Prevention of Abusive Head Trauma in Infants by Educating Pregnant and Expecting Adolescents
Mortality rates from child abuse are highest in infancy and are often due to abusive head trauma. The purpose of this study was to determine the efficacy of a school-based educational intervention in increasing awareness of shaken baby syndrome, normal infant crying behavior, how to soothe an infant and how to self-soothe when stressed, in expectant adolescents. Eligible participants who consented participated in a pre- and post-intervention test with a subjective questionnaire to determine knowledge of shaken baby syndrome, normal infant crying behaviors and their ability to soothe a crying infant and self-soothe.
PI: Kiyetta Alade, M.D.
Mentors: Michelle Lyn, M.D.; Reena Isaac, M.D.
Relationship of asthma and body mass index in children presenting to the emergency department with acute asthma
This is a retrospective and prospective study of children who present to the emergency department with an acute asthma exacerbation and the relationship to their body mass index. The aim is to determine whether children with a BMI greater than the 95th percentile for age and sex present to the emergency department for asthma exacerbation more often than do non-obese children. We hope to compare chronic asthma severity of obese children who present to the emergency department with that of non-obese children. We will further assess asthma severity via pulmonary function testing six months following the acute exacerbation to compare baseline lung functions of obese and non-obese children.
The data will be collected from the Texas Emergency Department Asthma Surveillance. Only patients without cardiovascular or pulmonary disease age 8-18 years will be recruited due to spirometry limitations. The recruited patients will be contacted to return for spirometry and BMI re-calculated at the follow-up visit.
PI: Shannon Wai, M.D.
Mentors: Charles G. Macias, M.D., M.P.H.; Marianna Sockrider, M.D.
Utility of Hospital Observation for Children with Skull Fractures and/or Minor Intracranial Injuries
The goal of this study is to review the outcomes of patients with minor changes on their head CT scans secondary to a closed head injury and to determine the safety of discharge home compared to inpatient hospital admission for observation. The retrospective chart review will look at all children coming into the ER with head injuries and abnormal head CTs during the last 10 years. We will then follow their cases through admission to the hospital, the observation unit, the PICU, or discharge home. With the assistance of Neuroradiology, we hope to determine if those children who have only minor changes on head CT and who are asymptomatic in the emergency room are safe for discharge home with appropriate follow-up.
PI: Roxanna Lefort, M.D.
Mentors: Ade Ojo, M.D.; Pratip Nag, M.D., Ph.D.; Andrea Cruz, M.D., M.P.H.
Early Rehabilitation in the Functional Recovery of Grade II Ankle Sprains in Children
Acute ankle sprains are one of the most common injuries presenting to emergency department, and more than one-third of all ankle sprains seen in the ED, were in children. Despite the high incidence of this injury, the variation of treatment practice suggests a lack of evidence-based management strategies for the acutely injured lateral ankle ligament complex. The objective of this study was to determine whether the addition of early rehabilitation to the conventional RICEM (rest, ice, compression, elevation, medication) protocol would improve functional recovery seven to ten days and four weeks post acute Grade two, inversion ankle sprains. This prospective, randomized, single-blinded study was conducted at a university-affiliated emergency department ED, of a 715-bed tertiary care children’s hospital. Patients between the ages of 8 to 18 years of age who had sustained a grade II, inversion ankle sprain in the previous 48 hours were randomly assigned to a control (RICEM) or intervention (RICEM and rehabilitation exercises) group. A previously validated scoring scale was used to evaluate the acute ankle injury and assess functional recovery of patients in both groups. Every patient, regardless of group assignment, was instructed verbally and in written form on each component of the RICEM protocol (Rest, Ice, Compression, Elevation,Medication). Patients enrolled in the intervention group were also shown a set of muscle strengthening and range of motion exercises to be performed twice a day. Prior to discharge, every patient was given a calendar logbook to measure compliance and adherence to the RICEM protocol +/- early rehabilitation exercises. All patients were given appointments to the sports medicine clinic at Texas Children’s Hospital for follow-up at seven-ten days and four weeks post-injury.
PI: Kay Leaming-Van Zandt, M.D.
Mentor: Joseph Chorley, M.D.
