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Desai S, Remick KE. Overcoming Vulnerabilities in Our Emergency Care System Through Pediatric Readiness. Pediatr Clin North Am 2024; 71:371-381. [PMID: 38754930 DOI: 10.1016/j.pcl.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Although children account for 20% of all emergency department (ED) visits, the majority of children seek emergency care in hospitals that see fewer than 10 children per day. The National Pediatric Readiness Project has defined key system-level standards for all EDs to safely care for ill and injured children. High pediatric readiness is associated with improvement in mortality for critically ill and injured children. However, to improve readiness and sustain system-level changes, hospitals must invest in pediatric champions and empower them to engage in continuous quality improvement. Finally, incorporating pediatric readiness into policy is crucial for its long-term sustainability.
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Affiliation(s)
- Sanyukta Desai
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX 78723, USA
| | - Katherine E Remick
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX 78723, USA.
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Owen MM, Workman CD, Angileri HS, Terry MA, Tjong VK. Musculoskeletal injuries during trail sports: Sex- and age-specific analyses over 20 years from a national injury database. Wilderness Environ Med 2024; 35:138-146. [PMID: 38454756 DOI: 10.1177/10806032241234029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Musculoskeletal (MSK) injuries in US trail sports are understudied as trail sport popularity grows. This study describes MSK injury patterns among hikers, trail runners, and mountain bikers from 2002 through 2021 and investigates MSK injury trends acquired during mountain sports. METHODS The National Electronic Injury Surveillance System (NEISS) was used to identify US emergency department (ED) patients from 2002-2021 (inclusive) who endured MSK injuries during hiking, trail running, or mountain biking. Injury rates and national estimates were calculated across demographics. RESULTS 9835 injuries were included (48.4% male, 51.6% female). Injuries increased over time, with 1213 from 2002-2005 versus 2417 from 2018-2021. No sex differences existed before 2010, after which female injury rates exceeded those of males. The following findings were statistically significant, with P<0.05: females endured more fractures and strains/sprains; males endured more lacerations; concussions and head injuries were higher among those <18 y; dislocations and strains/sprains were higher for 18 to 65 y; fractures were higher for >65 y; <18 y had high mountain-biking and low running rates; 18 to 65 y had high running rates; and >65 y had low biking and running rates. Although all diagnoses increased in number over time, no significant differences existed in the proportion of any given diagnosis relative to total injuries. CONCLUSIONS MSK injuries during trail sports have increased since 2002. Males endured more injuries until 2009, after which females endured more. Significant sex and age differences were found regarding injury diagnosis and body parts. Further studies are needed to confirm these trends and their causes.
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Affiliation(s)
- Madeline M Owen
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Connor D Workman
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Michael A Terry
- Division of Orthopaedic Surgery, Northwestern University, Chicago, IL
| | - Vehniah K Tjong
- Division of Orthopaedic Surgery, Northwestern University, Chicago, IL
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Krack AT, Eckerle M, Mahajan P, Ramilo O, VanBuren JM, Banks RK, Casper TC, Schnadower D, Kuppermann N. Leukopenia, neutropenia, and procalcitonin levels in young febrile infants with invasive bacterial infections. Acad Emerg Med 2024. [PMID: 38661246 DOI: 10.1111/acem.14921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND OBJECTIVE Serum procalcitonin (PCT) is a highly accurate biomarker for stratifying the risk of invasive bacterial infections (IBIs) in febrile infants ≤60 days old. However, PCT is unavailable in some settings. We explored the association of leukopenia and neutropenia with IBIs in non-critically ill febrile infants ≤60 days old, with and without PCT. METHODS We conducted a secondary analysis of a prospective observational cohort consisting of 7407 non-critically ill infants ≤60 days old with temperatures ≥38°C. We focused on the risk of IBIs in patients with leukopenia (white blood cell [WBC] count <5000 cells/μL) or neutropenia (absolute neutrophil count [ANC] <1000 cells/μL), categorized to extremes of lower values, and the impact of PCT on these associations. Multiple logistic regression was used to identify independent predictors of IBIs. RESULTS Final analysis included 6865 infants with complete data; 45% (3098) had PCT data available. Of the 6865, a total of 111 (1.6%) had bacteremia without bacterial meningitis, 18 (0.3%) had bacterial meningitis without bacteremia, and 19 (0.3%) had both bacteremia and bacterial meningitis. IBI was present in four of 20 (20%) infants with WBC counts ≤2500 cells/μL and four of 311 (1.3%) with ANC <1000 cells/μL. In multivariable logistic regression analysis not including PCT, a WBC count <2500 cells/μL was significantly associated with IBI (OR 13.48, 95% CI 2.92-45.35). However, no patients with leukopenia or neutropenia and PCT ≤0.5 ng/mL had IBIs. CONCLUSIONS Leukopenia ≤2500 cells/μL in febrile infants ≤60 days old is associated with IBIs. However, in the presence of normal PCT levels, no patients with leukopenia had IBIs. While this suggests leukopenia ≤2500 cells/μL is a risk factor for IBIs in non-critically ill young febrile infants only when PCT is unavailable or elevated, the overall low frequency of leukopenia in this cohort warrants caution in interpretation, with future validation required.
