1.56; 95% CI: 1.09–2.22), while findings were opposite for those without concurrent mental health disorders (aOR 0.64; 95% CI: 0.51–0.71; P for interaction <0.0001).

Conclusion

Substance use- and mental health-related ED visits are rising, and they are associated with increased resource utilization. Further studies are needed to provide more guidance in the approach to acute services in this vulnerable population.

Prediction of the Development of Severe Sepsis Among Children With Intestinal Failure and Fever Presenting to the Emergency Department

OBJECTIVES

Children with intestinal failure (IF) and fever are frequently bacteremic, but risk factors for development of sepsis in this population are not well delineated. Our objective was to determine what clinical factors available on arrival to the emergency department (ED), including commonly used vital sign thresholds, predicted the subsequent development of severe sepsis in children with IF and fever.

STUDY DESIGN

This was a retrospective cohort study of children younger than 21 years with IF presenting to a tertiary care ED between 2010 and 2016 with fever who did not have hypotensive septic shock on arrival. The primary outcome was development of severe sepsis within 24 hours of ED arrival, as defined by consensus criteria. We identified predictors of severe sepsis using both univariate and multivariate models and calculated the test characteristics of 3 different sets of vital sign criteria in determining risk of severe sepsis.

RESULTS

In 26 (9.4%) of 278 encounters, the patient developed severe sepsis within 24 hours of arrival to the ED; 3 were excluded due to hypotensive shock on arrival. Predictors of severe sepsis included history of intestinal pseudo-obstruction (odds ratio, 8.2; 95% confidence interval, 2.3-30.2) and higher initial temperature (odds ratio, 1.7; 95% confidence interval, 1.2-2.3). The 3 sets of vital sign criteria had widely varying sensitivity and specificity in identifying development of severe sepsis.

CONCLUSIONS

History of intestinal pseudo-obstruction and higher fever predicted increased risk of severe sepsis among children with IF and fever presenting to an ED. No single set of vital sign criteria had both high sensitivity and specificity for this diagnosis.

Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine

Background

Pediatric Early Warning Scores (PEWS) are nurse-administered clinical assessment tools utilizing vital signs and patient signs and symptoms to screen for patients at risk for clinical deterioration.^1–3 When utilizing a PEWS system, which consists of an escalation algorithm to alert physicians of high risk patients requiring a bedside evaluation and assessment, studies have demonstrated that PEWS systems can decrease pediatric intensive care (PICU) utilization, in-hospital cardiac arrests, and overall decreased mortality in high income settings. Yet, many hospital based settings in low and lower middle income countries (LMIC) lack systems in place for early identification of patients at risk for clinical deterioration.

Methods

A contextually adapted 16-h pediatric resuscitation program included training of a PEWS tool followed by implementation and integration of a PEWS system in a pediatric hematology/oncology ward in Beit Jala, Palestine. Four PDSA cycles were implemented post-implementation to improve uptake and scoring of PEWS which included PEWS tool integration into an existing electronic medical record (EMR), escalation algorithm and job aid implementation, data audits and ward feedback.

Results

Frequency of complete PEWS vital sign documentation reached a mean of 89.9%. The frequency and accuracy of PEWS scores steadily increased during the post-implementation period, consistently above 89% in both categories starting from data audit four and continuing thereafter. Accuracy of PEWS scoring was unable to be assessed during week 1 and 2 of data audits due to challenges with PEWS integration into the existing EMR (PDSA cycle 1) which were resolved by the 3rd week of data auditing (PDSA cycle 2).

Conclusions

Implementation of a PEWS scoring tool in an LMIC pediatric oncology inpatient unit is feasible and can improve frequency of vital sign collection and generate accurate PEWS scores.

Contribution to the literature

This study demonstrates how to effectively implement a PEWS scoring tool into an LMIC clinical setting.

This study demonstrates how to utilize a robust feedback mechanism to ensure a quality program uptake.

This study demonstrates an effective international partnership model that other institutions may utilize for implementation science.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07157-x.

Outcomes of Patients with Sepsis in a Pediatric Emergency Department after Automated Sepsis Screening

OBJECTIVE

To determine the effect of an automated sepsis screening tool on treatment and outcomes of severe sepsis in a pediatric emergency department (ED).

