Publications by authors named "Anupam B Kharbanda"

66 Publications

Improving Appendicitis Care for All Patients.

JAMA Netw Open 2021 Aug 2;4(8):e2124523. Epub 2021 Aug 2.

Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.24523DOI Listing
August 2021

Electrocardiogram as a Lyme Disease Screening Test.

J Pediatr 2021 Jul 12. Epub 2021 Jul 12.

Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.

Objective: To examine the association between electrocardiographic (ECG) evidence of carditis at the time of Lyme disease evaluation and a diagnosis of Lyme disease.

Study Design: We performed an 8-center prospective cohort study of children undergoing emergency department evaluation for Lyme disease limited to those who had an ECG obtained by their treating clinicians. The study cardiologist reviewed all ECGs flagged as abnormal by the study sites to assess for ECG evidence of carditis. We defined Lyme disease as the presence of an erythema migrans lesion or a positive 2-tier Lyme disease serology. We used logistic regression to measure the association between Lyme disease and atrioventricular (AV) block or any ECG evidence of carditis.

Results: Of the 546 children who had an ECG obtained, 214 (39%) had Lyme disease. Overall, 42 children had ECG evidence of carditis, of whom 24 had AV block (20 first-degree). Of the patients with ECG evidence of carditis, only 21 (50%) had any cardiac symptoms. The presence of AV block (OR 4.7, 95% CI 1.8-12.1) and any ECG evidence of carditis (OR 2.3, 95% CI 1.2-4.3) were both associated with diagnosis of Lyme disease.

Conclusions: ECG evidence of carditis, especially AV block, was associated with a diagnosis of Lyme disease. ECG evidence of carditis can be used as a diagnostic biomarker for Lyme disease to guide initial management while awaiting Lyme disease test results.
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http://dx.doi.org/10.1016/j.jpeds.2021.07.010DOI Listing
July 2021

Validation of Septic Knee Monoarthritis Prediction Rule in a Lyme Disease Endemic Area.

Pediatr Emerg Care 2021 May 13. Epub 2021 May 13.

From the *Brown University, Providence, RI †Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA ‡Division of Pediatric Emergency Medicine, Children's Hospital of Wisconsin, Milwaukee, WI §Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA ∥Departments of Pediatrics and Emergency Medicine, Hasbro Children's Hospital, Providence, RI ¶Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Wilmington, DE #Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN **Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.

Objective: In Lyme disease endemic areas, Lyme and septic arthritis often present similarly. A published septic knee arthritis clinical prediction rule includes 2 high-risk predictors: absolute neutrophil count of 10,000 cells/mm or greater and erythrocyte sedimentation rate of 40 mm/h or greater. The objective of the study was to externally validate this prediction rule in a multicenter prospective cohort.

Methods: We enrolled a prospective cohort of children with knee monoarthritis undergoing evaluation for Lyme disease at 1 of 8 Pedi Lyme Net emergency departments located in endemic areas. We defined a case of septic arthritis with a positive synovial fluid culture or a synovial fluid white blood cell count of 50,000 or greater per high powered field with a positive blood culture and Lyme arthritis with a positive or equivocal C6 EIA, followed by a positive supplemental immunoblot. Other children were classified as having inflammatory arthritis. We report the performance of the septic arthritis clinical prediction rule in our study population.

Results: Of the 543 eligible children, 13 had septic arthritis (2.4%), 234 Lyme arthritis (43.1%), and 296 inflammatory arthritis (54.5%). Of the 457 children (84.2%) with available laboratory predictors, all children with septic arthritis were classified as high risk (sensitivity, 100%; 95% confidence interval [CI], 62.8%-100%; specificity, 68.1%; 95% CI, 63.6-73.3; negative predictive value, 278/278 [100%]; 95% CI, 98.6%-100%). Of the 303 low-risk children, 52 (17.2%) underwent diagnostic arthrocentesis.

Conclusions: The septic knee arthritis clinical prediction rule accurately distinguished between septic and Lyme arthritis in an endemic area. Clinical application may reduce unnecessary invasive diagnostic procedures.
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http://dx.doi.org/10.1097/PEC.0000000000002455DOI Listing
May 2021

Validation of the Rule of 7's for Identifying Children at Low-risk for Lyme Meningitis.

Pediatr Infect Dis J 2021 04;40(4):306-309

Pediatric Emergency Medicine, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.

