Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments

OBJECTIVES

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs).

METHODS

Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use.

RESULTS

Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82).

CONCLUSIONS

BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Learning From a National Quality Improvement Collaborative for Brief Resolved Unexplained Events

OBJECTIVE

In 2016, the American Academy of Pediatrics published the Brief Resolved Unexplained Event (BRUE) Clinical Practice Guideline (CPG). A multicenter quality improvement (QI) collaborative aimed to improve CPG adherence.

METHODS

A QI collaborative of 15 hospitals aimed to improve testing adherence, the hospitalization of lower-risk infants, the correct use of diagnostic criteria, and risk classification. Interventions included CPG education, documentation practices, clinical pathways, and electronic medical record integration. By using medical record review, care of emergency department (ED) and inpatient patients meeting BRUE criteria was displayed via control or run charts for 3 time periods: pre-CPG publication (October 2015 to June 2016), post-CPG publication (July 2016 to September 2018), and collaborative (April 2019 to June 2020). Collaborative learning was used to identify and mitigate barriers to iterative improvement.

RESULTS

A total of 1756 infants met BRUE criteria. After CPG publication, testing adherence improved from 56% to 64% and hospitalization decreased from 49% to 27% for lower-risk infants, but additional improvements were not demonstrated during the collaborative period. During the collaborative period, correct risk classification for hospitalized infants improved from 26% to 49% (ED) and 15% to 33% (inpatient) and the documentation of BRUE risk factors for hospitalized infants improved from 84% to 91% (ED).

CONCLUSIONS

A national BRUE QI collaborative enhanced BRUE-related hospital outcomes and processes. Sites did not improve testing and hospitalization beyond the gains made after CPG publication, but they did shift the BRUE definition and risk classification. The incorporation of caregiver perspectives and the use of shared decision-making tools may further improve care.

Impact of a hypothetical COVID-19 vaccine mandate on parental likelihood to vaccinate children: Exploring school-related concerns and vaccination decision-making

OBJECTIVE

We assessed the impact of a hypothetical school-entry COVID-19 vaccine mandate on parental likelihood to vaccinate their child.

METHODS

We collected demographics, COVID-19-related school concerns, and parental likelihood to vaccinate their child from parents of patients aged 3-16 years seen across nine pediatric Emergency Departments from 06/07/2021 to 08/13/2021. Wilcoxon signed-rank test compared pre- and post-mandate vaccination likelihood. Multivariate linear and logistic regression analyses explored associations between parental concerns with baseline and change in vaccination likelihood, respectively.

RESULTS

Vaccination likelihood increased from 43% to 50% with a hypothetical vaccine mandate (Z = -6.69, p < 0.001), although most parents (63%) had no change, while 26% increased and 11% decreased their vaccination likelihood. Parent concerns about their child contracting COVID-19 was associated with greater baseline vaccination likelihood. No single school-related concern explained the increased vaccination likelihood with a mandate.

CONCLUSION

Parental school-related concerns did not drive changes in likelihood to vaccinate with a mandate.

Resource Utilization for Pediatric Patients Discharged After Interhospital Transfer

BACKGROUND

Transfers to a pediatric emergency department (ED) with subsequent discharge home should be optimized. Transfers to a pediatric ED (PED) from community and academic general EDs are compared with a focus upon subsequent resource utilization with the PED to identify patterns of resource and education needs within general EDs.

METHODS

Patients younger than 21 years transferred to a PED from general EDs over a 1-year period and discharged home were retrospectively reviewed. The referring institutions were categorized as academic or community. Demographic and clinical variables reflecting PED care were abstracted and referrals from the academic and community institutions were compared.

RESULTS

Among 5675 interfacility transfers, 1603 (28.2%) were discharged home from the PED. Most patients were transferred from a community ED (n = 1081, 67.4%). Laboratory testing, ancillary studies, and medication administration did not differ between patients transferred from an academic or community ED. Patients from a community ED were more likely to have a procedure performed (44% vs 39%, P = 0.04). Patients from a community ED were also more likely to have high resource utilization in the PED (61% vs 55%, P = 0.03).

