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Pediatric patients historically have had a lower level of consistency in triage decisions, and up to 50% of patients with acute myocardial infarction are undertriaged or assigned an acuity level that is lower than what it should be based on their final diagnosis.4-6 Mis-triage is a problem among nurses of all experience levels4 and can lead to dangerous delays in care.Clinical Decision Support Systems Clinical decision support systems (CDSSs) were first introduced into health care in the 1970s and experienced renewed focus in the 2000s after the Centers for Medicare and Medicaid Services began incentivizing health care institutions for programs that utilized them to improve patient care, processes, and outcomes. CDSSs suggested, studied, or utilized in the emergency department include those designed to help nurses and other health care professionals assess and stratify risk for acute coronary syndrome, acute myocardial infarction,5,6,8 sepsis,9 syncope,10 and head injuries.11,12 These conditions all represent potential life-threatening situations and are known for their sometimes subtle or atypical clinical presentations.Identifying Clinical Deterioration and Sepsis Abnormalities in vital signs captured in the electronic health record can help identify septic shock or other clinical deterioration up to several hours prior to a serious adverse event.13 For example, studies have shown that at least 80% of adult patients who have experienced severe sepsis have had tachycardia and tachypnea.9 However, studies also have shown that many septic children present in compensated shock, with tachycardia being the only indicator of potential decompensation.14 These physiologic differences, and the fact that febrile illnesses are so common in children, make sepsis very challenging to identify in the pediatric population. Early warning scores that provide real-time alerts based on vital signs and laboratory data also have been successful in supporting early identification and treatment of patients at risk for myocardial infarction.9Stratifying Risk for Pediatric Head Injuries Another challenge within the process of triage decision making is predicting which children younger than 2 years are at risk for underlying skull fracture or intracranial bleeding after a sustained or suspected minor head injury.3,17 Head injury risk variances stratified by the age of the child, the mechanism of injury, the region of skull injured, and the presence or size of a hematoma are reflected in validated medical decision rules for pediatric patients.

Injury remains the leading cause of death for children age 1 to 18 years, yet the initial care of most injured children also takes place in emergency departments primarily designed and equipped to treat adults.5 The results of recent studies have shown that even trauma centers are inconsistent in their level of readiness to care for children.6,7 For example, while the majority of trauma centers have a tool to use for precalculated pediatric drug dosing, many lack other important parameters such as recording pediatric weights in kilograms only and the presence of a quality improvement process that includes pediatric-specific metrics.6 A recently published study of injured children brought to 832 emergency departments in US trauma centers was the first to dig deeper and evaluate the association between pediatric readiness of emergency departments verified as trauma centers (as per the 2013 NPRP nationwide assessment), in-hospital mortality, and in-hospital complications.7 In the study of over 372 000 injured children, receiving initial care in an emergency department that had a pediatric readiness score within the highest quartile of readiness was associated with 42% lower odds of death. The authors concluded that if all the children included in the study had been treated in emergency departments in the highest quartile of readiness, an additional 126 lives (95% confidence interval 97-154 lives) might have been saved in each of the 6 years for which data were collected.7 That is over 700 children’s lives that might have been saved if the trauma centers had all invested the time and resources required to better prepare for stabilizing pediatric emergency care! The presence of a PECC has been identified as the single most important factor that influences the readiness of any emergency department that cares for pediatric patients.10 The 2018 American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Surgery, American College of Emergency Physicians Pediatric Emergency Medicine Committee, and Emergency Nurses Association Pediatric Committee Joint Policy Statement, “Pediatric Readiness in the Emergency Department,”9 identified the presence of 2 PECCs, one a physician and one a nurse, as central to the readiness of any emergency department that cares for children. “Implementing a Novel Nursing Site Manager Role in the Pediatric Emergency Department for Patient and Staff Safety during the COVID-19 Pandemic,”12 published in this current issue of the Journal of Emergency Nursing (JEN) described the way the Boston Children’s Hospital emergency department pivoted quickly at the onset of the pandemic to meet the specialized needs of their multidisciplinary staff during this time, while ultimately also benefiting their pediatric patients.

