Pediatric Emergency Care[JOURNAL]
Sun
200 papers
Performance and Yield of Retinal Examinations in Cases of Suspected Physical Abuse Without Intracranial Injury.
Hamlin I, Breeden-Carino K, Christian CW … +14 more , Wood JN, Binenbaum G, Campbell KA, Lindberg DM, Bachim A, Frasier L, George CLS, Horton D, Laub N, Letson MM, Valente M, Leonard J, Kiely J, Henry MK
Pediatr Emerg Care · 2026 Jul · PMID 42400419 · Publisher ↗
OBJECTIVES: Retinal hemorrhages (RHs) are reported as rare in children with concerns for physical abuse without intracranial injury (ICI). The current performance of retinal examinations in this population is unknown. We...
OBJECTIVES: Retinal hemorrhages (RHs) are reported as rare in children with concerns for physical abuse without intracranial injury (ICI). The current performance of retinal examinations in this population is unknown. We sought to assess factors associated with performing a retinal examination in young children without ICI and describe the yield of these examinations. METHODS: We performed a retrospective, multicenter cross-sectional study of children younger than 2 years undergoing subspecialty physical abuse evaluations between February 2021 and August 2023. Children were excluded if they had ICI, lacked neuroimaging, had RHs prompting evaluation for abuse, or died. Outcomes were (1) performance of a retinal examination and (2) yield of these examinations. We used descriptive statistics to report frequencies and proportions, and χ2 or Fisher exact tests to assess unadjusted associations between clinical and consult characteristics with performance of retinal examinations. RESULTS: Among 2591 children without ICI, retinal examinations were obtained in 10.5% (272). Performance of a retinal examination was significantly associated with younger age, in-person CAP evaluation, transfer status, CAPNET site, presence of high-risk bruising, presence of high-risk fractures, presence of subconjunctival hemorrhage, evidence of head trauma, and ill appearance. Four (1.5%) of the 272 children receiving retinal examinations had RHs on examination, all of which had potential alternate explanations for the RHs. CONCLUSION: Retinal examinations rarely reveal RHs in young children without ICI who are undergoing abuse evaluations, suggesting that these examinations may be safely deferred in this population. Retinal examinations may be warranted in cases of suspected strangulation or other signs of ocular trauma.
Using Quality Improvement Methodology to Inform Safe Implementation of Propofol Procedural Sedation in a Pediatric Emergency Department.
Wiersma A, Habermehl N, Helmuth R … +2 more , Brown J, Roback MG
Pediatr Emerg Care · 2026 Jul · PMID 42400418 · Publisher ↗
OBJECTIVES: This study used quality improvement (QI) methodology to safely introduce propofol for use in pediatric procedural sedation across a multisite emergency department (ED) system and to evaluate its impact on len...
OBJECTIVES: This study used quality improvement (QI) methodology to safely introduce propofol for use in pediatric procedural sedation across a multisite emergency department (ED) system and to evaluate its impact on length of sedation, length of stay (LOS), and serious adverse events (SAEs). METHODS: We conducted a QI initiative across 4 pediatric EDs within a quaternary children's hospital network. A multidisciplinary team used the Define-Measure-Analyze-Improve-Control (DMAIC) framework to develop and implement a standardized propofol sedation protocol for short procedures in low-risk patients. Interventions included protocol development, multidisciplinary education, simulation training, electronic medical record (EMR) order set modifications, and phased site rollout. The primary outcome measure was median length of sedation. Secondary outcomes included ED LOS and proportion of sedations using propofol. The balancing measure was airway-related SAEs. All outcomes were analyzed using statistical process control charts and nonparametric testing. RESULTS: During the study period, 2368 children underwent procedural sedation with ketamine (2251) or propofol (117). Median length of sedation for all sedations showed no special cause variation. However, propofol sedation duration was significantly shorter than ketamine across sites (18 to 24 vs. 33 to 52 min; P < 0.001). At the primary site, propofol sedation was shorter than ketamine sedations performed within propofol scope (23 vs. 32.5 min; P < 0.001). ED LOS was shorter for propofol sedations at the primary and secondary sites. SAE rates remained low and stable, with propofol‑associated SAEs occurring in 2.6% of cases. Propofol accounted for 4.9% of all sedations and 20% of sedations among eligible patients. CONCLUSIONS: Using QI methodology, propofol was feasibly and safely implemented across a multi‑site pediatric ED system. While the overall length of sedation did not change, propofol use within a defined clinical scope was associated with shorter length of sedation and LOS for selected patients, providing a reproducible framework for implementation.
Response to Ortiz-Santiago et al: Reasons for Ordering a Computed Tomography Scan and Abnormalities Found in Pediatric Intermediate-Risk Mild Head Trauma.
Mintegi S, Santos-Zorrozua B
Pediatr Emerg Care · 2026 Jul · PMID 42391019 · Publisher ↗
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Response to Ortiz-Santiago et al, "Reasons for Ordering a Computed Tomography Scan and Abnormalities Found in Pediatric Intermediate-Risk Mild Head Trauma".
