Chapters Transcript Video 10th Annual GME / Fellowship Research Symposium Good morning, everyone. It's a pleasure and honor to introduce doctors Monica Charpentier and Adnan Hack, our graduating pediatric emergency medicine fellows who will be presenting scholarly work for us today. I'll be introducing both at this time, and I'll be starting with Monica. Monica completed her MBA and PhD from the University of Maryland and her residency at the University of Washington Seattle Children's, where she was particularly interested in QI methodology. Monica is an astute teacher and researcher and has received multiple awards. She's completed 11 publications and 15 conference abstracts during her training. Monica has many hobbies and interests, which include competitive partner dancing, West Coast swing, and Brazilian Zoo. Monica will be working as a PEM physician in Maryland, splitting her time between Sinai Hospital in Baltimore, Maryland, and Adventist Healthcare Shady Grove Methodist Medical Center in Rockville, Maryland. This, uh, this morning, Monica will be presenting antibiotic treatment of community acquired pneumonia, a quality improvement project to increase pediatric ED discharge prescription adherence to shorter antibiotic duration guidelines. And now on to Adnon. A native of the Bay Area, Adnon went to medical school at NYU and completed a residency in pediatrics at the University of Chicago. After a year at the University of Alabama working in primary care, we were thrilled that he matched into our program 3 years ago, bringing him back to the Bay Area. Adnan is an outstanding bedside teacher. He's passionate about injury prevention and sports medicine. Most importantly, Dr. Adnan is an incredibly thoughtful and self-reflective person with And an incredible PEM physician. He's known as an accomplished break dancer, and he's most proud of his beautiful wife and two adorable children. Adnan will be staying close to family and friends in the Bay Area, where he'll be a PEM physician at CPMC and an urgent care physician at PAMF in Dublin. Adnan will, will be presenting pediatric sport injuries following the initiation of COVID study this morning. Thank you very much. All right. OK, to get started? Yes. Awesome. Thank you so much for that kind introduction, Jackie. Um, And, uh, as she mentioned, we're going to talk a little bit about a quality improvement project on um antimicrobial stewardship for treatment of community acquired pneumonia through the emergency department. And for the residents that may be tuning in, I'll just say that my initial background was in molecular biology. I hadn't given too much of a thought to quality improvement work. Um, we did some in residency, of course, as is required. But it wasn't until I started working that I really got interested in QI work and really saw the value, um, of doing QI projects in the day to day, um, patient care that we are providing. So, um, I've gone from a little bit of very much bench to much more bedside. Um, and I just want to let you know, you can, you can change your mind a little bit as, uh, your patient, let your patients inspire you for the work that you want to do. Um, anyways, this work would not be possible without a big team of supporters, including Doctor Green Hopkins and Doctor Werner, my primary mentor and reviewer for this project along with Dr. Roen and Shapiro from the emergency department, Rob Lewis, who's one of the QR. Experts for UCSF, um, and one of my co-fellows who's done a lot of this work, um, Doctor Morgan Layton, um, along with all of our other fellows who've provided some critical input to this project. So I want to start off by thanking them for all of their help and support. Um, and why do we want to do this study? Well, you all know, community acquired pneumonia is an incredibly common medical problem in pediatric patients. There's over 1.5 million ambulatory visits a year for pediatric acquired pneumonia, acquired pneumonia. Um, so it makes A really ripe target due to this high disease prevalence for improving antimicrobial stewardship. And I like to think about antimicrobial stewardship as comprising the four right D's. So we have to make the right diagnosis. Do we correctly diagnose the condition that needs treatment with antibiotics. We have to choose the right drug. In this case, we want to pick the narrowest spectrum of antibiotics that can effectively treat this condition. We want to make sure we're choosing the right dose for effective therapy, and then we want to pick the right duration. So we want to choose the shortest effective duration possible to reduce the overall exposure of this antibiotic in the community. And this study particularly focuses on the duration component of antibiotic stewardship. Why does it matter? Um, well, there's been a lot of literature over the years looking at downstream effects of overuse of antibiotics. We see that there is increasing antimicrobial resistance across the world. We know that, um, overuse leads to increased adverse medication reactions and even alterations in the microbiome that can affect chronic conditions such as inflammatory bowel disease and asthma. So when we do have a safe and effective option to prescribe antibiotics for a shorter duration, we should take. It. It also comes with the, uh, bonus benefit of less doses of a potentially icky tasting medicine for our young patients to take. And we've now had multiple randomized controlled trials, um, in the pediatric population that show that a 5-day course of antibiotics for uncomplicated community acquired pneumonia are just as effective for longer courses. Um, and in fact, one of these studies even showed that, um, it, doing a shorter course of antibiotics led to a lower frequency of antibiotics. Resistance genes at the end of therapy, um, when they did respiratory swabs on patients. These studies are only a few years old, and it does take some time for new data to be reflected in both guideline updates and, uh, implementation in real-world settings. So the guidelines that we tend to follow were updated in 2021 to recommend a shorter course of antibiotics for community acquired pneumonia. So our first question was, OK, the new guidelines went into effect in 2021. I know that our residents and, um, our staff here are aware of the