Background: The Rule of 7's classifies children as low-risk for Lyme meningitis with the absence of the following: ≥7 days of headache, any cranial neuritis or ≥70% cerebrospinal fluid mononuclear cells. We sought to broadly validate this clinical prediction rule in children with meningitis undergoing evaluation for Lyme disease.

Methods: We performed a patient-level data meta-analysis of 2 prospective and 2 retrospective cohorts of children ≤21 years of age with cerebrospinal fluid pleocytosis who underwent evaluation for Lyme disease. We defined a case of Lyme meningitis with a positive 2-tier serology result (positive or equivocal first-tier enzyme immunoassay followed by a positive supplemental immunoblot). We applied the Rule of 7's and report the accuracy for the identification of Lyme meningitis.

Results: Of 721 included children with meningitis, 178 had Lyme meningitis (24.7%) and 543 had aseptic meningitis (75.3%). The pooled data from the 4 studies showed the Rule of 7's has a sensitivity of 98% [95% confidence interval (CI): 89%-100%, I2 = 71%], specificity 40% (95% CI: 30%-50%, I2 = 75%), and a negative predictive value of 100% (95% CI: 95%-100%, I2 = 55%).

Conclusions: The Rule of 7's accurately identified children with meningitis at low-risk for Lyme meningitis for whom clinicians should consider outpatient management while awaiting Lyme disease test results.
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http://dx.doi.org/10.1097/INF.0000000000003003DOI Listing
April 2021

Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial.

JAMA Netw Open 2021 02 1;4(2):e2036344. Epub 2021 Feb 1.

Division of Research, HealthPartners Institute, Minneapolis, Minnesota.

Importance: Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis.

Objective: To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis.

Design, Setting, And Participants: In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019.

Interventions: AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care.

Main Outcomes And Measures: Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool.

Results: We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group.

Conclusions And Relevance: In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score.

Trial Registration: ClinicalTrials.gov Identifier: NCT02633735.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.36344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873779PMC
February 2021

Racial Inequities in Pediatric Emergency Care.

JAMA Netw Open 2021 01 4;4(1):e2034019. Epub 2021 Jan 4.

Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.34019DOI Listing
January 2021

Pediatric Lyme Disease Biobank, United States, 2015-2020.

Emerg Infect Dis 2020 12;26(12):3099-3101

In 2015, we founded Pedi Lyme Net, a pediatric Lyme disease research network comprising 8 emergency departments in the United States. Of 2,497 children evaluated at 1 of these sites for Lyme disease, 515 (20.6%) were infected. This network is a unique resource for evaluating new approaches for diagnosing Lyme disease in children.
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http://dx.doi.org/10.3201/eid2612.200920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706969PMC
December 2020

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years.

Acad Emerg Med 2020 09 2;27(9):821-831. Epub 2020 Apr 2.

Division of Research, Kaiser Permanente, Oakland, CA.

Objectives: Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions.

Methods: This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates.

Results: Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05).

Conclusion: Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.
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http://dx.doi.org/10.1111/acem.13931DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310728PMC
September 2020

Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection.

Pediatr Emerg Care 2020 Mar 6. Epub 2020 Mar 6.

Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN.

Objectives: Septic arthritis (SA) is responsible for 20% of pediatric musculoskeletal infections (MSKI) and can have significant consequences. Early detection of SA is critical, and procalcitonin (PCT) has emerged as a promising biomarker. This study assessed the test performance of PCT and traditional biomarkers for suspected SA.

Methods: We conducted a prospective study at two pediatric emergency departments (ED). Data collected measured serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and PCT. Box and whisker plots were generated to compare the of the biomarkers by positive MSKI or a non-MSKI diagnosis. The diagnostic performance of biomarkers was examined using the area under the receiver operating characteristic curve (AUC), and optimal cut -points were identified using the Liu method.

Results: Procalcitonin performed reasonably well for detection of MSKI (AUC, 0.72; confidence interval [95% CI], 0.59-0.84). However, CRP and ESR performed better (AUC, 0.88 and 0.78, respectively). White blood cell count was not predictive of MSKI. Patients with a PCT value >0.1 ng/mL, ESR values >19.5 mm/h, and a temperature higher than 99.0°F were more than twice as likely to have acute MSKI. A high CRP level was most predictive of acute MSKI, and patients with levels >2.38 mg/dL were 3.5 times more likely to have acute MSKI.