Description Earth's climate is changing more rapidly than at any other point in the history of modern civilization, and it is largely a result of human activity.1-7 The impact of climate change is being experienced globally and is projected to intensify in the future.4,6,8 Climate change affects communities in many ways: the economy, social systems, quality of water, ecosystems, agriculture and food, infrastructures, oceans and coasts, tourism, human health, and quality of life.4,6,7 A major contributor to the warming of the climate system is the health care sector, accounting for 8% of greenhouse gas emissions in the United States and 4.5% globally.8-10 The main greenhouse gases responsible for climate change are carbon dioxide, methane, nitrous oxide, and fluorinated gases.11 In conjunction with black carbon, these gases impair the earth's reflective capacity while simultaneously absorbing solar radiation that is re-emitted to Earth's atmosphere, ultimately leading to surface warming.11 Rising global temperatures are associated with more frequent and severe storms, intense heat, drought, worsening air quality, and changes in the distribution of pathogens.8,11-16 Water scarcity, land degradation, and desertification also have accelerated in the past century owing to natural disasters, environmental pollution, and destruction of green space.12,17-21 More frequent and intense extreme weather and climate-related events, as well as changes in average climate conditions, are expected to damage infrastructure, ecosystems, and social systems that provide essential benefits to communities. The physical environment where people live, learn, work, and play, which is affected by rising global temperatures, is a social determinant of health.22,23 Future climate change is expected to further disrupt many aspects of life, posing challenges to those most vulnerable populations including children, older adults, pregnant women, some communities of color, immigrants, lower-income and under-resourced communities, and those with comorbidities (eg, immunocompromised, allergies, respiratory disease) who have a lower capacity to prepare for and cope with extreme weather and climate-related events.1,2,4,6-8,24-26 Ambient air pollution contributes to 4.2 million premature deaths worldwide and is associated with increased morbidity from numerous illnesses.27,28 More than 90% of children are subjected to fine particulate matter that exceeds health standards, whereas maternal exposure is associated with an increase in preterm births, low birth weight, and stillbirths.29 Poor air quality also leads to emergency visits for asthma, chronic obstructive pulmonary disease, cardiovascular events, and mental health complaints.7,12,26-28,30 In 2018, a record number of older adults (220 million) were exposed to at least 1 heatwave,8 with exposure to the stress of extreme heat causing nephropathy, electrolyte disturbances, cerebrovascular events, congestive heart failure, and preterm births.8,12,31,32 Psychological stress owing to displacement, socioeconomic consequences, and exposure to trauma is anticipated to rise with the increased prevalence of climate-related natural disasters.12 Providing education to patients and their families on climate change and disaster readiness may help them prepare and mitigate these consequences. According to the World Health Organization,28 climate change can be mitigated by transitioning to sustainable and efficient energy practices, conserving and protecting resources, designing climate-resilient infrastructure, and adopting methods of sustainable waste disposal and management practices. [...]emergency care settings can upgrade to energy-efficient equipment, replace incandescent light bulbs with LED bulbs, and install lighting control systems such as occupancy sensors.16,20,24,59-61 The use of renewable and alternative energy sources (eg, solar-powered photovoltaic, water pumps, wind) are additional means of reducing fossil fuel use.9,16,59-62 Combined heat and power technology is another alternative; this technology captures excess heat from electricity generation and uses it for thermal energy.9 Energy production is not the only source of carbon emission: more than half of the nitrogen oxides emitted globally are from fuels used for transportation.8 Using locally sourced food and on-site food production (eg, rooftop gardens) in hospital cafeterias and catering are methods of reducing emissions from transporting supplies while modeling sustainable food practices.8,16,24 Emergency care settings can further reduce transport emissions by supporting staff use of environmentally conscious forms of transport (eg, cycling) and advocating for vehicles (eg, ambulances) that use alternative fuel, are electric, or have zero emissions.12,63 Emergency nurse leaders can incorporate climate resilient solutions into facility renovation and future design.8,12,59 For example,

