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Article ; Online: Using Outcome-Based Vital Sign Ranges can Enhance the Identification of Major Trauma in Children.

Ramgopal, Sriram

2024

Language	English
Publishing date	2024-03-02
Publishing country	United States
Document type	Letter
ZDB-ID	80165-3
ISSN	1531-5037 ; 0022-3468
ISSN (online)	1531-5037
ISSN	0022-3468
DOI	10.1016/j.jpedsurg.2024.02.032
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Article ; Online: Nonspecific Diagnoses and Return Visits Among Children Discharged From the Emergency Department.

Ramgopal, Sriram

Hospital pediatrics

2023 Volume 13, Issue 6, Page(s) 518–532

Abstract: Objectives: Previous work has suggested an association between diagnostic uncertainty and the use of nonspecific diagnostic billing codes. We sought to evaluate differences in emergency department (ED) return visits among children discharged from the ED ...

Abstract	Objectives: Previous work has suggested an association between diagnostic uncertainty and the use of nonspecific diagnostic billing codes. We sought to evaluate differences in emergency department (ED) return visits among children discharged from the ED with specific and nonspecific discharge diagnosis codes. Methods: We performed a retrospective study including children (aged <18 years) discharged from 40 pediatric EDs between July 2021 and June 2022. Our primary and secondary outcomes were 7-day and 30-day ED return visits, respectively. Our predictor of interest was diagnosis, classified as nonspecific (only signs/symptoms diagnoses, e.g., "cough") or specific (≥1 specific diagnosis, e.g., "pneumonia"). We evaluated for associations using Cox proportional hazard models adjusted for race/ethnicity, payer status, age, medical complexity, and neighborhood opportunity. Results: Among 1870100 discharged children, 7-day return visits occurred in 73956 (4.0%); of these, 15.8% had nonspecific discharge diagnoses. The adjusted hazard ratio (aHR) of a return visit among children with a nonspecific diagnosis on their index visit was 1.08 (95% confidence interval, 1.06-1.10). Nonspecific diagnoses with the highest aHR of return visits were for fever, convulsions, digestive system, abdominal signs/symptoms, and headache. Respiratory and emotional/behavior signs or symptoms had a lower aHR of 7-day return visits. The aHR of nonspecific diagnosis on 30-day return visits was 1.01 (95% confidence interval 1.01-1.03). Conclusions: Children with nonspecific diagnoses discharged from the ED had distinct patterns of health care utilization compared with those having specific diagnoses. Further research is required to evaluate the role of diagnostic uncertainty with diagnosis code application in the ED.
MeSH term(s)	Humans ; Child ; Patient Discharge ; Retrospective Studies ; Fever ; Emergency Service, Hospital ; Headache ; Patient Readmission
Language	English
Publishing date	2023-05-03
Publishing country	United States
Document type	Journal Article
ISSN	2154-1671
ISSN (online)	2154-1671
DOI	10.1542/hpeds.2022-007081
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Article ; Online: Is it time to incorporate viral testing results within clinical practice guidelines for febrile infants?

Money, Nathan / Ramgopal, Sriram

Emergency medicine journal : EMJ

2024 Volume 41, Issue 4, Page(s) 226–227

MeSH term(s)	Humans ; Infant ; Bacterial Infections ; Emergency Service, Hospital ; Fever/diagnosis ; Practice Guidelines as Topic
Language	English
Publishing date	2024-03-21
Publishing country	England
Document type	Journal Article
ZDB-ID	2040124-3
ISSN	1472-0213 ; 1472-0205
ISSN (online)	1472-0213
ISSN	1472-0205
DOI	10.1136/emermed-2023-213779
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Article ; Online: New AAP guidelines for evaluation and treatment of infants 8-60 days old.

Ramgopal, Sriram

The Journal of pediatrics

2021 Volume 238, Page(s) 338–342

MeSH term(s)	Guideline Adherence ; Humans ; Infant
Language	English
Publishing date	2021-10-27
Publishing country	United States
Document type	Journal Article ; Comment
ZDB-ID	3102-1
ISSN	1097-6833 ; 0022-3476
ISSN (online)	1097-6833
ISSN	0022-3476
DOI	10.1016/j.jpeds.2021.08.058
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Article ; Online: Interfacility transports by emergency medical services in the United States: Estimates from the National Hospital Ambulatory Medical Care Survey.

