First name
Pediatric
Middle name
Emergency Care Applied Research
Last name
Network
Nickname
PECARN

Title

Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results.

Year of Publication

2022

Date Published

09/2022

ISSN Number

1098-4275

Abstract

 

OBJECTIVE: To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results.

METHODS: Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results.

RESULTS: Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL.

CONCLUSIONS: Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

DOI

10.1542/peds.2021-055633

Alternate Title

Pediatrics

PMID

36097858

Title

Racial/Ethnic Differences in Pediatric Emergency Department Wait Times.

Year of Publication

2021

Date Published

2021 Jun 15

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVES: </strong>Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure.</p>

<p><strong>RESULTS: </strong>Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)].</p>

<p><strong>CONCLUSIONS: </strong>In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.</p>

DOI

10.1097/PEC.0000000000002483

Alternate Title

Pediatr Emerg Care

PMID

34140453

Title

Racial and Ethnic Disparities in the Delayed Diagnosis of Appendicitis Among Children.

Year of Publication

2020

Date Published

2020 Sep 29

ISSN Number

1553-2712

Abstract

<p><strong>BACKGROUND: </strong>Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of: 1) appendiceal perforation; 2) delayed diagnosis of appendicitis; 3) diagnostic imaging during prior visit(s).</p>

<p><strong>METHODS: </strong>3-year multicenter (7 EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7 days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, Other) with: 1) appendiceal perforation; 2) delayed diagnosis of appendicitis; 3) diagnostic imaging during prior visit(s).</p>

<p><strong>RESULTS: </strong>Of 7298 patients with appendicitis and documented race/ethnicity, 2567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; aOR 1.21 [95% CI 1.01, 1.45]). 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR 1.81 [1.09, 2.98]. Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR 0.41 [0.18, 0.96]), or definitive imaging (e.g. US/CT/MRI) (10.3% vs. 35.9%; aOR 0.15 [0.05, 0.50]) during prior visits.</p>

<p><strong>CONCLUSIONS: </strong>In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis, and thus, may contribute to higher perforation rates demonstrated among minority children.</p>

DOI

10.1111/acem.14142

Alternate Title

Acad Emerg Med

PMID

32991770

Title

Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures.

Year of Publication

2020

Date Published

2020 Apr 20

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction.</p>

<p><strong>METHODS: </strong>We performed a 3-year retrospective cross-sectional study of children &lt;18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≥2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain).</p>

<p><strong>RESULTS: </strong>In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51-1.95]; Hispanic: 1.32 [1.16-1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14-1.76]; Hispanic: 1.38 [1.04-1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77-0.95]; Hispanic: aOR 0.86 [0.76-0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67-0.90]; Hispanic: aOR 0.80 [0.67-0.95]).</p>

<p><strong>CONCLUSIONS: </strong>There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.</p>

DOI

10.1542/peds.2019-3370

Alternate Title

Pediatrics

PMID

32312910

Title

Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry.

Year of Publication

2020

Date Published

2020 Mar 05

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry.</p>

<p><strong>STUDY DESIGN: </strong>This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17&nbsp;years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72&nbsp;hours.</p>

<p><strong>RESULTS: </strong>Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154&nbsp;minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg.</p>

<p><strong>CONCLUSIONS: </strong>In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.</p>

DOI

10.1016/j.jpeds.2020.01.062

Alternate Title

J. Pediatr.

PMID

32147221

Title

Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support.

Year of Publication

2017

Date Published

2017 Mar 24

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma.</p>

<p><strong>METHODS: </strong>Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were &lt;18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend.</p>

<p><strong>RESULTS: </strong>We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P &lt; .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%).</p>

<p><strong>CONCLUSIONS: </strong>The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.</p>

DOI

10.1542/peds.2016-2709

Alternate Title

Pediatrics

PMID

28341799

Title

Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection: A Multi-Center Study of Clinical Decision Support for Children with Head Trauma.

Year of Publication

2015

Number of Pages

521-35

Date Published

2015

ISSN Number

1869-0327

Abstract

<p><strong>BACKGROUND: </strong>Overuse of cranial computed tomography scans in children with blunt head trauma unnecessarily exposes them to radiation. The Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma prediction rules identify children who do not require a computed tomography scan. Electronic health record (EHR) based clinical decision support (CDS) may effectively implement these rules but must only be provided for appropriate patients in order to minimize excessive alerts.</p>

<p><strong>OBJECTIVES: </strong>To develop, implement and evaluate site-specific groupings of chief complaints (CC) that accurately identify children with head trauma, in order to activate data collection in an EHR.</p>

<p><strong>METHODS: </strong>As part of a 13 site clinical trial comparing cranial computed tomography use before and after implementation of CDS, four PECARN sites centrally developed and locally implemented CC groupings to trigger a clinical trial alert (CTA) to facilitate the completion of an emergency department head trauma data collection template. We tested and chose CC groupings to attain high sensitivity while maintaining at least moderate specificity.</p>

<p><strong>RESULTS: </strong>Due to variability in CCs available, identical groupings across sites were not possible. We noted substantial variability in the sensitivity and specificity of seemingly similar CC groupings between sites. The implemented CC groupings had sensitivities greater than 90% with specificities between 75-89%. During the trial, formal testing and provider feedback led to tailoring of the CC groupings at some sites.</p>

<p><strong>CONCLUSIONS: </strong>CC groupings can be successfully developed and implemented across multiple sites to accurately identify patients who should have a CTA triggered to facilitate EHR data collection. However, CC groupings will necessarily vary in order to attain high sensitivity and moderate-to-high specificity. In future trials, the balance between sensitivity and specificity should be considered based on the nature of the clinical condition, including prevalence and morbidity, in addition to the goals of the intervention being considered.</p>

DOI

10.4338/ACI-2015-02-RA-0019

Alternate Title

Appl Clin Inform

PMID

26448796

Title

Clinical Decision Support for a Multicenter Trial of Pediatric Head Trauma: Development, Implementation, and Lessons Learned.

Year of Publication

2016

Number of Pages

534-42

Date Published

2016

ISSN Number

1869-0327

Abstract

<p><strong>INTRODUCTION: </strong>For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial.</p>

<p><strong>METHODS: </strong>Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic(®) EHR. All sites implementing EHR-based CDS built the rules by using the vendor's CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations.</p>

<p><strong>RESULTS: </strong>The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed.</p>

<p><strong>CONCLUSIONS: </strong>The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial.</p>

DOI

10.4338/ACI-2015-10-CR-0144

Alternate Title

Appl Clin Inform

PMID

27437059

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