OBJECTIVE Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries. METHODS We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time. RESULTS We included 6851 ED visits of which 4242 (62%) occurred in the post–guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation. CONCLUSIONS An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries.

BACKGROUND: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care. METHODS: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability. RESULTS: The national median HCI was 0.06 (interquartile range: 0.01-0.17) in 2008 and 0.02 (interquartile range: 0.00-0.09) in 2016 (P , .001). Definitive care became less common regardless of annual pediatric volume, urban or rural designation, or condition frequency. In 2016, 2171 EDs (49.0%) had HCIs ,0.013, which represented the lowest 25% of ED HCIs in 2008. Pediatric visits to EDs categorized in the bottom 2008 capability quartile more than doubled from 2.5 million in 2008 to 5.3 million in 2016. Despite decreasing capability, centers with higher annual pediatric volume and urban centers provided more definitive inpatient care and had fewer inter-ED transfers than lower-volume and rural centers. CONCLUSIONS: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children. WHAT'S KNOWN ON THIS SUBJECT: Definitive care provision has decreased over time in certain states. WHAT THIS STUDY ADDS: Between 2008 and 2016, most hospitals decreasingly provided definitive pediatric acute care and increasingly transferred emergency patients. Low-volume hospitals were least likely to provide definitive care. Pediatric inpatient care is becoming concentrated in fewer centers, decreasing initial access to definitive acute care.

An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.

Study Objective To determine the optimal correction factor for cerebrospinal fluid (CSF) white blood cell (WBC) counts in infants with traumatic lumbar punctures (LPs). Methods We performed a secondary analysis of a retrospective cohort of infants ≤ 60–days-old with a traumatic LP [CSF red blood cell (RBC) count ≥ 10,000 cells/mm3] at 20 participating centers. CSF pleocytosis was defined as a CSF WBC count ≥ 20 cells/mm3 for infants ≤ 28 days, ≥ 10 cells/mm3 for infants 29–60 day and bacterial meningitis as growth of pathogenic bacteria from CSF culture. Using linear regression, we derived a CSF WBC correction factor and compared the uncorrected to the corrected CSF WBC count for the detection of bacterial meningitis. Results Of the eligible 20,319 LPs, 2,880 (14%) were traumatic of whom 33 (1.1%) had bacterial meningitis. The derived CSF RBCs:WBCs ratio was 877:1 [95% confidence interval (CI) 805–961:1]. Compared with the uncorrected CSF WBC count, the corrected CSF WBC count had lower sensitivity for bacterial meningitis [88% uncorrected vs. 67% corrected; difference 21%, 95% CI 10–37%] but resulted in fewer infants with CSF pleocytosis [78% uncorrected vs. 33% corrected; difference 45%, 95% CI 43–47%]. CSF WBC count correction resulted in 7 additional infants with bacterial meningitis being misclassified as not having CSF pleocytosis; only one of these infants was > 28-days-old. Conclusion Correction of the CSF WBC count substantially reduced the number of infants with CSF pleocytosis while misclassifying only one infant with bacterial meningitis 29 to 60 days of age.

Background: Prior studies have shown racial differences in concussion awareness and outcome. Objective: To assess if racial or ethnic differences exist in Emergency Department (ED) utilization and diagnosis for children with sports-related head injuries. Methods: We performed a retrospective, cross-sectional analysis of ED visits from 2008 to 2017 using National Electronic Injury Surveillance System (NEISS) data. Population-weighted ED visits for children age 7–18 years with a sport-related injury were included. We compared the probability of an ED visit being for an injury to the head or diagnosed as a concussion between children of different races/ethnicities. Analyses were adjusted for age, gender, sport, year, and location where the injury occurred. Results: We identified 11,529,994 population-weighted ED visits for pediatric sports-related injuries, of which 1,497,717 (13.0%) were injuries to the head and 619,714 (5.4%) received a diagnosis of concussion. Black children were significantly less likely than non-Hispanic white children to have their ED visit be for an injury to the head [Odds Ratio (OR) 0.72, 95%CI 0.65–0.79] or concussion (OR 0.58, 95%CI 0.50–0.68). Black children presenting to the ED with an injury to their head were less likely than non-Hispanic white children to be diagnosed with a concussion (OR = 0.71, 95%CI 0.59–0.85). Conclusions: Racial differences exist in both ED utilization for pediatric sports-related head injuries and in the diagnosis of concussion. Further work is needed to understand these differences to ensure all brain injured athletes receive optimal care, regardless of race.

Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement.

Summary: Deficiency of adenosine deaminase 2 is characterized by vasculitis, early-onset strokes, immunodeficiency, and bone marrow failure. We describe a novel pathogenic mutation affecting a consensus N-linked glycosylation sequence and illustrate the essential role of glycosylation in the biology of ADA2.

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