None of the current clinical decision rules are designed to aid the ED triage nurse in age-specific assessments and triage-acuity decisions for children below age 2.4 The data regarding the specific variables to consider in the assessment of these children have not been widely disseminated to the nursing profession.4 This is a problem because ED triage nurses are typically the first health care professionals to assess patients who present to emergency departments for evaluation, and they are tasked with acuity decisions that help to determine the initial prioritization of care.Results Many children below age 2 who present to emergency departments for the evaluation of suspected minor head injuries are clinically asymptomatic, yet some of these children have sustained underlying CHIs.4,8,12 Nationwide, approximately half of the children below age 2 who present to emergency departments for evaluation of head injuries receive neuroimaging (eg, computed tomography [CT] scans), of whom approximately 10% have some degree of documented underlying CHI.13 Only approximately 1% of children below age 2 who have sustained head injuries will have underlying CHIs requiring life-saving intervention; this increases to 4% for children of any age with altered mental status and/or known skull fractures.1Triage Accuracy A study by Griffin et al4 collected acuity-level information for 200 head-injured children aged 0 to 17 in a southeastern children’s emergency department. For those who do present with visible injuries, evidence-based triage assessment by nurses who are aware of developmentally appropriate injuries in children below age 2 can aid in the early identification of the abuse.Significance of Fall Characteristics As falls represent the most common mechanism of head injuries in children, several studies have sought specifically to examine falls to determine which falls pose higher risks for sustaining underlying CHI in infants and young children.16,21,22 Overall, the literature related to fall heights and surfaces indicates that falls—including being dropped by caregivers—are responsible for 70% to 80% of CHIs in children below age 2,5,14,22 many of whom have few, if any, symptoms of injury other than scalp hematoma.5,22 Studies also indicate that age in months, especially for children below 12 months of age, is a major factor to consider when predicting risk of underlying CHI due to falls.4,18,21,23 Although the literature is limited regarding specific fall surfaces, several studies have found that hard fall surfaces, such as concrete, are associated with a higher risk of CHI in children below age 2.16,21,24 Assessing the severity of the injury mechanism can be particularly challenging when a child has been injured as the result of a fall because the risk of CHI varies in relation to the child’s height and the height of the fall, both of which are usually reported as estimates by caregivers. For those who do not meet national trauma criteria, there are other resources—such as the Pediatric Emergency Care Advanced Research Network (PECARN) Head Injury Algorithm1—which define mild, moderate, and severe mechanisms of injury based on the risk of underlying skull fracture and/or intracranial injury, but this information is not present in existing ED triage nurse resources.Anatomical and Physiological Differences In comparison with older children, children below age 2 have a higher risk for sustaining underlying CHIs secondary to minor head trauma owing to several anatomical and physiological differences.5,13,15,26 The heads of children below age 2 are proportionately larger than the rest of their bodies; their neck muscles are weaker; and their motor abilities are underdeveloped, all of which contribute to a higher incidence of skull fracture in the first year of life when compared with older children.15,26 As a result, their heads are more likely to hit surfaces when they fall, and their ability to change positions during falls or brace the falls is limited. The temporal region, in particular, includes an area near the ear that is the thinnest area of the skull17 and is more likely to contribute to a higher incidence of fracture with blunt-force impact (such as by a baseball that hits a child’s head). [...]for patients of all ages, an injury to the temporal-parietal region is more likely to result in significant intracranial bleeding than an injury to another region.