Conclusions: Procalcitonin is a potential biomarker for the clinical differential of MSKI in the pediatric ED. Additional research is warranted to establish the optimal diagnostic level for PCT, to increase sample size, and to examine any impact on cost.
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http://dx.doi.org/10.1097/PEC.0000000000001978DOI Listing
March 2020

The Impact of Health Equity Coaching on Patient's Perceptions of Cultural Competency and Communication in a Pediatric Emergency Department: An Intervention Design.

J Patient Exp 2019 Dec 9;6(4):257-264. Epub 2018 Sep 9.

Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA.

Purpose: American Indian (AI) children experience significant disparities in health-care access. As a result, they are more likely to use the emergency department (ED) for nonemergent visits than white children. In a recent study, pediatric ED providers have shown an implicit bias for white children over AI children. To combat implicit bias in an ED setting, we created a protocol for training ED providers as health equity coaches.

Methods: The intervention took place during the fall of 2016 and was composed of 4 educational lectures, 6 to 8 hours of service learning in AI communities, and the participant's dissemination of what was learned through formal presentations and informal conversations with other ED staff. We measured the impact of this intervention on the intervention participants with a group interview at the completion of the intervention.

Results: The findings from the group interview provide feedback on what was learned during the intervention, how it impacted providers, and feedback on the structure of the intervention. Overall ED providers reported the intervention improved awareness of their implicit bias and ways to improve communication and care for AI patients. Additional institutional policy and procedural changes are necessary to effectively and sustainably address health disparities affecting AI populations.

Conclusions: The participating providers identified their lack of knowledge regarding AI cultures at the start of the intervention and it became clear that their knowledge, comfort, and relationships with AI communities increased as a result of this intervention.
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http://dx.doi.org/10.1177/2374373518798111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908992PMC
December 2019

What is the effect of a decision aid in potentially vulnerable parents? Insights from the head CT choice randomized trial.

Health Expect 2020 02 23;23(1):63-74. Epub 2019 Nov 23.

Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.

Objective: To test the hypotheses that use of the Head CT Choice decision aid would be similarly effective in all parent/patient dyads but parents with high (vs low) numeracy experience a greater increase in knowledge while those with low (vs high) health literacy experience a greater increase in trust.

Methods: This was a secondary analysis of a cluster randomized trial conducted at seven sites. One hundred seventy-two clinicians caring for 971 children at intermediate risk for clinically important traumatic brain injuries were randomized to shared decision making facilitated by the DA (n = 493) or to usual care (n = 478). We assessed for subgroup effects based on patient and parent characteristics, including socioeconomic status (health literacy, numeracy and income). We tested for interactions using regression models with indicators for arm assignment and study site.

Results: The decision aid did not increase knowledge more in parents with high numeracy (P for interaction [P ] = 0.14) or physician trust more in parents with low health literacy (P  = 0.34). The decision aid decreased decisional conflict more in non-white parents (decisional conflict scale, -8.14, 95% CI: -12.33 to -3.95; P  = 0.05) and increased physician trust more in socioeconomically disadvantaged parents (trust in physician scale, OR: 8.59, 95% CI: 2.35-14.83; P  = 0.04).

Conclusions: Use of the Head CT Choice decision aid resulted in less decisional conflict in non-white parents and greater physician trust in socioeconomically disadvantaged parents. Decision aids may be particularly effective in potentially vulnerable parents.
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http://dx.doi.org/10.1111/hex.12965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978876PMC
February 2020

Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment.

J Am Med Inform Assoc 2019 11;26(11):1360-1363

Division of Research, Kaiser Permanente, Oakland, California, USA.

Prospective enrollment of research subjects in the fast-paced emergency department (ED) is challenging. We sought to develop a software application to increase real-time clinical trial enrollment during an ED visit. The Prospective Intelligence System for Clinical Emergency Services (PISCES) scans the electronic health record during ED encounters for preselected clinical characteristics of potentially eligible study participants and notifies the treating physician via mobile phone text alerts. PISCES alerts began 3 months into a cluster randomized trial of an electronic health record-based risk stratification tool for pediatric abdominal pain in 11 Northern California EDs. We compared aggregate enrollment before (2577 eligible patients, October 2016 to December 2016) and after (12 049 eligible patients, January 2017 to January 2018) PISCES implementation. Enrollment increased from 10.8% to 21.1% following PISCES implementations (P < .001). PISCES significantly increased study enrollment and can serve as a valuable tool to assist prospective research enrollment in the ED.
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http://dx.doi.org/10.1093/jamia/ocz118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6798557PMC
November 2019

Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting.

