Febrile seizures are common in children, who are often brought to the nearest emergency department (ED). Patients who meet the case definition of simple febrile seizure are not at higher risk for serious bacterial illness than clinically similar febrile children who have not experienced a convulsion. Children who have had complex febrile seizures must be evaluated on a case-by-case basis, and treated with diagnostic and therapeutic measures based on the differential diagnosis. Round-the-clock prophylactic administration of antipyretics has not been demonstrated to affect recurrence of simple febrile seizure. Parents should be informed that recurrence is common, and that these convulsions are benign with an excellent prognosis. Care-givers should be informed that the risk of developing epilepsy after a simple febrile seizure is low, but that complex febrile seizures carry a significantly higher risk.

Children with chronic medical conditions rely on complex management plans for problems that cause them to be at increased risk for suboptimal outcomes in emergency situations. The emergency information form (EIF) is a medical summary that describes medical condition(s), medications, and special health care needs to inform health care providers of a child's special health conditions and needs so that optimal emergency medical care can be provided. This statement describes updates to EIFs, including computerization of the EIF, expanding the potential benefits of the EIF, quality-improvement programs using the EIF, the EIF as a central repository, and facilitating emergency preparedness in disaster management and drills by using the EIF.

CONTEXT: Language barriers affect health care interactions. Large, randomized studies of the relative efficacy of interpreter modalities have not been conducted. OBJECTIVE: To compare the efficacy of telephonic and in-person medical interpretation to visits with verified bilingual physicians. METHODS: This was a prospective, randomized trial. The setting was an urban pediatric emergency department at which ∼20% of visits are by families with limited English proficiency. The participants were families who responded affirmatively when asked at triage if they would prefer to communicate in Spanish. Randomization of each visit was to (1) remote telephonic interpretation via a double handset in the examination room, (2) an in-person emergency department–dedicated medical interpreter, or (3) a verified bilingual physician. Interviews were conducted after each visit. The primary outcome was a blinded determination of concordance between the caregivers' description of their child's diagnosis with the physician's stated discharge diagnosis. Secondary outcomes were qualitative measures of effectiveness of communication and satisfaction. Verified bilingual providers were the gold standard for noninferiority comparisons. RESULTS: A total of 1201 families were enrolled: 407 were randomly assigned to telephonic interpretation and 377 to in-person interpretation, and 417 were interviewed by a bilingual physician. Concordance between the diagnosis in the medical record and diagnosis reported by the family was not different between the 3 groups (telephonic: 95.1%; in-person: 95.5%; bilingual: 95.4%). The in-person–interpreter cohort scored the quality and satisfaction with their visit worse than both the bilingual and telephonic cohorts (P < .001). Those in the bilingual-provider cohort were less satisfied with their language service than those in the in-person and telephonic cohorts (P < .001). Using the bilingual provider as a gold standard, noninferiority was demonstrated for both interpreter modalities (telephonic and in-person) for quality and satisfaction of the visit. CONCLUSIONS: Both telephonic and in-person interpretation resulted in similar concordance in understanding of discharge diagnosis compared with bilingual providers. In general, noninferiority was also seen on qualitative measures, although there was a trend favoring telephonic over in-person interpretation.

Objective To report an experience with large-scale rapid transportation of hospitalized children, highlighting elements applicable to a disaster event.Study design This was a retrospective study of the relocation of an entire pediatric inpatient population. Mitigation steps included postponement of elective procedures, implementation of planned discharges, and transfer of selected patients to satellite hospitals. Drills and simulations were used to estimate travel times and develop contingency plans. A transfer queue was modified as necessary to account for changing acuity. The Hospital Incident Command System was used.Results Thirteen critical care teams, 5 general crews, 2 vans, and 4 other vehicles transferred a total of 111 patients 8.5 miles in 11.6 hours. Patients were transferred along parallel (vs series) circuits, allowing simultaneous movement of patients from different areas. Sixty-four patients (including 32 infants) were considered critically ill; 24 of these patients required ventilator support, 3 required inhaled nitric oxide, 30 required continuous infusions, and 4 had an external ventricular drain. There were no adverse outcomes.Conclusions Mass inpatient pediatric transfers can be managed rapidly and safely with parallel transfers. Preexisting agreements with regional pediatric teams are imperative. Disaster preparedness concepts, including preplanning, evacuation priorities, recovery analysis, and prevention/mitigation, can be applied to this event. (J Pediatr 2010;157:138-43).