STUDY DESIGN

Retrospective cohort study of encounters of patients with severe sepsis in a pediatric ED with a high volume of pediatric sepsis cases over a 2-year period. The automated sepsis screening algorithm replaced a manual screen 1 year into the study. The primary outcome was the proportion of patients treated for sepsis while in the ED. Secondary outcomes were time from ED arrival to first intravenous (IV) antibiotic and first IV fluid bolus, volume of fluid administered in the ED, 30-day mortality, intensive care unit-free days, and hospital-free days.

RESULTS

In year 1 of the study, 8910 of 61 026 (14.6%) of encounters had a manual sepsis screen; 137 patients met criteria for severe sepsis. In year 2, 100% of 61 195 encounters had an automated sepsis screen and there were 136 cases of severe sepsis. There was a higher proportion of patients with severe sepsis who had an active malignancy and indwelling central venous catheter in year 2. There were no differences in the proportion of patients treated for sepsis in the ED, time to first IV antibiotic or first IV fluid bolus, fluid volume delivered in the ED, hospital-free days, intensive care unit-free days, or 30-day mortality after implementation of the automated screening algorithm.

CONCLUSIONS

An automated sepsis screening algorithm introduced into an academic pediatric ED with a high volume of sepsis cases did not lead to improvements in treatment or outcomes of severe sepsis in this study.

Comparison of Manual and Automated Sepsis Screening Tools in a Pediatric Emergency Department

OBJECTIVES

To compare the performance and test characteristics of an automated sepsis screening tool with that of a manual sepsis screen in patients presenting to a pediatric emergency department (ED).

METHODS

We conducted a retrospective cohort study of encounters in a pediatric ED over a 2-year period. The automated sepsis screening algorithm replaced the manual sepsis screen 1 year into the study. A positive case was defined as development of severe sepsis or septic shock within 24 hours of disposition from the ED. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios with 95% confidence intervals (CIs) for each.

RESULTS

There were 122 221 ED encounters during the study period and 273 cases of severe sepsis. During year 1 of the study, the manual screen was performed in 8910 of 61 026 (14.6%) encounters, resulting in the following test characteristics: sensitivity of 64.6% (95% CI 54.2%-74.1%), specificity of 91.1% (95% CI 90.5%-91.7%), PPV of 7.3% (95% CI 6.3%-8.5%), and NPV of 99.6% (95% CI 99.5%-99.7%). During year 2 of the study, the automated screen was performed in 100% of 61 195 encounters, resulting in the following test characteristics: sensitivity of 84.6% (95% CI 77.4%-90.2%), specificity of 95.1% (95% CI 94.9%-95.2%), PPV of 3.7% (95% CI 3.4%-4%), and NPV of 99.9% (95% CI 99.9%-100%).

CONCLUSIONS

An automated sepsis screening algorithm had higher sensitivity and specificity than a widely used manual sepsis screen and was performed on 100% of patients in the ED, ensuring continuous sepsis surveillance throughout the ED stay.

Association of State-Level Opioid-Reduction Policies With Pediatric Opioid Poisoning

IMPORTANCE

Opioid-reduction policies have been enacted by US states to address the opioid epidemic. Evidence of an association between policy implementation and decreased rates of pediatric opioid poisoning provides further justification for expanded implementation of these policies.

OBJECTIVE

To examine the association of 3 state-level opioid-reduction policies with the rate of opioid poisoning in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series analysis used data from the National Poison Data System (NPDS), a database of poisoning information reported to poison control centers across the US. Individuals younger than 20 years who experienced poisoning associated with 1 or more prescription opioids from January 1, 2005, to November 30, 2017, were included. The analysis focused on 3 widespread policy interventions: the prescription drug monitoring program (PDMP), pain clinic legislation, and opioid prescribing guidelines. Data analysis was performed from January 30, 2020, to March 30, 2020.

EXPOSURES

Any opioid poisoning in individuals younger than 20 years that was reported to the NPDS.

MAIN OUTCOMES AND MEASURES

Opioid poisoning rates per million person-months before and after implementation of each of the 3 policies, overall and stratified by age (≤4 years, 5-9 years, 10-14 years, and 15-19 years).