DISCUSSION

Most children transferred to a PED from a general ED required few resources in the PED before discharge home. The pattern of care delivered in the PED differed by the designation of the transferring ED providing insight into the differential educational and resource needs of general EDs in caring for pediatric patients.

Diagnostic testing for evaluation of brief resolved unexplained events

BACKGROUND

Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients.

METHODS

Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results.

RESULTS

Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit.

CONCLUSIONS

Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.

Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events

BACKGROUND

A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse.

OBJECTIVES

To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age.

PARTICIPANTS AND SETTING

Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits.

METHODS

This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)).

RESULTS

Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation.

CONCLUSION

There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.

Impact of COVID-19 on the associated complications of high-risk conditions in a statewide pediatric emergency network

BACKGROUND

The COVID-19 pandemic affected the volume and epidemiology of pediatric emergency department (ED) visits. We aimed to determine the rate of associated complications for 16 high-risk conditions in a Michigan statewide network of academic and community EDs during the pandemic.

METHODS

We conducted a cross-sectional study of pediatric ED visits among a network of 5 Michigan health systems during the pre-pandemic (March 1, 2019-March 10, 2020) and pandemic (March 11, 2020-March 31, 2021) periods. Data were collected from the medical record and included patient demographics, ED visit characteristics, procedure codes, and final International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. Selection of codes for 16 high-risk conditions and diagnostic complications were identified using previously described methods. Characteristics of ED visits were compared before versus during the pandemic using χ² and Fisher's exact tests. We used multilevel logistic regression to analyze covariates and potential confounders for being diagnosed with a high-risk condition or a complication of a high-risk condition.

RESULTS

A total of 417,038 pediatric ED visits were analyzed. The proportion of patients presenting with 10 of 16 high-risk conditions (including appendicitis, sepsis, and stroke) was higher in the pandemic period compared with pre-pandemic (P < 0.01). Despite this, there was no significant increase in the frequency of complications for any of the 16 high-risk conditions during the pandemic. The adjusted odds of being diagnosed with appendicitis (pre-pandemic 0.23% vs pandemic 0.52%; odds ratio [OR], 1.19 [95% confidence interval, CI, 1.00-1.41]), diabetic ketoacidosis (pre-pandemic 0.16% vs pandemic 0.52%; OR, 2.40 [95% CI, 2.07-2.78]), intussusception (pre-pandemic 0.05% vs pandemic 0.07%; OR, 1.64 [95% CI, 1.22-2.21)], and testicular torsion (pre-pandemic 0.10% vs pandemic 0.14%; OR, 1.64 [95% CI, 1.18-2.28]) was higher during the pandemic.

CONCLUSIONS

Despite a higher proportion of ED visits attributed to high-risk conditions, there was no increase in complications, suggesting minimal impact of the pandemic on outcomes of pediatric ED visits.

Characteristics of Adult Rapid Response Events in a Freestanding Children's Hospital

OBJECTIVES

To describe nonhospitalized adult rapid response events (adult RREs) in a freestanding children's hospital and examine the relationship between various demographic and clinical factors with the final patient disposition.

METHODS

We retrospectively reviewed records for nonhospitalized patients ≥18 years of age from events that occurred in a freestanding pediatric hospital between January 2011 through December 2020. We examined the relationship between adult RREs and patient demographic information, medical history, interventions, and patient disposition following an adult RRE.

RESULTS

Four hundred twenty-nine events met inclusion criteria for analysis. Most events (69%) occurred in females, 49% of events occurred in family members of patients, and 47% occurred on inpatient floor and ICU areas. The most common presenting complaint was syncope or dizziness (36%). Delivery of bad news or grief response was associated with 14% of adult RREs. Overall, 46% (n = 196) of patients were transferred to the pediatric emergency department (ED). Patients requiring acute intervention or with cardiac or neurologic past medical histories were more likely to be transferred to the pediatric ED. Acute advanced cardiac life support interventions were infrequent but, of the patients taken to the pediatric ED, 1 died, and 3 were admitted to the ICU.

CONCLUSIONS

Adult RREs are common in freestanding children's hospitals and, although rare, some patients required critical care. Expertise in adult critical care management should be available to the rapid response team and additional training for the pediatric rapid response team in caring for adult nonpatients may be warranted.