A careless shoe-string, in whose tieI see a wild civility:Do more bewitch me, than when artIs too precise in every part. “Delight in Disorder,” Robert Herrick (1591–1674)Herrick's 17th-century sonnet seems the antithesis of the scientific movement toward evidence-based medicine. And, of course, it mostly is: there is no place for the “careless” or the “wild.” Yet those of us who still exalt in the “art” of medicine are less “bewitched” when guidance becomes “too precise in every part.” This is a subversive sentiment and, if applied to our patients, must be done so thoughtfully and responsibly. However, it may lead us to a useful insight: evidence-based medicine is not incompatible with significant practice variation.In this month's issue of Pediatrics, Goldman et al1 describe (with a perceptible sense of dismay) practice variation across Canadian pediatric emergency departments in the management of febrile infants younger than 90 days. Although most infants had blood and urine work performed, the authors are particularly struck by the variability in lumbar puncture rates. They imply that such variability is hard to justify in the face of the availability of “several clinical guidelines” for the management of such children. They conclude with a call to devise “translation strategies” for practitioners regarding what is known about the management of febrile infants (presumably to limit such variation).But, what is known about the management of febrile infants? And, does such a fund of knowledge comprise an evidence base from which deviation is unjustified? Sometimes it is easier. The evidence is overwhelming, risk/benefit approaches are obvious, and “expert” consensus is wide-ranging and multidisciplinary. The American Academy of Pediatrics guidelines regarding hyperbilirubinemia in normal newborns or even the treatment and workup of urinary tract infections come to mind.2,3 No such case can be made for febrile infants. There has really only been 1 document (simultaneously published in 2 journals) bold enough to term itself a “guideline,” and it is controversial.4,5 The controversy stems not from the strength of the evidence (although that has been questioned) but, rather, from the conclusions of these experts as to how this evidence should dictate practice.6Economists observed many years ago that human behavior and decisions reflect variations in personal risk aversion. As Green and Rothrock7 emphasized a decade ago, individual practitioners will vary in their tolerance of risk. Goldman et al note that “incompliance” with the guidelines may be “associated … with the physicians.”1 This is true, but it is no bad thing. Two practitioners can be completely informed, aware, and have internalized all the relevant data regarding the risk of serious bacterial infection (SBI) in a given instance and still justifiably differ in their management approaches. One may weigh the risk of SBI against the risk of iatrogenesis (eg, a contaminated tap), unnecessary hospitalization, costs, etc and find the balance of “evidence” to lead him or her to forego a full sepsis workup. Another reasonable provider might come to a different conclusion. These practitioner differences in risk tolerance do not even account for the parents' wishes, which add yet another layer of variability to the decision-making process.8Goldman et al seem frustrated that their “study of a relatively homogenous group of pediatric emergency physicians still showed significant practice variation.”1 However, it is exactly this subset of practitioners who care for children who should be best informed about the risks, costs, and benefits of their decisions regarding a workup for SBI. This article's findings really speak to the variation in the views of the individuals who comprise this subspecialty regarding the validity of the “guidelines,” which the authors approach as a settled question. I would expect these providers to be the ones most likely to confidently challenge the tyranny of a cookbook approach when their own assessment of the evidence leads them to a different conclusion. As mentioned above, individual clinical decisions may not be “homogenous” even in the face of common training backgrounds and uniformly accepted evidence.Almost 30 years ago Wennberg and his Dartmouth colleagues9 first rattled the modern medical establishment by pointing out variations in practice that led to variations in costs without demonstrable effects on outcomes. The assumption was that such variation must be unjustified, and explanations were demanded: physicians were lazy creatures of habit; a small number of “opinion leaders” dominated regions; nefarious financial influences were at play; etc. There were more charitable explanations as well, of course, but the ultimate thesis is that such variation, in the absence of improved outcomes, is unjustified.10Now back to febrile infants. Fortunately, SBI is rare, and morbidity rates are low. Not one scintilla of evidence has linked any particular management approach to a difference in health outcomes (although costs clearly differ).11 Those who would use Wennberg's reasoning to indict the “careless shoestrings” who dare to stray from published interpretations of proper management are lacking an essential element, that is, the link to outcomes. Could our field bring us the evidence necessary to derive outcome-based guidelines that could define what is too risky or what is too costly? Perhaps someday. But, until then, because responsible practitioners, parents, and institutions all think for themselves, the management of febrile infants will be delightfully disordered.I thank Genie Roosevelt, MD, MPH, and Lalit Bajaj, MD, MPH, for thoughtful comments on drafts of this commentary.

