IV Bag

New study examines treatment for diabetic ketoacidosis

IV Bag

Brain injuries that happen during episodes of diabetic ketoacidosis (DKA) – where the body converts fat instead of sugar into energy, and where the pancreas is unable to process insulin, such as in type 1 diabetes – are rare, and happen in less than 1 percent of DKA episodes, but these injuries can carry lasting consequences – including mild to severe neurological damage.

A new 13-center, randomized, controlled trial published on June 13, 2018, in the New England Journal of Medicine finds two variables – the speed of rehydration fluids administered to patients and the sodium concentrations in these intravenous fluids – don’t impact neurological function or brain damage.

“One medical center would never be able to study this independently because of the relatively small volume of children with DKA that present to any one site,” says Kathleen Brown, M.D., a study author, the medical director of the emergency medicine and trauma center at Children’s National Health System and a professor of pediatrics and emergency medicine at George Washington University School of Medicine. “The strength of this research lies in our ability to work with 13 medical centers to study almost 1,400 episodes of children with DKA over five years to see if these variables make a difference. The study design showcases the efficiency of the Pediatric Emergency Center Applied Research Network, or PECARN, a federally-funded initiative that powers collaboration and innovation.”

Researchers have speculated about the techniques of administering intravenous fluids, specifically speed and sodium concentrations, to patients experiencing a DKA episode, with many assuming a faster administration rate of fluids would produce brain swelling. Others argued, from previous data, that these variables may not matter – especially since higher levels of brain damage were noted among children with higher rates of dehydration before they were treated. Some thought DKA created a state of inflammation in the brain, which caused the damage, and that speed and sodium concentration wouldn’t reverse this initial event. The researchers set out to determine the answers to these questions.

The PECARN research team put the data to the test: They created a 2-by-2 factorial design to test the impact of providing 1,255 pediatric patients, ages zero to 18, with higher (.9 percent) and lower (.45 percent) concentrations of sodium chloride at rapid and slow-rate administration speeds during a DKA episode. They administered tests during the first DKA episode and again during a recurrent episode. After analyzing 1,389 episodes, they found that the four different combinations did not have a statistically significant impact on the rate of cognitive decline during the DKA episode or during the 2-month and 6-month recovery periods.

“One of the most important lessons from this study is that diabetic ketoacidosis should be avoided because it can cause harm,” says Dr. Brown. “But the best way to treat diabetic ketoacidosis is to prevent it. Parents can monitor this by checking blood sugar for insulin control and taking their children for treatment as soon as they show signs or symptoms that are concerning.”

According to the National Institute of Diabetes and Kidney Disease, symptoms of diabetic ketoacidosis include nausea and vomiting, stomach pain, fruity breath odor and rapid breathing. Untreated DKA can lead to coma and death.

An accompanying video and editorial are available online in the New England Journal of Medicine.

The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the Health Resources and Services Administration. The PECARN DKA FLUID ClinicalTrials.gov number is NCT00629707.

Children’s National Health System’s Division of Pediatric Emergency Medicine has been a lead site for the PECARN network since its inception in 2001.

Stricter state firearms laws can save children’s lives

In a new study presented at the Pediatric Academic Societies (PAS) 2018 annual meeting, Children’s researchers find that states with stricter firearm laws have lower rates of firearm-related deaths in children. The same cross-sectional analyses also found that states with laws that mandate universal background checks prior to firearm and ammunition purchases were associated with lower rates of firearm-related mortality in children, compared with states that lack these laws.

“Injuries due to firearms are the nation’s third-leading cause of pediatric death,” says Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine and Trauma Services at Children’s National Health System and lead author of the research paper. “Firearm legislation at the state level varies significantly. Our findings underscore the need for further investigation of which types of state-level firearm legislation most strongly correlate with reduction in pediatric injuries and deaths.”

The research team analyzed data from the 2015 Web-based injury statistics query and reporting system maintained by the Centers for Disease Control and Prevention to measure the association between Brady Gun Law Scores – a scorecard that evaluates how strict firearms legislation and policies are in all 50 states – and state-based rates of firearm-related death among children aged 21 years and younger.

In 2015, 4,528 children died from firearm-related injuries. Eighty-seven percent were male; 44 percent were non-Latino black; their mean age was 18.

State-specific firearm-related mortality rates among children were as low as 0 per 100,000 to as high as 18 per 100,000. Median mortality rates were lower among the 12 states requiring universal background checks for firearm purchase at 3.8 per 100,000 children compared with 5.7 per 100,000 children in states that did not require background checks. Similarly, the five states with this requirement had a lower median mortality rate, 2.3 per 100,000 children, when compared with states that did not require background checks for ammunition purchase, 5.6 per 100,000 children.

“Newtown. Orlando. Las Vegas. Parkland. Those are among the mass shootings that have occurred across the nation in recent years. While these tragedies often are covered heavily by the news media, they represent a subset of overall pediatric injuries and deaths due to firearms. Pediatric firearm-related injuries are a critical public health issue across the U.S.,” Dr. Goyal adds.

“Pediatricians have helped to educate parents about other public health concerns, such as the danger posed by second-hand exposure to tobacco smoke or non-use of seat belts and car seats. In addition to presenting our most recent study results, members of our research group also hosted a workshop at PAS aimed at inspiring pediatric clinicians to similarly tackle this latest public health challenge and to advocate for firearm safety,” she says.

