Emergency Medicine

Head injuries in children and adults are common presentations to the emergency department. Minor head injury is characterized by: Glasgow Coma Scale (GCS) 13– 15, an event that is associated with either witnessed loss of consciousness, definite amnesia, or witnessed disorientation. Most adults and children with minor head injuries do not suffer from serious brain injuries that require hospitalization or surgery. CT head scans performed on patients who lack high-risk features can expose patients to unnecessary ionizing radiation that has the potential to increase patients’ lifetime risk of cancer. They also increase length of stay and increase the detection of false-positives (incidental, non-clinically relevant findings). There is strong evidence that physicians should not order CT head scans for patients with minor head injury unless validated clinical decision rules are used to make imaging decisions (i.e., Canadian CT head rule for adults, and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) and/or PECARN rules for children). However, CATCH has been shown to be less sensitive than PECARN at detecting any brain injury on CT. While we recommend the use of clinical decision rules (CDRs) for head injuries, these rules are meant to assist and not replace, clinical judgment.

Sources:

Babl FE, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017; 389 (10087):2393-2402. PMID:28410792.

Osmond MH, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182(4):341-8. PMID: 20142371.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Respiratory distress from bronchospasm/wheezing is a common presentation in both children (i.e., bronchiolitis) and adults (i.e., bronchitis/asthma) seen in the emergency department. Most patients with symptoms do not have bacterial infections that require antibiotic treatment or influence outcomes (i.e., hospitalization). Inappropriate administration of antibiotics can expose patients to unnecessary risks (i.e., allergies, rash, diarrhea and other side-effects) and has the potential to increase patients’ risk of antibiotic induced diarrhea, including infections with C. Difficile. These prescriptions also increase overall antibiotic resistance in the community, and limit the effectiveness of standard antibiotics in the treatment of legitimate bacterial infections. There is strong applied research evidence to recommend that physicians should not prescribe antibiotics in children (i.e., bronchiolitis) and adults (i.e., bronchitis and asthma) with wheezing presentations.

Sources:

Farley R, et al. Antibiotics for bronchiolitis in children under two years of age. Cochrane Database Syst Rev. 2014; 10:CD005189. PMID: 25300167.

Graham V, et al. Antibiotics for acute asthma. Cochrane Database Syst Rev. 2001; (3):CD002741. PMID: 11687022.

Ramakrishnan S, Couillard S. Antibiotics for asthma attacks: masking uncertainty. Eur Respir J. 2021 Jul 1;58(1):2100183. doi: 10.1183/13993003.00183-2021. PMID: 34215662.

Smith SM, et al. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014; 3:CD000245. PMID: 24585130.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Adults with non-specific lumbosacral (low back) pain, in the absence of significant trauma (i.e., car crash, acute axial loading, acute hyperflexion, etc.), commonly present to the emergency department. The evaluation of patients presenting with non-traumatic low back pain should include a complete focused history and physical examination to identify “red flags” that may indicate significant pathology. These may include, but are not limited to:  features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, patients with first episode of low back pain over 50 years of age and especially if over 65, abnormal reflexes, loss of motor strength or loss of sensation in the legs. In the absence of red flags, physicians should not order radiological images for patients presenting with non-specific low back pain. Imaging of the lower spine for symptomatic low back pain does not improve outcomes, exposes the patient to unnecessary ionizing radiation and contributes to flow delays without providing additional value.

Sources:

Chou R, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009; 373(9662):463-72. PMID: 19200918.

Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-91. PMID: 17909209.

Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain, 2nd Edition. Edmonton, AB: Toward Optimized Practice; 2011.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Patient Pamphlet: Imaging Tests for Lower Back Pain: When you need them and when you don’t

Neck pain resulting from trauma (such as a fall or car crash) is a common reason for people to present to the emergency department. Very few patients have a cervical spinal injury that can be detected on radiographs (“X-rays”). History, physical examination and the application of clinical decision rules (i.e., the Canadian C-spine rule) can identify alert and stable trauma patients who do not have cervical spinal injuries and therefore do not need radiography. The Canadian C-spine rule has been validated and implemented successfully in Canadian centres, and physicians should not order imaging unless this rule suggests otherwise. Unnecessary radiography delays care, may cause increased pain and adverse outcomes (from prolonged spinal board immobilization), and exposes the patient to ionizing radiation without any possible benefit. This strategy will reduce the proportion of alert patients who require imaging.