Kuas C
Pediatr Emerg Care · 2026 Jul · PMID 42391018 · Publisher ↗
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Improving Emergency Care for Children With Medical Complexity: A Pragmatic Review.
Dallas A, Pulcini CD
Pediatr Emerg Care · 2026 Jul · PMID 42391017 · Publisher ↗
Children with medical complexity (CMC) are defined by the presence of significant chronic health problems that affect multiple organ systems, often requiring medical technology, and result in functional limitations and h...
Children with medical complexity (CMC) are defined by the presence of significant chronic health problems that affect multiple organ systems, often requiring medical technology, and result in functional limitations and high health care needs, including frequent emergency department (ED) visits. CMC are an estimated 1.5% of the pediatric population in the United States, yet account for 20% of pediatric ED encounters and 33% of total pediatric health care costs. Beyond high utilization, significant challenges in providing high-quality emergency care for CMC have been identified. Communication with other providers and caregivers, extended treatment times, and limited access to data are among major challenges when caring for CMC in the ED. Insights have emerged in recent years to both (1) reduce the need for emergency care through targeted ambulatory care programs, and (2) improve quality of care when CMC do present to the ED. For example, access to next-day ambulatory appointments and 24/7 access to known providers are successful outpatient strategies to reduce ED visits, while efforts for improving care within the ED have focused on the ability to improve access to critical health information for emergency providers through emergency care plans. Future work may include leveraging electronic health records and artificial intelligence to create and manage emergency care plans while improving portability. As this population of children continues to grow, it will be imperative for emergency medicine providers to invest in collaborative care models that prevent acute illness exacerbations, while supporting innovative models to promote high-quality emergency care for this medically and socially vulnerable population.
Comparison of a Pediatric Emergency Care Database and the Pediatric Health Information System.
Kappy B, Ha T, McKinley K … +2 more , Badolato GM, Chamberlain JM
Pediatr Emerg Care · 2026 Jul · PMID 42391016 · Publisher ↗
BACKGROUND AND OBJECTIVES: As a clinical database, the newly released public use data set (PUD) from the Pediatric Emergency Care Applied Research Network (PECARN) Registry contains rich patient-level and operational gra...
BACKGROUND AND OBJECTIVES: As a clinical database, the newly released public use data set (PUD) from the Pediatric Emergency Care Applied Research Network (PECARN) Registry contains rich patient-level and operational granularity unavailable in large administrative databases. To determine whether the PECARN Registry PUD population is representative of the broader cohort of patients treated at US children's hospitals, we sought to compare the PECARN Registry PUD to the widely used Pediatric Health Information System (PHIS) administrative database across demographic, system-based, and clinical ED visit characteristics. METHODS: We analyzed 14,875,508 PHIS and 3,196,288 PECARN Registry PUD patient emergency department (ED) encounters from 2017 to 2021. We compared the databases for patient demographics, ED visit characteristics, and diagnosis groupings, as well as the number of medications administered, imaging rates, and diagnosis-specific quality indicators using standardized effect size differences. As 9 of the PECARN Registry PUD hospitals were also included in the PHIS database, we performed a secondary analysis to determine if the overlap inclusion of these 9 hospitals influenced effect sizes, comparing PHIS data from the 9 PECARN Registry PUD hospitals against PHIS data for the remaining non-PECARN Registry PUD hospitals. RESULTS: Nearly all effect size difference comparisons between PHIS and the PECARN Registry PUD were classified as small (Cohen's h <0.2). Only the proportion of non-Hispanic patients (68.0% vs. 77.2%; Cohen's h: 0.208, 99% CI: 0.206, 0.210) and head injury visits with CT scans (23.5% vs. 15.6%; Cohen's h: 0.200, 99% CI: 0.190, 0.211) had moderate effect size differences (Cohen's h 0.2 to 0.5) that did not dissipate in the secondary analysis. CONCLUSIONS: Comparisons between the clinical PECARN Registry PUD and administrative PHIS databases demonstrated substantial agreement, suggesting that the PECARN Registry PUD is generalizable and representative of national children's hospital populations.
How Accurate Is Point-of-Care Ultrasound for Detecting Pediatric Elbow Fractures Presenting to the Emergency Department?: A Systematic Review and Meta-Analysis.
Girdhar N, McCreary DJ, Chan N … +2 more , Nedyalkova A, Rees J
Pediatr Emerg Care · 2026 Jul · PMID 42390266 · Publisher ↗
OBJECTIVES: Primary: To evaluate the diagnostic accuracy of point-of-care ultrasound for the identification of elbow fractures in pediatric patients. METHODS: We searched MEDLINE, PubMed, CINAHL, and Cochrane Central Reg...
