Telemedicine in paediatric emergency care: A systematic review

INTRODUCTION

The impact of telemedicine on the access and quality of paediatric emergency care remains largely unexplored because most studies to date are focused on adult emergency care. We performed a systematic review of the literature to determine if telemedicine is effective in improving quality of paediatric emergency care with regards to access, process measures of care, appropriate disposition, patient-centred outcomes and cost-related outcomes.

METHODS

We developed a systematic review protocol in accordance with PRISMA (Preferred Reporting Items for Systematic Review) guidelines. We included studies that evaluated the impact of synchronous and asynchronous forms of telemedicine on patient outcomes and process measures in the paediatric emergency care setting. Inclusion criteria were study setting, study design, intervention type, age, outcome measures, publication year and language.

RESULTS

Overall, 1.9% (28/1434) studies met study inclusion and exclusion criteria. These studies revealed that telemedicine increased accuracy of patient assessment in the pre-clinical setting, improved time-to disposition, guided referring emergency department (ED) physicians in performing appropriate life-saving procedures and led to cost savings when compared to regular care. Studies focused on telepsychiatry demonstrated decreased length of stay (LOS), transfer rates and improved patient satisfaction scores.

DISCUSSION

Our comprehensive review revealed that telemedicine enhances paediatric emergency care, enhances therapeutic decision-making and improves diagnostic accuracy, and reduces costs. Specifically, telemedicine has its most significant impact on LOS, access to specialized care, cost savings and patient satisfaction. However, there was a relative lack of randomized control trials, and more studies are needed to substantiate its impact on morbidity and mortality.

Biomarkers and their association with bacterial illnesses in hypothermic infants

OBJECTIVES

To describe the association of biomarkers with serious bacterial infection (SBI; urinary tract infection [UTI], bacteremia and/or bacterial meningitis) in hypothermic infants presenting to the emergency department (ED).

METHODS

We performed a cross sectional study in four academic pediatric EDs from January 2015 through December 2019, including infants ≤90 days old presenting with a rectal temperature of ≤36.4 °C. We constructed receiver operating characteristic (ROC) curves to evaluate the accuracy of blood biomarkers including white blood cell count (WBC), absolute neutrophil count (ANC) and platelets for identifying SBI, with exploratory analyses evaluating procalcitonin and band counts.

RESULTS

Among 850 included infants (53.5% males; median days of age 13 [IQR 5-58 days]), SBI were found in 55 (6.5%). For infants with SBI, the area under the curve (AUC; 95% confidence interval) for WBC was 0.70 (0.61-0.78) with sensitivity 0.64 (0.50-0.74) and specificity 0.77 (0.74-0.80). The AUC for ANC was 0.77 (0.70-0.84) with sensitivity 0.69 (0.55-0.81) and specificity 0.77 (0.74-0.8). For platelets, the AUC was 0.6 (0.52-0.67) with sensitivity 0.73 (0.59-0.84) and specificity 0.5 (0.46-0.53). Both the WBC and ANC were minimally accurate for identifying hypothermic infants with SBI. When looking at the accuracy of these biomarkers for identifying invasive bacterial infection (IBI; bacteremia and/or bacterial meningitis), ANC again showed minimal accuracy with an AUC of 0.70 (0.55-0.85).

CONCLUSIONS

Biomarkers commonly used as part of an infectious workup are generally poor at identifying SBI in hypothermic infants. Our findings from this cohort of hypothermic infants are similar to those reported from febrile infants, suggesting similarities in the bioresponse to infection between hypothermic and febrile infants. Additional research is required to improve risk stratification for hypothermic infants, and to better guide evaluation and management.

Differences in concussion knowledge between parents and their children in a multidisciplinary concussion clinic sample

PURPOSE

This study assessed concussion knowledge in concussed youth and parents treated at a multi-disciplinary concussion center.

METHODS

Youth (n = 50) and parents (n = 36) were approached at the beginning of a clinical visit. Participants completed a 22-item, previously published concussion knowledge survey before the visit.

RESULTS

Responses were compared with previously collected, published data from adolescents in a high school setting (n = 500). The patient group was divided into those with one (n = 23) vs. two or more concussions (n = 27). Chi-square analyses compared total correct responses between youth, parents, and the high school sample. T-tests assessed differences in knowledge based on prior concussions, age, and gender. All groups showed high accuracy for return-to-play guidelines (>90%) and similar knowledge of concussion-related symptoms (72.3% vs. 68.6%). Significant knowledge gaps about diagnosis, neurological consequences, and long-term risks were present across groups (19% to 68% accuracy). The patient group more often misattributed neck symptoms to concussion (X2  < 0.005). Prior concussion and gender were not significant predictors of concussion knowledge (p > 0.5).

