February 2014's Weekly Articles

Week of Feb 3: By Alyssa Abo

This week's article is the "Effect of Bedside Ultrasound on Management of Pediatric Soft-Tissue Infection".  I'm sure you're not surprised that I would choose an ultrasound article.  

I was reminded of this article this week because of a case I had in the ED.  A young boy presented with cellulitis on his leg, and his mother reported draining the abscess at home.  Based on my clinical exam, I thought there was no underlying fluid collection, but I was suspicious and grabbed the ultrasound machine.  Low and behold, there was a residual abscess that needed drainage.

This article highlights the use of bedside ultrasound for soft tissue infections.  It demonstrates that the sensitivity and specificity of detecting a drainable fluid collection is higher with ultrasound than clinical exam alone.

I hope this article will encourage all of you to scan with Joanna and myself so you too can ultrasound and determine cellulitis vs drainable fluid collection (once we credential you of course... and then you can bill too!)

Week of Feb 10: By Sabah Iqbal

As I was taking a call from a random hospital the other night, I just WISHED I could see the baby... I couldn't really define exactly how that would have changed my management for that baby, at that moment, but still, the idea of seeing a patient in consultation seemed like a really good idea...

And then I stumbled upon this article from Pediatrics last year: Telemedicine consultations and medication errors in rural emergency departments.
 In short, it showed that for rural hospitals in N California, having a telemedicine consult (as opposed to a phone consult or no consult) resulted in fewer medication errors. While this is compelling, I wonder if the real answer is below the surface - are the decreased medication errors because the consult-doc is spending more time with the calling-doc? Is she looking at the patient? Is she providing a new, better, and potentially, different diagnosis than the calling-doc suggested? Was the consult doc staying online while the calling-doc ordered the medications? Was there more of a double-check?
I also found it interesting that errors occurred more frequently with trainees who were not primary peds trained - and that made me a bit worried about the calls I take from PAs at OSH... Again, it would be so neat to be able to see the patient on a video...

So, maybe this is the wave of the future for us as emergent consults...


Week of Feb 17: By Jim Chamberlain

For those of you who are at all concerned about the quality of pediatric care and unexplained variation, click on this week's article: Dartmouth has been gathering evidence of unexplained variation in care for about 20 years, and this is their most recent report from December 2013.

This is a detailed analysis of pediatric care in northern New England.

The variation in care by Hospital Service Area is substantial, even after adjusting for age, gender, and proportion of population receiving Medicaid. A few highlights:

• Inappropriate use of antibiotics for upper respiratory infection is lowest in cities where there is a major pediatric hospital. Radiation exposure, including chest x-rays and CAT scans of the head and abdomen, is lowest in cities where there is a major pediatric hospital.
• If you are a child in northern New England, you have a risk of tonsillectomy that varies fourfold depending on where you live; your risk of hospitalization is twice in some cities what it is in other cities
• Use of the emergency department is twice in some cities what it is in other cities
• The correlation between prescribing medications for ADHD and providing the recommended follow-up visits showed a correlation coefficient of zero. The implication is that physicians are prescribing ADHD medications willy-nilly without any systematic process for follow-up
• The variation in use of antibiotics among cities is 1.8 fold 

In summary, there is still a lot of unexplained variation in pediatric care.

Lest we become complacent and think that this is a problem "out there," take a look at some of our benchmarking graphs for quality in our own emergency department. We still have nearly 10-fold variation in some of our diagnostic testing, such as x-rays for asthma and laboratory testing for RTU patients.

Food for thought….

Week of Feb 24: By Monica Goyal

This week's article was published in this month's Pediatrics and titled, "Management of Febrile Neonates in US Pediatric Emergency Departments." 

I chose this article for 2 reasons:

1) I thought it was interesting that even among pediatric emergency departments there is considerable variation with respect to diagnostic testing, antibiotic administration, and admission rates for febrile infants aged 0-28 days. In this study, which was conducted using the PHIS database, 1/3 of febrile infants did not receive recommended management. And this number may even be higher if we were to take into account treatment provided in community, non-pediatric EDs.

2) As this was a study using a large administrative database, this is a shameless plug to support large database research and to attend a conference on conducting research with large databases on March 12th at noon, 5th Floor, Main, Classroom A.