OBJECTIVES: Primary: To evaluate the diagnostic accuracy of point-of-care ultrasound for the identification of elbow fractures in pediatric patients. METHODS: We searched MEDLINE, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) up until December 1, 2025 for studies involving pediatric patients presenting to the emergency department with suspected elbow fractures, who underwent POCUS. Studies were assessed for risk of bias using the QUADAS-2 framework. The primary outcome of interest was the ability of POCUS to accurately detect elbow fractures in terms of sensitivity and specificity. RESULTS: Nine studies were reviewed and included in the meta-analysis encompassing 1444 patients. POCUS demonstrated a sensitivity of 92.7% (95% CI: 87.9%-95.8%) with a specificity of 84.5% (75.4% to 90.7%). Once sample size was accounted for, the estimated heterogeneity between studies was small. The studies analyzed were generally of good quality with the reference standard and flow and timing being the main areas subject to bias. CONCLUSIONS: The findings of this systematic review and meta-analysis support the conclusion that POCUS is an effective tool in the diagnosis of pediatric elbow fractures presenting to the ED. Given its high sensitivity, a negative POCUS examination may be used to reliably rule out pediatric elbow fractures where the clinical suspicion is low. The moderately high specificity means that positive findings may require confirmatory radiography in cases where clinical findings are less convincing.
Etiologic Diversity and Diagnostic Yield of Multiplex PCR in Children With Bloody Diarrhea: A Prospective Study in a Pediatric Emergency Department.
Seçilmiş Y, Kara SS
Pediatr Emerg Care · 2026 Jul · PMID 42381152 · Publisher ↗
OBJECTIVES: Acute bloody diarrhea (hematochezia) in children is traditionally associated with invasive bacterial infection, but its etiologic spectrum is increasingly recognized as heterogeneous. We aimed to characterize...
OBJECTIVES: Acute bloody diarrhea (hematochezia) in children is traditionally associated with invasive bacterial infection, but its etiologic spectrum is increasingly recognized as heterogeneous. We aimed to characterize the etiologic distribution of acute bloody diarrhea in a pediatric emergency department and to compare the diagnostic yields of multiplex gastrointestinal PCR and conventional stool testing. METHODS: In this prospective observational study conducted between July 2018 and July 2019, consecutive children aged 0 to 18 years presenting with visible blood in stool (hematochezia) to a tertiary pediatric emergency department were enrolled. Disease severity was assessed using the Clinical Dehydration Scale (CDS) and the modified Vesikari score. All stool samples were tested with conventional methods (culture, antigen for rotavirus/adenovirus, microscopy) and a 22-target commercial multiplex gastrointestinal PCR panel. The contribution of multiplex PCR was analyzed as a descriptive diagnostic yield rather than as a predictor in a regression model, and a multivariable logistic regression model containing clinical variables only was used to test whether clinical severity independently predicted bacterial etiology. A sensitivity analysis used a stricter culture-confirmed definition of bacterial etiology. RESULTS: Eighty-three children were enrolled (median age 48 mo, IQR 21 to 84; 55% male). At least 1 enteropathogen was detected in 62 patients (74.7%). A bacterial pathogen was identified in 37 of 83 patients (44.6%), a viral-only infection in 14 (16.9%), a parasitic infection in 11 (13.3%), and a mixed viral-bacterial co-detection in 4 (4.8%). Of the 37 bacterial detections, 10 (27.0%) were identified by stool culture alone, 22 (59.5%) by multiplex PCR alone, 1 (2.7%) by both culture and PCR, and 4 (10.8%) by combined antigen and PCR in mixed infections. In the multivariable logistic regression model, none of CDS ≥5, fever, continuous modified Vesikari score, or recent antibiotic use was independently associated with bacterial etiology. Culture and PCR were complementary: 27.0% of bacterial pathogens were detected only by culture despite a negative bacterial PCR target. CONCLUSIONS: Pediatric acute bloody diarrhea is etiologically heterogeneous: fewer than half of the presentations had a bacterial etiology, and clinical severity alone did not reliably identify those with bacterial infection. Multiplex PCR expanded-but did not replace-stool culture, with more than a quarter of bacterial pathogens detected only by culture. Clinical management of children with bloody diarrhea should combine maintained clinical vigilance with comprehensive microbiological testing (stool culture plus multiplex PCR).
Pediatric Behavioral Health Emergencies Before, During, and After the COVID-19 Pandemic.
Chi V, Vongsachang H, Saynina O … +1 more , Wang NE
Pediatr Emerg Care · 2026 Jun · PMID 42374744 · Publisher ↗
OBJECTIVES: To describe rates and characteristics of pediatric behavioral health (BH) emergency department (ED) visits and hospitalizations before, during, and after the COVID-19 pandemic. METHODS: We performed a repeate...