In addition to Dr. Goyal, study co-authors include Gia Badolato; Shilpa Patel, M.D.; Sabah Iqbal; Katie Donnelly, M.D.; and Kavita Parikh, M.D., M.S.H.S.

inhaler

Keeping kids with asthma out of the hospital

inhaler

Pediatric asthma takes a heavy toll on patients and families alike. Affecting more than 7 million children in the U.S., it’s the most common nonsurgical diagnosis for pediatric hospital admission, with costs of more than $570 million annually. Understanding how to care for these young patients has significantly improved in the last several decades, leading the National Institutes of Health (NIH) to issue evidence-based guidelines on pediatric asthma in 1990. Despite knowing more about this respiratory ailment, overall morbidity – measured by attack rates, pediatric emergency department visits or hospitalizations – has not decreased over the last decade.

“We know how to effectively treat pediatric asthma,” says Kavita Parikh, M.D., M.S.H.S., a pediatric hospitalist at Children’s National Health System. “There’s been a huge investment in terms of quality improvements that’s reflected in how many papers there are about this topic in the literature.”

However, Dr. Parikh notes, most of those quality-improvement papers do not focus on inpatient discharge, a particularly vulnerable time for patients. Up to 40 percent of children who are hospitalized for asthma-related concerns come back through the emergency department within one year. One-quarter of those kids are readmitted.

“It’s clear that we need to do better at keeping kids with asthma out of the hospital. The point at which they’re being discharged might be an effective time to intervene,” Dr. Parikh adds.

To determine which interventions hold promise, Dr. Parikh and colleagues recently performed a systematic review of studies involving quality improvements after inpatient discharge. They published their findings in the May 2018 edition of the journal, Pediatrics. Because May is National Asthma and Allergy Awareness month, she adds, it’s a timely fit.

The researchers combed the literature, looking for research that tested various interventions at the point of discharge for their effect on hospital readmission anywhere from fewer than 30 days after discharge to up to one year later. They specifically searched for papers published from 1991, the year after the NIH issued its original asthma care guidelines, until November 2016.

Their search netted 30 articles that met these criteria. A more thorough review of each of these studies revealed common themes to interventions implemented at discharge:

  • Nine studies focused on standardization of care, such as introducing or revising a specific clinical pathway
  • Nine studies focused on education, such as teaching patients and their families better self-management strategies
  • Five studies focused on tools for discharge planning, such as ensuring kids had medications in-hand at the time of discharge or assigning a case manager to navigate barriers to care and
  • Seven studies looked at the effect of multimodal interventions that combined any of these themes.

When Dr. Parikh and colleagues examined the effects of each type of intervention on hospital readmission, they came to a stunning conclusion: No single category of intervention seemed to have any effect. Only multimodal interventions that combined multiple categories were effective at reducing the risk of readmission between 30 days and one year after initial discharge.

“It’s indicative of what we have personally seen in quality-improvement efforts here at Children’s National,” Dr. Parikh says. “With a complex condition like asthma, it’s difficult for a single change in how this disease is managed to make a big difference. We need complex and multimodal programs to improve pediatric asthma outcomes, particularly when there’s a transfer of care like when patients are discharged and return home.”

One intervention that showed promise in their qualitative analysis of these studies, Dr. Parikh adds, is ensuring patients are discharged with medications in hand—a strategy that also has been examined at Children’s National. In Children’s focus groups, patients and their families have spoken about how having medications with them when they leave the hospital can boost compliance in taking them and avoid difficulties is getting to an outside pharmacy after discharge. Sometimes, they have said, the chaos of returning home can stymie efforts to stay on track with care, despite their best efforts. Anything that can ease that burden may help improve outcomes, Dr. Parikh says.

“We’re going to need to try many different strategies to reduce readmission rates, engaging different stakeholders in the inpatient and outpatient side,” she adds. “There’s a lot of room for improvement.”

In addition to Dr. Parikh, study co-authors include Susan Keller, MLS, MS-HIT, Children’s National; and Shawn Ralston, M.D., M.Sc., Children’s Hospital of Dartmouth-Hitchcock.

Funding for this work was provided by the Agency for Healthcare Research and Quality (AHRQ) under grant K08HS024554. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ.

Human Rhinovirus

Finding the root cause of bronchiolitis symptoms

Human Rhinovirus

A new study shows that steroids might work for rhinovirus but not for respiratory syncytial virus.

Every winter, doctors’ offices and hospital emergency rooms fill with children who have bronchiolitis, an inflammation of the small airways in the lung. It’s responsible for about 130,000 admissions each year. Sometimes these young patients have symptoms reminiscent of a bad cold with a fever, cough and runny nose. Other times, bronchiolitis causes breathing troubles so severe that these children end up in the intensive care unit.

“The reality is that we don’t have anything to treat these patients aside from supportive care, such as intravenous fluids or respiratory support,” says Robert J. Freishtat, M.D., M.P.H., chief of emergency medicine at Children’s National Health System. “That’s really unacceptable because some kids get very, very sick.”

Several years ago, Dr. Freishtat says a clinical trial tested using steroids as a potential treatment for bronchiolitis. The thinking was that these drugs might reduce the inflammation that’s a hallmark of this condition. However, he says, the results weren’t a slam-dunk for steroids: The drugs didn’t seem to improve outcomes any better than a placebo.

But the trial had a critical flaw, he explains. Rather than having one homogenous cause, bronchiolitis is an umbrella term for a set of symptoms that can be caused by a number of different viruses. The most common ones are respiratory syncytial virus (RSV) and rhinovirus, the latter itself being an assortment of more than 100 different but related viruses. By treating bronchiolitis as a single disease, Dr. Freishtat says researchers might be ignoring the subtleties of each virus that influence whether a particular medication is useful.

“By treating all bronchiolitis patients with a single agent, we could be comparing apples with oranges,” he says. “The treatment may be completely different depending on the underlying cause.”

