Faculty Bibliography

OBJECTIVE:Rates of suicide, anxiety, and depression have soared in US youth, and professional organizations strongly urge earlier identification, particularly in pediatric emergency departments (PEDs). However, there are few commonly used suicide screeners that also identify other mental health (MH) problems. A new, electronically administered instrument, the K-CAT, screens for suicide and multiple MH problems. We hypothesized that the K-CAT would enhance suicide identification compared with routine screening and identify significant anxiety and depression in youth presenting with non-MH chief complaints. METHODS:This observational study was conducted in 2 PEDs. Eligible youth were 7 to 17 accompanied by a caregiver without: severe medical concerns, difficult behaviors, limited verbal language, or only a psychiatric complaint. Of the 341 eligible, 241 (70.7%) were screened, and 228 both presented with a non-MH problem and had complete K-CAT data. A Fisher exact test determined whether suicidal behaviors/ideation rates differed between the K-CAT and retrospective chart review data. RESULTS:Seventy-four or 32.46% of youth scored positive for suicide, anxiety, and/or depression on the K-CAT. Females were more likely to screen positive (P<0.001). Compared with the retrospective data, more youth were identified with suicide risk by the K-CAT (3.95% vs. 0%; P=0.004). Youth identified by the K-CAT were 62.5% female and 33.3% 7 to 11 years. CONCLUSIONS:The K-CAT increases the identification of suicidal ideation and behaviors overall and in younger children. It identifies significant rates of depression and anxiety in youth and could be an important first step in identifying MH problems in youth.

OBJECTIVE:Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs. METHODS:Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported. RESULTS:Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening. CONCLUSIONS:Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

OBJECTIVE:Because changes to pediatric emergency medicine (PEM) education may help address barriers to youth suicide risk screening programs, this study aimed to understand the impact of formal training in areas that likely include suicide-related practices, developmental-behavioral pediatrics (DBP) and adolescent medicine (AM), on PEM physician-perceived level of training, attitudes, and confidence assessing and managing youth suicide risk. METHODS:Twenty-seven PEM attendings and trainees completed an online survey and were divided into 2 groups: those who had completed DBP and AM rotations (DBP/AM+; n = 20) and those who had not completed either rotation (DBP/AM-; n = 7). We compared perceived level of training, attitudes, and confidence in assessing and managing suicide risk across groups. We also examined the relationship between perceived level of training and confidence. Finally, we conducted exploratory analyses to evaluate the effect of an additional formal rotation in child psychiatry. RESULTS:The DBP/AM+ and DBP/AM- groups did not differ on perceived level of training or on attitudes and confidence in suicide risk assessment or management. Perceived level of training in assessment and management predicted confidence in both assessing and managing suicide risk. Additional training in child psychiatry was not associated with increased perceived level of training or confidence. CONCLUSIONS:The DBP and AM rotations were not associated with higher perceived levels of suicide risk training or greater confidence; however, perceived level of training predicted physician confidence, suggesting continued efforts to enhance formal PEM education in mental health would be beneficial.

INTRODUCTION/BACKGROUND:Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. METHODS:After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. RESULTS:82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. CONCLUSION/CONCLUSIONS:ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

OBJECTIVE:Given the increasing rates of youth suicide, it is important to understand the barriers to suicide screening in emergency departments. This review describes the current literature, identifies gaps in existing research, and suggests recommendations for future research. METHODS:A search of PubMed, MEDLINE, CINAHL, PsycInfo, and Web of Science was conducted. Data extraction included study/sample characteristics and barrier information categorized based on the Exploration, Preparation, Implementation, Sustainment model. RESULTS:All studies focused on inner context barriers of implementation and usually examined individuals' attitudes toward screening. No study looked at administrative, policy, or financing issues. CONCLUSIONS:The lack of prospective, systematic studies on barriers and the focus on individual adopter attitudes reveal a significant gap in understanding the challenges to implementation of universal youth suicide risk screening in emergency departments.

OBJECTIVES/UNASSIGNED:To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts. METHODS/UNASSIGNED:A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included. RESULTS/UNASSIGNED:All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%. CONCLUSIONS/UNASSIGNED:Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

Background and Objectives: The 2018-2019 measles outbreak saw 1123 cases in the United States, the most since measles was declared eradicated in 2000, with 654 of those cases identified in New York City. Because measles is extremely contagious, it can lead to dangerous complications in immunodeficient populations. As a result, it is important to determine which presenting factors are high risk in order to isolate these patients early, and prevent further exposure Methods: This study examines factors including demographics, signs and symptoms, vital signs, and labs in 112 patients who were tested for measles throughout the NYU Langone Health system. Primary outcomes included positive measles diagnosis by either confirmatory test, while secondary outcomes included admission to hospital or ICU. Chart review data was collected in REDCap. All statistical analysis was done in SPSS Statistics. Independent predictors were measured through a binary logistic regression model Results: Throughout the study time period, 112 patients were tested for measles. Three of these patients were excluded due to a lack of confirmatory test results. In the 84 pediatric patients, either not being immunized to measles or having a fever at the time of presentation were independent predictors of having measles in those who were tested (p<0.05). Of the 31 pediatric patients who had confirmed measles, the presence of conjunctivitis or tachypnea were independent predictors of being admitted to the hospital from the emergency department (p<0.05). Additionally, it was found that physicians ordered only one of two available confirmatory tests for measles detection in 37 patients. There were 11 instances of patients testing positive for one test and negative for the other, leaving the possibility that measles could have been missed in some patients who only received one of these diagnostic studies
Conclusion(s): In pediatric patients, vaccination status and the presence of fever can be used to indicate if a patient is at risk for measles, while the presence of conjunctivitis or tachypnea suggests that the patient may require hospitalization. Additionally, both confirmatory tests should be run in order to prevent underdiagnoses. These findings have the potential to change hospital protocols for suspected measles patients to better detect and isolate potentially infectious emergency department patients

The clinical management of well-appearing febrile infants 7-60 days of age remains variable due in part to multiple criteria differentiating the risk of a serious bacterial infection. The purpose of this quality improvement study was to standardize risk stratification in the emergency department and length of stay in the inpatient unit by implementing an evidence-based clinical practice guideline (CPG).

Anaphylactic and anaphylactoid reactions are serious, potentially life-threatening reactions with well-described clinical manifestations. Although the pathophysiology of these reactions varies with the offending agent and route of exposure, the treatment remains the same. Attention to airway, breathing, and circulation and the prompt administration of epinephrine remain the mainstays of therapy. Once an at-risk individual is identified, the proper instruction on the avoidance of the offending agent, the use of the EpiPen, and referral to a specialist in the treatment of allergic reactions may be instrumental in the future health and safety of that patient