Description In 2002, the World Health Organization declared workplace violence to be a global epidemic with a negative impact on the retention of health personnel and delivery of health care.1 The violence also results in significant economic, personal, and professional costs.1-3 In the United States, the prevalence of workplace violence in the health care industry is 4 times higher than in other private industries.4 Ease of public access, crowding, long wait times, presence of weapons, and other factors make the emergency department a highly vulnerable area,5-9 especially where triage occurs.10,11 Emergency nurses and other ED staff are at serious occupational risk of experiencing workplace violence, including verbal and physical assaults.5-7 For these reasons, workplace violence has been recognized in many states as a violent crime.12 Yet, at the time of this publication, only about 30 states have adopted laws that make it a felony to assault a registered nurse.13 Other ongoing legislative initiatives include the introduction of the “HR 1309: 1 Both definitions demonstrate that workplace violence manifests in myriad ways as emotional or verbal abuse, coercive or threatening behavior, or physical and sexual assault,4 and can involve consumers, providers, and organizations.15 The patient population (eg, active substance use), along with work schedule (ie, night shift) experience level, and younger age of the health care provider, are consistent risk factors for WPV.8-10,16-18 Acts of workplace violence can cause physical and/or psychological harm to emergency nurses leading to job dissatisfaction, emotional exhaustion, burnout, secondary trauma stress, posttraumatic stress disorder, absenteeism, and intention to leave the job or the nursing profession,4,9,16-25 all of which have potential impacts on patient care due to nurses' decreased productivity, organizational commitment, and engagement.9,18,25-27 Workplace violence is seen as a contributing driver of poor nurse retention and recruitment, further exacerbating the nursing shortage and its costly consequences for health care organizations and their patients.4,18,20,25,27-29 Despite continued education, legislation, and research to increase awareness and understanding of the issue, emergency nurses are reluctant to report incidents of WPV because they believe it is not violence if they did not sustain an injury, reporting can be laborious and futile, patients are not seen as responsible because of their age or illness, and WPV is an expected part of the job.23,28 Different types of violence exist independently, overlap, and enable each other. Background To increase program effectiveness, it is recommended that a workplace violence prevention program include training; formal incident reporting procedures; administrative, environmental, and consumer risk assessment; physical design; and security components to address all types of violence.3,4,6,28,31-38 When establishing a WPV prevention program, WPV experts recommend health care organizations adopt a multi-faceted, collaborative, interdisciplinary approach that includes a variety of stakeholders, such as health care administrators, ED managers, clinicians and staff, law enforcement and security personnel, and specialty providers such as mental health practitioners.28-30,32,33,35,38 Given the crucial focus on prevention of workplace violence by patients, visitors, coworkers, and intimate partners, coordination and advocacy among employees, health care employers, managers, and nursing leadership is considered necessary for effective implementation of educational, administrative, behavioral, legislative, and engineering approaches necessary for mitigating workplace violence.3,4,33-35,37,38 Emergency nurses, with their high risk for experiencing WPV, can serve an integral role in all aspects of violence prevention, planning, monitoring, and reporting.

APRNs have existed for more than 50 years and are established members of emergency care teams throughout the United States (US) and in many countries worldwide.2-6 Nearly a decade ago, the Institute of Medicine identified APRNs as necessary for the future of health care delivery in the US.7,8 Since then emergency departments (EDs) in the US and abroad have become increasingly overcrowded, in part due to their status as a health care safety net for those who cannot access a primary care provider.9,10 It is estimated that EDs provide more than 47% of all hospital-associated health care in the US.9 As a result, there is currently a substantial mismatch between the need for emergency services and the available resources to provide that care.10 APRNs have been identified as particularly important for bridging this gap in both urban and rural settings.11-14 The regulatory landscape for APRNs in the US continues to evolve, and APRNs who work in the emergency care setting face a few unique licensing and certification challenges. The Consensus Model’s licensing paradigm could create barriers to APRN practice in the emergency care setting because it would require APRNs who treat the full population of the emergency care setting to complete three courses of graduate study and to obtain and maintain three certifications (eg, Family Nurse Practitioner, Adult-Gerontological Acute Care Nurse Practitioner, and Pediatric Acute Care Nurse Practitioner).1,17 CNSs, for whom there are fewer courses of study than for NPs, would be required to have and maintain 2 licenses (Adult-Gerontology CNS and Pediatric CNS), but they would be restricted to either primary or acute care.18ENA Position The following are the positions of the Emergency Nurses Association (ENA): APRNs are established members of the emergency care team and are critical to the future of quality health care across the US and worldwide. Background The emergency care setting is unique when compared to most other practice settings in that its patient population consists of all ages and all combinations of medical history and chief complaint, rather than a narrow subset of them, as is the case with most other specialties (eg, pediatric oncology, adult cardiology, etc).19 Although some APRNs only treat a subset of the patients in the emergency care setting, for example, only pediatric patients or only adults with urgent or chronic