To test this idea, Dr. Freishtat and colleagues examined nasal secretions from 32 infants who had been hospitalized with bronchiolitis from 2011 to 2014 at 17 medical centers across the country that participate in a consortium called the 35th Multicenter Airway Research Collaboration. In half of these patients, lab tests confirmed that their bronchiolitis was caused by RSV; in the other half, the cause was rhinovirus.

From these nasal secretions, the researchers extracted nucleic acids called microRNAs. These molecules regulate the effects of different genes through a variety of different mechanisms, usually resulting in the effects of target genes being silenced. A single microRNA typically targets multiple genes by affecting messenger RNA, a molecule that’s key for producing proteins.

Comparing results between patients with RSV or rhinovirus, the researchers found 386 microRNAs that differed in concentration. Using bioinformatic software, they traced these microRNAs to thousands of messenger RNAs, looking for any interesting clues to important mechanisms of illness that might vary between the two viruses.

Their findings eventually turned up important differences between the two viruses in the NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells) pathway, a protein cascade that’s intimately involved in the inflammatory response and is a target for many types of steroids. Rhinovirus appears to upregulate the expression of many members of this protein family, driving cells to make more of them, and downregulate inhibitors of this cascade. On the other hand, RSV didn’t seem to have much of an effect on this critical pathway.

To see if these effects translated into cells making more inflammatory molecules in this pathway, the researchers searched for various members of this protein cascade in the nasal secretions. They found an increase in two, known as RelA and NFkB2.

Based on these findings, published online Jan. 17, 2018, in Pediatric Research, steroids might work for rhinovirus but not for RSV, notes Dr. Freishtat the study’s senior author.

“We’re pretty close to saying that you’d need to conduct a clinical trial with respect to the virus, rather than the symptoms, to measure any effect from a given drug,” he says.

Future clinical trials might test the arsenal of currently available medicines to see if any has an effect on bronchiolitis caused by either of these two viruses. Further research into the mechanisms of each type of illness also might turn up new targets that researchers could develop new medicines to hit.

“Instead of determining the disease based on symptoms,” he says, “we can eventually treat the root cause.”

Study co-authors include Kohei Hasegawa, study lead author, and Carlos A. Camargo Jr., Massachusetts General Hospital; Marcos Pérez-Losada, The George Washington University School of Medicine and Health Sciences; Claire E. Hoptay, Samuel Epstein and Stephen J. Teach, M.D., M.P.H., Children’s National; Jonathan M. Mansbach, Boston Children’s Hospital; and Pedro A. Piedra, Baylor College of Medicine.

Omar-Ahmed

Child abuse prevention efforts should reach beyond parents

Omar-Ahmed

The findings of a study performed by Omar Z. Ahmed, M.D., should prompt widening the net when attempting to prevent child abuse.

Non-accidental injuries of children by a parent are more common but are likely to be less severe than those caused by a parent’s male partner, a babysitter or a daycare worker, according to a Children’s National study presented during the 2017 American Academy of Pediatrics (AAP) national conference. Based on their findings, the researchers recommend that efforts to prevent child abuse be extended to these additional types of caregivers.

The study performed by Omar Z. Ahmed, M.D., retrospectively reviewed the records of children admitted from 2013 to 2015 to evaluate and treat non-accidental trauma and identified 225 cases of child abuse. The 150 cases for which the perpetrator was identified were included in their analyses. The research team performed multivariate analyses to determine the association between the gender of the alleged perpetrator, the perpetrator’s relationship to the child and the severity of the child’s injuries.

“Among the 150 children hospitalized after suffering non-accidental trauma during the study period, 68.4 percent were injured by a parent; 14 percent were injured by a stepparent, boyfriend or girlfriend; 9.7 percent were injured by a daycare staff member or babysitter; and 4.6 percent were injured by a relative,” says Dr. Ahmed, a research fellow in Children’s Division of Trauma and Burn Surgery. “By far, parents were more likely to be perpetrators of the confirmed or suspected child abuse. However, children injured by a parent’s partner – a group that was overwhelmingly male – were more likely to be more severely injured, to experience severe head injuries and were more likely to require intubation compared with children who were abused by a parent.”

The research team says that the findings should prompt widening the net when attempting to prevent child abuse.

“It confirmed a lot of what we already knew and what was suspected,” Dr. Ahmed says. ”By taking the research a step further – characterizing the severity of injuries and treatments provided within the hospital – we identified caregiver types who are associated with severe child abuse. It gives parents a warning as to what to look out for when children are cared for by other people in the child’s life.”

A next step for the research group: Pre-emptive approaches to target the caregiver groups more likely to place children at risk of injury, he adds. These strategies could include educating caregivers, teaching coping mechanisms and modeling behavior for a wider group of individuals caring for young children, such as how to manage children appropriately when things get difficult, rather than letting anger take over.

“Parents rely on daycare, babysitters and significant others to provide child care while they work; it is not realistic to expect that to change. But we can target these groups for behavior modification in order to decrease the risk of children being injured,” Dr. Ahmed adds.

group of teenagers sitting on a wall

Better PID management for adolescents in the ED

group of teenagers sitting on a wall

Since adolescents account for half of all new sexually transmitted infection (STI) diagnoses, increasing screening rates for STIs in the emergency department could have a tremendous impact.

Emergency departments at U.S. children’s hospitals had low rates of complying with recommended HIV and syphilis screening for at-risk adolescents, though larger hospitals  were more likely to provide such evidence-based care, according to a study led by Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National Health System.

