It is estimated that 30 million children in the US participate in organised sports programmes. As more and more children participate in sports and recreational activities, there has been an increase in acute and overuse injuries. Emergency department visits are highest among the school-age to young adult population. Over one-third of school-age children will sustain an injury severe enough to be treated by a doctor or nurse. The yearly costs have been estimated to be as high as 1.8 billion US dollars. There are physical and physiological differences between children and adults that may cause children to be more vulnerable to injury. Factors that contribute to this difference in vulnerability include: children have a larger surface area to mass ratio, children have larger heads proportionately, children may be too small for protective equipment, growing cartilage may be more vulnerable to stresses and children may not have the complex motor skills needed for certain sports until after puberty. The most commonly injured areas of the body include the ankle and knee followed by the hand, wrist, elbow, shin and calf, head, neck and clavicle. Contusions and strains are the most common injuries sustained by young athletes. In early adolescence, apophysitis or strains at the apophyses are common. The most common sites are at the knee (Osgood-Schlatter disease), at the heel (Sever's disease) and at the elbow (Little League Elbow). Non-traumatic knee pain is one of the most common complaints in the young athlete. Patellar Femoral Pain Syndrome (PFPS) has a constellation of causes that include overuse, poor tracking of the patellar, malalignment problems of the legs and foot problems, such as pes planus. In the child, hip pathology can present as knee pain so a careful hip exam is important in the child presenting with an insidious onset of knee pain. Other common injuries in young athletes discussed include anterior cruciate ligament injuries, ankle sprains and ankle fractures. Prevention of sports and recreation-related injuries is the ideal. There are six potential ways to prevent injuries in general: (i) the pre-season physical examination; (ii) medical coverage at sporting events; (iii) proper coaching; (iv) adequate hydration; (v) proper officiating; and (vi) proper equipment and field/surface playing conditions.
On March 23, 2010, the President signed into law the Affordable Care Act (Public Law 111-148), which included an amendment of Title V of the Social Security Act authorizing the creation of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Authorized and funded at $1.5 billion for 5 years, the MIECHV represents a large investment in health and development outcomes for at-risk children through evidence-based home visiting programs. The MIECHV presents unprecedented opportunities to integrate early childhood services systems, not only on the federal level but also within states and local communities. The MIECHV is funded in escalating amounts over 5-year period authorized, as follows: $100 million in fiscal year (FY) 2010, $250 million in FY 2011, $350 million in FY 2012, $400 million in FY 2013, and $400 million in FY 2014. Most of the funding is being provided to states and territories to provide home visiting services in their at-risk communities. In addition, the legislation included a 3% set-aside for tribes, tribal organizations, and urban Indian organizations and a 3% set-aside for research and evaluation. This investment has spurred the creation of more comprehensive and coordinated early childhood service systems across the United States. This article provides an overview of the MIECHV program, including descriptions of the various requirements under the Affordable Care Act. These include partnering with states to provide evidence-based home visiting services to at-risk families, working with tribal communities to implement culturally competent home visiting programs, and developing a mechanism to systematically review the evidence of effectiveness for home visiting program models and to conduct a national evaluation of the MIECHV program.
Intrathecal baclofen (ITB) therapy is being used increasingly to treat medically intractable spasticity in children with cerebral palsy and spinal cord injuries. Baclofen overdose and withdrawal are potentially life-threatening complications of pump and spinal catheter system malfunction. We report a case of a 12-year-old boy, on long-term ITB therapy, who presents to our emergency department with an overdose of ITB, which is followed by withdrawal symptoms. The patient initially presented obtunded and in respiratory arrest. His symptoms of respiratory arrest, obtundation, fixed pupils, and hypotension mimicked other diagnoses, such as head trauma. The history obtained from the family about the pump reservoir being refilled just before the onset of symptoms led to the diagnosis. During hospitalization, as the patient recovered from the overdose, he began to experience symptoms of baclofen withdrawal, including hypertension, hyperthermia, and hallucinations. The pump was found to be disconnected and was revised. The patient was discharged home without permanent sequelae. With increased use of ITB, emergency medicine physicians must be aware of the mechanics of these pumps and the management of baclofen toxicity and withdrawal.
Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. In this Policy Statement, we provide an update to the 2011 Policy Statement "Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care." BACKGROUND INFORMATION Patient safety is defined as the prevention of harm to patients. 1 Although patient safety is only 1 of the 6 domains of quality of care defined by the National Academy of Medicine (formerly the Institute of Medicine [IOM]), 2 it is undoubtedly one of the most important. There are real and growing concerns regarding pediatric errors and harms reported related to specific populations, such as with the use of temporary names in newborn care, 3 as well as issues spanning all populations, such as diagnostic errors in ambulatory and hospital settings 4 and information technology errors in prescribing. 5 Pediatricians in all practice settings can help champion the
Quality measures are used for a variety of purposes in health care, including clinical care improvement, regulation, accreditation, public reporting, surveillance, and maintenance of certifi cation. Most quality measures are 1 of 3 types: structure, process, or outcome. Health care quality measures should address the domains of quality across the continuum of care and refl ect patient and family experience. Measure development for pediatric health care has a number of important challenges, including gaps in the evidence base; the fact that measures for most conditions must be agespecifi c; the long, resource-intensive development process; and the national focus on measure development for adult conditions. Numerous national organizations focus on the development and application of quality measures, including the Pediatric Quality Measures Program, which is focused solely on the development and implementation of pediatric-specifi c measures. Once a quality measure is developed for use in national measurement programs, the organization that develops and/or "stewards" the measure may submit the measure or set of measures for endorsement, which is recognition of the scientifi c soundness, usability, and relevance of the measure. Quality measures must then be disseminated and applied to improve care. Although pediatric health care providers and child health care institutions alike must continually balance time and resources needed to address multiple reporting requirements, quality measurement is an important tool for advancing high-quality and safe health care for children. This policy statement provides an overview of quality measurement and describes the opportunities for pediatric health care providers to apply quality measures to improve clinical quality and performance in the delivery of pediatric health care services.
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