Ann Emerg Med 2019 10 19;74(4):471-480. Epub 2019 Jun 19.

Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, San Rafael Medical Center, San Rafael, CA.

Study Objective: The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS).

Methods: We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC.

Results: We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS.

Conclusion: The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.
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http://dx.doi.org/10.1016/j.annemergmed.2019.04.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364751PMC
October 2019

Emergency Department Visits for Pediatric Firearm Injuries by Trauma Center Type.

Pediatr Emerg Care 2019 May 22. Epub 2019 May 22.

Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN.

Objectives: This study aimed to characterize pediatric visits to emergency departments (EDs) for firearm injuries and examine differences by trauma center type.

Methods: Analyses included all patients younger than 19 years from the National Trauma Data Bank, years 2009 to 2014. Trauma centers were categorized as adult, mixed adult and pediatric, or pediatric based on certification level. Baseline characteristics were compared between subgroups using χ tests. Multivariable logistic regression was used to examine risk of death.

Results: Of 466,403 pediatric ED visits, 21,416 (4.6%) resulted from a firearm injury. Most firearm injuries were treated at an adult (64.9%) or mixed trauma center (29.1%) and involved patients that were male (87.1%), in the 15- to 18-year age group (83.2%), and black or African American (61.3%). Most visits were for injuries resulting from assault (78.1%), followed by unintentional (12.6%) and self-inflicted (4.7%) injuries, undetermined intent (3.7%), and legal intervention (0.8%). Patients visiting EDs for firearm injuries had more than 7 times the odds of dying compared with patients with other injuries (odds ratio, 7.30; 95% confidence interval, 6.82-7.72), and firearm injuries were responsible for more than a quarter (26.1%) of the total pediatric deaths in the National Trauma Data Bank (n = 2866). Assault-related injuries resulted in the most deaths (n = 2010; 70.1%), but the case fatality rate was highest for self-inflicted (n = 453; 44.6%).

Conclusion: We identified more than 20,000 firearm-related ED visits by pediatric patients from 2009 to 2014, averaging nearly 10 visits per day. Findings from this study can inform strategic planning in hospitals focused on preventing firearm injuries in children and adolescents.
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http://dx.doi.org/10.1097/PEC.0000000000001846DOI Listing
May 2019

Development of a Clinical Decision Support System for Pediatric Abdominal Pain in Emergency Department Settings Across Two Health Systems Within the HCSRN.

EGEMS (Wash DC) 2019 Apr 12;7(1):15. Epub 2019 Apr 12.

Children's MN, Department of Pediatric Emergency Medicine, Minneapolis, Minnesota, US.

Background: Appendicitis is a common surgical emergency in children, yet diagnosis can be challenging. An electronic health record (EHR) based, clinical decision support (CDS) system called Appy CDS was designed to help guide management of pediatric patients with acute abdominal pain within the Health Care Systems Research Network (HCSRN).

Objectives: To describe the development and implementation of a clinical decision support tool (Appy CDS) built independently but synergistically at two large HCSRN affiliated health systems using well-established platforms, and to assess the tool's Triage component, aiming to identify pediatric patients at increased risk for appendicitis.

Results: Despite differences by site in design and implementation, such as the use of alerts, incorporating gestalt, and other workflow variations across sites, using simple screening questions and automated exclusions, both systems were able to identify a population with similar appendicitis rates (11.8 percent and 10.6 percent), where use of the full Appy CDS would be indicated.

Discussion: These 2 HCSRN sites designed Appy CDS to capture a population at risk for appendicitis and deliver CDS to that population while remaining locally relevant and adhering to organizational preferences. Despite different approaches to point-of-care CDS, the sites have identified similar cohorts with nearly identical background rates of appendicitis.

Next Steps: The full Appy CDS tool, providing personalized risk assessment and tailored recommendations, is undergoing evaluation as part of a pragmatic cluster randomized trial aiming to reduce reliance on advanced diagnostic imaging. The novel approaches to CDS we present could serve as the basis for future ED interventions.
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http://dx.doi.org/10.5334/egems.282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6460497PMC
April 2019

Shock Index as a Predictor of Morbidity and Mortality in Pediatric Trauma Patients.

Pediatr Emerg Care 2019 Feb;35(2):132-137

From the Departments of Pediatric Emergency Medicine and.

Objectives: Compared with unadjusted shock index (SI) (heart rate/systolic blood pressure), age-adjusted SI improves identification of negative outcomes after injury in pediatric patients. We aimed to further evaluate the utility of age-adjusted SI to predict negative outcomes in pediatric trauma.