guidelines because I hear it from them when we talk about it, but how are we actually implementing it in practice? Is there a gap? Did we immediately go to the shorter courses or not? Um, so our first step was to scope the problem. So we looked back at the years immediately after this guideline changed. Um, so we pulled data from 2022 to um the start of respiratory season in 2024 for all visits to both sides of our bay, uh, our Mission Bay and our, um, Oakland pediatric emergency departments for community acquired pneumonia. And we excluded anyone who was admitted or transferred because we specifically wanted to focus on discharge prescribing patterns. We also excluded anyone who left without an antibiotic prescribed, or anyone who was previously prescribed antibiotics within the last 14 days, because we wanted to reduce the potential confounding effects for patients who had either been um previously treated for community acquired pneumonia in a different setting or were currently being treated with antibiotics for another infection such as acute otitis media. And that left us with about 594 patients, and then we excluded anyone who didn't have a um recorded weight because we wanted to make sure that we're looking at our dose calculations as part of our antimicrobial steroid chip checks. That left us with almost um just shy of 600 patients for our background data set. And what we saw there just kind of looking at the total data is that um if we looked to see how many of these match that new recommendation for shorter antibiotic duration, you're only at about 51% um total um when we combined both sides of the bay. And then if we looked to see on our discharge prescriptions that had both a narrow spectrum antibiotic at the correct dose for that shorter duration, our concordance dropped to only about a third of patients meeting all three of those criteria. So we definitely had some room to improve, um, kind of confirming that this was a ripe opportunity for some quality improvement work. So we set a pretty ambitious goal. Uh, we were hoping to get to concordance with those guidelines of about 75% by now. Um, and one of the things that you always want to do in QI work is make sure that the changes that you're implementing are sustainable. Um, so we have some ongoing efforts for this that I'll mention at the end, um, and we wanna make sure that this kind of next winter respiratory cycle, we're able to sustain our, uh, the improvements that we've made and even go up a little. Um, so we use QI methodology. Um, the first part of this was to conduct a gap analysis where we tried to identify root causes for our performance gap followed by cycles of intervention called PDSA cycles or plan do study act cycles, and then we used a quantitative time series, a study design with statistical process control methods to monitor changes and improvement, and we'll talk about what that looks like in a moment. So our gap analysis, we identified multiple potential domains that could contribute to the performance gap. Um, chief among them were kind of variation in knowledge among our very diverse pool of prescribers. Um, in the emergency department, we have our awesome residents, um, in pediatrics on both sides of the bay. We also have visiting pediatric. Residents from other institutions, um, like such as Kaiser, we have emergency medicine residents from many different programs, um, all the way from San Francisco to the Valley, and we have family medicine residents. So a wide variety of backgrounds in education and comfort and familiar with pediatrics specific, um. Treatments. We also noticed that there was a lot of different resources that these different providers were using to um look up information for antibiotic treatment that they didn't know. Um, so we had a variety of sources of truth, some of which were updated to reflect the newer guidelines and Some of which were not. Um, and the other area that we noticed seemed right for potential intervention was the electronic ordering, uh, entry system and in the computer, there's some mechanical factors there that we noticed led to a number of mistakes in ordering when we looked at repeat prescriptions that were being sent. So our, our first cycle was primarily focused on education among residents, fellows, uh, faculty trying to get the word out about changing guidelines and do more double checks to make sure um that we're following the shorter duration recommendations. Um, so looking at our demographic measures for our pre-intervention period and our first PDSA cycle, um, for all the Patients that met inclusion criteria. Our groups were generally about the same. There was no statistical differences in gender, in language, in race or ethnicity. We did, however, see a statistically significant difference in age and months with the, um, average age or median age in the PTSA cycle one being, um, significantly elevated from our base. Line, which one hypothesis there is that because we had a bit of an unusual, um, increase in atypical pneumonia, um, we were potentially seeing more, um, older children, school children and um, teens coming in, um, and that could potentially explain our, uh, increase in age, but otherwise, the demographics were essentially, um, statistically the same in our intervention periods. We also did a variety of process measures including a multitude of different labs and studies that um I'm not showing here, but the two most relevant um that I wanted to mention were whether or not procalcitonin was ordered and if so, whether it was uh um elevated and our lab uses the cutoff of 0.5 here, um, and whether or not a chest X-ray was performed. And we saw that the rates of ordering, um, and the rates of elevated procals between the groups were essentially the same. So there wasn't a significant difference in our ordering between our um pre-intervention period and our first PTSA cycle. And I'm looking at our outcome measures here looking at whether the primary discharge prescription that was sent was amoxicillin, azithromycin, or other, um, and we looked at a variety of other antibiotics that were often prescribed typically for, um, history of patient allergies. What we saw here was actually a statistically significant change. Um, so the amoxicillin was the primary antibiotic prescribed