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Affiliation(s)
- Andrew T Krack
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michelle Eckerle
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | | | | | | | | | - David Schnadower
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nathan Kuppermann
- University of California Davis, School of Medicine, Sacramento, California, USA
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Abu-Sultanah M, Lutfi R, Abu-Sultaneh S, Pearson KJ, Montgomery EE, Whitfill T, Auerbach MA, Abulebda K. The Effect of a Collaborative Pediatric Emergency Readiness Improvement Intervention on Patients' Hospital Outcomes. Acad Pediatr 2024:S1876-2859(24)00149-9. [PMID: 38657901 DOI: 10.1016/j.acap.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 04/07/2024] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE We hypothesized that collaborative intervention to improve weighted pediatric readiness score (WPRS) will be associated with decreased pediatric intensive care (PICU) mortality, PICU and hospital length of stay. METHODS This study analyzes the transfer of acutely ill and injured patients from general emergency departments (GEDs) to our institution. The intervention involved customized assessment reports focusing on team performance and systems improvement for pediatric readiness, sharing best practices and clinical resources, designation of a nurse PECC at each GED and ongoing interactions at 2 and 4 months. Data was collected from charts before and after the intervention, focusing on patients transferred to our pediatric emergency department (ED) or directly admitted to our PICU from the GEDs. Clinical outcomes such as PICU length of stay (LOS), hospital LOS, and PICU mortality were assessed. Descriptive statistics were used for demographics, and various statistical tests were employed to analyze the data. Bivariate analyses and multivariable models were utilized to examine patient outcomes and the association between the intervention and outcomes. RESULTS There were 278 patients in the pre-intervention period and 314 patients in the post-intervention period. Multivariable analyses revealed a significant association between the change in WPRS and decreased PICU LOS (β=-0.05 [95% CI: -0.09, -0.01), p=0.023), and hospital LOS (β=-0.12 [95% CI: -0.21, -0.04], p=0.004), but showed no association between the intervention and other patient outcomes. CONCLUSIONS In this cohort, improving pediatric readiness scores in GEDs was associated with significant improvements in PICU and hospital length of stay. Future initiatives should focus on disseminating pediatric readiness efforts to improve outcomes of critically ill children nationally. WHATS NEW Improving pediatric readiness scores in general emergency departments is associated with improved downstream clinical outcomes demonstrated by reduced PICU and hospital length of stay.
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Affiliation(s)
- Mohannad Abu-Sultanah
- The Department of Pediatrics, Division of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Indianapolis
| | - Riad Lutfi
- The Department of Pediatrics, Division of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Indianapolis
| | - Samer Abu-Sultaneh
- The Department of Pediatrics, Division of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Indianapolis
| | - Kellie J Pearson
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Marc A Auerbach
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Kamal Abulebda
- The Department of Pediatrics, Division of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Indianapolis.