Methods: We performed an analysis of patients younger than 15 years using the National Trauma Data Bank. Elevated SI was defined as high normal heart rate divided by low-normal blood pressure for age. Our primary outcome measure was mortality. Secondary outcomes included need for a blood transfusion, ventilation, any operating room/interventional radiology procedures, and intensive care unit stay. Multiple logistic regressions were performed.

Results: Twenty-eight thousand seven hundred forty-one cases met the study criteria. The overall mortality rate was 0.7%, and 1.7% had an elevated SI. Patients with an elevated SI were more likely (P < 0.001) to require blood transfusion, ventilation, an operating room/interventional radiology procedure, or an intensive care unit stay. An elevated SI was the strongest predictor for mortality (odds ratio [OR] 22.0) in pediatric trauma patients compared with hypotension (OR, 12.6) and tachycardia (OR, 2.6).

Conclusions: Elevated SI is an accurate and specific predictor of morbidity and mortality in pediatric trauma patients and is superior to tachycardia or hypotension alone for predicting mortality.
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http://dx.doi.org/10.1097/PEC.0000000000001733DOI Listing
February 2019

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial.

JAMA Netw Open 2018 09 7;1(5):e182430. Epub 2018 Sep 7.

Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis.

Importance: The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI.

Objective: To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI.

Design, Settings, And Participants: This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents.

Interventions: Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care.

Main Outcomes And Measures: The primary outcome, selected by parent stakeholders, was knowledge of their child's risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI.

Results: A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0]; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD] decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, -4.4; 95% CI, -7.3 to -2.4), and were more involved in CT decision-making (observing patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI.

Conclusions And Relevance: Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury.

Trial Registration: ClinicalTrials.gov Identifier: NCT02063087.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.2430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324506PMC
September 2018

Epidemiology of Bloodstream Infections in Hospitalized Children in the United States, 2009-2016.

Clin Infect Dis 2019 08;69(6):995-1002

Pediatric Emergency Medicine, Chief of Critical Care Services, Children's Minnesota.

Background: Bloodstream infections (BSIs) cause significant morbidity and mortality in children. Recent pediatric epidemiological data may inform prevention strategies and empiric antimicrobial therapy selection.

Methods: We conducted a retrospective cohort study from 2009 through 2016 utilizing demographic and microbiologic data on inpatients aged <19 years using the Premier Healthcare Database. BSIs were positive blood cultures without known contaminants. Hospitalization rate was the number of BSI-positive encounters per 1000 admissions. Community-acquired infections (CAIs) were cultures positive ≤2 days of admission among nonneonates. BSI patients were compared to documented positive BSI patients (non-BSI); differences were analyzed using χ2 test, t test, and Cochran-Armitage test for time trends.

Results: Among 1 809 751 encounters from 162 US hospitals, 5340 (0.30%) were BSI positive; CAIs were most common (50%). BSI patients were more often aged 1-5 years and had complex chronic conditions or central lines compared to non-BSI patients. The BSI hospitalization rate declined nonsignificantly over time (3.13 in 2009 to 2.98 in 2016, P = .08). Among pathogens, Escherichia coli (0.80 to 1.26), methicillin-sensitive Staphylococcus aureus (0.83 to 1.98), and group A Streptococcus (0.16 to 0.37) significantly increased for nonneonates, while Streptococcus pneumoniae (1.07 to 0.26) and Enterococcus spp. (0.60 to 0.17) declined. Regional differences were greatest for E. coli and highest in the New England and South Atlantic regions.

Conclusions: Trends in pediatric BSI hospitalization rates varied by pathogen and regionally. Overall the BSI hospitalization rate did not significantly decline, indicating a continued need to improve pediatric BSI assessment and prevention.
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http://dx.doi.org/10.1093/cid/ciy1030DOI Listing
August 2019

Unintentional Injuries in Primary and Secondary Schools in the United States, 2001-2013.

J Sch Health 2019 01;89(1):38-47

Children's Minnesota Research Institute, Department of Pediatric Emergency Medicine, Children's Minnesota, 2525 Chicago Avenue South, MS 40-460, Minneapolis, MN.

Background: Unintentional injuries are the leading cause of youth morbidity. However, limited nationally representative data are available to characterize the occurrence of unintentional injuries at US schools. Given this paucity, we characterized secular trends in unintentional injuries at schools that led to emergency department (ED) visits.