about 90% of the time in our pre-intervention period. And it dropped to about 82% in our first PDSA cycle. And concomitantly, azithromycin prescribing, which was around 7.7% in our pre-intervention phase, um, essentially doubled to 15.9% in our, um, first PDSA cycle. And epidemiological studies have shown that there was indeed an increase in mycoplasma pneumonia in this 2024 to 2025 season, which is consistent with our results seen here. Um, and because of this change in this sort of seasonal patterns, um, the statistical process control data that I'm gonna show next, we're gonna exclude azithromycin, um, to, um, avoid any potential false improvements. Really gonna focus on beta lactam prescribing, which, um, is the target for the decreased, uh, duration, as azithromycin duration has remained the five-day course. There hasn't been a change in recommendation for that. So the next set of slides are gonna be, um, beta lactams only no azithromycin. Um, and then with QI, you always want to make sure that you're looking to see if your, um, intervention is having an unintended negative effect. And two of the balancing measures that we looked at were the emergency department length of stay, which does have many, many, many different variables that go into determining the EVD length of stay. Um, here we did see that there was a significant decrease in our pre-intervention period, um, compared to our PDSA cycle one, but we don't think we can attribute that to any of Our interventions here, I think there was a lot of other work that went into making that possible. Um, but one of the more relevant balancing measures that we looked at was whether or not there were, um, ED return visits within 7 days. We wanted to make sure that patients that were being sent home with shorter courses of antibiotics weren't having an increase in return to the emergency department. Um, and we saw that there was no statistical difference in our return visit percentage between our pre-intervention and our PSA cycle 1 groups. Um, so now getting into the, the need of the data, looking at what happens over time, um, and this is where, um, QI methodology, um, really shines, and what we use is statistical process control. These were, um, statistical methods developed in the manufacturing industry that have found their way into healthcare, and they're really a powerful tool to monitor how a process changes over time and to determine whether an intervention actually. Causes changes, um, so we essentially are looking to see, do, um, is a process in this case a prescribing pattern, um, does it have a very change due to, um, underlying causes or an intervention or are the changes that we're seeing due to random chance? Um, the statistical terms there we're looking at are special cause variation, um, which is what we are, um, trying to achieve as an intervention that affects the process. Um, so here on the Y axis, we have the percentage of discharge prescriptions that are concordant with guidelines. And on the other Y-axis on the right-hand side, we have the number of patients in each group cohort per month. Um, you can see that displayed in the bar graph along the bottom, um, and you will see a variety of lines on these charts. So the blue dots, uh, and connected by the blue line are our, um, percentage. In each month we grouped by month here um with the purple dashed line representing the what we call a center control line which is essentially the mean um uh in statistical speak, and then we have these dashed um or dotted red lines on the top and bottom that are called control limits. So we have an upper control limit and a lower control limit, um, and those are related to um 3 standard deviations from the mean here. And one thing that you might notice is that at times where we have lower um patient um volumes that meet our criteria, so we have a smaller and, um, we have OI increased um variation. So that, um, you can see that the sort of distance between the upper and lower control limits is wider in those periods of time where we have less patients in each group. And we can see our pre-intervention period here, kind of starting in the um 2022 to 2024 um baseline. And then we see an increase and actually what's called a shift shift in our center line where we're actually able to bring up that purple line um to an increased median here of closer. 60% um during our intervention period for um primary antibiotic prescriptions that match the correct lower, um, shorter duration here. So we didn't quite get to our goal of 75%, but we have actually made a statistical improvement in our discharge prescribing patterns. Um, and then if we look at any antibiotics that we sent patients home on, so that includes, um, one of the things we noticed was there was a lot of sort of re-prescribing. So someone puts in an initial prescription and they realized it wasn't what they wanted, they send another prescription. Um, so looking at any prescription, not just that first initial, um, antibiotic prescription. Um, here we also see that similar um trend where we have a shift in our percentage correct from um a little under 50% now up to, um, about almost 70%. So close to our goal, um, when we take into account any of our pediatric discharge prescriptions adhering to a shorter duration. And then when we look at the um prescription, primary prescription, so those first prescription that that would match a correct dose, spectrum, and duration. So kind of all three of those domains for anti microbial stero trip that we were looking for, um, we actually didn't see improvement there. Um, so we haven't made enough improvement that meets. The um statistical criteria for a shift. um, but we hope to do that within our next PTSA cycle because some of our next interventions um also address the dose and spectrum components. Um, so we're gonna be keeping a close eye out over the next few months to see if we make improvement in those domains as well. Um, but when we take a look at any of those discharge prescriptions, so the ones that were sent that were corrected, um, we actually did have an improvement in, um, the overall, uh, adherence to the recommendations for dose spectrum, and duration, um, of our antibiotics. So it looks like, um, people were able to go back and make some corrections. So, some brief