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Freiman EC, Monuteaux MC, Michelson KA. Variation and Drivers of Costs for Emergency Department Visits Among Children in 8 States. Hosp Pediatr 2024; 14:258-264. [PMID: 38505934 PMCID: PMC11015896 DOI: 10.1542/hpeds.2023-007417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To describe variation in costs for emergency department (ED) visits among children and to assess hospital and regional factors associated with costs. METHODS Cross-sectional study of all ED encounters among children under 18 years in 8 states from 2014 to 2018. The primary outcome was each hospital's mean inflation-adjusted ED costs. We evaluated variability in costs between hospitals and determined factors associated with costs using hierarchical linear models at the state, region, and hospital levels. Models adjusted for pediatric case mix, regional wages, Medicaid share, trauma status, critical access status, ownership, and market competitiveness. RESULTS We analyzed 22.9 million ED encounters across 713 hospitals. The median ED-level cost was $269 (range 99-1863). There was a 5.1-fold difference in median ED-level costs between the lowest- and highest-cost regions (range 119-605). ED-level costs were associated with case mix index (+38% per 10% increase, 95% confidence interval [CI] 30 to 47); wages [+7% per 10% increase, 95% CI 5 to 9]); critical access (adjusted costs, +24%, 95% CI 13 to 35); for profit status (-20%, 95% CI -26 to -14) compared with nonprofit, lowest trauma designation (+17%, 95% CI 5 to 30); teaching hospital status (+7%, 95% CI 1 to 14); highest number of inpatient beds (+13%, 95% CI 4 to 23); and Medicaid share versus quarter (Q)1 (Q2: -12%, 95% CI -18 to -7; Q3: -13%, 95% CI -19 to -7; Q4: -11%, 95% CI -17 to -4). CONCLUSIONS Our results suggest nonclinical factors are important drivers of pediatric health care costs.
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Affiliation(s)
- Eli C Freiman
- Division of Emergency Medicine, Newton Wellesley Hospital, Newton, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth A Michelson
- Division of Emergency Medicine, Lurie Children's Hospital of Chicago, Chicago, Illinois
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Baker AH, Lee LK, Sard BE, Chung S. The 4 S's of Disaster Management Framework: A Case Study of the 2022 Pediatric Tripledemic Response in a Community Hospital. Ann Emerg Med 2024:S0196-0644(24)00032-5. [PMID: 38363279 DOI: 10.1016/j.annemergmed.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/28/2023] [Accepted: 01/12/2024] [Indexed: 02/17/2024]
Abstract
Most children in the United States present to community hospitals for emergency department (ED) care. Those who are acutely ill and require critical care are stabilized and transferred to a tertiary pediatric hospital with intensive care capabilities. During the fall of 2022 "tripledemic," with a marked increase in viral burden, there was a nationwide surge in pediatric ED patient volume. This caused ED crowding and decreased availability of pediatric hospital intensive care beds across the United States. As a result, there was an inability to transfer patients who were critically ill out, and the need for prolonged management increased at the community hospital level. We describe the experience of a Massachusetts community ED during this surge, including the large influx in pediatric patients, the increase in those requiring critical care, and the total number of critical care hours as compared with the same time period (September to December) in 2021. To combat these challenges, the pediatric ED leadership applied a disaster management framework based on the 4 S's of space, staff, stuff, and structure. We worked collaboratively with general emergency medicine leadership, nursing, respiratory therapy, pharmacy, local clinicians, our regional health care coalition, and emergency medical services (EMS) to create and implement the pediatric surge strategy. Here, we present the disaster framework strategy, the interventions employed, and the barriers and facilitators for implementation in our community hospital setting, which could be applied to other community hospital facing similar challenges.
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Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA; Department of Pediatrics, St. Luke's Hospital, New Bedford, MA.
