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BACKGROUND: Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status. OBJECTIVES: The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions. METHODS: Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n = 671 [25%]), had procedural sedation not within the ASA guidelines (n = 555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n = 1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events. DISCUSSION: There was a significant difference in the length of stay and time from admission to sedation-both approximately 80 min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p < 0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n = 17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups. CONCLUSIONS: Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.

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INTRODUCTION: Asthma exacerbations are 1 of the leading causes of hospital admissions in children in the United States. High volumes in the emergency department can lead to delayed treatment. Several studies have shown that implementation of a standardized clinical pathway can improve adherence to evidence-based standards. The purpose of our quality improvement project was to develop a standardized pathway of care for children with asthma exacerbations to improve time to treatment and reduce admissions. METHODS: The team used process mapping to review the current process of care for patients with asthma exacerbations presenting to the Emergency Department. After identification of several barriers, the team used plan-do-study-act cycles to develop a standardized clinical pathway of care for children based on their respiratory clinical score. Further interventions occurred after data collection and analyzation through run charts. RESULTS: Implementation of a standardized clinical pathway for children with asthma presenting to the Emergency Department resulted in treatment with steroids in less than 60 minutes. Overall admissions were decreased from an average of 24% to 17% throughout the intervention period. We estimated cost savings for the institution at over $230,000 for the 2 years after implementation of the pathway. CONCLUSIONS: Using a multidisciplinary team approach to develop a standardized clinical pathway for a common childhood illness like asthma can result in reduced time to treatment and admissions.

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INTRODUCTION: Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival. METHODS: A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores. RESULTS: Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores. CONCLUSIONS: Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.

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BACKGROUND: Case series of anaphylaxis can vary regarding causes, treatments, and follow-up of patients. Unfortunately, case series that are specific to the pediatric population are few. OBJECTIVE: To describe confirmed cases of pediatric anaphylaxis in patients presenting to a pediatric hospital emergency department (ED). METHODS: We identified all ED visits with the International Classification of Diseases, Ninth Revision (ICD-9) codes 995.XX (allergic reactions) and 989.5 (sting or venom reaction) for 1 calendar year (January 1, 2014, through December 31, 2014). Cases were reviewed by an allergist and an emergency medicine physician to identify true anaphylaxis cases using National Institute of Health/National Institute of Allergy and Infectious Diseases criteria. Any questionable or debatable cases were evaluated and adjudicated by a second allergist. RESULTS: We identified 927 unique ED visits. Of these visits, 40 were determined to definitively meet anaphylaxis criteria. Median age of the patients was 6.5 years. A total of 70% of patients were male, and 80% were African American. Causes included foods (65%), venom or insect sting (12.5%), and medications (5%), and 17.5% were idiopathic. All patients had multiorgan involvement, with 98% having skin involvement, 78% having lower respiratory tract symptoms, and 40% having gastrointestinal symptoms. There were no deaths. Only 33% of patients received epinephrine at some point in their care. Only 12 patients were referred to an allergist, and only 4 of these were actually seen by an allergist. CONCLUSION: At our center, foods are the most common trigger for pediatric anaphylaxis. Patients continue to be undertreated, and referral to an allergist from the ED is rare.

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OBJECTIVE: Currently, pediatric emergency medicine (PEM) physicians have limited data on point-of-care echocardiography (POCE). Our goals were to (1) determine the overall accuracy of POCE by PEMs in assessing left ventricular (LV) systolic function visually, presence or absence of pericardial effusion, and cardiac preload by estimating inferior vena cava (IVC) collapsibility, in acutely ill children in the pediatric emergency department; and (2) assess interobserver agreement between the PEM physician and pediatric cardiologist. METHODS: This is a prospective, observational study conducted in an urban, tertiary pediatric facility with an annual census of 67,000 emergency department visits. Patients between the ages of 0 and 18 years meeting 1 or more of the following inclusion criteria were recruited: (1) cardiopulmonary arrest, (2) fluid refractory shock requiring vasoactive infusions, (3) undifferentiated cardiomegaly on chest radiography, and (4) receiving emergent formal echocardiography. All eligible patients underwent POCE by 1 of 2 trained PEM physicians. Dynamic video clips were recorded and reviewed by a pediatric cardiologist who was unaware of the clinical condition of the study patients. RESULTS: For a period of 18 months, we recruited 70 patients. Diminished LV function was noted in 17, pericardial effusion in 16, and abnormal IVC collapsibility in 35 patients. The κ statistics of agreement between the PEM and the cardiologist for detection of LV function, IVC collapsibility, and effusion were 0.87 (95% confidence interval [CI], 0.73-1.00), 0.73 (95% CI, 0.59-0.88), and 0.77 (95% CI, 0.58-0.95), respectively. The overall sensitivity and specificity of POCE compared with a formal echocardiogram was 95% (95% CI, 82%-99%) and 83% (95% CI, 64%-93%), respectively. CONCLUSIONS: With goal-directed training, PEM physicians may be able to perform POCE and accurately assess for significant LV systolic dysfunction, vascular filling, and the presence of pericardial effusion. The model may be expanded to train physicians to use POCE.

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