Sources:

Michaleff ZA, et al. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012; 184(16):E867-76. PMID: 23048086.

Stiell IG, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ. 2009; 339:b4146. PMID: 19875425.

Stiell IG, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003; 349(26):2510-8. PMID: 14695411.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Abscesses are walled off collections of pus in soft tissue, with Staphylococcus aureus (both sensitive and resistant to methicillin) being the microbe most frequently involved. Most uncomplicated abscesses should undergo incision in an acute care setting such as the emergency department, using local anesthesia or procedural sedation, with complete drainage and appropriate follow-up. Antibiotics may be considered when patients are immunocompromised, systemically ill, or exhibit extensive surrounding cellulitis or lymphangitis. In populations with a high [methicillin-resistant S. aureus] MRSA prevalence, there is some evidence to suggest that antibiotics in addition to incision and drainage of uncomplicated abscesses may confer some benefit. However, we encourage physicians to discuss the use of antibiotics in uncomplicated abscesses with patients as the benefits conferred by antibiotics may not outweigh the risks associated with their use (i.e. nausea, diarrhea, and allergic reactions), and the possible benefit to a small percentage of patients may not balance the significant public health and societal effects of antibiotic overuse.

Sources:

Daum RS, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J of Med. 2017; 376(26):2545-2555. PMID:28657870.

Talan DA, et al. Trimethoprim-Sulfamethoxazole versus placebo for uncomplicated skin abcess.  N Engl J Med. 2016; 374(9):823-32. PMID:26962903.

Vermandere, M, et al. Antibiotics after incision and drainage for uncomplicated skin abcesses: a clinical practice guideline. BMJ. 2018; 360:k243. PMID: 29437651.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Patients commonly present to the emergency department with syncope. Syncope is a transient loss of consciousness followed by a spontaneous return to baseline neurologic function that does not require resuscitation. The evaluation of syncope should include a thorough history and physical exam to identify high-risk clinical predictors for CT head abnormalities. These high-risk predictors include, but are not limited to: trauma above the clavicles, headache, persistent neurologic deficit, age over 65, patients taking anticoagulants, or known malignancies. Many patients with syncope receive a CT scan of the head; however, in the absence of these predictors, a CT head is unlikely to aid in the management of syncope patients. CT scans can expose patients to unnecessary ionizing radiation that has the potential to increase patients’ lifetime risk of cancer. Unwarranted imaging also increases length of stay and misdiagnosis.

Sources:

Goyal N, et al. The utility of head computed tomography in the emergency department evaluation of syncope. Intern Emerg Med. 2006;1(2):148-50. PMID: 17111790.

Grossman SA, et al. The yield of head CT in syncope: a pilot study. Intern Emerg Med. 2007 Mar;2(1):46-9. Epub 2007 Mar 31. PMID: 17551685.

Sheldon RS, et al. Standardized approaches to the investigation of syncope: Canadian Cardiovascular Society position paper. Can J Cardiol. 2011 Mar-Apr;27(2):246-53. PMID: 21459273.

Sweanor RAL, et. al.  Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review. Acad Emerg Med. 2021 May;28(5):502-510. Epub 2021 Jan 28. PMID: 33382159.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Many adults present to the emergency department with chest pain and/or shortness of breath. The majority of adult patients with these symptoms do not have a pulmonary embolism (PE) that requires investigation with a CT pulmonary angiogram (CTPA) or ventilation perfusion (VQ) lung scan. CTPAs or VQ scans expose patients to ionizing radiation that has the potential to increase patients’ lifetime risk of cancer.  CTPAs also place patients at risk for potential allergic reaction and acute kidney injury from the intravenous contrast required for the CTs. Imaging also increases length of stay and may contribute to misdiagnosis. Evidence demonstrate that physicians should not order CTPAs or VQ scans to diagnose PE until risk stratification with a clinical decision rule (Wells score, PERC rule) has been applied and d-dimer biomarker results are obtained for those patients where it is indicated. For high-risk populations in which the clinical decision rules have not been validated (i.e., pregnancy, hypercoagulability disorders), physicians are urged to exert their clinical judgment.

Sources:

Kline JA, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008 May;6(5):772-80. PMID: 18318689.

Singh B, et al. Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis. Ann Emerg Med. 2012 Jun;59(6):517-20.e1-4. PMID: 22177109.