OBJECTIVES: To describe rates and characteristics of pediatric behavioral health (BH) emergency department (ED) visits and hospitalizations before, during, and after the COVID-19 pandemic. METHODS: We performed a repeated cross-sectional analysis of data from the California Department of Health Care Access and Information Emergency Discharge database, a database of visits to all California EDs. We included all patients aged 6 to 17 who presented to the ED between September 2018 and December 2022. We compared rates and disposition of BH ED visits during 3 time periods: prepandemic, pandemic, and postpandemic. We conducted logistic regression analysis to assess patient-level characteristics associated with BH visits, including race and ethnicity, socioeconomic status, and distance from the ED. RESULTS: We assessed 5,228,930 ED visits, of which 215,460 had a primary BH diagnosis. The pandemic was associated with a relative increase in rates of BH visits and admissions/transfers, compared with prepandemic. Postpandemic, rates of visits and admissions/transfers were similar to prepandemic, with notable exceptions among certain diagnoses and demographic groups. Across time periods, the most common BH visit diagnosis was suicide attempt/ideation, with suicide attempt/ideation remaining elevated postpandemic. Racial and ethnic minority groups had lower odds of BH visits but similar or higher rates of admission/transfer, compared with white patients. Postpandemic, children with public insurance and who live further from a hospital had higher severity of BH ED visits. CONCLUSIONS: Postpandemic, there appears to be an ongoing pediatric BH crisis and persistent disparities. There is a continued need for improved and equitable access to BH care.
Evaluating the Accuracy of Chest Tube Thoracostomy Site Selection by Pediatric Emergency Medicine Physicians Using Point-of-Care Ultrasound.
Biela CM, Ruthford MR, Shah A … +4 more , Wolf BJ, Kane ID, Borg K, Moake MM
Pediatr Emerg Care · 2026 Jun · PMID 42366752 · Publisher ↗
OBJECTIVES: Chest tube thoracostomy is a core skillset within pediatric emergency medicine (PEM); however, few PEM physicians perform this procedure regularly. Site selection is typically performed through landmark ident...
OBJECTIVES: Chest tube thoracostomy is a core skillset within pediatric emergency medicine (PEM); however, few PEM physicians perform this procedure regularly. Site selection is typically performed through landmark identification of the fifth intercostal space (ICS), and incorrect placement can result in serious morbidity. The aims of this study were to evaluate the accuracy of safe thoracostomy site selection among PEM providers, and to identify relationships between provider demographics and experience with performance in this selection process. METHODS: This was a single-center observational study using a convenience sample of pediatric emergency department (PED) patients. Providers marked the fifth ICS bilaterally using the landmark technique, and the ICS and diaphragm levels were subsequently confirmed using point-of-care ultrasound (POCUS). Descriptive statistics were calculated for patient and provider characteristics. Associations between provider characteristics with location of the ICS mark were evaluated using a generalized estimating equation approach. RESULTS: Fifteen participating PEM providers performed 120 bilateral landmark-based ICS identifications. Among all identified sites (n=240), only 37.1% (n=89) were accurately confirmed as the fifth ICS, with 12.9% (n=31) being below the fifth ICS. Furthermore, 9.2% (n=22) of all sites were located below the diaphragm during resting breathing. Providers with longer tenure, more PED experience, greater number of chest tubes placed, and greater comfort with identifying the fifth ICS were more likely to mark below the fifth ICS (P=0.004, 0.026, <0.001, <0.001, respectively). CONCLUSIONS: This study demonstrates a considerable gap in thoracostomy site selection accuracy among PEM physicians. A significant number of chosen sites were found to be below the fifth ICS, and there was a surprising discordance between provider experience and accuracy. These findings highlight a critical gap in performance and the need for ongoing training. Incorporating POCUS into standard practice may improve site selection accuracy and patient outcomes in the PED setting.
Implementing the National Pediatric Readiness Project in Community Emergency Departments: A CFIR 2.0-Guided Qualitative Study of Academic Medical Center Partner Perceptions.
Sanseau E, Cochran C, Meah I … +4 more , Montgomery E, Michaels B, Mollen C, Auerbach M
Pediatr Emerg Care · 2026 Jun · PMID 42359817 · Publisher ↗
OBJECTIVES: The National Pediatric Readiness Project (NPRP) offers an evidence-based framework for pediatric emergency readiness, yet implementation in general emergency departments (GEDs) remains variable. The Pediatric...
