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Background: Multi-institutional, international practice variation of pediatric anaphylaxis management by healthcare providers has not been reported.Objective: Characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. Methods:A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 healthcare institutions in six countries. The on-duty healthcare team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.Results: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15/37) of institutions. Teams used a cognitive aid for medication dosing 41% (15/37) of the time and 32% (12/37) for preparation. Epinephrine auto injectors (EAIs) were not available in 54% (20/37) of institutions and were used in only 14% (5/37) simulations. Median time to epinephrine administration was 95 seconds (IQR 77, 252) for EAI and 263 seconds (IQR 146, 407.5) for manually prepared epinephrine (p=.12). At least one medication error occurred in 68% (25/37) of simulations. Prior nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (p=.04) and administration (p=.01) errors.Latent safety threats (LSTs) were reported by 30% (11/37) of institutions, more than half of these (6/11) involved a cognitive aid. Conclusion and Relevance:A multicenter, international study of simulated pediatric anaphylaxis reveals: 1) variation in management between institutions in usage of protocols,

Nearly one half of EDs at PEM fellowship training institutions are reported not to have a departmental policy regarding the management of febrile infants, and departmental policies rarely conform to any of the PGs. There is substantial interdepartmental and intradepartmental practice variability regarding the management of febrile infants and a strong consensus regarding the need for a new guideline.

Objectives: Most children in the United States who visit the emergency department (ED) with fever have minor illnesses not requiring treatment or hospitalization. However, when a child has recently immigrated or traveled abroad, internationally acquired severe systemic infections (ISSIs) must be considered. We sought to describe children who have traveled internationally and present to the ED with a complaint of fever and to determine risk factors associated with ISSIs in these patients. Methods:We conducted a retrospective study of children younger than 18 years who presented to 2 pediatric EDs in Bronx, NY (June 2007 to May 2017). Patients were included if they had both fever within 24 hours and international travel within 30 days. We compared groups using bivariate analyses and created a prediction model for ISSIs using multivariable logistic regression.Results: Of the 353 children included, 44 (12%) had ISSI: 25 (57%), malaria; 6 (14%), dengue; and 13 (30%), bacteremia. Eight (18%) of those with ISSI presented with fever to another medical provider in the week prior but did not receive bloodwork. Four variables were independently associated with ISSIs: headache (odds ratio [