Presented during the 2017 American Academy of Pediatrics (AAP) national conference, the study also found low compliance with CDC recommendations for antibiotic treatment of adolescents diagnosed with pelvic inflammatory disease (PID), a complication of undiagnosed or undertreated sexually transmitted infection that can signal heightened risk for syphilis or HIV.

“Adolescents account for half of all new sexually transmitted infections (STIs) and often view the emergency department (ED) as the primary place to receive health care. If we are able to increase screening rates for sexually transmitted infections in the ED setting, we could have a tremendous impact on the STI epidemic,” Dr. Goyal says.

Although gonorrhea and chlamydia are implicated in most cases of PID, The Centers for Disease Control and Prevention (CDC) recommend that all women diagnosed with PID be screened for HIV and also recommends syphilis screening for all people at high risk for infection. The research team conducted a cross-sectional study using a database that captures details from 48 children’s hospitals to determine how often the CDC’s recommendations are carried out within the nation’s EDs.

The research team combed through records from 2010 to 2015 to identify all ED visits by adolescent women younger than 21 and found 10,698 PID diagnoses. The girls’ mean age was 16.7. Nearly 54 percent were non-Latino black, and 37.8 percent ultimately were hospitalized.

“It is encouraging that testing for other sexually transmitted infections, such as gonorrhea and chlamydia, occurred for more than 80 percent of patients diagnosed with PID. Unfortunately, just 27.7 percent of these young women underwent syphilis screening, and only 22 percent were screened for HIV,” Dr. Goyal says.

premature baby in hospital incubator

Improving neonatal intubation training to boost clinical competency

premature baby in hospital incubator

A research team from Children’s National Health System outlined gaps between current simulation training and clinical competency among pediatric residents and then shared recommendations to address them.

Redesigning the mannequins used in medical simulation training could improve residents’ readiness for clinical practice. Presenting at the 2017 American Academy of Pediatrics (AAP) national conference, a research team from Children’s National Health System outlined gaps between current simulation training and clinical competency among pediatric residents and then shared recommendations to address them.

The team noted that the transfer of skill from simulations to clinical encounters does not occur readily. They identified a number of differences between working with a training mannequin and caring for an actual infant: The mannequin’s tongue and head do not move naturally, no fluid lubricates its mouth and throat and, when tilting the head to insert the endotracheal tube, the mannequin’s neck does not flex realistically.

“Current mannequins lack physical and functional fidelity and those shortcomings take a toll on competency as pediatric residents transition from practice simulation sessions to the actual clinic,” says Children’s National Neonatologist Lamia Soghier, M.D., lead author of the poster presented during AAP. “Our work tried to tease out the most important differences between simulating neonatal intubation and actual clinical practice in order to ensure the next generation of mannequins and practice sessions translate to improved clinical competency.”

The study team conducted in-depth interviews with 32 members of the clinical staff, including attending neonatologists and second- and third-year fellows, asking about critical differences in environment, equipment and context as they participated in practice intubations as well as actual intubations in the clinic.

Four key themes emerged, Dr. Soghier and co-authors say:

  • Mannequins’ vocal cords are marked clearly in white, a give-away for trainees tasked with correctly identifying the anatomical feature. In addition, the mannequins are so stiff they need more force when practicing how to position them properly. In the NICU, using that much force could result in trauma.
  • Because current equipment does not simulate color change with a Pedi-Capa non-toxic chemical that changes color in response to exhaled carbon dioxidetrainees can develop poor habits.
  • Training scenarios need to be designed with the learner in mind offering an opportunity to master tasks in a step-by-step fashion, to practice appropriate sedation techniques and for beginners to learn first before being timed.
  • There is a marked mismatch between the feel of a simulated training and the electric urgency of performing the same procedure in the clinic, eroding trainees’ ability to adjust to wildcards in the clinic in real time.

“We carefully design our sessions to provide trainees with the suite of skills they will need to perform well in clinic. Still, there is more we can do inside the hospital and in designing the next generation of mannequins to lead to optimal clinical outcomes,” Dr. Soghier adds. “As a whole, mannequins need to more closely resemble an actual newborn, with flexible vocal cord design in natural colors. The mannequin’s neck should flex with more degrees of freedom. The model’s skin and joints also need to be more flexible, and its head and neck need to move more naturally.”

Pediatric ED visits and regional firearm laws

A Children’s research team led by Monika Goyal, M.D., M.S.C.E., found that the Northeast region had the most restrictive firearm laws and the lowest overall burden of firearm-related pediatric emergency department visits.

Pediatric emergency department (ED) visits for gun-related injuries were lower in regions with stronger firearm legislation, according to a five-year study led by Children’s National Health System.

Presenting the findings during the 2017 American Academy of Pediatrics (AAP) national conference, the Children’s research team found that the Northeast region had the most restrictive gun laws and the lowest overall burden of firearm-related pediatric ED visits. Firearm-related pediatric ED visits were significantly higher in the West, South and Midwest, according to the study.

“Firearm-related injuries are a leading cause of injury and death among children and represent a significant public health concern,” says Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National and senior study author. “This study provides compelling data that an evidence-based approach to public policy may help to reduce firearm-related injuries among children.”

The research team extracted data from the Nationwide Emergency Department Sample, the nation’s largest such database, and included ED visits from 2009 to 2013 by patients younger than 21. The team excluded emergency visits due to air, pellet, BB or paintball guns because they are not governed by firearm legislation. They used state-level Brady gun law scores to calculate median regional scores as measures of firearm legislation strictness.