Influenza vaccination coverage among an urban pediatric asthma population: Implications for population health

INTRODUCTION

Asthma is the most common chronic disease in children. Children with asthma are at high risk for complications from influenza; however annual influenza vaccination rates for this population are suboptimal. The overall aim of this study was to describe the characteristics of a high-risk population of children with asthma presenting to an urban pediatric emergency department according to influenza vaccination status.

METHODS

The study was a retrospective chart review of 4355 patients aged 2 to 18 years evaluated in a Michigan pediatric emergency department (PED) between November 1, 2017 and April 30, 2018 with an ICD-10-CM code for asthma (J45.x). Eligible patient PED records were matched with influenza vaccination records for the 2017-2018 influenza season from the Michigan Care Improvement Registry. Geospatial analysis was employed to examine the distribution of influenza vaccination status.

RESULTS

1049 patients (30.9%) with asthma seen in the PED had received an influenza vaccine. Influenza vaccination coverage varied by Census Tract, ranging from 10% to >99%. Most vaccines were administered in a primary care setting (84.3%) and were covered by public insurance (76.8%). The influenza vaccination rate was lowest for children aged 5-11 years (30.0%) and vaccination status was associated with race (p<0.001) and insurance type (p<0.001).

CONCLUSIONS

Identification of neighborhood Census Tract and demographic groups with suboptimal influenza vaccination could guide development of targeted public health interventions to improve vaccination rates in high-risk patients. Given the morbidity and mortality associated with pediatric asthma, a data-driven approach may improve outcomes and reduce healthcare-associated costs for this pediatric population.

Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19

OBJECTIVES

To describe the epidemiology of pediatric injury-related visits to children's hospital emergency departments (EDs) in the United States during early and later periods of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

METHODS

We conducted a cross-sectional study using the Pediatric Health Information System, an administrative database to identify injury-related ED visits at 41 United States children's hospitals during the SARS-CoV-2 pandemic period (March 15, 2020 to March 14, 2021) and a 3 year comparator period (March 15-March 14, 2017-2020). For these 2 periods, we compared patient characteristics, injury type and severity, primary discharge diagnoses, and disposition, stratified by early (March 15, 2020 to June 30, 2020), middle (July 1, 2020 to October 31, 2020), and late (November 1, 2020 to March 14, 2021) pandemic periods.

RESULTS

Overall, ED injury-related visits decreased by 26.6% during the first year of the SARS-CoV-2 pandemic, with the largest decline observed in minor injuries. ED injury-related visits resulting in serious-critical injuries increased across the pandemic (15.9% early, 4.9% middle, 20.6% late). Injury patterns with the sharpest relative declines included superficial injuries (41.7% early) and sprains/strains (62.4% early). Mechanisms of injury with the greatest relative increases included (1) firearms (22.9% early; 42.8% middle; 37% late), (2) pedal cyclists (60.4%; 24.9%; 32.2%), (3) other transportation (20.8%; 25.3%; 17.9%), and (4) suffocation/asphyxiation (21.4%; 20.2%; 28.4%) and injuries because of suicide intent (-16.2%, 19.9%, 21.8%).

CONCLUSIONS

Pediatric injury-related ED visits declined in general. However, there was a relative increase in injuries with the highest severity, which warrants further investigation.

Impact of the AAP Guideline on Management of Brief Resolved Unexplained Events

OBJECTIVES

In May 2016, the American Academy of Pediatrics published a clinical practice guideline (CPG) defining apparent life-threatening events (ALTEs) as brief resolved unexplained events (BRUEs) and recommending risk-based management. We analyzed the association of CPG publication on admission rate, diagnostic testing, treatment, cost, length of stay (LOS), and revisits in patients with BRUE.

METHODS

Using the Pediatric Health Information Systems database, we studied patients discharged from the hospital with a diagnosis of ALTE/BRUE from January 2012 to December 2019. We grouped encounters into 2 time cohorts on the basis of discharge date: preguideline (January 2012-January 2016) and postguideline (July 2016-December 2019). We used interrupted time series to test if the CPG publication was associated with level change and change in slope for each metric.

