WHAT'S KNOWN ON THIS SUBJECT: Various low-risk criteria have been developed to guide management of the febrile young infant (,90 days), but they differ in age criteria, recommendations, and implementation. Therefore, variation in care is likely but has not been previously studied. WHAT THIS STUDY ADDS:There is wide variation in testing, treatment, and overall resource utilization in management of the febrile young infant across all 3 age groups: #28, 29 to 56, and 57 to 89 days. There may be opportunities to improve care variation without compromising outcomes. abstract BACKGROUND AND OBJECTIVES: Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs). METHODS:Retrospective cohort study of infants ,90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient-and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: #28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization. RESULTS:We identified 35 070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates #28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R 2 = 0.10, P = .06) or revisits resulting in hospitalization (R 2 = 0.08, P = .09).

Objectives: The authors sought to describe the epidemiology of and risk factors for recurrent and highfrequency use of the emergency department (ED) by children.Methods: This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use.Results: A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p < 0.001). Highfrequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Conclusions:Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.ACADEMIC EMERGENCY MEDICINE 2014;21:365-373

Prevalence of occult bacteremia in the post-HIB vaccine era is lower than previously reported. S pneumoniae is the most common causative organism and resolves without parenteral antibiotics in the vast majority of cases. Continuously monitoring blood culture systems allow for early identification and can aid in differentiating contaminated from true pathogenic cultures by time to positive culture. Serious adverse outcome is an uncommon result of occult bacteremia. Updated epidemiology and microbiologic technology may impact the evaluation and treatment of children at risk for occult bacteremia.

Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.