During the five years covered by the study, there were 111,839 ED visits for pediatric firearm-related injuries, or 22,368 per year. The mean age of patients with firearm-related injuries was 18 years old. The majority were male. Across all age groups, 62.8 percent of firearm-related ED visits were because of accidental injuries, a statistic that rose to 81.4 percent for children aged 6 to 10. Six percent of patients died from their injuries, and 29.8 percent of injuries were serious enough to prompt hospital admission.

When compared with the low rates of firearm-related ED visits in the Northeast, the odds of children visiting EDs for firearm-related injuries were significantly higher in other U.S. regions, including the West (2.5), the South (1.9) and the Midwest (1.8).

“Regions with higher Brady scores – and, by extension stricter gun laws – had lower rates of ED visits by children and youth,” Dr. Goyal adds. “To our knowledge, this is the first study to characterize the relationship between children’s firearm-related injuries and the rigor of regional firearm legislation.”

The authors note that unlike adults, most children rushed to the Emergency Department overwhelmingly suffered from accidental firearm injuries. This fact underscores the importance of robust research that focuses specifically on children.

“Despite the importance of this topic, there has been a paucity of published research about firearm-related injuries and how they may be prevented. Most existing data have focused on adults; these findings cannot necessarily be extrapolated to children,” Dr. Goyal says.

White children more likely to receive unnecessary antibiotics in ED

Although antibiotics can turn the tide for a variety of illnesses, they are ineffective against those caused by viruses. Despite this well-known fact, doctors often prescribe antibiotics for viral illnesses.

Infections now considered relatively easy to treat, including some forms of diarrhea and pneumonia, were the leading cause of death throughout the developed world until the 20th century. Then, scientists developed what eventually turned into a miracle cure: Antibiotics that could kill or thwart the growth of a broad array of bacterial species.

Although antibiotics can turn the tide for a variety of illnesses, they are ineffective against those caused by viruses. Despite this well-known fact, doctors often prescribe antibiotics for viral illnesses. Taking these drugs unnecessarily can fuel antibiotic resistance, giving rise to bacteria that don’t respond to the drugs that kept them in check in the past.

A new multicenter study shows how prevalent this scenario can be in hospitals’ Emergency Departments. This research, led by Monika K. Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National Health System, shows that non-Latino white children seeking treatment for viral infections in the Emergency Department (ED) are about twice as likely to receive an antibiotic unnecessarily compared with non-Latino black children or Latino children.

These findings, published online Sept. 5, 2017 in Pediatrics, echo similar racial and ethnic differences in treating acute respiratory tract infections in the primary care setting.

“It is encouraging that just 2.6 percent of children treated in pediatric EDs across the nation received antibiotics for viral acute respiratory tract infections since antibiotics are ineffective in treating viral infections,” Dr. Goyal says. “However, it is troubling to see such persistent racial and ethnic differences in how medications are prescribed, in this case in the ED. In addition to providing the best evidence-based care, we also strive to provide equitable care to all patients.”

Acute respiratory tract infections are among the most common reasons children are rushed to the ED for treatment, Dr. Goyal and co-authors write. Overprescribing antibiotics is also rampant for this viral ailment, with antibiotics erroneously prescribed for 13 percent to 75 percent of pediatric patients.

In the retrospective cohort study, the research team pored over deidentified electronic health data for the 2013 calendar year from seven geographically diverse pediatric EDs, capturing 39,445 encounters for these infections that met the study’s inclusion criteria. The patients’ mean age was 3.3 years old. Some 4.3 percent of non-Latino white patients received oral, intravenous or intramuscular antibiotics in the ED or upon discharge, compared with 2.6 percent of Latino patients and 1.9 percent of non-Latino black patients.

“A number of studies have demonstrated disparities with regards to how children of different ethnicities and races are treated in our nation’s pediatric EDs, including frequency of computed tomography scans for minor head trauma, laboratory and radiology tests and pain management. Unfortunately, today’s results provide further evidence of racial and ethnic differences in providing health care in the ED setting,” Dr. Goyal says. “Although, in this case, minority children received evidence-based care, more study is needed to explain why differences in care exist at all.”

At a time of growing antibiotic resistance, the study authors underscored the imperative to decrease excess antibiotic use in kids. Since the 1940s, the nation has relied on antibiotics to contend with diseases such as strep throat. Yet, according to the Centers for Disease Control and Prevention, at least 2 million people in the United States are infected with antibiotic-resistant bacteria each year.

According to the study authors, future research should explore the reasons that underlie racial and ethnic differences in antibiotic prescribing, including ED clinicians eager to appease anxious parents as well as implicit clinical bias. Dr. Goyal recently received a National Institutes of Health grant to further study racial and ethnic differences in how children seeking treatment at hospital EDs are managed.

“It may come down to factors as simple as providers or parents believing that ‘more is better,’ despite the clear public health risks of prescribing children antibiotics unnecessarily,” Dr. Goyal adds. “In this case, an intervention that educates parents and providers about appropriate antibiotic use could help the pediatric patients we care for today as well as in the future.”

Children's National Red Badge Project

The Red Badge Project: expediting ED care

Children's National Red Badge Project

A red badge allows newly diagnosed cancer patients and BMT patients to bypass security and triage so they can receive lifesaving antibiotics within an hour of fighting fever.

Chemotherapy and bone marrow transplant procedures leave cancer patients with compromised immune systems, leading many to develop life-threatening infections or other complications. In particular, neutropenia, or abnormally low levels of white blood cells that are critical to fighting off infections, is prevalent among this population. Fever with neutropenia can be fatal.

