Cain, Meghan

Objectives: Telemedicine is a growing field, with limited data around its utility supporting pediatric emergency care telephone triage. We instituted telemedicine physician support for nurse telephone triage decisions. When the nursing protocols recommended urgent or emergent care, a telemedicine physician reviewed and modified care urgency if appropriate. Our primary study objectives were to evaluate the proportion of patients who were downgraded to less urgent care and assess for potential harm related to the downgrade in care urgency. Methods: We conducted a retrospective observational cohort study of pediatric telephone calls to the Mayo Clinic Health System nurse triage line that were directed to the emergency department telemedicine physician from January 1, 2019, to December 31, 2019. Electronic medical records of patients whose care urgency was downgraded and presented to medical care within 72 hours of the triage call were reviewed. Results: There were 8559 nurse line calls regarding pediatric patients, 882 of which were referred to the telemedicine physician. Among these, 396/882 (44.9%, 95% confidence interval 41.6–48.3) were downgraded. Of downgraded cases, 198 (50.0%) patients sought care within 72 hours of the original call, of which 193 (97.5%) patients were discharged home from that medical visit and 5 (2.5%) patients required admission. No patients were determined to have suffered harm due to the downgrade of visit urgency. Conclusions: Our data suggests that telemedicine physicians can safely downgrade nurse triage care recommendations for pediatric patients. Most downgraded patients sought outpatient care, avoiding unnecessary utilization of the emergency department without evidence of associated harm.

Background: Nasopharyngeal (NP) swabbing is a technique that is commonly used to test pediatric patients for viral infections with increased use during the coronavirus disease 2019 pandemic. Complications from NP swabbing are rare and seem to occur more frequently in patients at risk of bleeding. Little is known about institutional or individual practices and experiences with NP swab testing in pediatric patients with risk factors for bleeding. Methods: We conducted a survey study of pediatric hematology/oncology (PHO) attending physicians to assess practices and experiences with NP swab testing in pediatric patients with thrombocytopenia and/or on anticoagulation. Results: There were 130 total respondents (5.6%, n = 130/2327) from 6 countries. Relatively few respondents (n = 17/130, 13.1%) reported that their institution had a policy specifying a lower-level platelet cutoff for patients undergoing NP swabbing. The median platelet cutoff below which NP swabs are not performed according to existing policies is 30,000×10(9)/L (interquartile range: 20,000 to 40,000). The median cutoff based on the opinion of the respondents was 10,000 (interquartile range: 10,000 to 20,000). There were 24 episodes of epistaxis among PHO patients that were NP swabbed; many adverse events (56.5%, n = 13/23) were described as persistent, severe, and/or required intervention. Three reported cases of epistaxis with anticoagulation or antiplatelet therapy occurred in patients with concomitant thrombocytopenia. Only 1 respondent (n = 1/130, 0.7%) reported an institutional policy for limiting NP swabs in patients on anticoagulant therapy. NP (66.9%) and nares (33.1%) were the most common sources of coronavirus disease 2019 testing that were reported. Conclusion: A small percentage of institutions in this survey have a policy restricting NP swabs in PHO patients. The discrepancy between lower platelet cutoffs proposed by experts and institutional policy suggests that existing policies may be too conservative. Expert guidelines are needed on this topic. Other bleeding risk factors (eg, aspirin use and von Willebrand disease) should be considered in policies and guidelines.

Abstract We report the case of a 16-year-old healthy adolescent male who presented to the local emergency department with altered mental status. En route to a tertiary care facility, he began to decompensate and was found to be markedly acidotic. Further investigation revealed an elevated anion gap, and physical examination showed only abdominal pain and decreased level of consciousness. A broad differential diagnosis was considered at the time of the patient's presentation at the tertiary care center including ingestion of a volatile alcohol, sepsis, and an abdominal catastrophe. Although fomepizole and emergent dialysis were being initiated, laboratory tests confirmed ethylene glycol poisoning. This case demonstrates the importance of early recognition of potential ingestions in patients with altered mental status and supportive laboratory findings.

This report describes a toddler who presented to the emergency department with reported leg weakness and a petechial rash who ultimately was diagnosed with severe ascorbic acid deficiency (scurvy) due to restricted dietary intake. The diagnosis was delayed, and this report highlights the role of a detailed dietary history as part of the diagnostic process.