RESULTS

A total of 338 476 opioid poisoning incidences in children and young adults were reported to the NPDS within the study period. Of this study population, the mean (SD) age was 9.74 (7.15) years, and 179 011 (52.9%) were female. The implementation of a PDMP was associated with a reduction in the monthly rate of opioid poisoning in children and adolescents (-0.07 per million person-months; 95% CI, -0.09 to -0.04) in the postimplementation period. This reduction was observed for all age groups except for the 10- to 14-year age group (-0.03 per million person-months; 95% CI, -0.05 to 0.00). Pain clinic legislation was associated with an immediate reduction in opioid poisoning (-6.22 per million person-months; 95% CI, -8.98 to -3.47). This association was statistically significant across all ages except for the 4 years or younger group. Analysis of the association of implementation of opioid prescribing guidelines was limited because of insufficient follow-up data and did not show an immediate or monthly change in the rate of opioid poisoning.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that certain state-level opioid-reduction policies were associated with decreases in pediatric opioid exposures across age groups. Further examination of the underlying mechanisms of these associations, including age group-specific outcomes, may expand and strengthen policies that reduce opioid poisoning, misuse, and overdoses in children and adolescents.

Central Line-Associated Bloodstream Infection among Children with Intestinal Failure Presenting to the Emergency Department with Fever

OBJECTIVES

To determine which factors confer the greatest risk of central line-associated bloodstream infection (CLABSI) in children with intestinal failure and fever presenting to an emergency department (ED), and to assess whether a low-risk group exists that may not require the standard treatment of admission for 48 hours on intravenous antibiotics pending culture results.

STUDY DESIGN

This retrospective cohort study included children with intestinal failure and fever presenting to an ED over a 6-year period. Multivariable models were created using risk factors selected a priori to be associated with CLABSI as well as univariate predictors with P < .2.

RESULTS

Among 81 patients with 278 ED encounters, 132 (47.5%) CLABSI episodes were identified. Multivariable models showed higher initial temperature in the ED (aOR, 1.99; 95% CI, 1.25-3.17) and low white blood cell count (aOR, 2.65; 95% CI, 1.03-6.79) and platelet count (aOR, 2.65; 95% CI, 1.20-5.87) relative to age-specific reference ranges were strongly associated with CLABSI. Among the 63 encounters in which the patient had none of these risk factors, the rate of CLABSI was 25.4%.

CONCLUSIONS

Children with intestinal failure who present to the ED with fever have high rates of CLABSI. Although higher temperature in the ED, lower white blood cell count, and lower platelet count are strongly associated with CLABSI, patients without these risk factors frequently have positive blood cultures as well. Antibiotics should, therefore, be given to all children with intestinal failure and fever until CLABSI is ruled out.

Financial conflicts of interest and conclusions about neuraminidase inhibitors for influenza: an analysis of systematic reviews

BACKGROUND

Industry funding and financial conflicts of interest may contribute to bias in the synthesis and interpretation of scientific evidence.

OBJECTIVE

To examine the association between financial conflicts of interest and characteristics of systematic reviews of neuraminidase inhibitors.

DESIGN

Retrospective analysis.

SETTING

Reviews that examined the use of neuraminidase inhibitors in the prophylaxis or treatment of influenza, were published between January 2005 and May 2014, and used a systematic search protocol.

MEASUREMENTS

Two investigators blinded to all information regarding the review authors independently assessed the presentation of evidence on the use of neuraminidase inhibitors as favorable or not favorable. Financial conflicts of interest were identified using the index reviews, other publications, and Web-based searches. Associations between financial conflicts of interest, favorability assessments, and presence of critical appraisals of evidence quality were analyzed.

RESULTS

Twenty-six systematic reviews were identified, of which 13 examined prophylaxis and 24 examined treatment, accounting for 37 distinct assessments. Among assessments associated with a financial conflict of interest, 7 of 8 (88%) were classified as favorable, compared with 5 of 29 (17%) among those without a financial conflict of interest. Reviewers without financial conflicts of interest were more likely to include statements about the quality of the primary studies than those with financial conflicts of interest.

LIMITATIONS

The heterogeneity in populations and outcomes examined in the reviews precluded analysis of the contribution of selective inclusion of evidence on the discordance of the assessments made in the reviews. Many of the systematic reviews had overlapping authorship.

CONCLUSION

Reviewers with financial conflicts of interest may be more likely to present evidence about neuraminidase inhibitors in a favorable manner and recommend the use of these drugs than reviewers without financial conflicts of interest.

PRIMARY FUNDING SOURCE

Australian National Health and Medical Research Council.