Parental Education Appropriate Car Seat Installation
Parents will be educated in the acute setting about proper child safety seat restraint using two educational tools. Their prior knowledge of child restraint will be compared to post-interventional knowledge via use of a questionnaire. The efficacy of educational tools will also be evaluated. If efficacious, these tools can be used to educate more caregivers on appropriate car seat installation.
PI: Nakia Johnson, M.D.
Mentor: Rohit Shenoi, M.D.
Efficacy of a Near Infrared Light Venipuncture Aid for Pediatric Intravenous Cannulation
An emergency department-based randomized clinical trial of the VeinViewer, a commercially available near-infrared light aid in locating and cannulating veins for placement of IV lines and lab draws.
PI: Andrew Perry, M.D.
Mentor: Deborah C. Hsu, M.D., M.Ed.
Curriculum Development in Pediatric Prehospital Medicine
Many emergency medical services personnel have limited experience in pediatric-specific problems. The hypothesis of this study was that the implementation of a hands-on pediatric hospital-based clinical rotation curriculum would improve the pediatric knowledge retention of skills of EMS personnel. The study design was that EMS personnel would visit Texas Children's: half day in the operating room practicing airway management with endotracheal intubation, bag-valve-mask ventilation, and laryngeal mask airway; half day in the emergency department; and one day in the simulation center. Evaluation tools will include a survey evaluating EMS personnel comfort (before and after completion of curriculum), a pre-test written examination, and post-test written examinations (immediately after completion of curriculum and three months after completion) to assess skill retention.
PI: Thuy Ngo, D.O.
Mentors: Deborah C. Hsu, M.D., M.Ed.; Jennifer Arnold, M.D.; Cara B. Doughty, M.D.; Manish I. Shaw, M.D.; Paul E. Sirbaugh, D.O.
Health Services Research
Neonatal Revisits and Risk of Fever in a Pediatric Emergency Department
A chart review of neonatal patients visiting the emergency department twice in a five-day period aiming to identify risk factors (diagnoses, chief complaints, demographic features including stated primary-care access and insurance payor status) for return visits and risk of subsequent hospital admission, respiratory distress, and fever.
PI: Andrew Perry, M.D.
Mentor: Joseph Allen, M.D.
Emergency Department Overcrowding and Outcomes of Children with Sepsis
Emergency department crowding is a growing national health problem compromising safe, effective and timely patient care. The effect of ED crowding on critically ill children has not been studied. The timely recognition and resuscitation of patients with septic shock has been shown to improve outcomes in children. We hypothesize that the care of septic shock patients awaiting PICU admission is affected by ED crowding; specifically looking at outcomes of mortality and length of stay.
PI: Sandhya Sasi, M.D.
Mentors: Rohit Shenoi, M.D.; Trung Nguyen, M.D.
Impact of Media Reports on Pediatric Call Volume to the Texas Poison Center Network
Poison Control Centers receive numerous calls regarding toxicologic and environmental health concerns. PCCs often receive sentinel information about community exposures, particularly after media reports of ingestions, outbreaks, or recalls, leading to increased PCC utilization. The objectives were to assess the impact on TPCN call volume during notable media events and to evaluate referral rates to healthcare providers after these reports. We conducted a retrospective database review of TPCN call volume and composition from January 2006 - July 2009. Pediatric (0-19 yrs) and total call volumes and referrals to HCPs were determined for food poisoning, lead exposure, and over-the-counter medication utilization and were compared to average call volumes and referrals for each event.
PI: Elaine Fielder, M.D.
Mentors: John Thompson; Wayne Snodgrass, M.D.; Andrea Cruz, M.D., M.P.H.
Effect of Prehospital Administration of Methylprednisolone on Asthma Exacerbation Outcomes in Children
This is a retrospective study evaluating asthmatic patients aged 2-18 years transported to Texas Children's Hospital Emergency Center via Houston Fire Department Emergency Medical Services for the treatment of an asthma exacerbation. The purpose of this study is to evaluate the effect of the prehospital administration of methylprednisolone to pediatric asthma patients after the implementation of the HFD EMS asthma treatment protocol. Specifically, this study will examine the effect on the time to remission of symptoms (as evidenced by total time spent in the emergency center) and rates of admission to hospital for further care in pediatric asthma patients who did and did not receive IV or IM methylprednisolone in the prehospital setting.
