Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), an entity in children initially characterized by milder case presentations and better prognoses as compared with adults. Recent reports, however, raise concern for a new hyperinflammatory entity in a subset of pediatric COVID-19 patients. Methods: We report a fatal case of confirmed COVID-19 with hyperinflammatory features concerning for both multi-inflammatory syndrome in children (MIS-C) and primary COVID-19. Results: This case highlights the ambiguity in distinguishing between these two entities in a subset of pediatric patients with COVID-19-related disease and the rapid decompensation these patients may experience. Conclusions: Appropriate clinical suspicion is necessary for both acute disease and MIS-C. SARS-CoV-2 serologic tests obtained early in the diagnostic process may help to narrow down the differential but does not distinguish between acute COVID-19 and MIS-C. Better understanding of the hyperinflammatory changes associated with MIS-C and acute COVID-19 in children will help delineate the roles for therapies, particularly if there is a hybrid phenotype occurring in adolescents.

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Rapid response systems (RRSs) have become a common presence in hospitals globally since their first formal description by Lee et al 1 in 1995. Given the success of these teams at improving pediatric outcomes, rapid response team implementation in pediatric institutions has an established foothold as well, spreading from tertiary hospitals to affiliated satellite institutions and community hospitals. The gap in knowledge now is how patient outcomes may vary across these settings and what features of RRSs and escalation systems need adaptation or are not relevant.In the article by Bavare et al, 2 the authors have designed a multisite single institution retrospective observational study to evaluate patient characteristics, outcomes, and use differences between sites with similar RRSs. The strength of this study is the relatively consistent framework and policies implemented from an institutional level at sites where patient characteristics, staffing experience, subspecialist availability, and other contextual factors vary significantly. The authors present the principles of a "realist evaluation" to consider the effects of local context and social structure on program performance. 3 A total of 2935 rapid response team activations were evaluated across 3 medical campuses (1816 at the central campus and 405 at 2 satellite campuses). As would be expected, there was a larger proportion of medically complex patients at the central campus. Although the central campus and satellite campuses had identical RRS protocols, they had variations in team composition. Central campus teams were led by postdoctoral fellows or ICU attending physicians, whereas satellite campus teams were led by a critical care advanced practice provider.Several interesting and important findings were highlighted by Bavare et al. 2 First, rapid response teams were activated primarily by nurses at the central campus, whereas attending physicians were activated more frequently at the satellite campuses. Second, acute respiratory compromise and cardiopulmonary arrests at the time of rapid response team calls were rare, and rates were no different across all sites. Third, ICU length of stay (LOS) was higher at the satellite sites. The reason for this discrepancy is unclear. However, the authors suppose it may be due to higher stepdown bed availability at the central campus and a proportionally higher number of ICU beds at the