needs, other APRNs are called upon to treat all patients and conditions, from nonemergent, episodic chronic care to acute, complex, life-threatening traumatic and medical conditions.2,20-23 APRNs are licensed and regulated by state law, and reciprocity across state lines is determined by each state. The Consensus Model’s proposal that US states license APRNs as “primary care” or “acute care” APRNs, along with its stipulation that an APRN only be allowed to expand his or her scope of practice by completing another graduate program of study, stands in contrast to how APRNs are currently licensed and regulated today.24-29 In nearly all states, APRNs are licensed at the role level, and the scope of practice is determined not only by formal education and national certification but by clinical experience as well.30 Degree-granting programs are designed to prepare APRNs for entry-level competency, and postgraduate training after one’s formal course of education confers clinical expertise.6,29,31-34 It is, therefore, no surprise that APRNs who are currently providing safe and effective primary and acute care across the country are certified as family nurse practitioners (FNPs), acute care nurse practitioners (ACNPs), Adult NPs, Pediatric NPs, Adult-Gerontological NPs, Adult-Gerontological CNSs, and Pediatric CNSs, among others.15,21,35,36 The Consensus Model has been a powerful force for raising the quality of APRN education and training in the US and has successfully championed full practice authority for APRNs in all states.15 Regardless of the outcome of these and future discussions over whether and how to implement the Consensus Model’s definitions of primary care, acute care, and scope of practice, APRNs will continue their long tradition of providing safe, effective care in the emergency care setting, and ENA will remain committed to interprofessional collaboration and advocacy on their behalf.Resources Advanced Practice Registered Nursing Consensus Work Group, The National Council of State Boards of Nursing APRN Advisory Committee.

This review of the literature was conducted to define avoidant restrictive food intake disorder (ARFID) and provide the current evidence-based treatment modalities and implications for Nurse Practitioners. A specific case is used to illustrate the daily struggles of a pediatric patient with ARFID that include bullying, self-doubt, and anxiety related to eating. There is a need for increased awareness of the disorder to increase identification of the disorder, enhance the research on treatment modalities for the disorder, and most importantly, to increase the quality of life for those with the disorder and their family members. •Avoidant restrictive food disorder (AFRID) is a relatively new diagnosis and remains widely unrecognized by health care professionals and the general public.•Patients with AFRID suffer multiple negative consequences secondary to the condition, including growth issues, dental issues, body image disturbances, and bullying.•A lack of awareness of ARFID contributes to misdiagnoses and improper treatment.•Increased diagnosis of the disorder will support evidence-based treatment and, thus, a higher quality of life for both the patient and their family.

The purpose of the current study was to identify the variables associated with the risk of closed head injury (CHI) in children under age two with suspected minor head injuries based on age-appropriate, or near age-appropriate, mental status on exam, as defined by a Glascow Coma Score (GCS) of 15 or 14, respectively. The goal was to propose a set of variables that, when considered together, have a high degree of predictive accuracy in identifying CHI in this population. This set of variables could eventually be used to inform a clinical decision rule which may help triage nurses make acuity decisions in a more evidence-based manner. The study was guided by Donabedian’s Structure, Process, Outcome model that allows for the assessment of the various factors that inform and influence the ED triage process. The current study was a secondary data analysis of the public-use dataset from the largest prospective, multi-center pediatric head injury study found in the current literature. As part of the secondary analysis, an existing clinical decision rule by Greenes and Schutzman (2001) (Greenes and Schutzman Risk Scoring System [the Scalp Score]), was examined using a sample of 3,329 children under age two to determine whether it, or the individual variables within it, could be utilized alone, or in conjunction with other variables to accurately predict the risk of underlying CHI in this population. In consideration of the factors related to best practice for clinical decision rule development, the optimal set of variables for a clinical decision rule to predict CHI in children under age two would include the following variables: age in months, a composite variable representing hematoma presence/size, and location; and severity of injury mechanism. An evidence-based, nurse-driven clinical decision rule designed as a risk scoring system could serve to improve the “structure” of ED triage. Such a resource could influence the “process” of the triage assessment and acuity assignation to be more accurate, ultimately also optimizing the primary “outcome” of triage accuracy for children under age two with CHIs. Such a tool could help overcome inconsistencies in triage acuity decisions due to variation in knowledge, thereby improving triage accuracy and consistency for children under age two who present for evaluation of suspected minor head injuries. The results of this study could also be used to inform more age-specific recommendations for children under age two in triage and educational resources and in national trauma criteria. The findings from this study add to the body of knowledge regarding what variables are, and are not, associated with CHI in children under age two with suspected minor head injuries. The key to an accurate triage assessment for children under age two with suspected minor head injuries includes familiarity with the main regions of the skull, being able to assess for the presence and size of any scalp hematoma and having access to accurate information regarding the child’s age and the details of the injury mechanism.