CONCLUSION

Community and clinically-based educational techniques may not be effectively communicating knowledge about concussion diagnosis, symptoms, long-term risks, and neurological implications of concussion. Educational tools need to be tailored to specific settings and populations.

Traditional bone setting and trauma care in South-Eastern Chad

Background

Traditional bonesetters are the main providers of fracture treatment and trauma care in much of Africa. However, there is a paucity of literature on bonesetters in Chad.

Objectives

Our study sought to investigate Chadian bonesetter practices, their relationship to the community, and the complex local perspectives on trauma care in Am Timan, Chad.

Methods

Thirty-three semi-structured interviews were conducted with community members, traditional bonesetters, and physicians in Am Timan using a constructivist grounded theory approach. Responses were coded, categorized, and compared within and across study populations to identify themes.

Results

Most community members (n=25) interviewed preferred bonesetters for trauma care due to their affordability, continuity and convenience of care, and the community's fear of Western medical practices. Although the Chadian bonesetters' fracture management mirrored bonesetters in neighboring African countries, the Chadian bonesetters have a much wider scope of practice, including treatment for both medical and spiritual ailments. Both Jabari (n=6) and physicians (n=2) emphasized the need for more training and collaboration.

Conclusion

As in much of Africa, bonesetters perform a major role in providing trauma care in Chad. Our research identifies an opportunity to maximize trauma care in Chad through dialogue, training, and collaboration between bonesetters and physicians.

Characteristics Associated With Presence of Pediatric Mental Health Care Policies in Emergency Departments

OBJECTIVES

The majority of US children do not have access to an emergency department (ED) with a pediatric mental health care policy in place. Our objective was to understand factors associated with whether US EDs have a pediatric mental health care policy.

METHODS

We analyzed data from the National Pediatric Readiness Project, a nationally representative cross-sectional survey of US EDs. Nurse managers reported whether their hospitals had a policy to care for children with social/mental health concerns (n = 3612). We calculated prevalence estimates, prevalence ratios (PRs), and confidence intervals (CIs) for regional and ED characteristics (eg, rurality and types of personnel) by whether EDs had a pediatric mental health care policy.

RESULTS

Overall, 46.2% (n = 1668/3612) of EDs had a pediatric mental health care policy. Emergency departments located in remote areas were 60% less likely to have such a policy compared with EDs in urban areas (PR, 0.4; CI, 0.3-0.5). Emergency department characteristics associated with having a pediatric mental health care policy included having a policy to transfer children with social/mental health concerns (PR, 5.4; CI, 4.7-6.2), having a policy to address maltreatment (PR, 3.4; CI, 2.6-4.4), and having nurse and physician pediatric emergency care coordinators (PR, 1.6; CI, 1.5-1.8).

CONCLUSIONS

Lower prevalence of pediatric mental health policies in rural EDs is concerning considering EDs are often the first point of contact for pediatric patients. This work highlights the importance of pediatric emergency care coordinators in fostering ED capacity to meet children's mental health needs.

The Feasibility of Using Comic-Based Concussion Discharge Instructions: Gauging Likeability and Knowledge Improvement Among Adolescents and Parents

OBJECTIVE

The objective of this study was to evaluate feasibility of supplementing emergency department (ED) concussion discharge instructions for adolescents and parents with a newly created educational comic and a publicly available comic-based video at an outpatient sports neurology clinic.

METHODS

We created a gender-neutral, 2-page comic to augment text-only ED concussion discharge instructions. A sample of patients evaluated at a sports neurology clinic and their parents/guardians participated. Patients and their parents were randomized to view either the comic only or both the comic and publicly available comic-based video. Patients and parents completed preintervention and postintervention surveys to assess likeability and concussion knowledge including concussion definition, symptoms, return-to-ED criteria, and resuming normal activity. Data were analyzed using descriptive and comparative statistics.

RESULTS

A total of 57 patients (47.4% female; mean age, 15 years) and 37 guardians were enrolled. Most (73%) concussions were sports related, with the majority having sought care within 24 hours in an ED (80%). Over half (51%) had experienced 2 or more prior concussions. Overall, 31 adolescents and 20 guardians viewed both comic and video, whereas 26 adolescents and 17 guardians viewed the comic only. Both comic and video were favorably reviewed, but a higher proportion of respondents rated the video more positively than the comic for likability (P < 0.01), comprehensibility (P < 0.05), and increasing understanding (P < 0.05). Patients' knowledge of some concussion symptoms emphasized in the comic increased after reading (emotional changes, P = 0.02; vomiting, P = 0.04).