Ramgopal, Sriram

The American journal of emergency medicine

2020 Volume 38, Issue 10, Page(s) 2244.e3–2244.e6

Abstract: Objective: To describe characteristics of encounters in U.S. emergency departments (EDs) brought by interfacility transport by emergency medical services (EMS) from other EDs or urgent care settings.: Methods: We performed a cross-sectional study of ... ...

Abstract	Objective: To describe characteristics of encounters in U.S. emergency departments (EDs) brought by interfacility transport by emergency medical services (EMS) from other EDs or urgent care settings. Methods: We performed a cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a multistage probability survey of nonfederal of visits to U.S. EDS. We evaluated patients who were brought to the ED as an interfacility transport by EMS from another ED or urgent care setting between 2014 and 2017. We report demographics, clinical characteristics and treatment factors of ED encounters brought interfacility transport and assessed factors associated with discharge from the receiving ED. Results: Of 562.9 million ED encounters during the assessed period, 4.5 million were brought by interfacility transport by EMS (1.1 million per year). This represented 0.8% (95% CI 0.6-1.0%) of all ED encounters and 5.3% (95% CI 4.4-6.3%) of ED encounters transported by EMS. Most encounters brought by interfacility transport were adults (85%) who were publicly insured (62%). 39% had at least one abnormal vital sign. Most encounters received diagnostic testing (84%) and were seen within 30 min of presentation (61%). 54% were admitted, and 36% were discharged from the ED. Encounters without chronic complex conditions and with normal triage vital signs were associated with ED discharge (p < 0.01). Discussion: Interfacility transports between EDs transported by EMS account for <1% of ED encounters in the U.S. Nearly 40% of such encounters are ultimately discharged. Further research is needed to identify a low-risk cohort among patients in need of secondary transport.
MeSH term(s)	Adolescent ; Adult ; Aged ; Aged, 80 and over ; Cross-Sectional Studies ; Emergency Medical Services/methods ; Emergency Medical Services/statistics & numerical data ; Female ; Health Care Surveys/statistics & numerical data ; Hospitalization/statistics & numerical data ; Humans ; Male ; Middle Aged ; Patient Transfer/methods ; Patient Transfer/statistics & numerical data ; United States
Language	English
Publishing date	2020-05-22
Publishing country	United States
Document type	Case Reports
ZDB-ID	605890-5
ISSN	1532-8171 ; 0735-6757
ISSN (online)	1532-8171
ISSN	0735-6757
DOI	10.1016/j.ajem.2020.05.047
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Article ; Online: Deviation From National Dosing Recommendations for Children Having Out-of-Hospital Emergencies.

Ramgopal, Sriram / Martin-Gill, Christian

Pediatrics

2023 Volume 152, Issue 2

Abstract: Background: Previous evaluations of medication dosing variance for children in the prehospital setting have been limited regionally or to specific conditions. We sought to describe pediatric dosing deviations from nationally recommended guidelines for ... ...