| | - Lois K Lee
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA
| | - Brian E Sard
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA; Department of Pediatrics, St. Luke's Hospital, New Bedford, MA
| | - Sarita Chung
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA
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Iqbal AU, Whitfill T, Tiyyagura G, Auerbach M. The Role of Advanced Practice Providers in Pediatric Emergency Care Across Nine Emergency Departments. Pediatr Emerg Care 2024; 40:131-136. [PMID: 38286004 DOI: 10.1097/pec.0000000000003120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
OBJECTIVES Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients. METHODS We performed a retrospective chart review of encounters in patients aged younger than 18 years across 9 EDs from January 2018 to December 2019. Data on age, acuity level, International Classification of Diseases, Tenth Revision code, procedures performed, disposition, provider type, and length of stay were extracted from the electronic health record. RESULTS Of 159,035 patient encounters, 37% were cared for by an APP (30% APP independently, 7% physician + APP) and 63% by physicians independently. Advance practice providers were more likely to care for lower acuity patients (60.8% vs 4.4%, P < 0.05) and those in EDs with less pediatric emergency medicine (PEM) coverage (33.4% vs 6.8%, P < 0.05). In an adjusted multinomic regression model, APPs were less likely than physicians to care for high-acuity patients (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.09), admitted patients (OR, 0.31; CI, 0.28-0.35) and patients in EDs with more PEM coverage (OR, 0.09; CI, 0.09-0.09). CONCLUSIONS Advance practice providers cared for more than one third of pediatric patients and tended to care for lower acuity patients and for patients in EDs with less PEM coverage. These data highlight the importance of integrating APPs into initiatives aiming to improve pediatric emergency care.
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Affiliation(s)
| | | | | | - Marc Auerbach
- From the Yale University School of Medicine, New Haven, CT
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Grover P, Kumar M. Pediatric Psychiatric Emergencies. Emerg Med Clin North Am 2024; 42:151-162. [PMID: 37977747 DOI: 10.1016/j.emc.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early diagnosis and treatment improve clinical outcome. Medical reasons for the patient's presentation should be explored. Both physical and emotional safety must be ensured. A multidisciplinary approach, utilizing local primary care and psychiatric resources, is recommended.
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Affiliation(s)
- Purva Grover
- Cleveland Clinic, 6780 Mayfield Road, Mayfield Heights, OH 44124, USA.
| | - Manya Kumar
- Vardhman Mahavir Medical College, Safdarjung Hospital, Ansari Nagar East, New Delhi, Delhi 110029, India
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Belfer J, Roskind CG, Grock A, Jung J, Bae SW, Zhao L, Sobolewski B. Systematic online academic resource (SOAR) review: Pediatric respiratory infectious disease. AEM Educ Train 2024; 8:e10945. [PMID: 38510728 PMCID: PMC10950020 DOI: 10.1002/aet2.10945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/28/2023] [Accepted: 12/05/2023] [Indexed: 03/22/2024]
Abstract
Background Free open access medical education (FOAM) resources have become increasingly popular in graduate medical education. Despite their accessibility, the assessment of FOAM resources' quality is challenging due to their decentralized nature and the diverse qualifications of their authors and distribution platforms. In this first pediatric systematic online academic resource (SOAR) review, we utilized a systematic methodology to aggregate and assess the quality of FOAM resources on pediatric respiratory infectious disease topics. Methods We searched 177 keywords using FOAMSearch, the top 50 FOAM websites on the Social Media Index, and seven additional pediatric emergency medicine-focused blogs. Following a basic initial screen, resources then underwent full-text quality assessment utilizing the revised Medical Education Translational Resources: Impact and Quality (rMETRIQ) tool. Results The search yielded 44,897 resources. After 44,456 were excluded, 441 underwent quality assessment. A total of 36/441 posts (8% of posts) reached the high-quality threshold score (rMETRIQ ≥ 16). The most frequent topics overall were pneumonia and bronchiolitis. A total of 67/441 posts (15% of posts) were found to have a rMETRIQ score of less than or equal to 7, which may indicate poor quality. Conclusions We systematically identified, described, and performed quality assessment on FOAM resources pertaining to the topic of pediatric respiratory infectious disease. We found that there is a paucity of high-quality posts on this topic. Despite this, the curated list of high-quality resources can help guide trainees and educators toward relevant educational information and suggest unmet needs for future FOAM resources.