As part of the Children’s National Health System commitment to deliver better outcomes and safer care through innovative approaches, the Hematology/Oncology/Bone Marrow Transplant (BMT) Family Advisory team developed a protocol to rapidly identify BMT and cancer patients with suspected neutropenia to receive antibiotics within 60 minutes of arriving at the Emergency Department (ED). The Red Badge Project was born with the following goals:

• Decrease the median triage-to-antibiotic time in cancer patients with fever and suspected neutropenia or bone marrow transplant patients to 30 minutes
• Increase the proportion of patients receiving antibiotics within one hour to 90 percent

As part of the protocol, newly diagnosed cancer and bone marrow transplant patients receive a Red Badge and education regarding how to use it. If they run a fever and need medical attention, the patient and family present the Red Badge upon arrival at the ED in order to bypass the welcome desk and ED triage. This action accelerates the process, keeps the child from waiting in an area where there are other sick children and ensures the patient receives lifesaving antibiotics as fast as possible.

Work done before the patient walks through the ED doors contributes to the success of this program. When a patient runs a fever, the family is instructed to call the Hematology Oncology Fellow on-call. If it is determined that the patient needs to come to the ED, the Fellow then: 1) receives the patient’s estimated arrival time so that staff can clean and prep a room 2) reminds them to apply their topical analgesia to numb the port site where the antibiotic will be administered 3) reminds them to bring their Red Badge.

From there, swift action is taken. By the time the patient arrives, he or she has already been registered and the appropriate medications have been ordered. The patient bypasses security and triage using their Red Badge as a visual cue and is then directed to a prepped room complete with medications ready for administration.

To date, the median time from triage to administration of antibiotics has decreased nearly 50 percent while the proportion of patients who received antibiotics within 60 minutes of triage improved to 90 percent.

Leveraging that success, the next step is to develop education for non-English speaking families in order to extend the reach of this lifesaving practice.

Sabah IqbShilpa Patel, Monika Goyal

Stronger firearm laws reduce ED visits

Sabah Iqbl, Shilpa Patel, Monika Goyal

Children’s National researchers Sabah F. Iqbal, M.D., Shilpa J. Patel, M.D., and Monika K. Goyal, M.D., M.S.C.E., found that regions of the United States with the strictest gun laws also have fewer emergency department visits for pediatric firearm-related injuries.

A new study by researchers from Children’s National Health System find that regions of the United States with the strictest gun laws also have the fewest emergency department visits for pediatric firearm-related injuries. The work is among the few studies to evaluate the association between local laws and firearm-related injury to children and youth. The results, presented at the 2017 annual meeting of the Pediatric Academic Societies, could inform policies at the state and regional levels.

“Our results suggest an association between regional gun laws and firearm-related injuries in children,” says Monika K. Goyal, M.D., M.S.C.E., director of research within Children’s Division of Emergency Medicine and senior author of the poster. “Regions with stricter gun laws had lower incidence rates of firearm-related emergency department visits by children.”

Firearm-related injuries are a leading cause of death and disability among children and adolescents in the United States. It is well established that states with more restrictive gun laws have fewer firearm-related fatalities. However, it has been unclear how these laws affect the rates of firearm-related injuries among children.

To investigate this question, Children’s National researchers gathered data from the Nationwide Emergency Department Sample (NEDS), a set of hospital-based emergency department databases created by the federal Agency for Healthcare Research and Quality to aggregate data about emergency department visits across the country. The researchers matched NEDS data from 2009 to 2013 in patients 21 and younger with state-level Brady Gun Law Scores, a measure of the strength of firearm laws, in four geographic regions: The Midwest, Northeast, South and West.

The researchers found that during this five-year study period, there were 111,839 emergency department visits for pediatric firearm-related injuries nationwide, an average of 22,368 per year. The mean age of patients was 18 years, and the vast majority was male. Just over one-third were publicly insured. About 30 percent of these recorded injuries resulted in hospital admission, and about 6 percent resulted in death.

Overall, firearm-related visits to emergency departments remained consistent over time at a rate of 65 per every 100,000 visits until 2013, when they decreased slightly to 51 per 100,000 visits. However, these rates varied significantly by geographic region. The Northeast had the lowest rate at 40 per 100,000 visits. This was followed by the Midwest, West and South at 62, 68 and 71 per 100,000 visits, respectively.

These numbers roughly matched the Brady Gun Law Scores for each region. The Northeast had the highest Brady score at 45, followed by 8, 9 and 9 for the South, West and Midwest.

These findings, the study authors say, suggest that stricter gun laws might lead to fewer fatalities as well as fewer gun-related injuries among children. Future studies about the role of regional gun culture and its impact on firearm legislation at the regional level, they say, is an important next step in advocating for changes to firearm legislation and reducing pediatric firearm-related injuries.

“Future research work should seek to elucidate the association of specific gun laws with the incidence rates of pediatric firearm-related injuries,” says Shilpa Patel, M.D., M.P.H., an assistant professor of pediatrics and emergency medicine at Children’s National and co-author of the poster. “This work also could evaluate how regional differences — such as social gun culture, gun ownership and other factors — contribute to the significant regional variation in firearm legislation.”

The American Academy of Pediatrics, an organization of 66,000 pediatricians, has repeatedly advocated for stricter gun laws, violence prevention programs, research for gun violence prevention and public health surveillance, physician counseling to patients on the health hazards of firearms and mental health access to address exposure to violence.

Boy and Mom with Doctor

Straightening out testicular torsion care

Boy and Mom with Doctor

A new collaborative accelerated care pathway for testicular torsion assessment and treatment may save critical time between diagnosis and intervention.

The clock starts ticking for a child with testicular torsion as soon as the pain starts. To increase the likelihood of successfully salvaging the twisted testicle and spermatic cord, surgical intervention – which involves restoring blood flow to the testis – should ideally occur within six hours from the onset of pain.