CONCLUSIONS

Patients showed increased concussion knowledge using the favorably endorsed comic-based discharge instructions. Using comic-based supplemental discharge tools may optimize concussion education for adolescents.

Exploring Camp Policies and Leadership Opinions on Digital Media Use in Camps

While summer camps provide children a unique experience away from home, this environment may lead to increased and unsupervised use of digital media. Camps’ policies and leaderships’ views on digital media consumption in camps are currently unknown. To elucidate current trends, we partnered with CampDoc.com to survey a national sample of camp leadership about digital media policies and practices. A single response was selected from each camp and analyzed using descriptive statistics. Free text responses reflecting on positive and negative experiences with digital media were assessed using thematic analysis. We received 722 responses from 363 of the 950 camps within the Camp Doc network. Respondents represented camps in 45 states in the United States. Internet and cell service were available in 22.3% and 34.7% of camps, respectively. Approximately 60% of camps reported a digital media policy for campers and staff. Most policies (67.9%) did not allow use of digital media devices. Camp leadership reported that smartphones (51.3%) and social media apps (42.2%) were most difficult to restrict. Qualitative themes focused on the benefits of digital media for creativity and connection, but also the interruption of camp experiences. Camp personnel described positive media uses aligned with American Academy of Pediatrics media guidelines, for teaching creativity, acquiring new skills, and understanding the value of unplugging for creating social connections. Although most camps have policies restricting digital media use, complete restriction may be difficult.

Tongue protrusion as the presenting symptom of parapharyngeal abscess

Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age-related factors in children and non-specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2-year-old female with Trisomy 21 who presented with a chief concern of "tongue swelling" per parents. After initially failing treatment for presumed angioedema caused by an angiotensin-converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children.

Pediatric Head Injuries in Summer Camps

Summer camps have a unique supervisory environment that may lead to increased head injury risk for children. The epidemiology of head injuries in camps is unclear. We partnered with CampDoc.com to review head injury reports from camp nurses in 2016 from 197 camps in 36 states. A total of 4290 (92%) reports were coded as definite head injuries, 47% (n = 2002) in female campers, with median camper age of 10 years. Head injury severity was coded as mild (94%, n = 4040), moderate (6%, n = 248), or severe (<1%, n = 2). Only 3% (n = 134) were medically evaluated, and 29% (n = 1221) were sports-related. Head injuries were categorized as definite (3%, n = 137) and probable (13%, n = 572) concussions, with 39% (n = 277) being sports-related and 61% (n = 83) of definite concussions incurred by female campers. Summer camps, while an important location of head injury risk, appear to be a safe environment for youth.

School Readiness

School readiness includes the readiness of the individual child, the school's readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to meet the needs of all children at all levels of readiness. Children's readiness for kindergarten should become an outcome measure for a coordinated system of community-based programs and supports for the healthy development of young children. Our rapidly expanding insights into early brain and child development have revealed that modifiable factors in a child's early experience can greatly affect that child's health and learning trajectories. Many children in the United States enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification and attention to child and family needs. A strong correlation between social-emotional development and school and life success, combined with alarming rates of preschool expulsion, point toward the urgency of leveraging opportunities to support social-emotional development and address behavioral concerns early. Pediatric primary care providers have access to the youngest children and their families. Pediatricians can promote and use community supports, such as home visiting programs, quality early care and education programs, family support programs and resources, early intervention services, children's museums, and libraries, which are important for addressing school readiness and are too often underused by populations who can benefit most from them. When these are not available, pediatricians can support the development of such resources. The American Academy of Pediatrics affords pediatricians many opportunities to improve the physical, social-emotional, and educational health of young children, in conjunction with other advocacy groups. This technical report provides an updated version of the previous iteration from the American Academy of Pediatrics published in 2008.

Parents' awareness of disaster plans in children's early learning settings

OBJECTIVE

Children in early learning settings are vulnerable to site-specific emergencies because of physical and developmental limitations. We examined parents' knowledge of disaster plans in their child's early learning settings.

METHODS

In May 2015, we conducted a nationally representative online household survey, including parents of children ages 0-5 years in child care settings. Parents were asked about their center's disaster plans and key components: evacuation, special needs children, and disaster supplies. Bivariate analyses and logistic regression were conducted to identify factors associated with parental awareness of disaster plans.