Abstract	Background: Previous evaluations of medication dosing variance for children in the prehospital setting have been limited regionally or to specific conditions. We sought to describe pediatric dosing deviations from nationally recommended guidelines for commonly administered medications from a registry of prehospital encounters. Methods: We evaluated prehospital patient care records for children (<18 years) from approximately 2000 emergency medical services agencies from 2020 to 2021. We investigated dosing deviations (defined as being ≥20% of the weight-appropriate dose from national guidelines) for the following: lorazepam, diazepam, and midazolam for seizures; fentanyl, hydromorphone, morphine, and ketorolac; intramuscular epinephrine and diphenhydramine for children with allergy or anaphylaxis; intravenous epinephrine; and methylprednisolone. Results: Of 990 497 pediatric encounters, 63 963 (6.4%) received at least 1 nonnebulized medication. Among nonnebulized doses, 53.9% were for the studied drugs. Among encounters who received a study drug and which had a documented weight (80.3%), the overall consistency with national guidelines was 42.6 per 100 administrations. Appropriate dosing was most common with methylprednisolone (75.1%), intramuscular epinephrine (67.9%), and ketorolac (56.4%). Medications with the lowest consistency with national guidelines were diazepam (19.5%) and lorazepam (21.2%). Most deviations represented an underdose, which was greatest with lorazepam (74.7%) and morphine (73.8%). Results were similar when estimating dosages from weights calculated by age. Conclusions: We identified variance in weight-based dosing from national guidelines for common pediatric medications in the prehospital setting, which may be attributable to protocol differences or dosing errors. Addressing these should be a target for future educational, quality improvement, and research activities.
MeSH term(s)	Child ; Humans ; Lorazepam ; Ketorolac ; Emergencies ; Diazepam ; Epinephrine ; Emergency Medical Services/methods ; Morphine ; Methylprednisolone ; Hospitals
Chemical Substances	Lorazepam (O26FZP769L) ; Ketorolac (YZI5105V0L) ; Diazepam (Q3JTX2Q7TU) ; Epinephrine (YKH834O4BH) ; Morphine (76I7G6D29C) ; Methylprednisolone (X4W7ZR7023)
Language	English
Publishing date	2023-07-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	207677-9
ISSN	1098-4275 ; 0031-4005
ISSN (online)	1098-4275
ISSN	0031-4005
DOI	10.1542/peds.2023-061223
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Article ; Online: Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample.

Ramgopal, Sriram / Heneghan, Julia A

Journal of the American College of Emergency Physicians open

2023 Volume 4, Issue 3, Page(s) e12950

Abstract: Objective: The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide ... ...

Abstract	Objective: The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs. Methods: We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes. Results: Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%). Conclusions and relevance: The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.
Language	English
Publishing date	2023-04-26
Publishing country	United States
Document type	Journal Article
ISSN	2688-1152
ISSN (online)	2688-1152
DOI	10.1002/emp2.12950
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Article ; Online: Prehospital Seizure Management in Children: An Evaluation of a Nationally Representative Sample.

Ramgopal, Sriram / Martin-Gill, Christian

The Journal of pediatrics

2023 Volume 257, Page(s) 113379

Abstract: Objective: To describe the characteristics and emergency medical services (EMS) interventions, appropriateness of medication dosing, and factors associated with use of any or multiple doses of benzodiazepines for children with seizures in the ... ...

Abstract	Objective: To describe the characteristics and emergency medical services (EMS) interventions, appropriateness of medication dosing, and factors associated with use of any or multiple doses of benzodiazepines for children with seizures in the prehospital setting from a nationally representative dataset. Methods: We performed a retrospective study of EMS encounters within the National EMS Information System between 2019 and 2021, including children (<18 years) with an impression of seizures. We identified (1) factors associated with the use of benzodiazepines in a logistic regression model and (2) factors associated with multiple doses of benzodiazepines in an ordinal regression model. Results: We included 361 177 encounters for seizure. Among transports with an Advanced Life Support clinician, 89.9% were given no benzodiazepines and 7.7%, 1.9%, and 0.4% were given 1, 2, and ≥3 doses of benzodiazepines, respectively. Encounters given more doses of benzodiazepines had increased use of supplemental oxygen. A high proportion (43.4%) of EMS-provided initial benzodiazepine doses were inappropriately low. EMS-provided benzodiazepine use was associated with use of benzodiazepine prior to EMS arrival. Provision of multiple doses of EMS-provided benzodiazepines was associated with use of a low initial dose of benzodiazepine and use of lorazepam or diazepam compared with midazolam. Conclusion: A large proportion of prehospital pediatric patients with seizure are given inappropriately low dose of benzodiazepines. Use of a low dose of benzodiazepine and use of benzodiazepines other than midazolam are associated with additional benzodiazepine usage. Our findings have implications for future research and quality improvement needs in pediatric prehospital seizure management.
MeSH term(s)	Child ; Humans ; Midazolam/therapeutic use ; Retrospective Studies ; Seizures/drug therapy ; Benzodiazepines/therapeutic use ; Emergency Medical Services
Chemical Substances	Midazolam (R60L0SM5BC) ; Benzodiazepines (12794-10-4)
Language	English
Publishing date	2023-03-06
Publishing country	United States
Document type	Journal Article
ZDB-ID	3102-1
ISSN	1097-6833 ; 0022-3476
ISSN (online)	1097-6833
ISSN	0022-3476
DOI	10.1016/j.jpeds.2023.02.023
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Article ; Online: Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers.