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Affiliation(s)
- Joshua Belfer
- New York–Presbyterian Columbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Cindy G. Roskind
- New York–Presbyterian Columbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Andrew Grock
- DGOSM at UCLA, VAGLA HospitalLos AngelesCaliforniaUSA
| | - JooYeon Jung
- University of California DavisDavisCaliforniaUSA
| | | | - Lisa Zhao
- DGOSM at UCLA, VAGLA HospitalLos AngelesCaliforniaUSA
| | - Brad Sobolewski
- Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- University of Cincinnati College of Medicine Department of PediatricsCincinnatiOhioUSA
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Nocera Kelley M, Lynders W, Pelletier E, Petrucelli M, Emerson B, Tiyyagura GK, Goldman MP. Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative. Emerg Med J 2024; 41:116-122. [PMID: 38050053 DOI: 10.1136/emermed-2023-213232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/09/2023] [Indexed: 12/06/2023]
Abstract
Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these gaps using quality improvement (QI) methodology. Project champion from a community hospital network identified the use of safe pharmacological and non-pharmacological anxiolysis and analgesia (A&A) as one such gap and partnered with EMSC to address it. Our primary Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) aim was to increase intranasal midazolam (INM) use for common, anxiety-provoking procedures on children <8 years of age from 2% to 25% in a year.EMSC facilitated a QI team with representation from the CED and regional children's hospitals. Following the model for improvement, we initiated a process analysis of this CED A&A practice. Review of all paediatric procedural data identified common anxiety-provoking simple procedures as laceration repairs, abscess drainage and foreign body removal. Our SMART aims were benchmarked to two regional PEDs and tracked through statistical process control. A balancing metric was ED length of stay (ED LOS) for patients <8 years of age requiring a laceration repair. Additionally, we surveyed CED frontline staff and report perceptions of changes in A&A knowledge, attitudes and practice patterns. These data prioritised and informed our key driver diagram which guided the Plan-Do-Study-Act (PDSA) cycles, including guideline development, staff training and cognitive aids.Anxiety-provoking simple procedures occurred on average 10 times per month in children <8 years of age. Through PDSA cycles, the monthly average INM use increased from 2% to 42%. ED LOS was unchanged, and the perceptions of provider's A&A knowledge, attitudes and practice patterns improved.A CED-initiated QI project increased paediatric A&A use in a CED network. An A&A toolkit outlines our approach and may simplify spread from academic children's hospitals to the community.
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Affiliation(s)
- Mariann Nocera Kelley
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine/Traumatology, University of Connecticut School of Medicine, Connecticut Children's Hospital, Hartford, Connecticut, USA
- Emergency Medical Services for Children, Connecticut, New Haven, Connecticut, USA
| | - Willliam Lynders
- Emergency Medical Services for Children, Connecticut, New Haven, Connecticut, USA
- Emergency Medicine, Middlesex Health, Middletown, Connecticut, USA
| | - Emily Pelletier
- Emergency Medicine, Middlesex Health, Middletown, Connecticut, USA
| | - Megan Petrucelli
- Emergency Medical Services for Children, Connecticut, New Haven, Connecticut, USA
- Emergency Medicine, Middlesex Health, Middletown, Connecticut, USA
| | - Beth Emerson
- Department of Pediatrics and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gunjan K Tiyyagura
- Department of Pediatrics and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Paul Goldman
- Emergency Medical Services for Children, Connecticut, New Haven, Connecticut, USA
- Department of Pediatrics and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Utsumi S, Amagasa S, Moriwaki T, Uematsu S. Oral analgesic for musculoskeletal injuries in children: A systematic review and network meta-analysis. Acad Emerg Med 2024; 31:61-70. [PMID: 37688572 DOI: 10.1111/acem.14803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE Pain in pediatric musculoskeletal (MSK) injuries can lead to increased anxiety, fear, and avoidance of medical care, making analgesic management critical. Therefore, we evaluated analgesic efficacy and adverse effects to select the optimal analgesic agent in pediatric patients with MSK injuries. METHODS Four databases were searched from inception to March 2023 for peer-reviewed, open randomized controlled trials (RCTs). Inclusion criteria were: (1) trials with RCT design, (2) children aged 1 month-18 years with MSK injury, (3) outpatient setting, (4) interventions and control, (5) primary outcome of pain score at 60 and 120 min and secondary outcome of adverse effects, and (6) full-text and peer-reviewed articles. Two reviewers screened, extracted data, and assessed the risk of bias. A frequentist random-effects network meta-analysis (NMA) was performed. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach. RESULTS We included eight trials comprising 1645 children. Ibuprofen was significantly associated with pain reduction at 120 min, compared with acetaminophen (SMD 0.31 [95% CI 0.11-0.51]; moderate certainty) and opioids (SMD 0.34 [95% CI 0.20-0.48]; moderate certainty). Compared with opioids alone, ibuprofen-opioid combination was significantly associated with pain reduction at 120 min (SMD 0.19 [95% CI 0.03-0.35]). No significant differences were found in pain interventions at 60 min. Ibuprofen had statistically fewer adverse events than opioids (RR, 0.54 [95% CI 0.33-0.90]; moderate certainty) and ibuprofen with opioids (RR 0.47 [95% CI 0.25-0.89]; moderate certainty). In terms of limitations, the eight RCTs included had relatively small sample sizes; only two were high-quality RCTs. CONCLUSIONS Our NMA found ibuprofen to be the most effective and least adverse analgesic in pediatric patients with MSK injuries.