Key Points Cyclin D–cyclin-dependent kinase 4 (CDK4) or CDK6 activation promotes cell cycle progression through the phosphorylation of substrates, including RB and transcription factors with roles in proliferation and differentiation. These kinase complexes also target substrates with roles in centrosome duplication, mitochondrial function, cell growth, cell adhesion and motility, and cytoskeletal modelling. D-type cyclins have non-catalytic roles in which interactions with chromatin-modifying enzymes and diverse transcription factors, including steroid hormone receptors, leads to the transcriptional regulation of suites of genes that are involved in proliferation and differentiation. Independently of CDK activation, the D-type cyclins also facilitate efficient DNA repair and indirectly activate CDK2 through the sequestration of CDK inhibitors. CCND1 is an established human oncogene that is commonly overexpressed through copy number alterations, or more rarely by mutation, or as a consequence of the deregulation of mitogenic signalling downstream of oncogenes such as ERBB2. CCND1 overexpression causes a number of potentially oncogenic responses in experimental models and is associated with poor patient outcome. Cyclin D1 and its associated CDKs are potential therapeutic targets. Promising results from early CDK inhibitors in experimental systems were not followed by evidence for efficacy in clinical trials. Possible reasons for this disappointing outcome include poor pharmacokinetics, suboptimal dosing schedules and clinical testing in unselected patient populations. Second-generation, more selective inhibitors of CDK4 and CDK6 are now undergoing clinical testing. Possible alternative approaches to targeting cyclin D1 include the use of compounds that affect CCND1 transcription or cyclin D1 protein turnover, and the use of combination therapies that simultaneously target multiple end points of cyclin D1 action. Central to the effective use of these novel approaches is the better selection of patient subgroups that are likely to respond. Is the ability of D-type cyclins to activate cyclin-dependent kinases an effective means of targeting these oncogenes, and how might the patient subgroups that are most likely to benefit be identified? Cyclin D1, and to a lesser extent the other D-type cyclins, is frequently deregulated in cancer and is a biomarker of cancer phenotype and disease progression. The ability of these cyclins to activate the cyclin-dependent kinases (CDKs) CDK4 and CDK6 is the most extensively documented mechanism for their oncogenic actions and provides an attractive therapeutic target. Is this an effective means of targeting the cyclin D oncogenes, and how might the patient subgroups that are most likely to benefit be identified?

The RPE65 gene encodes the isomerase of the retinoid cycle, the enzymatic pathway that underlies mammalian vision. Mutations in RPE65 disrupt the retinoid cycle and cause a congenital human blindness known as Leber congenital amaurosis (LCA). We used adeno-associated virus-2-based RPE65 gene replacement therapy to treat three young adults with RPE65-LCA and measured their vision before and up to 90 days after the intervention. All three patients showed a statistically significant increase in visual sensitivity at 30 days after treatment localized to retinal areas that had received the vector. There were no changes in the effect between 30 and 90 days. Both cone- and rod-photoreceptor-based vision could be demonstrated in treated areas. For cones, there were increases of up to 1.7 log units (i.e., 50 fold); and for rods, there were gains of up to 4.8 log units (i.e., 63,000 fold). To assess what fraction of full vision potential was restored by gene therapy, we related the degree of light sensitivity to the level of remaining photoreceptors within the treatment area. We found that the intervention could overcome nearly all of the loss of light sensitivity resulting from the biochemical blockade. However, this reconstituted retinoid cycle was not completely normal. Resensitization kinetics of the newly treated rods were remarkably slow and required 8 h or more for the attainment of full sensitivity, compared with <1 h in normal eyes. Cone-sensitivity recovery time was rapid. These results demonstrate dramatic, albeit imperfect, recovery of rod- and cone-photoreceptor-based vision after RPE65 gene therapy.