Saper, Jennifer K / Macy, Michelle L / Martin-Gill, Christian / Ramgopal, Sriram

Academic pediatrics

2024

Abstract: Objective: National efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, ... ...

Abstract	Objective: National efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs. Methods: We performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019-2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed. Results: Of 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital. Conclusions: EMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.
Language	English
Publishing date	2024-03-16
Publishing country	United States
Document type	Journal Article
ZDB-ID	2483385-X
ISSN	1876-2867 ; 1876-2859
ISSN (online)	1876-2867
ISSN	1876-2859
DOI	10.1016/j.acap.2024.03.008
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Article ; Online: Factors Associated with Pathway-Concordant Neuroimaging for Pediatric Ischemic Stroke.

Gorski, Jillian K / Mithal, Divakar S / Mills, Michele G / Ramgopal, Sriram

The Journal of pediatrics

2024 Volume 268, Page(s) 113905

Abstract: Objective: To determine factors associated with magnetic resonance imaging (MRI) and noninvasive diagnostic angiography among children presenting to the emergency department (ED) with acute ischemic stroke.: Study design: We performed a cross- ... ...

Abstract	Objective: To determine factors associated with magnetic resonance imaging (MRI) and noninvasive diagnostic angiography among children presenting to the emergency department (ED) with acute ischemic stroke. Study design: We performed a cross-sectional study using data from >50 US children's hospitals. We included children 29 days through 17 years old hospitalized from the ED with an International Classification of Diseases, Tenth Revision, Clinical Modification, diagnosis code for acute ischemic stroke between October 1, 2015, and November 30, 2022. We excluded children with a principal diagnosis code of trauma/external injury, without neuroimaging on day of presentation, and into-ED transfers. Our outcomes were defined as acquisition of MRI (vs computed tomography only) and angiography (vs no angiography) on day of presentation. We performed generalized linear mixed modeling with hospital as a random effect to determine the association of demographics, known comorbidities, and treatment factors with each outcome. Results: We included 1601 children. In multivariable analysis, younger age, mechanical ventilation, and Black race were associated with lower odds of MRI acquisition, whereas history of moyamoya disease and sickle cell disease were associated with greater odds. Younger age, mechanical ventilation, Hispanic ethnicity, Black race, other races, history of metabolic disease, and history of seizures were associated with lower odds of angiography. Conclusions: Younger and non-White children experienced lower odds of MRI and angiography, which may be driven by health system limitations or provider implicit biases or both. Our results expose risk factors for underdiagnosis of ischemic stroke and provide opportunities to tailor institutional pathways reflective of underlying pathophysiology.
MeSH term(s)	Humans ; Female ; Male ; Child ; Child, Preschool ; Cross-Sectional Studies ; Adolescent ; Ischemic Stroke/diagnostic imaging ; Infant ; Neuroimaging ; Magnetic Resonance Imaging ; Infant, Newborn ; Emergency Service, Hospital/statistics & numerical data ; United States/epidemiology ; Risk Factors ; Cerebral Angiography ; Tomography, X-Ray Computed ; Retrospective Studies ; Critical Pathways
Language	English
Publishing date	2024-01-06
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Multicenter Study
ZDB-ID	3102-1
ISSN	1097-6833 ; 0022-3476
ISSN (online)	1097-6833
ISSN	0022-3476
DOI	10.1016/j.jpeds.2024.113905
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