PI: David Hooke, D.O.
Mentor: Paul E. Sirbaugh, D.O.; Manish I. Shah, M.D.
Risk Factors for Complicated Hospitalization in Well-Appearing Young Infants with Pertussis
Due to concern for potentially life-threatening complications from pertussis, wide practitioner variation exist when deciding whether to hospitalize these young infants. Scant data exists to delineate which infants are at higher risk for complicated disease. Such data could be used to develop standardized admission criteria. The objective was to identify risk factors for in-hospital adverse events for infants with pertussis. This was a retrospective case-control study of hospitalized infants 0-6 months old with confirmed pertussis from 2005 to 2009. Cases were infants with apnea, pneumonia, seizure or encephalopathy. Continuous and dichotomous clinical variables from case and control groups were compared using t-test and chi-square, respectively.
PI: Sowdhamini S. Wallace, D.O.
Mentors: Andrea T. Cruz, M.D., M.P.H.; Ricardo A. Quinonez, M.D.
Implementation of a Pediatric Triage Protocol in a Botswana Emergency Department
Effective triage is necessary in the developing world in order to optimize limited staff resources and to limit morbidity and mortality in the emergency room setting. At Princess Marina Hospital in Gaborone, Botswana, an independent consultancy group commissioned by the Ministry of Health reported triage in the Accident and Emergency department to be an area in need of considerable improvement. The medical staff has adopted a modified version of the validated South African Triage Scale. The efficacy of the training of SATS for the entire medical staff will be measured with written case scenarios to determine the reliability of the scale. Three months after implementation, the rates of undertriage and overtriage will be determined using admission rates to the hospital and death in the A&E as clinical endpoints. The modified SATS will then be altered to optimize the performance of the triage tool and will be renamed the Botswana Triage for Hospitals scale. The BOTHO scale will then be prospectively validated over a second period of three months. The number of patients presenting within each triage category, the chronology of patient presentation, and the medical provider resources available will be described in order to effectively allocate human resources in the A&E. Waiting times and lengths of stay for patients presenting to the A&E at PMH will be assessed before and after the institution of the new triage systems.
PI: Paul Mullen, M.D.
Mentor: Sue Torrey, M.D.
An Emergency Department Quality Improvement Initiative in Pediatric Shock
This is a multiphase project involving a review of cases of missed or inadequately resuscitated shock presenting to the emergency department requiring subsequent ICU transfer and care followed by a department-specific implementation of PALS/American College of Critical Care Medicine guidelines for septic shock management. Outcomes and clinical variables will be documented as the protocol is implemented. A review of pre- and post-protocol outcomes will be conducted.
PI: Andrew Perry, M.D.
Mentors: Binita Patel, M.D.; Andrea Cruz, M.D., M.P.H.
Triage-Based Protocol for the Administration of Steroids for Moderate/Mild Asthma Exacerbations
Emergency center overcrowding often leads to significant delays in steroid administration to asthmatics, possibly contributing to poor outcomes. Triage-based steroid protocols for asthmatics have not been studied. The objective of this study was to decrease the time to steroid administration and time in department for patients with a mild or moderate asthma exacerbation via a triage-based protocol for the administration of steroids. The study design was a cluster randomized controlled trial conducted over 12 weeks. During intervention weeks, steroid orders were initiated in triage to patients with mild or moderate acute asthma exacerbations. Exclusion criteria included children younger than two years of age, patients who received recent systemic oral steroids, and those with chronic medical problems. Time to steroids and TID were described using medians and statistically compared using Mann-Whitney U tests.
PI: Julieanna Sahouria, M.D.
Mentors: A. Chantal Caviness, M.D., M.P.H., Ph.D.; Charles G. Macias, M.D., M.P.H.: Binita Patel, M.D.
