The program seems to have resulted in reduction of the rate of epinephrine dosing errors in the prehospital treatment of children in cardiopulmonary arrest in Los Angeles County.

Behavioral health census and bed hold hours were significantly associated with increased LOS and LWBS rates and with our inability to meet desired LOS and LWBS rates. These associations support the existence of a threshold where the ED has reached capacity and is no longer able to absorb BH patients. Improving BH facility access may help improve overall pediatric ED patient care.

Flushing of the skin of an infant may be a sign of the child's first allergic reaction to food, insect envenomation, or other allergens, a sign of sepsis, or due to dilation of cutaneous vessels caused by a vasodilator substance or neural mechanisms. A rare cause of this condition results in the release of mast cell mediators such as histamine, prostaglandin D2, tryptase, chymase, and leukotrienes. We present a case of a 6-month-old with severe total body flushing and a yellow-tan, raised, well-demarcated lesion on the thigh consistent with a solitary mastocytoma. Erythema was most pronounced adjacent to the lesion, suggesting a positive Darier sign. Subsequent evaluation by a dermatologist confirmed the diagnosis, and the patient underwent no further therapy; however, the family was appropriately counseled on management if the symptoms were to reappear. Appropriate diagnosis and management of this patient and other forms of mastocytosis in children are discussed.

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Background There is an increased emphasis on reducing exposure to ionizing radiation in pediatric patients. Guidelines from the Pediatric Emergency Care Applied Research Network help practitioners identify patients at low risk for clinically important traumatic brain injury after head injury. Objectives We seek to determine whether the institution of a pediatric track staffed by pediatric emergency medicine physicians (PEMs) within a community emergency department (ED) impacts the overall utilization of head computed tomography (CT) on children younger than 15 years with head injury. Methods We used a retrospective cohort analysis of patients under the age of 15 years presenting to a community ED in the year before and the year of institution of a pediatric emergency track. Relative risk estimates were used to determine the risk of CT use associated with nonpediatric-trained emergency providers. Results The community ED saw 11,094 patients and 14,639 patients younger than 15 years in fiscal years 2014–2015 and 2015–2016, respectively. In the year before PEMs, there were 312 children younger than 15 years seen for head injury; 47.09% received head CTs. After PEM coverage, there were 396 children younger than 15 years seen for head injury; 17.17% received head CTs. Pediatric patients with head injury were 2.2 times more likely to receive CTs before the institution of the pediatric track (95% confidence interval, 1.8–2.6). Conclusion The implementation of a pediatric emergency track demonstrated a significant decrease in CT utilization for head injury. Continued development of pediatric tracks in community EDs can lead to reduction of CTs.

Objectives: Limited data are available on how the closure of pediatric dental clinics because of the COVID-19 pandemic affected hospital pediatric emergency department (ED) visits in the United States. We evaluated changes in dental-related visits at a pediatric ED and associated urgent care centers (UCCs) after the shutdown of a large pediatric dental clinic because of the COVID-19 pandemic. Methods: We conducted a single-center retrospective medical record review of 811 patients aged 0 to 17 years who presented to a pediatric ED or associated UCC at Rady Children’s Hospital–San Diego for dental-related concerns from March 19, 2019, through January 17, 2021. Patients were classified into 3 periods: before shutdown, during shutdown, and after shutdown. We collected data on demographic characteristics; International Classification of Diseases, Tenth Revision codes; dental diagnosis; treatment; and COVID-19 test results. We compared the frequency and proportion of patients seen for dental-related concerns, dental diagnosis, and treatment during the 3 periods. Results: The proportion of dental-related concerns in the ED doubled during the shutdown (0.7%) and was 1.5 times higher after the shutdown (0.6%) compared with before the shutdown (0.4%; P < .001). Significantly more patients were seen in EDs than in UCCs during and after the shutdown than before the shutdown ( P = .005). During and after the shutdown, admission to the hospital for antibiotic treatment increased significantly to 6.5% and 7.9%, respectively, compared with before the shutdown (2.8%; P = .022), and nonaerosolized procedures and ED/UCC discharge increased to 13.4% and 9.3%, respectively, compared with before the shutdown (6.2%; P = .015). Conclusions: Mitigating future closures of dental offices is important given the shifted burden of dental care to the ED.

Background Management of urinary tract infections (UTIs) is highly variable and ∼50% of affected women may receive inappropriate antimicrobials. Precision Metagenomics-based detection of pathogens and antimicrobial resistance (AMR) markers can inform antimicrobial selection in support of stewardship practices. We investigated inter-physician agreement of culture and metagenomic results in a retrospective analysis. Methods We used de-identified urine samples with results of urine culture & antimicrobial susceptibility testing (AST, n=25, 76% culture-positive) and the Explify® Urinary Pathogen ID/AMR Panel (UPIP, IDbyDNA Inc). UPIP is a Precision Metagenomics method to detect &gt;170 uropathogens and &gt;2,000 AMR markers. Four physicians reviewed culture/AST and UPIP results independently to assess if and how they would treat based on each set of results in a middle-aged, female patient with uncomplicated UTI (no comorbidities or medication allergies). Consensus was defined by simple majority; treatment decisions and antimicrobial choice were adjudicated by an infectious disease trained pharmacist. Inter-rater agreement (Fleiss’ kappa) and reliability for accurate case management (reference: adjudicator) were estimated for each method. Results Analytical agreement for uropathogen identification between the two methods was 72% with 95% positive agreement for common uropathogens. Consensus on whether or not to treat was reached for 96% (24/25) of cases for both culture/AST and UPIP; decisions were concordant between methods for 88% of cases (22/25). Inter-rater agreement was high (culture: k=0.73, UPIP: k=0.68; p&lt; 0.05). Physicians were more likely to decide to treat based on culture results (17/25, 68%) than UPIP (15/25, 60%). UPIP detected additional organism(s) and/or AMR marker(s) compared with culture/AST alone that were informative for stewardship-guided treatment decisions in 28% (7/25) of samples. Figure 1: Physician Consensus Treatment Decisions Based on Results of Urine Sample Analysis by Precision Metagenomics or Urine Culture/AST Four infectious disease physicians independently reviewed paired results from analysis of a set of 25 clinical remnant urine samples by an investigational Precision Metagenomics method (UPIP) and by standard urine culture/AST and determined whether or not treatment would be warranted. Figure 2:Summary of Changes in Antimicrobial Selection based on Interpretation of Precision Metagenomics vs Culture/AST Results An infectious disease pharmacist reviewed and adjudicated hypothetical antimicrobial selections. All antimicrobial selections based on the results of the Precision Metagenomics method (UPIP) were found to be appropriate; in 7/15 cases, hypothetical treatment based on UPIP results would have resulted in a change in management that was evaluated to be consistent with stewardship practices. Conclusion Physician agreement on hypothetical treatment recommendations was comparable between the investigational method (UPIP) and the reference method (urine culture/AST). In no case was there inappropriate consensus to treat based on UPIP results alone. The findings from this pilot analysis support the feasibility of metagenomics-guided management of UTIs. Disclosures Benjamin Briggs, MD, PhD, CloudCath: Advisor/Consultant|CosmosID: Employee Benjamin Briggs, MD, PhD, CloudCath: Advisor/Consultant|CosmosID: Employee Robert Schlaberg, MD, MPH, IDBYDNA INC: Board Member|IDBYDNA INC: Explify-related IP|IDBYDNA INC: Employee|IDBYDNA INC: Stocks/Bonds.

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