Wells PS, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. PMID: 11453709.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Adults and children frequently present to the emergency department with sore throats (pharyngitis). The vast majority of cases of pharyngitis are caused by self-limiting viral infections that do not respond to antibiotics. The benefit of antibiotics for the approximately 10% of cases in adults (25% in children), caused by bacteria (principally Group A Streptococcus [GAS]) is modest at best, although they are associated with fewer complications and a slightly shorter course of illness. Inappropriate administration of antibiotics can expose patients to unnecessary risks (i.e., allergies, rash, and diarrhea) and increase overall antibiotic resistance in the community. Evidence suggests that antibiotics should only be used in patients with intermediate and high clinical prediction scores for GAS (CENTOR or FeverPAIN score) AND confirmatory testing (throat cultures or rapid testing) that is positive for GAS.

Sources:

Centor RM, Witerspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis making. 1981;1:239-46. PMID: 6763125 

Institut national d’excellence en santé et en services sociaux (INESSS). Pharyngite-amygdalite chez l’enfant et l’adulte [En ligne]. Mise à jour en septembre 2017 [consulté le 14 février 2018].

Little P, Moore M, Hobbs FD, Mant D, McNulty C, Williamson I, et al. PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. 2013;3. PMID: 24163209.

Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;2013(11):CD000023. Published 2013 Nov 5. PMID: 24190439.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Foot and ankle injuries in children and adults are very common presentations to emergency departments. The Ottawa Ankle Rules (OAR) have been validated in both children (greater than 2 years old) and adult populations, and have been shown to reduce the number of X-rays performed without adversely affecting patient care. In alert, cooperative and sensate patients with blunt ankle and/or foot trauma within the previous ten days and who are not distracted by other injuries, only those who fulfill the OAR should undergo ankle and/or foot X-rays. Imaging of the ankle and/or foot in patients who are negative for the OAR does not improve outcomes, exposes the patient to unnecessary ionizing radiation and contributes to flow delays without providing additional value.

Sources:

Plint AC, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9. PMID: 10530658.

Stiell IG. Ottawa Ankle Rules by Dr. Ian Stiell [Video file]. 2015 Jul 7 [cited 2015 Nov 23].

Stiell IG, et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32. PMID: 8114236.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Both adults and children commonly present to the emergency department with symptoms of a middle ear infection, or acute otitis media (AOM). The symptoms of AOM include fever, earache, discharge from ear, and/or decreased hearing. Evidence suggests that adults and children with uncomplicated AOM do not need antibiotics. Treatment should focus on analgesia and the use of antibiotics should be limited to complicated or severe cases. A watch and wait approach (analgesia and observation for 48 to 72 hours) should be considered for healthy, non-toxic appearing children older than six months of age with no craniofacial abnormalities, mild disease (mild otalgia, temperature < 39°C without antipyretics), and who have reliable medical follow-up. Antibiotics should be considered if the child’s illness does not improve during the observation period, and for those children who are < 24 months of age with infection in both ears, and in those with AOM and ear discharge. Similarly, antibiotics should not be used for the initial treatment of uncomplicated AOM in adults. Delayed antibiotics are an effective alternative to immediate antibiotics to reduce antibiotic use. Inappropriate administration of antibiotics can expose patients to unnecessary risks (i.e., allergies, rash and diarrhea), and increase overall antibiotic resistance in the community.

Sources:

Centre for Clinical Practice at NICE (UK). Respiratory Tract Infections – Antibiotic Prescribing: Prescribing of Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in Primary Care. London: National Institute for Health and Clinical Excellence (UK); 2008 Jul. PMID: 21698847.

Spurling GK, et al. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2013 Apr 30;4:CD004417. PMID: 23633320.

Venekamp RP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015 Jun 23;6:CD000219. PMID: 26099233.