RESULTS

Overall, 1,413 of 2,550 parents responded (rate = 55 percent). Sample included 1,119 parents of children 0-5 years old, with 24 percent (n = 264) requiring child care. Parents' reported knowledge of five types of disaster plans: evacuation (66 percent), power outage (63 percent), severe weather (62 percent), lock-down (57 percent), and delayed parent pick-up (57 percent). Only 21 percent reported if plans included all four key components of evacuation (child identification, parent identification, rapid communication, and extra car seats). One-third (36 percent) reported plans accommodating special needs children. Parents' knowledge of disaster supplies varied: generator (31 percent), radio (42 percent), water (57 percent), food (60 percent), and first aid (82 percent). Parents attending any disaster training events (34 percent) were more likely to be aware of all five types of disaster plans compared with parents who had not attended.

CONCLUSIONS

Many parents were unaware of disaster plans at their children's early learning settings. Although few parents attended training events, such participation was associated with higher levels of parental awareness.

Heterotypic Infection and Spread of Rhinovirus A, B, and C among Childcare Attendees

Background

Despite the frequency of human rhinovirus (HRV), data describing the molecular epidemiology of HRV in the community are limited. Childcare centers are optimal settings to characterize heterotypic HRV cocirculation.

Methods

HRV specimens were prospectively obtained from a cohort of childcare attendees at enrollment and weekly during respiratory illness. The 5' noncoding region sequences were used to determine HRV species (A, B, C) and genotypes.

Results

Among 225 children followed, sequence data were available for 92 HRV infections: HRV-A (n = 80; 59%) was most common, followed by HRV-C (n = 52, 39%), and HRV-B (n = 3, 2%). Forty-one genotypes were identified and cocirculation was common. Frequent spread between classrooms occurred with 2 HRV-A genotypes. Repeated detections within single illnesses were a combination of persistent (n = 7) and distinct (n = 7) genotypes. Prevalence of HRV among asymptomatic children was 41%. HRV-C was clinically similar to HRV-A and HRV-B.

Conclusions

HRV epidemiology in childcare consists of heterotypic cocirculation of genotypes with periodic spread within and among classrooms. Based on our finding of multiple genotypes evident during the course of single illnesses, the use of sequence-based HRV type determination is critical in longitudinal studies of HRV epidemiology and transmission.

Accuracy of Smartphone-Based Pulse Oximetry Compared with Hospital-Grade Pulse Oximetry in Healthy Children

BACKGROUND

Pulse oximetry, a ubiquitous, noninvasive method to monitor oxygen saturation (SpO₂), requires larger, nonportable equipment. Smartphone pulse oximeter applications (apps) provide a portable, cost-effective option, but are untested in children. We hypothesize that smartphone pulse oximetry will not be inferior to standard pulse oximetry measured in healthy children.

MATERIALS AND METHODS

Two main types of pulse oximetry apps, a camera-based app (CBA) that uses a phone camera flash and lens and a probe-based app (PBA) that uses an external plug-in probe, were compared with standard pulse oximetry measured in children ages 2-13 years without a respiratory complaint and a triage SpO₂ ≥97% seen in a pediatric Emergency Department. Two investigators obtained heart rate and SpO₂ using each app. Inter-rater reliability was tested using interclass correlations (ICCs), and Bland-Altman method was used to compare app values to triage measurements.

RESULTS

Eighty-one patients were enrolled. ICC for SpO₂ for PBA and CBA were 0.73 and -0.24, respectively. The 95% limits of agreement between the PBA SpO₂ and triage SpO₂ were -2.8 to +2.5 compared with -4.1 to +3.5 for the CBA SpO₂ and triage SpO₂. Mean differences between triage SpO₂ and the PBA SpO₂ (-0.17%) and triage SpO₂ and CBA SpO₂ (-0.33%) were not statistically significant.

DISCUSSION AND CONCLUSIONS

Smartphone-based pulse oximetry is not inferior to standard pulse oximetry in pediatric patients without hypoxia. Reliability was superior for PBA compared with CBA, with more precise agreement for the PBA compared with the CBA. Future studies should test pulse oximetry apps in a hypoxic pediatric population.