RESULTS

The study included 27 941 hospitalizations for ALTE/BRUE from 36 hospitals. There was an early decrease in 12 diagnostic tests that the CPG strongly recommended against. There was a positive change in the use of electrocardiogram (+3.5%, P < .001), which is recommended by CPG. There was a significant reduction in admissions (-13.7%, P < .001), utilization of medications (-8.3%, P < .001), cost (-$1146.8, P < .001), and LOS (-0.2 days, P < .001), without a change in the revisit rates. In the postguideline period, there were an estimated 2678 admissions avoided out of 12 508 encounters.

CONCLUSIONS

Publication of the American Academy of Pediatrics BRUE CPG was associated with substantial reductions in testing, utilization of medications, admission rates, cost, and LOS, without a change in the revisit rates.

Child Opportunity Index and Changes in Pediatric Acute Care Utilization in the COVID-19 Pandemic

BACKGROUND

Pediatric acute care utilization decreased dramatically during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the association between the Child Opportunity Index (COI), a multidimensional neighborhood measure of childhood opportunity, and changes in acute care utilization at US pediatric hospitals during the COVID-19 pandemic compared with the previous 3 years.

METHODS

This observational study used administrative data across 41 US-based pediatric hospitals. Children aged 0 to 17 years with emergency department (ED) encounters during the study period were included. The COVID-19 pandemic time period (March 15, 2020-March 14, 2021) was the primary exposure. The primary outcome was the relative volume drop in ED encounters and observation/inpatient admissions through the ED by COI quintile.

RESULTS

Of 12 138 750 encounters, 3 705 320 (30.5%) were among the very low COI quintile. Overall, there was a 46.8% relative volume reduction in the pandemic period compared with the prepandmic period. This drop in volume occurred disproportionately among the very low COI quintile (51.1%) compared with the very high COI quintile (42.8%). The majority of clinical diagnosis groups demonstrated larger relative volume drops among the very low COI quintile.

CONCLUSIONS

Acute care utilization decreased the most among children from very low COI neighborhoods, narrowing previously described acute care utilization disparities. Additional study of patient perspectives on health care needs and access during this period is required to understand these changes.

Pediatrician Perspectives on Brief Resolved Unexplained Events

BACKGROUND AND OBJECTIVE

The objective with this study was to describe pediatric emergency department (ED) physicians' perspective on the evaluation and management of brief resolved unexplained events (BRUEs) to help support the development of quality improvement interventions for this population.

METHODS

We conducted qualitative semistructured interviews with pediatric ED providers who practice in a single state. Interviews were audio-recorded and transcribed and demographic information was also obtained. The 6-phase approach to reflexive thematic analysis was used to conduct the qualitative analysis.

RESULTS

Nineteen pediatric ED physicians practicing in 4 institutions across our state participated in the study. The majority of participants (95%) practice in a university-affiliated setting. The primary themes related to providing care for patients with a BRUE identified in our analysis were (1) reassurance, (2) caregiver or provider concern, and (3) clinical practice guideline availability and interpretation. Closely intertwined underlying topics informing BRUE patient management were also noted: (1) ambiguity in the BRUE diagnosis and its management; (2) a need for shared decision-making between the caregiver and the provider; and (3) concern over the increased time spent with caregivers during an ED visit for a diagnosis of BRUE. These complex relationships were found to influence patient evaluation and disposition.

CONCLUSION

Multifaceted quality improvement interventions should address caregiver and provider concerns regarding the diagnosis of BRUE while providing decision aids to support shared decision-making with caregivers.

Early versus delayed administration of intravenous magnesium sulfate for pediatric asthma

OBJECTIVE

This study aims to describe and examine the factors associated with the early administration of intravenous magnesium sulfate (IV Mg) in children presenting to the pediatric emergency department (ED) for an asthma exacerbation.

METHODS

Retrospective cohort study of children aged 5-11 years who received IV Mg in the pediatric ED between September 1, 2018 and August 31, 2019 for management of an asthma exacerbation. Primary outcome was administration of IV Mg in ≤60 min from ED triage ('early administration'). Comparison of clinical management and therapies in children who received early versus delayed IV Mg and the factors associated with early administration of IV Mg were examined.

