INTRODUCTION:Bronchiolitis, a viral lower respiratory tract infection, is the leading cause of hospitalisation for infants, with healthcare utilisation highest among young infants (aged ≤90 days). Clinical models to predict respiratory deterioration in infants with bronchiolitis have been developed for a broad age group that includes children up to 2 years old, not focusing specifically on young infants. These models have also been limited by exclusion of viral aetiology and by use of vital signs measured at a single time point during clinical evaluation, overlooking the variable and dynamic course of bronchiolitis. This study aims to combine clinical history and examination factors with viral aetiology (primary aim) and continuous physiological data from bedside monitors (secondary aim) to develop accurate prediction models to identify young infants at low risk of respiratory deterioration and enable safe discharge to home. METHODS AND ANALYSIS:We are conducting a single-centre, prospective cohort study of young infants with bronchiolitis presenting to the paediatric emergency department (ED) of a tertiary care children's hospital. Enrolment began in November 2021 and will end in April 2027. Young infants with a clinical diagnosis of bronchiolitis are included. Infants with hospitalisation within 1 week of the index ED visit or baseline (home) use of supplemental oxygen or respiratory support are excluded. We are collecting clinical, laboratory, imaging and treatment data from the ED and hospitalisation, if admitted. All patients have a standardised initial examination as well as a repeat examination at 2-4 hours if still physically located in the ED. We are also obtaining swabs from the anterior nares and the nasopharynx. Continuous physiological data are collected through pulse oximetry and 5-lead ECG. We will contact parents or guardians at 7, 14 and 21 days for follow-up of symptom resolution and unplanned visits to a healthcare provider. The primary outcome is the development of respiratory deterioration within 24 hours of ED presentation. Respiratory deterioration is defined as new use of non-invasive or invasive respiratory support within 24 hours of ED arrival. For the primary aim, regression and recursive partitioning techniques will create the low-risk model. For the secondary aim, we will use machine learning models such as Lasso regression and support vector machines. ETHICS AND DISSEMINATION:Ethics approval was obtained through the Columbia University Institutional Review Board (IRB-AAAT8528). Written informed consent will be obtained for all patients. Results will be disseminated through academic conferences, peer-reviewed publications and appropriate free open-access medical education.

OBJECTIVES To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality.METHODS Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored.RESULTS A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores.CONCLUSIONS A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.

Objective: Our objectives were to assess the comfort level of pediatric emergency physicians (PEPs) providing urgent care to adult patients on telemedicine (APOTM) when redeployed during the coronavirus disease 2019 (COVID-19) pandemic, how it changed over time, and what resources were helpful. Materials and methods: We conducted a retrospective pre-post cross-sectional survey of PEPs providing urgent care to APOTM with COVID-19 symptoms during the COVID-19 surge from March 12, 2020, to June 12, 2020 (the "care period') at two academic pediatric emergency departments in New York City. A retrospective chart review was also conducted. We include data on demographics of PEPs and adult patients; comfort level of PEPs providing urgent care to APOTM with COVID-19 symptoms pre- and post-three-month care period and effective resources. Results: Sixty-five PEPs provided urgent care to 1515 APOTM with COVID-19 symptoms during the care period. Pre-pandemic, 22/43 (51%) of responders feared caring for APOTM; 6/43 (14%) were comfortable. At the end of the care period, 25/42 (58%) of the responders stated they were comfortable caring for these patients. Factors associated with increased comfort level were: increased volume of patients over time, treatment algorithms, group support via electronic communication, and real-time back-up by a general emergency medicine (GEM) physician. Reduced medicolegal liability was also cited. Conclusion: With minimal additional training and resources, PEPs can increase their comfort to provide urgent care to APOTM with COVID-19 symptoms. As future pandemics may disproportionately affect certain patient populations (adults versus pediatrics), interventions such as treatment algorithms, group support via emails and texts, and sub-specialty backup should be incorporated into redeployment plans for urgent care telemedicine programs. Future research is needed to determine the adaptability of other medical specialties to cross-cover a different specialty from their own if needed.

Purpose/Background: There are disparities in pediatric emergency readiness, quality of care, and outcomes across U.S. emergency departments (EDs). Pediatric Emergency Readiness is a term used to describe compliance with AAP, ACEP, and ENA guidelines for emergency care that is measured using the Pediatric Readiness Survey (PRS) that involves six domains and a total validated score of 0-100. On average, Children’s Hospitals score 25 points higher than Community Hospitals. However, over 90% of pediatric emergency care is provided in Community Hospitals nationally. We developed and implemented ImPACTS, an innovative improvement intervention involving Children’s “hubs” collaborating with …

Objectives-Sonographic visualization of an empty esophagus to confirm endotracheal tube placement during intubation may be more reliable than identifying an endotracheal tube within the trachea. Our objective was to determine the frequency in which the normal empty esophagus can be identified at or below the level of the cricoid ring in children.Methods-A prospective cohort of children and young adults presenting to the emergency department were examined by sonography to determine the dynamic anatomic relationship of the trachea and esophagus at or below the level of the cricoid ring. For children with the esophagus behind or partially behind the trachea, cricoid pressure was applied using a linear array transducer to visualize the presence of lateral sliding of the esophagus from behind the trachea.Results-A total of 55 patients 21 years or younger were examined; 51% (28) were male. Sixty-two percent (34) had esophagi positioned partially to the left of the cricoid ring, 20% (11) completely to the left of the cricoid ring, 16% (9) behind the cricoid ring, and 2% (1) partially to the right of the cricoid ring. When cricoid pressure was applied using the ultrasound transducer, the esophagus was visualized lateral to the trachea in all patients (54 to the left and 1 to the right; n = 55 of 55; 95% confidence interval, 94%-100%).Conclusions-With cricoid pressure applied using a linear transducer, the esophagus was visualized lateral to the trachea in all children and young adults. Visualizing an empty esophagus by point-of-care sonography may be feasible to confirm endotracheal tube placement by a process of elimination.

Purpose of reviewWe present data from recently conducted research regarding the diagnosis of blunt cervical spine injury (CSI) in children.Recent findingsResearch in the prehospital setting to evaluate the need for cervical spine immobilization in children, regardless of clinical findings or mechanism of injury, suggests that low-risk prediction rules may be safely utilized by prehospital providers, although more data is needed. Their size, developing skeleton and unique anatomy leave children vulnerable to particular injury patterns, namely cephalad bony fractures and ligamentous and spinal cord injuries without radiographic abnormality. Low-risk clinical prediction rules have been developed but need to be further validated. For those children at higher risk of CSI, diagnostic imaging strategies are evolving, with computed tomography and MRI becoming more prominent.SummaryEvidence in the management of children with CSI has expanded in recent years, but further large prospective studies are needed. We present a review of some recent developments influencing clinical practice.

From the ∗Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York Presbyterian Morgan Stanley Children's Hospital †Department of Emergency Medicine, Weill Cornell Medical College, New York Presbyterian Komansky Center for Children's Health, New York, NY. Disclosure: The authors declare no conflict of interest. Reprints: Joan Bregstein, MD, Department of Emergency Medicine, Columbia University Medical Center, CHN-1, 3959 Broadway, New York, NY 10032 (e-mail: [email protected]).