Faculty Bibliography

BACKGROUND:Multisystem inflammatory syndrome in children (MIS-C) is a newly recognized condition affecting children with recent infection or exposure to coronavirus disease 2019 (COVID-19). MIS-C has symptoms that affect multiple organs systems, with some clinical features resembling Kawasaki disease (KD) and toxic shock syndrome (TSS). OBJECTIVE OF THE REVIEW/UNASSIGNED:Our goal was to review the current literature and describe the evaluation and treatment algorithms for children suspected of having MIS-C who present to the emergency department. DISCUSSION/CONCLUSIONS:MIS-C has a wide clinical spectrum and diagnosis is based on a combination of both clinical and laboratory findings. The exact mechanism of immune dysregulation of MIS-C is not well understood. Physical findings may evolve and do not necessarily appear at the same time. Gastrointestinal, cardiac, inflammatory, and coagulopathy manifestations and dysfunction are seen frequently in MIS-C. CONCLUSIONS:The diagnosis of MIS-C is based on clinical presentation and specific laboratory findings. In the emergency setting, a high level of suspicion for MIS-C is required in patients exposed to COVID-19. Early diagnosis and prompt initiation of therapy offer the best chance for optimal outcomes.

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.

Rationale: In March of 2020, New York City became an epicenter of COVID-19. Due to the risk of airborne transmission and limited personal protective equipment, hospitals restricted patient visitations to protect both healthcare workers and patients. In response to the initiation of this visitation restriction at our hospital on March 18, 2020, we piloted a video-based communication program for families to virtually "visit" their family members in the hospital. This is a quality improvement project designed to evaluate the utility and limitations of these virtual family visits during the pandemic.
Method(s): A retrospective chart review was conducted of all patients over 17 years-old hospitalized between March 18 and May 31, 2020 for documented video encounters performed by hospital staff at a New York City public hospital. All video calls were performed using Whatsapp, Facetime, or Google Hangout communication app on a hospital-issued smartphone or tablet. Data collected included date of call, patient age, call facilitator, preferred language, patient location during hospitalization, use of mechanical equipment for assisted breathing, hospital length of stay, patient disposition, discharge diagnosis, and any additional limitations noted by the staff during video visits. Patients admitted to the psychiatric, rehabilitation, pediatric, labor and delivery, forensics wards, or if only a voice call was performed, were excluded.
Result(s): Of the 2068 hospitalizations qualified for chart review, 177 patients have thus far been identified with documented video visits. A total of 1416 video visits were performed in these patients. 71.0% of the patients were intubated during their hospitalization and when video visits occurred. 37.3% of the patients expired, while 24.9% were discharged home or to a short-term rehabilitation center (38.9%). The average length of stay was 35.2 days (SD 2.1). Majority of the diagnoses were COVID-related illnesses (61.0%). Social workers conducted 78.5% of the video visits, followed by physicians (57.7%) and hospital chaplains (9.6%). Average patient age was 62 years-old. Chart review process is currently ongoing.
Conclusion(s): The use of smartphones and tablets for video visits facilitated communication between patients and their families when in-person visits were restricted. We were able to provide visual visits to families when patients were intubated and were unable to verbalize. While a significant number of patients expired during this period, families were able to "see" and communicate with their family members prior to their deaths. The use of this technology is an invaluable tool for families to communicate and partake in patient care.

Multiple sclerosis (MS) is a progressive demyelinating disease of the central nervous system with a wide array of symptoms. We present a healthy young woman who came to the Emergency Department with two days of isolated vertical nystagmus and was subsequently diagnosed with MS on imaging. Although bilateral vertical nystagmus is not a common presentation of MS, its presence should prompt inclusion of this disease process in the differential diagnosis.

Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.

Background and Objectives: Medical response teams deployed by the Emergency Department (ED) may be necessary to provide care for non-hospitalized patients outside of the ED. Knowledge and consistency of the medical response flow may vary by practitioners. The impact of targeted training videos for these medical response teams has not been well studied. The objective of this study is to assess the use of a training video to provide education of the medical response workflow to ED providers in the delivery of medical care to non-hospitalized patients outside of the ED Methods: A training video was developed to address medical response flow, including coverage hours, team assignments, medical equipment accessibility, hospital coverage areas, and building entry points. The video was shown to Emergency Medicine attendings, fellows, residents, and nurse practitioners during academic conferences. A survey using a Likert scale and multiple answer questions was administered prior to showing the video to assess baseline knowledge. The same questions were surveyed upon conclusion of the video. Analysis using independent sample t-test were used to assess group responses in the pre and post training video questions. Mean scores were also stratified by provider groups Results: 64 of the 79 surveyed completed both pre and post training video questions. There were significant increases in mean scores from the groups overall between the pre and post video surveys when participants were asked who would respond to medical requests outside the ED (M=6.9, SD=2.7 vs M=8.6, SD=2.0; t(133)=-3.9, p=<0.001), knowledge of response team coverage area (M=5.8, SD=3.1 vs M=8.6, SD=2.0; t(133)=-6.2, p=<0.001), building entry points (M=5.7, SD=3.0 vs M=8.7, SD=1.8; t(133)=-4.0, p=<0.001), medical equipment accessibility (M=5.5, SD=3.2 vs M=8.9, SD=1.9; t(133)=-6.7, p=<0.001), and coverage hours (M=5.5, SD=3.2 vs M=8.9, SD=1.9; t(133)=-7.3, p=<0.001). The mean score differences were often more significant in resident groups than other provider groups on the same surveyed questions
Conclusion(s): Training video may be used as an education tool for ED providers who response to medical response team requests for non-hospitalized patients outside the ED. Future assessments should be evaluated for knowledge retention and consistency in medical response team flow among providers