OBJECTIVES: The National Pediatric Readiness Project (NPRP) offers an evidence-based framework for pediatric emergency readiness, yet implementation in general emergency departments (GEDs) remains variable. The Pediatric Emergency Care Coordinator (PECC) is the central driver of NPRP operationalization. The Improving Pediatric Acute Care Through Simulation (ImPACTS) collaborative formalized the Academic Medical Center (AMC) Partner role-experienced pediatric emergency clinicians providing structured NPRP implementation support to GED PECCs. We characterized AMC Partners' perceptions of barriers and facilitators to GED NPRP implementation and how AMC Partner facilitation supports PECC operationalization across diverse community settings. METHODS: Using the Consolidated Framework for Implementation Research (CFIR 2.0), we conducted semi-structured interviews with 23 AMC Partners (11 physicians, 12 nurses) from the 2023 ImPACTS collaborative, analyzed using hybrid thematic analysis organized by CFIR 2.0 domains. RESULTS: Implementation determinants spanned all 5 CFIR 2.0 domains. AMC Partners described the NPRP as a legitimizing framework, with GED implementation depending on leadership engagement, protected administrative time, and relationship-based facilitation. Workforce instability, role ambiguity, and low pediatric volume were persistent barriers. AMC Partners functioned as boundary spanners, translating NPRP standards into local action through site visits, simulation-based systems testing, Pediatric Readiness Score audit and feedback, and iterative mentorship. Absence of regional AMC Partner networks was a critical gap. CONCLUSIONS: Successful NPRP implementation requires more than PECC designation. Leadership support, protected time, and structured AMC Partner facilitation are essential. These findings inform development of regional AMC Partner network models to extend support to community, rural, frontier, and Tribal emergency departments.
Ultrasound-Guided Nerve Blocks in Pediatric Emergency Medicine: A Scoping Review of the Published Literature.
Gawel RJ, Hong JX, Stegall CL … +4 more , Lege J, Chen AE, Claiborne MK, Shalaby M
Pediatr Emerg Care · 2026 Jun · PMID 42357805 · Publisher ↗
CONTEXT: Ultrasound-guided nerve blocks (UGNBs) are increasingly used in the emergency department (ED) to provide effective, opioid-sparing analgesia. Although their use is well described in adult emergency medicine, the...
CONTEXT: Ultrasound-guided nerve blocks (UGNBs) are increasingly used in the emergency department (ED) to provide effective, opioid-sparing analgesia. Although their use is well described in adult emergency medicine, the scope, indications, and safety of UGNBs in pediatric emergency medicine remain less well defined. OBJECTIVE: To characterize the published literature describing emergency physician-performed UGNBs in pediatric emergency medicine to identify trends and directions for future research. DATA SOURCES: We electronically searched the PubMed/MEDLINE, Scopus, Embase, and Wiley Cochrane libraries from database inception through March 23, 2026. STUDY SELECTION: We included original studies describing UGNBs performed in pediatric patients by emergency physicians in the ED. DATA EXTRACTION: Three authors independently reviewed included articles and abstracted data on study characteristics, patient populations, UGNB types, clinical indications, anesthetics and adjuvants, and reported adverse events. RESULTS: From an initial database search of 5917 unique articles, 37 articles were included encompassing 440 pediatric patients who received 462 UGNBs. Twenty-one different UGNB types were described, most commonly femoral nerve blocks (8 articles, 22%; 128 blocks, 28%) and fascia iliaca compartment blocks (3 articles, 8.1%; 124 blocks, 27%) for hip and femur fracture analgesia. Two self-limited UGNB-related adverse events (0.5%) were reported, with no long-term sequelae. Study designs were heterogeneous, with substantial variability in reporting practices and frequent inclusion of mixed adult-pediatric cohorts. CONCLUSIONS: Emergency physician-performed UGNBs are increasingly reported in pediatric emergency medicine. Reported complication rates are low. The overall heterogeneous and limited evidence base highlights the need for larger, prospective studies to better define the role of UGNBs in pediatric emergency care.
Hypodermoclysis for Fluid Administration in Hospitalized Pediatric Patients: A Scoping Review.
Silva MS, Sarinho BB, Feres TDS … +4 more , Teixeira YF, Brassica SC, Rotta I, Visacri MB
Pediatr Emerg Care · 2026 Jun · PMID 42318902 · Publisher ↗
OBJECTIVE: Hypodermoclysis is an alternative for hydrating children with difficult venous access. This study aimed to map the literature on its use for fluid administration in neonates, infants, and children up to 12 yea...
OBJECTIVE: Hypodermoclysis is an alternative for hydrating children with difficult venous access. This study aimed to map the literature on its use for fluid administration in neonates, infants, and children up to 12 years old in hospital settings. METHODS: A scoping review was conducted on December 4, 2024, and updated on July 25, 2025, in PubMed, Scopus, Web of Science, and CINAHL. Primary studies on hospitalized children (0 to 12 y) receiving fluids through hypodermoclysis were included. Two reviewers independently screened the articles. RESULTS: Ten studies, published between 1950 and 2025, were conducted in emergency, inpatient, and palliative care settings. The most used fluid was 0.9% sodium chloride; hyaluronidase was used in 8 studies. Outcomes most frequently assessed were safety (n=8), efficacy/effectiveness (n=4), and ease of use/comfort/satisfaction (n=3). The data demonstrate that hypodermoclysis is safe, with expected local adverse effects related to subcutaneous administration and rare severe local or systemic adverse effects. Moreover, dehydrated patients were successfully treated using this technique. The studies also indicate that hypodermoclysis is simple to perform, well accepted by health care professionals, facilitates parenteral rehydration with fewer needle insertions, and is satisfactory to caregivers. CONCLUSION: Hypodermoclysis appears to be a safe, effective, and well-accepted option for pediatric dehydration. Its incorporation into pediatric clinical protocols may reduce the need for repeated venipuncture and associated distress, thereby improving patient comfort and family satisfaction.