Introduction of a Handout Listing Ongoing Research Projects in the Pediatric Emergency Department to Improve Patient Enrollment
Prospective, clinical research in the emergency department is essential in enhancing the quality of acute care. The recruitment of ED patients into study protocols is hindered by large volume and critically ill patients, clinical personnel unaware of active studies and their eligibility criteria, and lack of time to obtain consent from and enroll patients themselves. The hypothesis was that providing caretakers with handouts listing active research projects would improve patient enrollment into study protocols. We conducted a prospective, quasi-randomized study in a high-volume, tertiary care pediatric hospital ED. Eight weeks were randomized into two study groups: weeks during which the handouts were distributed and weeks they were not. During intervention weeks, patient caretakers received a handout listing ten active research projects at registration. If they believed their child qualified for one or more of the listed projects, they were instructed to call a research-dedicated phone line for more study-specific information and possible enrollment. Separate questionnaires were completed based on whether caretakers placed a call to the research phone. During control weeks, patients were identified by the existing ED research infrastructure. Differences in overall enrollments were compared between the intervention and control weeks.
PI: Kay Leaming-Van Zandt, M.D.
Mentor: Charles G. Macias, M.D., M.P.H.
Mobile Pediatric Emergency Response Team: Patient Satisfaction During the Novel H1N1 Influenza Outbreak
During May, 2009, the Texas Children's emergency department utilized a six-bed outdoor facility to evaluate patients with suspected novel H1N1 influenza. In this study, the families of patients evaluated in the Mobile Pediatric Emergency Response Team area were surveyed by telephone using a validated questionnaire to evaluate guardian satisfaction with the facility. Overall, patient caretakers perceived the use of MPERT as an acceptable alternative to receiving care in the regular ED. Guardians felt that physicians and nurses communicated well, and that the medical care provided was good to excellent. Use of the MPERT did not negatively impact overall caregiver satisfaction with Texas Children's. These findings suggest that families of pediatric patients are amenable to non-traditional ED venues, like MPERT, during periods of ED overcrowding.
PI: Carla Laos, M.D.
Mentors: A. Chantal Caviness, M.D., M.P.H., Ph.D.; Deborah C. Hsu, M.D., M.Ed.; Andrea T. Cruz, M.D., M.P.H.; Binita Patel, M.D.
A Retrospective Evaluation of Sedation Management for Abscess Incision and Drainage in the Pediatric Emergency Department Versus the Operating Room
Skin and soft tissue infections are a common reason that children present to the emergency department. The decision to drain an abscess in the ED versus the operating room is not often based on objective criteria. The goals for this study were to compare charges incurred if abscess infectious disease is completed in the ED with moderate sedation versus the operating room under general anesthesia; to compare the outcome of abscess I&D completed in the ED with moderate sedation versus the operating room under general anesthesia; and to determine the characteristics of abscess I&D completed in the ED with moderate sedation versus the operating room under general anesthesia. The study design was a retrospective chart review of previously obtained information from standard medical care for children older than 60 days of age presenting to the ED from November 1, 2008 - November 1, 2009 with a primary or secondary discharge diagnosis of abscess. Demographic, clinical, microbiologic, and cost data will be abstracted from the medical record.
PI: Corrie Chumpitazi, M.D.
Mentor: Faria Pereira, M.D.
Randomized Controlled Trial of Oral Narcotic Medication for Pain and Anxiety Management During Laceration Repair in the Pediatric Emergency Department
Children presenting to the emergency department experience significant pain and anxiety when undergoing procedures. Management of procedural pain in children has been shown to be inadequate and much interest has increased over the past decade aimed at improving pain control, especially within the pediatric emergency department. Laceration repair accounts for a significant amount of the pain and anxiety seen daily in our emergency department patients. The purpose of this study is to determine whether oral narcotic medication versus placebo improves the pain and anxiety scores for pediatric patients (2-17 years of age) requiring laceration repair in the pediatric emergency department and receiving the standard of care with lidocaine treatment. Children age two-seven years will have pain scored by Certified Child Life Specialists using Children’s Hospital of Eastern Ontario Pain Score. All children age eight and greater will be asked to self-score their pain on the visual analog scale. In addition, all children older than eight years will be asked to complete the State-Trait Anxiety Inventory for Children, a 40-question survey that typically takes less than ten minutes. Pain scores are recorded 1) when the study medication is administered, 2) at the procedure start, 3) at 5 min, 4) at 10 min, 5) at 15 min, 6) at 20 min, and 7) at procedure completion.
PI: Corrie Chumpitazi, M.D.
Mentor: Glenda Grawe, M.D.