RESULTS

Early (n = 90; 31.6%) IV Mg was associated with more timely bronchodilators (47 versus 68 min; p ≤ 0.001) and systemic corticosteroids (36 versus 46.5 min; p ≤ 0.001). There was no difference between the two cohorts in returns to the ED within 72 h (1.1% versus 2.1%; p = .99) or readmissions within 1 week one week (2.2% versus 0.5%; p = .2). Hypoxia (aOR = 3.76; 95% CI = 2.02-7.1), respiratory rate (aOR = 1.04; 95% CI = 1.02-1.07), retractions (aOR = 2.21; 95% CI = 1.25-3.94), and prior hospital use for asthma-related complaints (aOR = 2.1; 95% CI = 1.16-3.84) were significantly associated with early IV Mg.

CONCLUSIONS

Early administration of IV Mg was associated with more timely delivery of first-line asthma therapies, was safe, and improved ED throughput without increasing return ED visits or hospitalizations for asthma.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study

BACKGROUND

The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes.

METHODS

This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE.

RESULTS

Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness (P < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%.

CONCLUSIONS

AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.

Accuracy of Diagnostic Codes for Identifying Brief Resolved Unexplained Events

OBJECTIVES

To evaluate International Classification of Diseases, 10th Revision (ICD-10) coding strategies for the identification of patients with a brief resolved unexplained event (BRUE).

METHODS

Multicenter retrospective cohort study, including patients aged <1 year with an emergency department (ED) visit between October 1, 2015, and September 30, 2018, and an ICD-10 code for the following: (1) BRUE; (2) characteristics of BRUE; (3) serious underlying diagnoses presenting as a BRUE; and (4) nonserious diagnoses presenting as a BRUE. Sixteen algorithms were developed by using various combinations of these 4 groups of ICD-10 codes. Manual chart review was used to assess the performance of these ICD-10 algorithms for the identification of (1) patients presenting to an ED who met the American Academy of Pediatrics clinical definition for a BRUE and (2) the subset of these patients discharged from the ED or hospital without an explanation for the BRUE.

RESULTS

Of 4512 records reviewed, 1646 (36.5%) of these patients met the American Academy of Pediatrics criteria for BRUE on ED presentation, 1016 (61.7%) were hospitalized, and 959 (58.3%) had no explanation on discharge. Among ED discharges, the BRUE ICD-10 code alone was optimal for case ascertainment (sensitivity: 89.8% to 92.8%; positive predictive value: 51.7% to 72.0%). For hospitalized patients, ICD-10 codes related to the clinical characteristics of BRUE are preferred (specificity 93.2%, positive predictive value 32.7% to 46.3%).

CONCLUSIONS

The BRUE ICD-10 code and/or the diagnostic codes for the characteristics of BRUE are recommended, but the choice between approaches depends on the investigative purpose and the specific BRUE population and setting of interest.

Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic.

METHODS

We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children's hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017-2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low-resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed.

RESULTS

ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017-2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low-resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period.

CONCLUSIONS

The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.

Diagnostic Evaluation Low Yield for Patients with a Lower-Risk Brief Resolved Unexplained Event

In contrast to patients with an apparent life-threatening event (ALTE), the American Academy of Pediatrics recommends very limited evaluation for patients categorized as lower-risk brief resolved unexplained event (BRUE). This retrospective review aims to explore potential missed diagnostic opportunities for patients with a lower-risk BRUE (n = 10) through comparison with a subset of patients with ALTE (n = 72). None of the patients with a lower-risk BRUE had laboratory, imaging or ancillary studies that were diagnostic. Among patients with ALTE, 5 had laboratory and 3 had imaging studies that were diagnostic. None of the patients with a lower-risk BRUE had recurrent events during hospitalization or a serious underlying diagnosis identified within the 90 day follow-up period. As recommended by the AAP, patients with a lower-risk BRUE do not need diagnostic evaluation and can be discharged home with outpatient follow-up.

Clinical factors associated with the use of dexamethasone for asthma in the pediatric emergency department

BACKGROUND

Dexamethasone is efficacious for the treatment of pediatric asthma exacerbations but is not specifically recommended by current national guidelines.