Optimizing a Level 1 Trauma Pediatric Emergency Department Tracking Board-A Quality Improvement Initiative.
Pasaret A, Mbadiwe N, Bickley D … +2 more , Baccile R, Sycip M
Pediatr Emerg Care · 2026 Jun · PMID 42308170 · Publisher ↗
BACKGROUND: Efficient monitoring of patient flow is essential to emergency department (ED) operations. Electronic tracking boards organize real-time clinical data but often display nonessential information. We evaluated...
BACKGROUND: Efficient monitoring of patient flow is essential to emergency department (ED) operations. Electronic tracking boards organize real-time clinical data but often display nonessential information. We evaluated whether optimizing an ED tracking board design was associated with improved throughput metrics in a pediatric ED. METHODS: The ED tracking board was optimized by removing 8 nonpertinent columns and adding vital signs, bed status, floor orders, and unassigned patients ready to be seen. Primary outcomes were mean daily door-to-doc, room-to-doc, doc-to-disposition, and bed-to-admit times in the postintervention period compared with the preintervention period. Analyses were stratified by provider type and adjusted for ED volume, patient acuity, provider coverage, and month. RESULTS: We analyzed 68,979 ED encounters from April 2022 to March 2024. Left without being seen (LWBS) rates decreased from 13.9% to 6.9% (P<0.001). Among all providers, the postintervention period was associated with lower door-to-doc time (82.9 vs. 59.1 min), room-to-doc time (9.8 vs. 7.2 min), and total ED length of stay (318.9 vs. 296.5 min; all P<0.001). These improvements persisted after the adjusted analysis. There was no significant difference in doc-to-disposition or bed-to-admit times. CONCLUSIONS: Multiple factors influence ED throughput. In this pediatric ED, tracking board optimization was associated with significant reductions in door-to-doc time, room-to-doc time, LWBS rates, and total ED LOS across all provider types, persisting after adjustment for volume, acuity, provider coverage, and month. As tracking boards are used by all ED providers, their optimization represents a broadly applicable and low-cost target for throughput improvement.
Ultrasonography-Based Prediction of the Need for Surgical Intervention in Pediatric Intussusception.
Akkış İH, Seyrek S, Durmaz S … +8 more , Kefçi MM, Kandemirli Z, Kandemirli VB, Baziki A, Tanriöver Gülağaci HH, Gün Soysal F, Bayramoğlu Z, Ertürk ŞM
Pediatr Emerg Care · 2026 Jun · PMID 42299054 · Publisher ↗
OBJECTIVES: Intussusception is a major cause of acute intestinal obstruction in children. While most cases resolve with nonsurgical methods, some require surgical intervention. This study aimed to evaluate ultrasonograph...
OBJECTIVES: Intussusception is a major cause of acute intestinal obstruction in children. While most cases resolve with nonsurgical methods, some require surgical intervention. This study aimed to evaluate ultrasonographic features that may predict the need for surgery in pediatric intussusception. METHODS: Medical records of patients under 18 years diagnosed with intussusception between January 2020 and June 2023 at a tertiary hospital were retrospectively reviewed. Patients were categorized into surgical and nonsurgical groups. Ultrasound examinations were performed by staff radiologists at our hospital with patients in the supine position using high-frequency linear probes. Demographic data and imaging features (segment length, type) were recorded. Data were analyzed in Python 3.10 using χ2 tests, ROC analysis, and multivariable logistic regression (statsmodels, no regularization). ORs with 95% CIs were obtained, the optimal cutoff was determined by the Youden index, and bootstrap resampling was used to account for the limited number of surgical events. RESULTS: A total of 101 patients (53 males, 48 females; median age, 2.5 years (range, 0.5-15 years)) were included. Ileocolic intussusception was the most common type (n=60, 59.4%). Overall, 18 patients (17.8%) required surgical intervention, while 83 (82.2%) were managed nonsurgically. When stratified by type, surgical intervention was required in 21% (13/60; 95% CI, 11%-30%) of ileocolic intussusceptions and 12% (5/41; 95% CI, 5.3%-25.5%) of small-bowel intussusceptions. The median length of the intussuscepted segment was significantly greater in the surgical group [55 mm (IQR, 32.5 to 90)] than in the nonsurgical group [25 mm (IQR, 15 to 40); P < 0.001]. A 30-mm cutoff yielded 100% sensitivity and 53% specificity (AUC, 0.80), whereas a 91-mm cutoff achieved 100% specificity with 28% sensitivity. CONCLUSION: Ultrasonographic measurement of the invaginated segment length is a valuable noninvasive predictor of surgical necessity in pediatric intussusception. A dual-threshold approach may help guide conservative versus surgical management.