That’s six hours for a parent to identify that there is a problem, bring a child to the emergency department (ED) and go through all the steps required to get the child to the operating room. This process starts with an emergency physician, who probably doesn’t see many cases of this relatively rare condition, being able to identify the potential issue and contact the pediatric urologist on call. Next, diagnostic imaging orders need to be placed and actual imaging needs to occur for the diagnosis to be made. Finally, the patient needs to be moved to the pre-operative area, assessed by the anesthesia team and then taken to surgery.

In April 2016, the Division of Urology at Children’s National launched a new, accelerated care pathway for testicular torsion assessment and treatment that was developed collaboratively with the Emergency Department, Diagnostic Imaging and Radiology, the Department of Anesthesiology, and the peri-operative and operating room team.

“What stood out to us when we looked at the total time from identifying the problem to getting to surgery, was the length of time from when the diagnosis was made in the emergency department to the operating room,” says Tanya Davis, M.D., a pediatric urologist who led this new initiative along with Harry Rushton, Jr., M.D., chief of the Division of Urology. “It was an area where we could easily identify and streamline the process to accelerate the time for a patient to get from arrival in the ED to the surgical suite.”

Now, when a patient presents in the emergency department with the symptoms of testicular torsion, there is a straightforward path mapped out for the physician. “Who you need to talk to, how to reach them, relevant phone numbers, details on when to communicate to the attending physician, the ideal order of activities, the ability for residents to quickly transport the patient rather than waiting for hospital transport to surgery, and, most important, making it clear to everyone involved that this condition is a true emergency when every second matters,” Dr. Davis adds.

Torsion ED to OR Graph

Analysis of the streamlined care pathway, which emphasizes communication that the condition is a true emergency, has improved time from ED to OR within target ranges.

Since the initiative’s launch, 21 cases, from referrals and direct diagnosis, have come into the ED. The new protocol is working efficiently, reducing the mean time from the ED to the OR by more than an hour, now averaging below the team’s target goal of less than 2.5 hours from ED arrival to the OR.

Though salvage rates have not improved yet, the team will continue to collect data and monitor the impact of the accelerated pathway. Additionally, Dr. Davis says that a significant need remains for referring emergency and primary care physicians, as well as parents, to understand the condition and its need for urgent treatment. Children’s National urologists are developing handouts for both physicians and families to help raise awareness.

The hope is that more general knowledge of testicular torsion will allow parents, primary care doctors and emergency department staff to expedite diagnosis when a child complains of scrotal pain or has visible discoloration, further reducing the time from onset of pain to successful intervention. With such a short window of time for treatment, the accelerated care pathway is showing promising results.

Cardiac Intensive Care Unit

Michael Bell to head Division of Critical Care

Cardiac Intensive Care Unit

Michael J. Bell, M.D., will join Children’s National as Chief of the Division of Critical Care Medicine, in April 2017.

Dr. Bell is a nationally known expert in the field of pediatric neurocritical care, and established the pediatric neurocritical care program at the Children’s Hospital of UPMC in Pittsburgh.

He is a founding member of the Pediatric Neurocritical Care Research Group, an international consortia of 40 institutions dedicated to advancing clinical research for children with critical neurological illnesses. Prior to joining the University of Pittsburgh, Dr. Bell served on the faculty at Children’s National and simultaneously conducted research on the impact of inflammation on the developing brain at the National Institute of Neurological Disorders and Stroke (NINDS), within the laboratory of the Chief of the NINDS Stroke Branch.

Dr. Bell also leads the largest study to date evaluating the impact of interventions on the outcomes of infants and children with severe traumatic brain injury (TBI) and analyzing findings to improve clinical practice across the world. The Approaches and Decisions for Acute Pediatric Traumatic Brain Injury (ADAPT) Trial, funded by NINDS, has enrolled 1,000 children through 50 clinical sites across eight countries and compiled an unmatched database, which will be used to develop new guidelines for clinical care and research on TBIs. Dr. Bell is currently working on expanding the scope and continuing the trial for at least the next 5 years.

In his time at Children’s National, he played a critical role in building one of the first clinical pediatric neuro-critical care consult services in the country, which established common protocols between Children’s Divisions of Critical Care Medicine, Neurology, and Neurosurgery aimed at improving clinical care of children with brain injuries. Dr. Bell’s current research interests include: barriers to implementation of traumatic brain injury guidelines, the effect of hypothermia on various brain injuries and applications for neurological markers in a clinical setting.

The Children’s National Division of Critical Care Medicine is a national leader in the care of critically ill and injured infants and children, with clinical outcomes and safety measures among the best in the country across the pediatric, cardiac, and neuro critical care units.

Improving asthma care at community emergency departments

Through partnerships with community health care facilities, children suffering from severe asthma attacks can receive the type of state-of-the-art care championed by Children’s National.

Asthma is an exceedingly common pediatric disease, affecting nearly 7 million children in the United States, particularly in urban areas. Asthma is responsible for more than 775,000 Emergency Department (EDs) visits each year. However, the vast majority of these visits are to community EDs closest to patients’ homes, rather than to medical centers that specialize in pediatric care.

This fact could potentially lead to big problems for small patients, says Theresa A. Walls, M.D., M.P.H., Director of Emergency Department Outreach at Children’s National Health System. Nearly 70 percent of EDs in the United States treat fewer than 14 children a day, leaving many without the requisite experience or resources critical to effectively treat pediatric patients. Research shows that children seen for asthma in general community EDs are less likely to receive corticosteroid medications systemically — an essential first-line therapy during an asthma attack per National Institutes of Health guidelines — compared with children seen at pediatric EDs. Additionally in these general EDs, children are also more likely to receive unnecessary testing and treatment.