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

OBJECTIVES:The American Academy of Pediatrics Section of Emergency Medicine's Subcommittee on Administration developed a survey tool targeting recent pediatric emergency medicine (PEM) fellowship graduates to assess the current PEM job market in a variety of areas including (1) the new positions accepted, (2) perspectives of fellowship training, and (3) the relationship between PEM and general emergency medicine practice. METHODS:The 40-question internet-based survey was developed through www.surveymonkey.com. Solicitations to PEM fellowship graduates who completed training between the years 2000 and 2005 were sent via the Section of Emergency Medicine member e-mail list as well as the PEM LISTSERV. Data collection occurred from April to May 2005. RESULTS:Of 125 survey respondents, 89% completed a 3-year pediatrics residency plus a 3-year PEM fellowship. Offers to graduates of positions with research expectations outnumbered clinical positions, 3:2, with an average of 5 total positions offered per respondent. Thirty-four percent remained at the institution of fellowship graduation, and 71% accepted faculty appointments with medical school affiliation. Seventy percent of work time was spent on clinical duties and 10% on research. Most felt better prepared in the areas of clinical training and teaching than in the areas of research and administration. Additional general emergency medicine exposure was not desired. Half of the respondents felt that a 2-year fellowship program would have met their career goals. CONCLUSIONS:Recent PEM fellowship graduates felt that job availability was good and were satisfied with their new positions. Respondents perceived better fellowship training in clinical and teaching aspects than in research and administration. New positions were heavily clinical and matched career goals.

The number of families with limited English proficiency seen in U.S. pediatric emergency departments (EDs) has been exploding. From 1990 to 2000, the number of people in the United States who don't speak English well grew 47% and now is above 22.3 million, according to the U.S. Census Bureau.[⇓][1

Objective: In 1996, the American Academy of Pediatrics published practice parameters for the acute management of febrile seizure. These guidelines emphasize the typically benign nature of the condition and discourage aggressive neurodiagnostic evaluation. The extent to which these suggestions have been adopted by general emergency medicine practitioners is unknown. We sought to describe recent patterns of the emergency department (ED) evaluation of febrile seizures with respect to these parameters.Methods: A retrospective review of records of children between 6 month and 6 years of age diagnosed with "febrile seizure" (international Classification of Diseases, Ninth Revision, Clinical Modification 780.31) at 42 community hospital general EDs nationwide was performed. Electronic records of an ED physician billing service from October 2002 to September 2003 were used to identify relevant records. Data had been entered into a proprietary template documentation system, and all charts were reviewed by a professional coder blinded to outcomes of interest. Rates of resource utilization (including lumbar puncture, radiography, hospital admission) were noted.Results: A total of 1029 charts met inclusion criteria. The overall rate of lumbar puncture was 5.2%, and variations were strongly associated with age (8.4% < 18 months old vs 3.3% > 18 months old). This low rate and age discrimination were consistent with the guidelines of the American Academy of Pediatrics. Although not recommended in the routine evaluation of febrile seizure, Computed tomography was part of the evaluation in 11%. The overall rate of admissions or transfers was 12%.Conclusions: Six years after publication of practice parameters, the use of lumbar puncture in the evaluation of febrile seizure is uncommon and most patients are discharged home. However, the relatively frequent use of head computed tomography is inconsistent with these practice guidelines and merits further investigation.

Although decision rules for radiographs of pediatric knee injuries have been suggested from retrospective studies, prospective evaluations of such rules have been limited. We sought to prospectively assess the performance of a rule in children presenting with acute knee injuries. Eligible participants were children aged 3–18 years with an acute knee injury. The settings for the study were a tertiary pediatric emergency department (ED), a community hospital ED, and a pediatric urgent care center. All of the participants received standard knee radiographs. Before radiography, each patient was assessed by a pediatrician or pediatric emergency physician for presence of the following: 1) inability to bear weight, 2) inability to flex the knee to 90°, 3) presence of bony tenderness. The radiographs were interpreted by a radiologist blinded to the study; those with findings reported as consistent with acute fracture were considered positive. A total of 146 patients were enrolled (65% male, mean age 11.6 years). Of these, 15 (10.3%) had a fracture on their radiograph, 6 of which were related to trampoline use. Seventy-seven (53%) were negative for criterion 1 (i.e., able to bear weight immediately after the accident and in the ED), none (0%) of whom had fractures. The negative predictive value of this criterion was 1.0 (95% CI 0.94–1.0). The positive predictive value was 0.22 (95% CI 0.13–0.34). The sensitivity was 1.0 (95% CI 0.82–1.0). The specificity was 0.59 (95% CI 0.50–0.67). Three patients negative for criterion 3 were found to have fractures. The proximal tibia was the most common fracture site (47%). In conclusion, assessment of the ability to bear weight would have decreased the use of radiography by 53% without missing any fractures in our study population. No additional value to the rule was found by adding assessment of the ability to flex the knee or bony tenderness.

Toddlers commonly ingest coins. Studies of the evaluation and management of such ingestions have focused on the risk of complications from impaction in the esophagus. It is commonly assumed that coins that have passed through the esophagus present little or no risk for distal complications. We present the first report of cecal retention of a penny in a previously healthy 2 year old, ultimately resulting in surgical intervention.