Improving Naloxone and Buprenorphine Provision in the Pediatric Emergency Department Through Education and Chief Complaint-Triggered Screening.
Buresh C, Kaplan R, Lowry S … +2 more , Sandelich S, Rutman L
Pediatr Emerg Care · 2026 Jun · PMID 42299025 · Publisher ↗
OBJECTIVE: Opioid use disorder (OUD) among US adolescents represents a public health crisis, with overdose deaths becoming a leading cause of mortality. Despite their efficacy, naloxone and buprenorphine remain underutil...
OBJECTIVE: Opioid use disorder (OUD) among US adolescents represents a public health crisis, with overdose deaths becoming a leading cause of mortality. Despite their efficacy, naloxone and buprenorphine remain underutilized. The pediatric emergency department (PED) presents an intervention opportunity, as many adolescents with OUD present there before fatal overdoses. This quality improvement initiative examined the use of education and hybrid screening to improve the provision of naloxone and buprenorphine in the PED. METHODS: A multifaceted OUD screening and treatment protocol was implemented in a PED using Best Practice Alerts (BPA) triggered by specific chief complaints (CC), alerting providers to the need for additional screening. Components included provider education, formulary changes, and clinical pathways. Data from adolescent encounters over 45 months were analyzed, comparing naloxone and buprenorphine prescribing rates before and after implementation. Secondary analyses examined demographics, insurance, and psychiatric comorbidities. RESULTS: During the study, 63 adolescents initiated buprenorphine, and 246 received naloxone. Among patients with BPA-qualifying CCs, naloxone dispensing increased from 3.89% to 11.39% and buprenorphine prescribing increased from 1.04% to 2.46%. Postimplementation, Black/African American adolescents and those with government insurance received more medications than peers, and overall naloxone prescribing increased from 0.4% to 0.79% of all visits. Patients triggering the BPA experienced longer ED stays regardless of medication receipt, with no increase in return visits. CONCLUSIONS: Electronic screening alerts coupled with provider education increased the provision of medications for adolescents at risk for opioid-related harm. The intervention is achievable in a PED without increasing return visits.
A 100-Day Workout Quality Improvement Project to Improve Value for the Care of Mental Health Conditions in a Pediatric Emergency Department.
Vega Castellvi C, Maniaci V, Czubkowski N … +7 more , Sukie I, Shikiar M, Reyes M, Ladd BF, Padilla A, Cordo J, Etinger V
Pediatr Emerg Care · 2026 Jun · PMID 42290282 · Publisher ↗
BACKGROUND: The escalating mental health crisis among children has led to increased visits to the emergency department. Routine laboratory testing in children with behavioral and mental health (BMH) concerns is a common...
BACKGROUND: The escalating mental health crisis among children has led to increased visits to the emergency department. Routine laboratory testing in children with behavioral and mental health (BMH) concerns is a common practice but rarely identifies clinically meaningful abnormalities. OBJECTIVE: We aimed to reduce low-value care for patients requiring admission to our inpatient psychiatry unit by decreasing unnecessary testing and costs by 25%. METHODS: We conducted a "100-day workout quality initiative" which used Lean Six Sigma methodology to implement an evidenced-based clinical pathway. RESULTS: After implementation, routine laboratory testing decreased from 96% to 20.8%. Overall costs associated with psychiatry admission in our institution decreased by 10%, with no adverse impact on clinical outcomes. CONCLUSIONS: This approach demonstrates a sustainable model for reducing low-value care in the emergency department setting for patients with BMH complaints.
Pediatric Emergency Care Coordinator-Facilitated Education Curriculum in Community Emergency Departments: A Multisite Evaluation.
Kaur S, Lenehan C, Montgomery E … +10 more , Abulebda K, Walls T, Dudas RA, Crellin J, Manga A, Knight L, Scherzer D, Sanseau E, Athanasopoulou SG, Auerbach M
Pediatr Emerg Care · 2026 Jun · PMID 42290206 · Publisher ↗
OBJECTIVES: This study aimed to evaluate a Pediatric Emergency Care Coordinator (PECC)-facilitated curriculum in Community Emergency Departments (CEDs). The objectives were to (1) increase CED staff engagement with pedia...