“In our experience, the emergency care of children with asthma in our area mirrors what has been found in national studies: Children are not treated as aggressively in community EDs. If we partner with them and get them to treat asthma as aggressively as we do, it would be a great thing for pediatric patients.”

That’s why when a nurse educator from a local community hospital’s ED contacted them to try to improve pediatric asthma care, Dr. Walls and Children’s colleagues jumped at the opportunity. “They were motivated participants,” she says. “It was a great way to start a partnership.”

The team worked with the community hospital’s ED to implement a pediatric asthma care plan known as a “pathway,” similar to the one currently in place at Children’s National, to ensure that children in the throes of an asthma attack receive evidence-based care that significantly decreases their chances of hospital admission or transfer to a specialty center.

The treatment pathway includes elements such as assigning each patient an asthma score — a number ranging from 1 to 10 that characterizes the severity of the patient’s asthma attack. The treatment plan also includes providing corticosteroids as quickly as possible to more eligible patients.

Effectively implementing this plan requires the efforts of a multidisciplinary team of providers and experts. Beyond the physicians, nurses and respiratory therapists who care for patients directly, this includes pharmacists to ensure proper doses of medications are available in child-friendly liquid forms and information technology specialists to revamp the hospital’s electronic charting system, automatically requesting an asthma score or recommending appropriate medication orders.

To gauge whether mimicking Children’s asthma pathway made a significant difference at the community ED, Dr. Walls and colleagues launched a study that was published online December 8, 2016, in Pediatrics. Comparing data collected for 19 months after the new guidelines were put into place with data from 12 months prior, the researchers made some promising initial findings. Following the pathway implementation, 64 percent of children ages 2 to 17 who arrived at the community ED with asthma symptoms received an asthma score. About 76 percent of these patients with asthma received corticosteroids after the pathway was in place, compared with 60 percent of comparable patients prior to the switchover. The mean time to corticosteroid administration dropped by nearly half, falling from 196 to 105 minutes. Additionally, Dr. Walls says, 10 percent of patients required transfer to another hospital after pathway implementation, compared with 14 percent before — another significant drop.

Dr. Walls notes that there is significant room for improving these metrics and overall asthma care at community EDs. The research team hopes to continue working with the first community hospital and expand their partnership to form a network of other local hospitals. By working together in a large collaboration, she says, hospitals can share resources and knowledge while learning from each other’s successes and mistakes.

“The more we can deliver this state-of-the-art care to the community,” she says, “the better, because that’s where most kids go.”

Treating injured adolescents at pediatric trauma centers associated with lower mortality

Swanson Russell photo shoot trauma emergency department Brand Photos FY13

As children mature into adolescence, they also transition from being cared for by pediatric healthcare providers to being cared for by health professionals who primarily treat adults. Controversy remains about whether a primarily pediatric or adult treatment location is optimal to meet the needs of injured adolescents. For this reason, the cutoff age for triaging children to pediatric versus adult trauma hospitals varies in different settings. A research team led by Randall S. Burd, MD, PhD, Chief of the Children’s National Health System Division of Trauma and Burn Surgery, found that injured adolescents treated at pediatric trauma centers (PTCs) had a lower mortality rate than injured adolescents treated at adult trauma centers (ATCs) or mixed trauma centers (MTCs), facilities that treat both adults and children, even when controlling for differences in patients.Trauma is a leading cause of death and acquired disability among adolescents. To determine any potential association between the type of trauma center and mortality rates, the research team examined 29,613  records for patients aged 15 to 19 years old drawn from the 2010 National Trauma Data Bank.“Trauma centers dedicated to the treatment of pediatric patients see a different adolescent population than do ATCs and MTCs,” Dr. Burd and colleagues write in an article published June 27 by JAMA Pediatrics. “After controlling for these differences, we observed that adolescent trauma patients have lower overall and in-hospital mortality when treated at PTCs.”

These findings, bolstered by additional research, have the potential to change the approach for triaging injured adolescents, says Dr. Burd, the paper’s senior author. The study findings suggest that commonly used age thresholds of 14 or 15 years might be safely adjusted higher.

Because the data were obtained from a large dataset, making that case will require closer examination – perhaps chart-by-chart analysis for each patient – to tease out nuances that differentiate care adolescents receive at different types of trauma hospitals, Dr. Burd says. “Are there differences in the process of care – or availability of specific resources – that account for the differences in outcome? Or, do the patients treated at each hospital type have differences in their injuries that we have not yet identified?”

Most adolescents (68.9 percent) included in the study were treated at an adult trauma center. In addition to being older, these youths were more likely to be severely injured and more frequently suffered severe injuries to the head, chest, and upper extremities. The most common traumatic injuries seen at adult centers resulted from children being passengers in motor vehicles (32.6 percent). Penetrating injuries from firearms (12 percent) and cutting or piercing (7.1 percent) were more common at adult centers.

Some 1,636 patients (5.5 percent) were treated at a pediatric trauma center, with many being transferred there from another hospital. Adolescents treated at pediatric trauma centers were more likely to be injured by a blunt rather than penetrating mechanism. The most common injuries seen at pediatric centers were injuries from a fall (25.9 percent) or injuries that resulted from being struck (26.1 percent).

“Because adolescents straddle the gap between pediatric and adult medicine, identifying differences in care among PTCs, ATCs, and MTCs will help determine the most appropriate triage strategies or identify practice strategies that can optimize the outcome for patients in this age group,” the authors conclude.

Related resources: Research at a Glance