Background: Hemolysis in pediatric specimens is common due to difficult blood draws and small-bore intravenous catheters. Values of serum K+ become falsely elevated secondary to release of intracellular contents. If a reliable correction factor existed for this factitious elevation, repeat K+ measurements might be avoided.Objective: The aim of the Study was to establish a correction factor for factitiously elevated K+, using free plasma hemoglobin (p-Hgb) a, a measure of in vitro hemolysis.Methods: Twenty whole-blood specimens drawn from healthy adults via a 23-gauge needle were divided into 4 aliquots: (1) no manipulation, (2) mechanical hemolysis via a 27-gauge needle, (3) addition of potassium acetate (KAc), and (4) addition of KAc and mechanical hemolysis. KAc was added to mimic potentially significant hyperkalemia. All specimens had standard K+ and p-Hgb measurements performed.Results: Nonhemolyzed and hemolyzed K+ ranged from 3.2 to 8.1 mEq/L and 3.5 to 10.0 mEq/L, respectively. A linear relationship existed between the change in K+ and p-Hgb from the nonhemolyzed to hemolyzed specimens. A correction factor for K+ of 0.00319 (95% confidence interval, 0.00290-0.00349) X p-Hgb was obtained.Conclusions: A reliable correction factor for factitious hyperkalemia in a clinically relevant range exists. By example, using the above correction factor, one call predict that the delta K+ in a specimen with 500 mg/dL of p-Hgb will be 1.6 mEq/L (range, 1.5-1.7). We suggest that when the lower bound of the predicted delta K+ results in a corrected value within the reference range, a second blood draw is unnecessary. (c) 2005 Elsevier Inc. All rights reserved.

OBJECTIVES:To describe the variation among physicians in test ordering when caring for children with gastroenteritis and to explore the effect of hospital charge information on such variation. DESIGN:Prospective, nonmasked, observational study and controlled trial of price information. SETTING:Urban, university-affiliated pediatric emergency department. PARTICIPANTS:Pediatric emergency medicine faculty (n = 10) and fellows (n = 5). METHODS:Test-ordering practices were reviewed during 3 periods: control, intervention, and washout. During the intervention period, test charge information was placed on patients' emergency department records. Telephone contact with families was initiated 7 days after care. RESULTS:We included 3198 visits. Individual physician mean test charges varied more than 2-fold during the control period (mean, 127 US dollars; range, 82 US dollars-185 US dollars). Based on their test charges (control period), physicians were assigned to the "high" (n = 8) or "low" (n = 7) test user group. Differences in mean charges in high vs low test users during the control period (144 US dollars vs 112 US dollars) persisted in the intervention period (80 US dollars vs 52 US dollars; Mann-Whitney P =.01), as did rates of intravenous fluid use (20% vs 14% in both periods). Among the lowest-acuity patients, low test users exhibited greater price sensitivity (vs high users). Patients treated by low test users did not differ in improved condition (82% vs 86%) or family satisfaction (93% vs 92%); they had more unscheduled follow-up (25% vs 17%; P<.01), but were no more often admitted (5% vs 3%; P =.11). CONCLUSIONS:Physicians varied in resource use when treating children with gastroenteritis. High and low test users were sensitive to price information. This intervention did not seem to compromise patient outcome.

OBJECTIVE To describe perceptions of how a lack of house staff Spanish proficiency adversely affects communication with Spanish-speaking families with limited English proficiency (LEP). METHODS An anonymous, structured questionnaire was administered to the house staff an of urban, university-affiliated children's hospital that serves a population in which 10%-20% have LEP. RESULTS Ninety-four percent (59 of 63) completed the questionnaire. Sixty-eight percent (40 of 59) reported that they spoke little or no Spanish (although 36 of 40 expressed a desire to learn Spanish). Fifty-three percent (21 of 40) of these nonproficient residents reported that they used their inadequate language skills in the care of patients "often" or "every day." Many of these residents believed that LEP families under their care "never" or only "sometimes" understood their child's diagnosis (21 of 40), medications (11 of 40), discharge instructions (17 of 40), or follow-up plan (16 of 40). Eighty percent (32 of 40) admitted to avoiding communication with such families. Although all (40 of 40) agreed that hospital interpreters were effective, 30 of 40 nonproficient residents reported use of hospital interpreters "never" or only "sometimes." Fifty-three percent (21 of 40) of these nonproficient residents reported calling on their proficient colleagues "often" or "every day" for assistance. Thirty-two percent (19 of 59) of residents described themselves as "fluent" or "proficient" in Spanish. Fifty-eight percent (11 of 19) reported that they were asked to interpret for fellow residents "often" or "every day." Proficient residents estimated that they spent a mean of 2.3 hours per week interpreting for other residents. CONCLUSIONS Despite a perception that they are providing suboptimal communication, nonproficient residents rarely use professional interpreters. Instead, they tend to rely on their own inadequate language skills, impose on their proficient colleagues, or avoid communication with Spanish-speaking families with LEP.