Methods: A retrospective analysis of the National Electronic Injury Surveillance System-All Injury Program from 2001 to 2013 compared injuries occurring at schools to injuries occurring elsewhere in youth ages 5-18 years. Incidence rates were calculated using weighted frequency estimates as numerators and US population estimates as denominators.

Results: School injuries accounted for 21% of unintentional injury-related ED visits, with an estimated annual incidence rate of 1385 injuries per 100,000 5- to 18-year-olds. Middle school-aged youth (10-13 years) had the highest annual incidence rate (1640 per 100,000 youth) compared with younger and older counterparts. School injuries were more likely to be due to sports/recreation than nonschool injuries (55% vs 41%, p < .0001). Importantly, no detectable change in incidence rates of school injuries between 2001 and 2013 was found (p = .11).

Conclusions: Stagnant annual incidence rates of unintentional injuries at schools and large numbers of school-based injuries demonstrate that school-based injuries are a notable opportunity for future prevention efforts.
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http://dx.doi.org/10.1111/josh.12711DOI Listing
January 2019

Emergency Department Use of Neuroimaging in Children and Adolescents Presenting with Headache.

J Pediatr 2018 10 14;201:196-201. Epub 2018 Jun 14.

Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN; Children's Minnesota Research Institute, Minneapolis, MN.

Objectives: To evaluate emergency department use and outcomes of neuroimaging for headache in a free-standing children's hospital system.

Study Design: We prospectively enrolled children aged 6-18 years who presented to the emergency department with a chief complaint of headache from September 2015 to September 2016. Standardized data collection was performed in real time, including telephone follow-up as needed, and imaging outcome was determined through a chart review. Using multivariable logistic regression, we estimated the associations between clinically important patient characteristics and neuroimaging.

Results: Of 294 enrolled patients, 53 (18%) underwent neuroimaging (computed tomography or magnetic resonance imaging) and 2 (0.7%) had clinically important intracranial findings. Presenting with abnormal neurologic examination findings (OR, 11.55; 95% CI, 3.24-41.22), no history of similar headaches (OR, 2.13; 95% CI, 1.08-4.18), and white race (OR, 3.04; 95% CI, 1.51-6.12) were significantly associated with an increased odds of undergoing imaging in multivariable regression models.

Conclusions: Our observed emergency department imaging rate was 26.5 times higher than our positive result rate, suggesting there is room to decrease unnecessary neuroimaging. Associations for abnormal examination and new headache type are consistent with the American Academy of Neurology clinical imaging recommendations. The increased odds of imaging white patients suggests bias that should be addressed. The low rate of positive findings supports the need for an evidence-based clinical decision tool for neuroimaging in the acute care setting.
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http://dx.doi.org/10.1016/j.jpeds.2018.05.023DOI Listing
October 2018

Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries.

Eur J Psychotraumatol 2018 8;9(1):1468703. Epub 2018 May 8.

Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia.

: Provision of psychosocial care, in particular trauma-informed care, in the immediate aftermath of paediatric injury is a recommended strategy to minimize the risk of paediatric medical traumatic stress. : To examine the knowledge of paediatric medical traumatic stress and perspectives on providing trauma-informed care among emergency staff working in low- and middle-income countries (LMICs). : Training status, knowledge of paediatric medical traumatic stress, attitudes towards incorporating psychosocial care and barriers experienced were assessed using an online self-report questionnaire. Respondents included 320 emergency staff from 58 LMICs. Data analyses included descriptive statistics, -tests and multiple regression. : Participating emergency staff working in LMICs had a low level of knowledge of paediatric medical traumatic stress. Ninety-one percent of respondents had not received any training or education in paediatric medical traumatic stress, or trauma-informed care for injured children, while 94% of respondents indicated they wanted training in this area. : There appears to be a need for training and education of emergency staff in LMICs regarding paediatric medical traumatic stress and trauma-informed care, in particular among staff working in comparatively lower income countries.
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http://dx.doi.org/10.1080/20008198.2018.1468703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944367PMC
May 2018

Leaving the emergency department without complete care: disparities in American Indian children.

BMC Health Serv Res 2018 04 10;18(1):267. Epub 2018 Apr 10.

Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA.

Background: Children who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns.

Methods: This is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0-17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level.

Results: LWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30-2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level.

Conclusion: Our results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.
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http://dx.doi.org/10.1186/s12913-018-3092-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5894126PMC
April 2018

Development and Validation of a Novel Pediatric Appendicitis Risk Calculator (pARC).