OBJECTIVES: This study aimed to evaluate a Pediatric Emergency Care Coordinator (PECC)-facilitated curriculum in Community Emergency Departments (CEDs). The objectives were to (1) increase CED staff engagement with pediatric education, (2) improve learners' pediatric knowledge and self-efficacy, and (3) explore PECCs' perceptions of the curriculum. METHODS: A prospective study evaluated a 12-week curriculum focused on the topics of pediatric status epilepticus and newborn resuscitation. The curriculum consisted of 10 weeks of brief asynchronous online weekly assignments (articles, videos, and podcasts), with in situ simulations in the first and last weeks. Engagement was measured by tracking learners' access to the content. Simulation performance was measured via case-specific checklists. Online surveys measured learners' pediatric knowledge and self-efficacy, and learners'/PECCs' satisfaction and perceptions. RESULTS: Twenty-one CED sites started the project, with 14 (67%) completing the curriculum. One hundred seventeen learners (53% nurse, 28% physician, 19% other staff) participated in the initial simulation, while 71 (61%) learners completed the follow-up simulation. Learners reported improvements in case-based pediatric knowledge and self-efficacy (P<0.001). No change was noted in simulation performance scores. The Net Promoter Score, indicating overall satisfaction with the curriculum, was high at 82%. CONCLUSIONS: A PECC-facilitated curriculum in CEDs was associated with an increase in pediatric educational activities as well as improved pediatric knowledge and self-efficacy, but not simulation performance. Learners and PECCs expressed a high level of satisfaction.
Multicenter Insights into Pediatric Extreme Leukocytosis: A 5-Year Retrospective Study.
Guzner N, Hashavya S, Barak-Corren Y … +6 more , Heiman E, Deena Z, Gordon O, Wieser G, Sedakah R, Gross I
Pediatr Emerg Care · 2026 Jun · PMID 42272271 · Publisher ↗
OBJECTIVE: This study compared the clinical outcomes of pediatric emergency department (PED) patients with extreme leukocytosis (EL; WBC >25,000/µL) to those with moderate leukocytosis (ML; WBC 15,000 to 25,000/µL). METH...
OBJECTIVE: This study compared the clinical outcomes of pediatric emergency department (PED) patients with extreme leukocytosis (EL; WBC >25,000/µL) to those with moderate leukocytosis (ML; WBC 15,000 to 25,000/µL). METHODS: We conducted a retrospective analysis using the MALRADI database, which includes pediatric visits to Jerusalem's 3 major hospitals, the largest urgent care network, TEREM. Demographics, clinical data, lab results, and outcomes were analyzed for culture positivity and WBC trends over time. RESULTS: Among 125,471 pediatric records, 19,955 (15.9%) had EL and 105,516 (84.1%) had ML. EL patients were younger (mean age 3.4 vs. 4.2 y, P <0.00001), had higher inflammatory markers (CRP 12.1 vs. 7.8 mg/L; ESR 46.6 vs. 34.6 mm/h; P <0.0001), and more frequently positive cultures (3% vs. 1.5%; P <0.0001). A rapid decline in WBC count within 24 hours was observed in EL patients, compared with a slight increase in the ML group. Malignancy was rare (0.06%) in EL cases, indicating that EL is generally infection-related in this population. CONCLUSION: Extreme leukocytosis in pediatric patients is more frequently associated with infections requiring targeted monitoring but rarely indicates malignancy. These findings highlight the clinical importance of extreme leukocytosis and support the need for careful evaluation and monitoring in affected patients.
Unplanned Return Visits to the Emergency Department Following Circumferential Cast Applications for Pediatric Forearm Fractures.
Romem R, Aliev E, Fainzack A … +2 more , Ohana N, Segal D
Pediatr Emerg Care · 2026 Jun · PMID 42266019 · Publisher ↗
INTRODUCTION: To quantify the incidence of and identify predictors for unplanned first-week return visits (1wRV) to the emergency department (ED) after circumferential casting (CC) application for pediatric forearm fract...
INTRODUCTION: To quantify the incidence of and identify predictors for unplanned first-week return visits (1wRV) to the emergency department (ED) after circumferential casting (CC) application for pediatric forearm fractures. MATERIALS AND METHODS: Retrospective, single-center study of patients aged 0 to 18 years with radius and/or ulna fractures. The primary outcome was unplanned ED revisit within 7 days (1wRV). Analyses included demographic variables, and fracture type, location, reduction versus casting in situ, and cast length. Multivariable logistic regression was used to identify predictors of 1wRV. RESULTS: A total of 4661 cases were reviewed, with detailed analysis of 551 patients treated with CC in 2022. Among these, 67 (12.2%) experienced a 1wRV, most commonly due to pain (92.5%), with 95.5% requiring cast modification. Revisit rates varied by fracture location: distal radius and ulna (23.8%), midshaft radius and ulna (15.7%), distal radius (8.5%), and other fractures (5.5%; P=0.007), and were higher following reduction versus in-situ casting (16.1% vs. 4.3%; P<0.001; OR 3.265), peaking at 27.1% for reduced distal radius and ulna fractures. No compartment syndrome occurred, and 98.4% of patients completed nonoperative treatment successfully. CONCLUSIONS: Rates of 1wRV ranged from 0 to 27.1%, depending on fracture pattern and the need for reduction, and constituted the most common adverse event associated with CC. These granular findings underscore the need for a more individualized approach to immobilization and may inform the development of tailored, evidence-based nonoperative protocols for pediatric forearm fractures. LEVEL OF EVIDENCE: Level.
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