Related Resources:

Patient Pamphlet: Avoid Unnecessary Treatments in the ED: Talking with the doctor can help you make the best decision

Respiratory illnesses are among the most common reasons for pediatric emergency department (ED) visits, with wheezing being a frequently encountered clinical finding. For children presenting with first-time wheezing or with typical findings of asthma, bronchiolitis, or croup, radiographs rarely yield important positive findings and expose patients to radiation, increase cost of care, and prolonged ED length of stay. National and international guidelines emphasize the value of the history and physical examination in making an accurate diagnosis and excluding serious underlying pathology. Radiography performed in the absence of significant findings has been shown to be associated with overuse of antibiotics. Radiographs should not be routinely obtained in these situations unless findings such as significant hypoxia, focal abnormalities on lung exam, prolonged course of illness, or severe distress are present. If wheezing is occurring without a clear atopic etiology or without upper respiratory tract infection symptoms (eg, rhinorrhea, nasal congestion, and/or fever), appropriate diagnostic imaging should be considered on a case-by-case basis

Sources:

Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. PMID: 25349312.

Trottier ED, Chan K, Allain D, Chauvin-Kimoff L. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438-439. PMID: 34777663.

Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. PMID: 28763554.

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. PMID: 17382126.

National Heart, Lung, and Blood Institute. Expert Panel Report 4: Guidelines for the Diagnosis and Management of Asthma; National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007:391.

The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.

Sources:

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163. PMID: 31978283.

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818. PMID: 25941283.

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677. PMID: 24342816.

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663. PMID: 24219903.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807. PMID: 24642041.

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department—epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85-89. PMID: 16481922.

Children presenting with unprovoked, generalized seizures or simple febrile seizures who return to their baseline mental status rarely have blood test or CT scan findings that change acute management.

Blood tests such as electrolyte panels should not be routinely ordered and are only indicated in specific circumstances based on history and clinical examination findings.

CT scans are associated with radiation-related risk of cancer, increased cost of care, and added risk if sedation is required to complete the scan. A head CT scan may be indicated in patients with a new focal seizure, new focal neurologic findings, or high-risk medical history (such as neoplasm, stroke, coagulopathy, sickle cell disease, age <6 months).

Sources:

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020. PMID: 10980722.

Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550. PMID: 17101884.

McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26(1):50-57. PMID: 33552322.

American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. PMID: 21285335.

Functional constipation and nonspecific, generalized abdominal pain are common presenting complaints for children in emergency departments. Constipation is a clinical diagnosis and does not require testing, yet many of these children receive an abdominal radiograph. However, subjectivity and lack of standardization result in poor sensitivity and specificity of abdominal radiographs to diagnose constipation. Use of abdominal radiographs to diagnose constipation has been associated with increased diagnostic error. Clinical guidelines recommend against obtaining routine abdominal radiographs in patients with clinical diagnosis of functional constipation. The diagnosis of constipation or fecal impaction should be made primarily by history and physical examination, augmented by a digital rectal examination when indicated.

Sources:

Freedman SB, Rodean J, Hall M, et al. Delayed diagnoses in children with constipation: multicenter retrospective cohort study. J Pediatr. 2017;186:87-94.e16. PMID: 28457526.

Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: Comparison of different scoring methods. J Pediatr Gastroenterol Nutr. 2010;51(2):155-159. PMID: 20453675.

Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA. Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review. J Pediatr. 2012;161(1):44–50.e502. PMID: 22341242.

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. PMID: 24345831.

Kearney R, Edwards T, Braford M, Klein E. Emergency provider use of plain radiographs in the evaluation of pediatric constipation. Pediatr Emerg Care. 2019;35(9):624-629. PMID: 30045349.

Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83-88.e2. PMID: 24128647.

Viral infections occur frequently in children and are a common reason to seek medical care. The diagnosis of a viral illness is made clinically and usually does not require confirmatory testing. Additionally, there is a lack of consistent evidence to demonstrate the impact of comprehensive viral panel (i.e., panels simultaneously testing for 8-20+ viruses) results on clinical outcomes or management, especially in emergency department settings. Hence, most national and international clinical practice guidelines do not recommend their routine use. Additionally, some viral tests are quite expensive, and obtaining nasopharyngeal swab specimens can be uncomfortable for children. Comprehensive viral panel testing can be considered in high-risk patients (eg, immunocompromised) or in situations in which the results will directly influence treatment decisions such as the need for antibiotics, performance of additional tests, or hospitalization. Testing for specific viruses might be indicated if the results of the testing may alter treatment plans (e.g., antivirals for influenza) or public health recommendations (e.g., isolation for SARS-CoV-2). For more specific recommendations related to diagnosis and management of SARS-CoV-2, please see https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/).

Sources:

Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804. PMID: 28672402.

Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494. PMID: 31167816.

Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562. PMID: 25136044.

Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5. PMID: 33323392.