limitations to this study. Um, first of all, we did this in two academic emergency departments in the San Francisco Bay region, not necessarily applicable to the sites where the vast majority of antibiotic prescriptions for community acquired pneumonia are happening. That would be general emergency departments that are not pediatrics specific and of course the ambulatory or outpatient clinical settings rather than the emergency department setting. Um, second, we use some IGC. The 10 codes to um develop our cohort um here and it's possible that there were some that didn't have the word pneumonia in them. We tried to use every single ICD 10 code that included the word pneumonia to generate our data set and pare down from there, but it's possible some never made it to that level of coding and only got coded as fever, for example. Um, and then kind of most interestingly, uh, as I mentioned, we had this surge in mycoplasma pneumonia, um, In this 2024 to 2025 season, and that is gonna require treatment with this 5 day course of macrolide antibiotics. Um, so it could potentially contaminate the data, which is why I showed you just the data with, um, azithromycin prescribing removed. However, um, we have the opportunity to look a little bit, um, to use this collected data to kind of probe into additional prescribing patterns in the future and try to look for associations with, um, Patient age, um, and azithromycin prescription, whether or not labs were obtained, including a viral swab to confirm mycoplasma infection, whether, um, chest X-rays were obtained that showed focal or multifocal pneumonia. So we, we can ask a bunch of other questions about um how our providers decide to treat with the zithromycin from this data set. So we should have some really interesting, um, data that, um, coming out of that as well. Um, so what we're doing next is Um, we're going to have a go live in the next few weeks that, um, we'll have a community acquired pneumonia discharge order set that should make it much easier and faster for all of our prescribers to complete discharge from the ED with these narrow spectrum, shorter duration antibiotics with much less clicks and pre-populated recommendations for follow-up and supportive care recommendations. Um, we're also looking at doing some indication-driven order sets that tied to kind of the manual typing in of amoxicillin and other beta lactam antibiotics into the discharge order set. Um, but I think that it'll be much more, um, streamlined to use, uh, the discharge order set. And we're also looking at doing some aggregated and individualized provider feedback throughout this next cycle, um, to continue to encourage people to use the order set and, um, use these more narrow antibiotic prescribing guidelines. Um, references here. I'm happy to share any of those if you have a particular interest. I also wanted to say thank you so much for your time and attention, and I will be tuning into the Q&A to see if I can help answer any individual questions before I have to head off to go take care of patients. Thank you all so much and I will stop sharing now. OK, I guess I'll move right along to my one. Hi everyone, I'm a Dad Hack. I'm one of the PE fellows, um, and I'll be presenting on my research topic, the pediatric sports injuries following the initiation of COVID study. Um, so this is a cross-sectional study of the long-term effects of the COVID pandemic on pediatric sports injury. Um, so, disclosure, no one, was, no one involved in planning or presentation of this, uh, has any relevant financial relationships. Um, so I'd like to thank all my team members, that includes, uh, my primary mentor, Aaron Kornblitz, as well as the Corn Blitz Data Lab, um, and, uh, my primary reviewer Annikahoo, and my program director is Heidi Eel. So thank you all. Um, so the purpose of my study is to evaluate, um, what the effects that the COVID pandemic had on pediatric sports injuries presenting to emergency departments. Um, in particularly, we're looking at the long term impacts, um, as compared to some of the more shorter term impacts that some other studies have evaluated. So we had four primary aims, one, to look at, um, how do pediatric sports injuries differ in a, in the long term compared to the short term. Um, what demographics were particularly affected and were any any return to pre-pandemic baselines, which type of activities led to pediatric sports injuries presenting to the emergency department, and what was the severity of these injuries, especially compared to the um to injuries that are presenting in the pre-pandemic period. So background, about 58% of children participate in sports of some sorts. This was in the pre-pandemic period, um, which was 6% of kids, it's a lot of kids, uh, that resulted in approximately 2.7 million ED visits, uh, for kids aged 5 to 24 years between 2010 and 2016. Um, and as you can see, um, the participation rate was relatively stable over time, um, about 55 to or about 4 to 58% of kids were participating in some sort of sports during this time. Um, well, and when it comes to what type of injury or what type of sports cause these injuries, a lot of them ended up being team-based sports, things like football, basketball, and soccer, um, where things like collisions and interaction with other kids was fairly common, leading to injuries. Um, though there was a substantial portion that also came from more individual sports like pedaling, cycling, ice skating, those type of things, um, where you'd expect a little bit more injuries that had to do with things like pulling a ligament or non-contact injuries. Um, and so why does that matter? Well, the reason it matters is because the type of sports you do, uh, will affect what type of injuries that you see. For example, if you, um, are doing things like running and jumping, um, you tend to have things that, like I said, have more uh ligamentous injuries, hip injuries, knee injuries, those type of things, injuries that affect joints. Um, what, uh, in contrast, if you are in a more contact-based sport or more team-based sport, you're more likely to have, um, an injury causing things like fractures or contusions. So what type of activity you're doing directly affects what type of injury you're, uh, seeing. And so if you see a shift in the type