Pediatrics 2018 04 13;141(4). Epub 2018 Mar 13.

Division of Research, HealthPartners Institute, Bloomington, Minnesota.

Objectives: We sought to develop and validate a clinical calculator that can be used to quantify risk for appendicitis on a continuous scale for patients with acute abdominal pain.

Methods: The pediatric appendicitis risk calculator (pARC) was developed and validated through secondary analyses of 3 distinct cohorts. The derivation sample included visits to 9 pediatric emergency departments between March 2009 and April 2010. The validation sample included visits to a single pediatric emergency department from 2003 to 2004 and 2013 to 2015. Variables evaluated were as follows: age, sex, temperature, nausea and/or vomiting, pain duration, pain location, pain with walking, pain migration, guarding, white blood cell count, and absolute neutrophil count. We used stepwise regression to develop and select the best model. Test performance of the pARC was compared with the Pediatric Appendicitis Score (PAS).

Results: The derivation sample included 2423 children, 40% of whom had appendicitis. The validation sample included 1426 children, 35% of whom had appendicitis. The final pARC model included the following variables: sex, age, duration of pain, guarding, pain migration, maximal tenderness in the right-lower quadrant, and absolute neutrophil count. In the validation sample, the pARC exhibited near perfect calibration and a high degree of discrimination (area under the curve: 0.85; 95% confidence interval: 0.83 to 0.87) and outperformed the PAS (area under the curve: 0.77; 95% confidence interval: 0.75 to 0.80). By using the pARC, almost half of patients in the validation cohort could be accurately classified as at <15% risk or ≥85% risk for appendicitis, whereas only 23% would be identified as having a comparable PAS of <3 or >8.

Conclusions: In our validation cohort of patients with acute abdominal pain, the pARC accurately quantified risk for appendicitis.
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http://dx.doi.org/10.1542/peds.2017-2699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869337PMC
April 2018

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis.

Acad Emerg Med 2018 07 24;25(7):785-794. Epub 2018 Mar 24.

Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY.

Objective: The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals.

Methods: This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration.

Results: Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites.

Conclusions: Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.
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http://dx.doi.org/10.1111/acem.13387DOI Listing
July 2018

Vaccine-preventable, hospitalizations among American Indian/Alaska Native children using the 2012 Kid's Inpatient Database.

Vaccine 2018 02;36(7):945-948

Critical Care Services, Children's Hospitals and Clinics of Minnesota, 910 Building, Suite 40-460, Minneapolis, MN 55404, United States. Electronic address:

Our aim was to assess the odds of hospitalization for a vaccine-preventable, infectious disease (VP-ID) in American Indian/Alaska Native (AI/AN) children compared to other racial and ethnic groups using the 2012 Kid's Inpatient Database (KID) The KID is a nationally representative sample, which allows for evaluation of VP-ID in a non-federal, non-Indian Health Service setting. In a cross-sectional analysis, we evaluated the association of race/ethnicity and a composite outcome of hospitalization due to vaccine-preventable infection using multivariate logistic regression. AI/AN children were more likely (OR=1.81, 95% CI=1.34, 2.45) to be admitted to the hospital in 2012 for a VP-ID compared to Non-Hispanic white children after adjusting for age, sex, chronic disease status, metropolitan location, and median household income. This disparity highlights the necessity for a more comprehensive understanding of immunization and infectious disease exposure among American Indian children, especially those not covered or evaluated by Indian Health Service.
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http://dx.doi.org/10.1016/j.vaccine.2017.02.051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806045PMC
February 2018

Community Perspectives on Emergency Department Use and Care for American Indian Children.

J Racial Ethn Health Disparities 2018 10 3;5(5):939-946. Epub 2017 Nov 3.

Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA.

Emergency department (ED) utilization by American Indian (AI) children is among the highest in the nation. Numerous health disparities have been well documented in AI children, but limited information is available on parental experiences of care for AI children in the ED. Our objective was to understand parental attitudes towards ED care for AI children. Focus groups were held with AI parents/caregivers at five sites in the Upper Midwest. Traditional content analysis was used to identify themes. A total of 70 parents participated in ten focus groups. Three main themes were identified: healthcare environment, access to care, and interaction with providers. Healthcare environment issues included availability of specialists, wait times, and child-friendly areas. Transportation and financial considerations were major topics in access to care. Issues in interaction with providers included discrimination, stereotyping, and trust. This is one of the first studies to assess parent perspectives on ED use for AI children. Obtaining parental perspectives on ED experiences is critical to improve patient care and provide important information for ED providers.
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http://dx.doi.org/10.1007/s40615-017-0442-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934340PMC
October 2018

Emergency Department Utilization by Native American Children.