OBJECTIVES

To describe the factors associated with prescribed dexamethasone in a pediatric emergency department (PED) and upon patient discharge.

METHODS

Retrospective chart review of patients aged 2 to 18 years discharged home from a PED with a diagnostic code for asthma (J45x). Descriptive statistics are reported and binary logistic regression with generalized estimating equations was used to examine the demographic and clinical factors associated with dexamethasone use in the PED and upon discharge.

RESULTS

594 children contributed 690 visits for asthma. Two-thirds of patients received prednisone in the PED (n = 430; 62%). Among 260 children who received dexamethasone, 76% (n = 198) were prescribed a second dose for post-discharge administration. Multivariable models showed that patients triaged as most urgent had a 50% reduction in the odds of receiving dexamethasone in the PED (OR = 0.5; 95% CI = 0.28-0.87). Patients seen by a pediatrician (OR 4.2; 95%CI 2.1-8.3) and those triaged as urgent (OR 2.9; 95% CI = 1.8-7.8) were more likely to receive a single dose of dexamethasone.

CONCLUSIONS

Dexamethasone is less commonly used in the PED for asthmatic patients triaged as most urgent. Triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Outcome Prediction of Higher-Risk Brief Resolved Unexplained Events

OBJECTIVES

Brief resolved unexplained events (BRUEs) are classified as higher risk on the basis of patient and event characteristics, but there is limited evidence to guide management decisions. The authors of this study aim to describe patients with a higher-risk BRUE, determine the yield of diagnostic evaluation, and explore predictors of clinical outcomes.

METHODS

A retrospective medical record review was conducted for patients ≤365 days of age who were evaluated in a tertiary-care pediatric emergency department with a discharge diagnostic code indicative of a BRUE. Demographic and clinical characteristics, including diagnostic evaluation, are reported. Univariate and multivariate analyses were used to test the association of risk factors with clinical outcomes (serious underlying diagnosis, recurrent events, and return hospitalization).

RESULTS

Of 3325 patients, 98 (3%) met BRUE criteria and 88 were classified as higher risk; 0.6% of laboratory and 1.5% of ancillary tests were diagnostic, with 4 patients having a serious underlying diagnosis. Nine patients had recurrent events during hospitalization, and 2 were readmitted for a recurrent BRUE after their index visit. Prematurity was the only characteristic significantly associated with an outcome, increasing the odds of a recurrent event (odds ratio = 9.4; P = .02).

CONCLUSIONS

The majority of patients with a BRUE are higher risk, but the yield of diagnostic evaluation is low. Published risk criteria do not appear to be associated with adverse clinical outcomes except for prematurity and recurrent events. Future multicentered prospective studies are needed to validate risk stratification and develop management guidance for the higher-risk BRUE population.

Examining the clinical management of asthma exacerbations by nurse practitioners in a pediatric emergency department

BACKGROUND

Little is known about the clinical management or quality of asthma care provided by nurse practitioners (NP) in a pediatric emergency setting.

OBJECTIVE

To describe the clinical management of asthma by NPs in our institution's emergency department, and to compare the treatment strategies between NPs, pediatricians, and pediatric emergency physicians.

METHODS

We conducted a retrospective chart review at a level-one pediatric trauma center. Data were extracted from electronic medical records for all patients between 2 and 18 years of age presenting to the emergency department with an asthma exacerbation. Data were analyzed using binary logistic regression with generalized estimating equations.

RESULTS

NPs evaluated 18% of all children presenting for asthma care. When compared to pediatric emergency physicians, patients treated by NPs had approximately twice the odds of receiving a β2-agonist (OR = 2.02; 95% CI 1.02 - 3.99) or a systemic corticosteroid (OR = 2.31; 95% CI 1.35 - 3.95) within 60 minutes of clinical evaluation. Adherence rates were similar for the other asthma quality measures between these two clinician groups.

CONCLUSIONS

NPs were best able to meet time-sensitive asthma quality measures in the emergency department. The addition of NPs to emergency staffing models may improve access to timely care for children with asthma.