of sports that we are seeing kids play, you'd expect differences in how patients are presenting to the emergency department. Um, and so how did the COVID pandemic affect all these things? Well, there were 3 studies that looked, uh, immediately at what happened in the immediate, uh, what the immediate effect of the pandemic was in like the first year, uh, following the pandemic start. Um, and what they found was that there was just a general reduction in pediatric emergency department visits as a whole, as I'm sure many of us experienced, but also a reduction in the amount of uh pediatric patients coming in for sports injuries, about a 33 to 45% reduction. What they did also notice though was that there seemed to be a pretty big increase in the severity of these injuries coming in with a 250% increase in patients coming in for surgeries. Why that was, it's unclear. Uh, one theory is that, um, patients were only presenting to emergency departments for severe injuries and going to. Either staying at home or going to other practices for um other injuries, but it's unclear. Um, they also noticed that the median age of patients presenting increased from about 11 to 13 years of age. Um, and then one of the big things they did find was that the type of activity did change, um, during this initiation period, particularly things like bicycling, skating, gymnastics, all things that were not as team-based and where people were not. Having to be exposed to other kids as much, um, they found a proportional increase in all those activities, while, um, team-based sports like basketball, soccer, baseball, football, those all saw a substantial decrease in the amount of patients presenting. Um, and so here was just a representation of what, uh, it looked like the, the number of presentations appearing, um, per month. Uh, you can see that in February and March, there was about 300,000 patients presenting while there was a steep drop off immediately in March once the pandemic started, um, and it started to climb back by the end, but really didn't get anywhere near the pre-pandemic levels. Um, and again, this is all for the short term period. Um, how these injuries, uh, differ from the pre-pandemic period. Uh, well, you saw a lot more injuries happening at home, and it, um, a lot more injuries happening at home and a lot less in organized sports in school, schools as you'd expect, given the fact that a lot of schools were closed down, um, and as expected, most of the injuries were happening in the place where kids were a lot of time, which was home. Um, they also saw again, a change in what type of activities, uh, led to patients presenting, particularly things like basketball, soccer, baseball, football, like I said, those all had a substantial decrease in the amount of presentations. Um, if you notice, the things like bicycling and skating did have an increase, not a huge increase, but had a small increase at the very least. Um, and here's just a visual representation of that, um, injuries from team-based sports had a decrease about 77% in the immediate post-pandemic period, while those from individual sports did have a decrease 66%. So a decrease just like all injuries were decreasing, but not nearly as much as the same as, uh, team-based sports. And then if you look at non-organized sports at the bottom, there's basically been no change at all. Um, it was pretty much the same pre-pandemic and post pandemic. So, um, our study was, again, looking at what the effects were in the long-term period and to do that, we looked at the National Electronic Injury Surveillance Database, which is a database maintained by the CDC. Um, this database looks at 100 ED sites throughout the United States with 20% of them focused on, um, pediatric emergency departments. Uh, using this data, we create, uh, we looked at, uh, weighted weekly rates of pediatric injury. Um, and for that, our inclusion criteria were any patients aged 2 to 18 years of age that, uh, had an injury categorized as sports and recreation equipment and presented between January 1st, uh, 2017 and December 31st, 2022. Um, our exclusion criteria included any visits between February 25th and March 23rd of 2020. And the reason we chose that as a buffer period was, that was 2 weeks before and 2 weeks after the WHO announced the initiation of the COVID pandemic, and our thought process was, with states responding very differently and having very different experiences with COVID during that one month period, um, it didn't seem reasonable to use that data set because people are just acting reacting in very different ways, so we use that as a buffer period. Uh, we also excluded anything, um, that was categorized as an injury from an amusement attraction, a barbecue grill, stove, and equipment, uh, beach picnic and camping equipment, and playground equipment, cause those are all considered sports and recreation equipment related injuries, but didn't really seem to fit into the scope of our, uh, study. So what data did we collect from this? We got demographic data, which included age, sex, race, and Hispanic identification, and then we looked at um incident or details about the incident and outcomes, um, that includes what type of sports led to these injuries, whether there was uh the primary diagnosis was an injury to the head, to upper extremities, lower extremities, or other, and what the overall disposition was of kids. Um, so, for the study, just to define our time period, we have the pre-pandemic period, which was again from January 1st of 2017 to February 24th of 2020. Uh, we had that buffer zone from February 25th um to March 23rd of 2020, and then we had the early pandemic period, which was March 24th of 2020 to March 23rd of 2021. Um, that's a lot of the same period that was evaluated by other, uh, some of the other studies, and then there was the period that we're most interested in the post-initiation period, which was March 24th of 2021 to December 31st of 2022, um, and that was our attempt to see what happened in the long-term period. So, for the study, uh, we use an interrupted time series, which helped us track the temporal trends um on a week to week basis. Uh, the using an interrupted time series allowed us to create like an intervention point, and we were able to evaluate what happened