Web-Based Surveillance of Illness in Childcare Centers

School absenteeism is an inefficient and unspecific metric for measuring community illness and does not provide surveillance during summertime. Web-based biosurveillance of childcare centers may represent a novel way to efficiently monitor illness outbreaks year-round. A web-based biosurveillance program ( sickchildcare.org ) was created and implemented in 4 childcare centers in a single Michigan county. Childcare providers were trained to report sick children who required exclusion or had parent-reported absences due to illness. Deidentified data on age range, number of illnesses, and illness categories were collected. Weekly electronic reports were sent to the county public health department. Data for reports were gathered beginning in December 2013 and were summarized using descriptive statistics. A total of 385 individual episodes of illness occurred during the study period. Children with reported illness were infants (16%, n = 61), toddlers (38%, n = 148), and preschoolers (46%, n = 176). Illness categories included: fever (30%, n = 116), gastroenteritis (30%, n = 115), influenzalike illness (8%, n = 32), cold without fever (13%, n = 51), rash (7%, n = 26), conjunctivitis (1%, n = 3), ear infection (1%, n = 5), and other (10%, n = 37). The majority of reports were center exclusions (55%, n = 214); others were absences (45%, n = 171). The detection of a gastroenteritis outbreak by web-based surveillance during winter 2013-14 preceded county health reports by 3 weeks; an additional outbreak of hand-foot-mouth disease was detected during June 2014 when standard school-based surveillance was not available. Web-based biosurveillance of illness in childcare centers represents a novel and feasible method to detect disease trends earlier and year-round compared to standard school-based disease surveillance.

Early Childhood Home Visiting

High-quality home-visiting services for infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic self-sufficiency. The American Academy of Pediatrics supports unwavering federal funding of state home-visiting initiatives, the expansion of evidence-based programs, and a robust, coordinated national evaluation designed to confirm best practices and cost-efficiency. Community home visiting is most effective as a component of a comprehensive early childhood system that actively includes and enhances a family-centered medical home.

Assessing Disaster Preparedness Among Select Children's Summer Camps in the United States and Canada

OBJECTIVE

Children's summer camps are at risk for multiple pediatric casualties during a disaster. The degree to which summer camps have instituted disaster preparedness is unknown. We assessed disaster preparedness among selected camps nationally for a range of disasters.

METHODS

We partnered with a national, web-based electronic health records system to send camp leadership of 315 camp organizations a 14-question online survey of disaster preparedness. One response from each camp was selected in the following order of importance: owner, director, physician, nurse, medical technician, office staff, and other. The results were analyzed using descriptive statistics.

RESULTS

A total of 181 camps responses were received, 169 of which were complete. Camp types were overnight (60%), day (21%), special/medical needs (14%), and other (5%). Survey respondents were directors (52%), nurses (14%), office staff (10%), physicians (5%), owners (5%), emergency medical technicians (2%), and other (12%). Almost 18% of camps were located >20 mi from a major medical center, and 36% were >5 mi from police/fire departments. Many camps were missing emergency supplies: car/booster seats for evacuation (68%), shelter (35%), vehicles for evacuation (26%), quarantine isolation areas (21%), or emergency supplies of extra water (20%) or food (17%). Plans were unavailable for the following: power outages (23%); lockdowns (15%); illness outbreaks (15%); tornadoes (11%); evacuation for fire, flood, or chemical spill (9%); and other severe weather (8%). Many camps did not have online emergency plans (53%), plans for children with special/medical needs (38%), methods to rapidly communicate information to parents (25%), or methods to identify children for evacuation/reunification with parents (40%). Respondents reported that staff participation in disaster drills varied for weather (58%), evacuations (46%), and lockdowns (36%). The majority (75%) of respondents had not collaborated with medical organizations for planning.

CONCLUSIONS

A substantial proportion of camps were missing critical components of disaster planning. Future interventions must focus on developing summer camp-specific disaster plans, increasing partnerships, and reassessing national disaster plans to include summer camp settings.

Development and characterization of human and mouse specific antibodies to CuZn-superoxide dismutase (SOD1)

Mutations in the copper/zinc superoxide dismutase (SOD1) gene are associated with 15-20% of the familial forms of motor neuron disease. Mice where a transgene has been incorporated that encodes for the human SOD1 mutation develop a form of motor neurone disease that closely resembles human forms of this disease. We have produced and characterized species-specific antibodies to epitopes in the SOD1 protein, amino acids 25-37, a region that distinguishes between the human and the mouse species of SOD1. The antisera generated were unable to immunoprecipitate the mouse or the human forms of SOD1 from tissue extracts unless the homodimeric complex of SOD1 was denatured. As SOD1 exists as a homodimeric complex in the cytoplasm of cells, this suggests that amino acids in position, 25-37 are close to the dimeric interface of SOD1.