Pediatr Emerg Care 2018 Nov;34(11):802-809

Center for Health Outcomes and Prevention Research, Sanford Research.

Objectives: The aims of this study were to determine differences in emergency department (ED) use by Native American (NA) children in rural and urban settings and identify factors associated with frequent ED visits.

Methods: This cross-sectional, cohort study examined visits to 6 EDs: 2 rural, 2 midsize urban, and 2 large urban EDs from June 2011 to May 2012. Univariate and multiple regression analyses were conducted. Frequent ED visitors had more than 4 visits in the study period.

Results: We studied 8294 NA visits (5275 patients) and 44,503 white visits (33,945 patients). Rural EDs had a higher proportion of NA patients, those below 200% of the income poverty level, and those who traveled more than 10 miles from their residence to attend the ED (all P < 0.05) compared with midsize and urban EDs. Native American patients had a high proportion of mental health diagnoses compared with whites (4.9% vs 1.9%, P < 0.001). Frequent ED visitors had greater odds of NA race, age younger than 1 year, public insurance, female sex, residence within less than 5 miles from the ED, and chronic disease.

Conclusions: Native American children seem to have greater challenges compared with whites obtaining care in rural areas. Native American children were more likely to be frequent ED visitors, despite having to travel farther from their residence to the ED. Native American children visiting rural and midsize urban EDs had a much higher prevalence of mental health problems than whites. Additional efforts to provide both medical and mental health services to rural NA are urgently needed.
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http://dx.doi.org/10.1097/PEC.0000000000001289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5867199PMC
November 2018

Racial/Ethnic Variation in Emergency Department Care for Children With Asthma.

Pediatr Emerg Care 2019 Mar;35(3):209-215

Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN.

Objective: To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients.

Methods: This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED.

Results: The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01).

Conclusions: In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.
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http://dx.doi.org/10.1097/PEC.0000000000001282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857394PMC
March 2019

Perspectives of hospital emergency department staff on trauma-informed care for injured children: An Australian and New Zealand analysis.

J Paediatr Child Health 2017 Sep 6;53(9):862-869. Epub 2017 Aug 6.

Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.

Aim: To examine Australian and New Zealand emergency department (ED) staff's training, knowledge and confidence regarding trauma-informed care for children after trauma, and barriers to implementation.

Methods: ED staff's perspectives on trauma-informed care were assessed using a web-based self-report questionnaire. Participants included 468 ED staff (375 nursing and 111 medical staff) from hospitals in Australia and New Zealand. Data analyses included descriptive statistics, χ tests and multiple regressions.

Results: Over 90% of respondents had not received training in trauma-informed care and almost all respondents (94%) wanted training in this area. While knowledge was associated with a respondent's previous training and profession, confidence was associated with the respondent's previous training, experience level and workplace. Dominant barriers to the implementation of trauma-informed care were lack of time and lack of training.

Conclusions: There is a need and desire for training and education of Australian and New Zealand ED staff in trauma-informed care. This study demonstrates that experience alone is not sufficient for the development of knowledge of paediatric traumatic stress reactions and trauma-informed care practices. Existing education materials could be adapted for use in the ED and to accommodate the training preferences of Australian and New Zealand ED staff.
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http://dx.doi.org/10.1111/jpc.13644DOI Listing
September 2017

Time From Emergency Department Evaluation to Operation and Appendiceal Perforation.

Pediatrics 2017 Jun 24;139(6). Epub 2017 May 24.

Department of Pediatric Emergency Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota.

Background And Objectives: In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children.

Methods: We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain (<96 hours). Time of initial physical examination and time of operation were recorded. The presence of AP was determined using operative reports. We analyzed whether duration of time from initial ED physician evaluation to operation impacted the odds of AP using multivariable logistic regression, adjusting for traditionally suggested risk factors that increase the risk of perforation. We also modeled the odds of perforation in a subpopulation of patients without perforation on computed tomography.

Results: Of 955 children with appendicitis, 25.9% ( = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8-8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96-1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89-1.02).

Conclusions: Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.
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http://dx.doi.org/10.1542/peds.2016-0742DOI Listing
June 2017
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