before that intervention point and what happened after that intervention point. Uh, to do that, we use the data from the pre-pandemic period and the early pandemic period to create regression models to estimate what exactly was gonna happen. Assuming that all assuming there was no pandemic and assuming that things maintained the way they did previously, um, and we use that as a counterfactual estimate in comparison to the post-pandemic period, uh, data that we had, um, and to compare the two, we use T test means of slopes, uh, means and slopes to check out what the differences in averages and the changes in rates were. So, what are the results? Well, overall, during this time period, there were about 21.5 million emergency department visits for pediatric sports injuries. Um, about 130 million of those were in the pre-pandemic period, 2.5 million in the early pandemic, and 6 million in the post-imization. Um, and when you look at what type of injuries were coming in, Um, here's just a breakdown of the weekly sports injuries. You can see the pre-pandemic period, about 46% of patients were coming in for a sports related injury, which had a pretty decent drop off to 41% during the early pandemic response, um, and then climbed back up to about 47% in the post-itation period. Um, so, the proportion of patients coming in for sports-related injury in the pre-pandemic and post-itation period were about the same, but, um, one thing you'll notice is that the overall amount of patients coming in in that post-initiation period was still a substantial drop from the pre-pandemic period with about 5000 less weekly patients coming in for a sports-related injury. Um, and here's just a visual representation of that. You can see the proportion in the pre-pandemic period dropped off during the early pandemic and came back in the post-initiation period. Um, what about when it comes to demographics? Well, um, I didn't, I've got to include the data here, but, um, in general, when it came to the demographics, there was no huge change between, um, any of the time periods in terms of race and Hispanic identification. And then when you look at age, there was a there was a slight change, um. In the especially early age period from 2 to 5 years of age, um, in the pre-pandemic period, they made up about 6% of patients. In the early pandemic response, they made up about 11%, and then that dropped back to 8.2%. So maybe a slight change, but really the age ranges were about the same regardless of um which time period we're looking at. Um, may maybe like slightly younger patients. Um, and then when we looked at the type of injuries that were coming in, um, when you look at team versus individual sports, what you'll see is with the individual sports, the red line, it's pretty stable throughout, regardless of what period you're looking at. There may, there was like a slight dip in the uh pandemic period, but really it's been pretty stable and has returned to the baseline. Um, in the post initiation stage, that is in contrast to the team-based injuries where you have like more than 30,000 patients coming in weekly in the pre-pandemic period, and then that just had a substantial drop to uh less than, or to 10,000 less patients coming in per week in the post-initiation period. Um, and then we're looking at the severity of injury, um, you can see that we used admission rates as a, um, as a substitute basically for severity of injury. Um, you can see in the pre-pandemic period, about 2% of patients were coming in and being admitted. Uh, that had a pretty substantial increase to almost double in the early pandemic period, um, and then did cool. Of in the postation period, um, but still you did see a rise in the number of patients who are coming in and being admitted, uh, about a 0.5% rise in patients and given the data set, including the United States, including hundreds of thousands of patients, that's a substantial amount of patients who are getting admitted more in the post-initiation period than they were in the pre-pandemic period. Um, when we looked at the location of injury, there really wasn't a huge difference. Maybe some slight increase in the amount of uh head injuries in the post-initiation period, but really the, uh, primary location of injury didn't seem to change all that much in any of the periods we're looking at. So, uh, why does that matter? Well, um, when we're looking at all the different trends that we did find, um, we, like I said, we found an increase in the number of injuries that happened to kids aged 2 to 5 years of age. And since kids do have, tend to have weaker bones and stronger ligaments, what we'd expect from that is that there might be more fractures, um, and particularly more, um, alter Harris fractures, um, that could affect growth going long term. Um, and you also kind of expect more non-specific injuries. Kids 2 to 5 years of age famously are not the best historians. So, um, you'd expect that, um, whatever the incident that caused the injury may have resulted in problems that you wouldn't expect to see. So, um, providers should just be on the lookout for that. Um. But in contrast, we did see a higher proportion of injuries coming from individual sports versus team-based sports, and that, on the other hand, would lead to an increase in ligamentous injuries, um, and less contact-based injuries. Um, and why that matters, a lot of it comes down to, um, provider familiarity with things. If you're seeing more things like tennis elbow and, um, gymnastics injuries, um, a lot of patients when they come to the emergency department, wanna know what's going on, want to have a good idea of what's going on. And, um, depending on what type of injuries we're seeing more of, we could do better jobs of um teaching like residents and medicines and learners as a whole, um, on how to diagnose these types of injuries and how to treat them and how to give patients an expectation of what, um, what they should expect going forward. If you've had kids who are coming in for, who are like high intensity sports or who are competitive, a lot of times they want to know, the first question on the mind is when can I get back into the game? Um, and having a better, having more understanding of these things and how to treat these, uh, injuries could help guide, um, those