Complex Febrile Seizures, Lumbar Puncture, and Central Nervous System Infections: A National Perspective

OBJECTIVES

The objective was to determine the national lumbar puncture (LP) practice patterns relative to the incidence of central nervous system (CNS) infections among children presenting to the emergency department (ED) with complex febrile seizures (CFS).

METHODS

This was a retrospective study of ED visits for CFS from 2007 to 2014 in patients aged 0 to 5 years using a national sample. Primary outcomes include the frequency of LP, incidence of CNS infections, and ED disposition.

RESULTS

Of 28,810 ED visits for CFS (44.4% female; mean age = 1.39 years), LP was performed in 7,445 (25.8%, 95% confidence interval [CI] 23.5%-28.2%). There was no significant difference in the proportion due to hospital teaching status or geographical region. The proportion decreased from 31.4% to 17.8% over the study period (Rao-Scott statistic = 5.85, p < 0.001). CNS infection was diagnosed in 80 (0.3%) encounters (95% CI = 41-112). The most commonly associated infections were otitis media (16.8%), upper respiratory infections (15.8%), and other viral infections (14.6%). A total of 14,696 encounters (51.0%, 95% CI = 47.9%-54.1%) resulted in a hospital admission.

CONCLUSIONS

Although rates have been declining, LP was performed in one-fourth of ED encounters for CFS over the 8-year study period. The incidence of CNS infections was very low, however, suggesting that this procedure could be avoided in many patients.

Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway

BACKGROUND

Acute stroke protocols improve delivery of care but it is unclear whether these resource intensive protocols are able to differentiate stroke from mimics in children. The aim of this study is to describe our institution's experience with stroke mimics identified through our pediatric stroke clinical pathway (PSCP).

METHODS

The PSCP was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. For patients managed using the PSCP from June 2014 to December 2016, demographic and clinical data were compared for patients diagnosed with stroke or a stroke mimic.

RESULTS

A total of 59 children were evaluated with the PSCP. Fourteen children were identified as having a stroke and 45 children had stroke mimics. The most common stroke mimics were functional neurological disorders (20.0%), transient neurological deficits (17.8%), migraine (15.6%), and seizure (11.1%). Patient demographics and time to neuroimaging did not differ between patients with and without stroke. Vomiting was commonly reported by patients with stroke (odds ratio: 4.00, 95% confidence interval: 1.12 to 14.35), whereas weakness was not (odds ratio: 0.7, 95% confidence interval: 0.07 to 0.90), but the physical examination did not differ between patients with and without stroke.

CONCLUSIONS

The PSCP ensures timely evaluation of patients presenting with neurological deficits but fails to reliably differentiate between patients with stroke and patients with stroke mimics. Further multicentered studies are needed to develop a "stroke screen" that reliably distinguishes pediatric stroke from its mimics.

Pediatric Stroke Clinical Pathway Improves the Time to Diagnosis in an Emergency Department

BACKGROUND

Identified barriers to the diagnosis of pediatric stroke include delays in provider recognition and definitive neuroimaging (magnetic resonance imaging). Clinical pathways are recommended to address these barriers; yet few studies have evaluated their impact. Our aim is to describe the effect of a pediatric stroke clinical pathway on the diagnosis of stroke in patients presenting with focal neurological dysfunction to a pediatric emergency department.

METHODS

The pediatric stroke clinical pathway was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. Demographic and clinical data were collected for patients ultimately diagnosed with stroke using the pediatric stroke clinical pathway and compared with data collected on patients diagnosed with stroke before implementation of the pediatric stroke clinical pathway.

RESULTS

The pediatric stroke clinical pathway was activated for 36 patients. Stroke was diagnosed in 11 patients (33%), of whom 55% were male with a median age 11 ± 7 years. Focal deficits (82%) and headache (55%) were common presenting complaints. There was a significant improvement in the median time to magnetic resonance imaging from arrival to the emergency department (before implementation of the pediatric stroke clinical pathway: 17 hours [interquartile range 6, 22] versus after implementation of the pediatric stroke clinical pathway: four hours [interquartile range 3, 12]; P = 0.02).

CONCLUSIONS

The pediatric stroke clinical pathway improved time to definitive diagnosis and streamlined the care provided to children presenting to the pediatric emergency department with focal neurological dysfunction.