provider discussions and help provide patients and parents either, uh, peace of mind or let them know that, no, this is a major injury and needs to be, um, needs to be treated as such. Um, it also helps people in the emergency department know what type of uh equipment they need and, um, can help develop pathways to working with orthopedics and sports medicine to help treat a lot of these injuries and make sure that we're not understaffed or, um, don't have the right equipment that we need. Um, other things we did notice again, the higher acuity patients, uh, coming in, um, that's just a good heads up to everybody to know that these injuries do tend to be a little bit more serious. Um, again, not a huge substantial increase, but enough so that we should just have it on our minds that maybe some of these patients need to be admitted in ways that we wouldn't expect, and that will affect things like bedtimes in the emergency department, which, as everyone knows, is a high, uh high cost commodity, so something that we would like to reduce as much as possible. Um, all that being said, um, a lot of these things were happening in emergency departments and in very specific situations, so future studies will help need to elucidate whether these, um, injuries are coming in because people are avoiding the emergency department or if people are just coming in with, uh, more severe injuries from things like not being trained as much or, um, a difference in how we're approaching sports in the post pandemic period. Um, and this can also help change some of the validity tools that we, a validity of protection tools that we have for figuring out what type of injuries patients are coming in for. Um, limitations of our studies, uh, we were limited in our ability to control for confounders. This was all coming from the NEISS database, um, which is again a national database, um, but that meant we didn't really have much effect on how we were able to code for things or, um, figure out, or we were limited in what they provided us basically. Um, they're all so possibly inconsistencies in how information was coded. Again, you have Like hundreds or 100 sites throughout the United States that theoretically should all be using in the same manual, but sometimes you'll have differences in how people approach um coding depending on the institution, um. There's also the limitation that this was limited to presentations to emergency departments. So what's going on in primary care settings and urgent cares, um, may possibly reflect this data, or it may be a situation where they are being the ones who see a lot more of these patients that are not coming to the emergency departments, and I think that's important for figuring out resource allocations and figuring out where we need to go from there. Um, and then another limitation was that only the most severe injury was coded. So for all we know, a lot of these injuries, kids were coming in with like multiple injuries and probably were, um, but only the most severe injury was coded, so that was all we could, um, glean from the data set. And so future studies could help figure out, are these kids the ones who are getting admitted coming in because they're having like 7 injuries that all need to be evaluated, or is it really just one type of injury that's like a very severe one? Um, here is my work site, and thank you, everybody. Hi, thank you Adnan, and thank you, Monica. Um, this is always like my favorite uh series in the grand rounds, um, especially because, uh, we see all of our fellows. In the ED and just knowing all the additional work that you guys are doing on the background is nice to know and see like the fruits of um all the things you've been doing in the background. So thank you guys so much. Um I had uh seen that Monica had answered a few questions in the Q and A function. Um, and I had a question for Adnan, um, specifically about training, um, because I was a resident here at CO, um, in the ED during the pandemic, as well as the recovering times, and I specifically remember not seeing as many sports injuries and the fellows saying, oh, this is odd that we don't see as many and we're seeing this sort of cases instead. So, um, I remember that distinctly when I did work with you, I'm not, um, do you, uh, see that as like a limitation in further like medical training in residents and fellows and like were there any talks on like how we can try to mitigate it, um, and how we can best support learners uh going into this role? I'm sure the injury rates have sort of rebounded up, but in The past 4 years, I guess, is when the big dip was. So, um, sorry, the question is, um, how we could help. Like some of the tradies who may not have had experiences with these things, so it might just be a me question of like how, how can I best learn uh um. Since I may have missed out on some more of these injuries that are more common and frequent. Yeah, I mean, I think that's part of the reason that I wanted to look at some of these trends to see like what type of injuries were, um, We be like what type of injuries were becoming more prevalent and what, where we could focus our attention on. Um, I think when it comes to training, like when you're in the emergency department, there's so many patients coming in with so many different type of injuries that it's hard to focus in on things at all times. So knowing which type of injuries, um, are coming in more often and figuring out which type of diagnosis and management is the like has the highest yield, um. Has the highest yield of um good teaching is a place that we can go. Um, sorry, there's a little bit messy answer. My I think my overall thought process is, um, with studies like these, we can figure out what the most high yield topics are, whether it is still things like, uh, ACL injuries, whether it's uh spatial long bone fractures, what type of injuries coming in, um, and using that data to help guide residents. Um, we're not gonna be able to teach everything, we're not gonna able to do all the sports medicine. Uh, talks, but maybe we could um teach on just the topics that are coming in the most and the type of injuries are coming in the most, because if we are seeing a substantial rate in like tennis elbow more than we did before, then that would be a place that we could focus our attention on and Use that to or to make sure that the uh attendings and fellows are more up to date on that information and use that to help guide the residents. So even if you're not gonna be in the emergency department, maybe it could be useful in your job as a primary care doctor or um even as like a specialist who has patients who come in asking questions that are well outside your specialty. And uh it sounds like maybe also to help guide future curriculums if we start to see these shifts become a long term sort of change, um, then do we have to go into like medical education and think about uh which curriculum should be reevaluated and uh have like higher priorities on that sort of thing. It sounds like it's uh the direction that you're going into. Yeah, that's, I guess that was a much more eloquent way of saying what I was trying to get at. No, no, no, I heard you. I heard you 100%. Um, OK, I have another question. Uh, from one of our attendees, uh, there must be a shortest treatment period. I think this one is in regards to, uh, monica. Um, there must be a shortest treatment period before resistant organisms are selected. In the past, that was 7 days of appropriate treatment. Uh, do you know of recent studies pointing to, uh, such a lower limit? Um, Monica, I don't think it's here anymore. I wasn't sure if uh Doctor Gruellin uh had any answers to this, but if not, we can forward this over to uh Monica, and they can get back to you. Yeah, I don't think I can add any additional information on the very lowest limit. Sounds good. Uh, I know per our IDMP, the UCSF IDMP, the pediatric empiric guidelines, um, suggest 5 days, uh, and so if you look at that, I'm sure they have their sources cited as well. Any other questions? We can give our attendees maybe a second or two more. Uh How accessible is the antibiogram to community PMDs? Um, I believe it is pretty available, um, if you just Google, and I do this on a daily basis, uh, UCSF IDMP, um, they have both the adult uh uh antibiogram as well as the Children's Hospital antibiograms, and there's a lot of good resources about empiric treatment. Dosing and duration for all common uh sorts of conditions. I can confirm that in my moonlighting job, I always use IDMP, so yes. And then I had another question for you, Adnan, um, for the uh ortho study, was the child's COVID status looked at at all and was at a data point that was collected? Um, no, we, we hadn't specifically looked at, uh, the, whether they had COVID or not at the time. I can't imagine it affecting necessarily, uh, too much in terms of the orthopedic injuries, but there could definitely be an effect of that in terms of which patients chose to present or not. And like, if you already had COVID and you sprained your ankle, did you really want to go to the emergency department or not? And then, um, I think a good follow up to that is, I know you mentioned that uh the there was a drop off in pediatric injury visits overall to the EDs. Um, do you think there's gonna be like a correlated increase in incidental X-rays that find healing fractures that weren't identified before, um, like, these kids were just sucking it up at home to avoid uh getting exposed to COVID, um, or do you think there's any like relevance in that at all? No, I mean, I think it's definitely a possibility. I mean, In the, what we noticed um in the initial studies that we were basing a lot of things off of was that the injuries tended to be more severe. So there's a chance that the patients who did end up actually coming in were the ones who had fractures. But I could easily imagine a situation where like a minor thumb fracture or um like a fracture that's not really affecting day to day life, like a patellar fracture was just missed, um, because people didn't want to risk coming to the emergency department. And so maybe in the long term, we would expect to see some of those. Um, hard to say, but definitely a possibility. Um, couple more questions. Um, is there any breakdown of uh traumatic brain injuries in team sports injuries and use of guardian caps or newer improved specialty position helmets, and if that improves TBIs overall? Um, I, I haven't specifically looked into Guardian caps or the newest technology, as far as I know, um, there has been an increase in TBIs in sports injuries, um, as a whole, uh, but a lot of that, I feel like is being attributed to the fact that people just have their flags up a little bit more than they used to. Um, every study I've seen previously looking at whether new technologies have limited, uh, TBIs hasn't showed a substantial decrease in that, aside from like, Like, you know, football helmets and bike helmets and stuff like that, decreasing major injuries, um, but I think for some of the lower case TBIs and concussions, as far as I've seen none of the new technologies helped out that much, but I don't specifically know about, uh, that particular technology. So I'm hoping maybe we'd love to have helmets that can help prevent some of these concussions, that'd be great. Yeah, me too, especially with how many uh scooter and electric bike injuries that we see so commonly in the ED. So, uh, we'll continue to push for our patients to keep wearing helmets in the primary setting as well as the ED. Um, I think, uh, this is a question from Doctor Leighton or a little addition, um, but they're saying that, uh, interestingly, some of the global guidelines from WHO actually endorse a treatment course for uncomplicated pneumonia in children, um, for as short as 3 days, which is new information to me, so that's fascinating. Uh, she adds that though this includes low resource settings where distinguishing viral from bacterial uh LRTIs is even more difficult, so. Um, a little bit more mixed data, I think we should think about, um, but 5 days is what I've seen so far, um, and I hope Monica, uh, in her absence agrees. Um, I think we can, uh, we've answered quite a lot of questions. We can, uh, close up a little bit early and we can return about 7 minutes back to, uh, the folks, um, but thank you guys as always for joining us on this Tuesday to do a little bit of learning and thank you so much to our speakers, Adnan and Monica and Doctor Gre Fallon. Uh, thank you so much for joining us. Thank you, everyone. Created by