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Affiliation(s)
- Shu Utsumi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Emergency and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Amagasa
- Department of Emergency and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Taro Moriwaki
- Department of Emergency and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoko Uematsu
- Department of Emergency and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan
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Schoppel K, Spector J, Okafor I, Church R, Deblois K, Della‐Giustina D, Kellogg A, MacVane C, Pirotte M, Snow D, Hays G, Mariorenzi A, Connelly H, Sheng A. Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates. AEM Educ Train 2023; 7:e10918. [PMID: 38037628 PMCID: PMC10685395 DOI: 10.1002/aet2.10918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 12/02/2023]
Abstract
Background More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency. Methods This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email. Results A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001). Conclusions/discussion This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.
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Affiliation(s)
- Kyle Schoppel
- Indiana University School of Medicine, Riley Hospital for ChildrenIndianapolisIndianaUSA
| | - Jordan Spector
- Boston University Chobanian & Avedisian School of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Ijeoma Okafor
- Boston University Chobanian & Avedisian School of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Richard Church
- University of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | | | | | | | - Casey MacVane
- Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | | | - David Snow
- Loyola University Medical CenterMaywoodIllinoisUSA
| | - Geoffrey Hays
- Indiana University School of Medicine, Riley Hospital for ChildrenIndianapolisIndianaUSA
| | - Amy Mariorenzi
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Haley Connelly
- Boston University Chobanian & Avedisian School of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Alexander Sheng
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
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13
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Chandler NM. Missed Diagnosis of Pediatric Appendicitis: It Takes a Village. Ann Surg 2023; 278:839-840. [PMID: 37724458 DOI: 10.1097/sla.0000000000006095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
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14
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Martin SR, Hung I, Heyming TW, Fortier MA, Kain ZN. Predictors of parental anxiety in a paediatric emergency department. Emerg Med J 2023; 40:715-720. [PMID: 37591685 DOI: 10.1136/emermed-2022-212917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 08/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates that parents experience anxiety surrounding their children's medical procedures, less is known about parental anxiety and factors that contribute to higher parental anxiety in the ED. This study aimed to assess parental anxiety in families presenting to a paediatric ED with a variety of presenting concerns and examine demographic and psychological factors associated with parental anxiety. METHODS This cross-sectional study included parents of children <18 years old presenting to a paediatric ED in Orange County, California, USA, for a non-psychiatric complaint between 20 January 2021 and 26 March 2021. Parents were, on average, 34.76±9.10 years old, 87.5% were mothers, 59.2% identified as non-Latinx and parents reported average levels of mental health (T-score=51.21±9.84). Parent state anxiety was assessed via the State-Trait Anxiety Inventory and validated instruments were used to measure child temperament (ie, emotionality, activity, sociability, shyness), previous medical anxiety, and parent physical and mental health. Data were analysed using multiple linear regression models. RESULTS Out of 201 families screened, 150 were eligible, and 120 enrolled. In the sample, 42.5% of parents endorsed clinically significant levels of anxiety in the ED. Regression analyses indicated that lower child activity temperament (ie, tendency to be less active/energetic; B=-3.20, 95% CI -5.70 to -0.70, p=0.012) and poorer parent mental health (B=-0.31, 95% CI -0.52 to -0.09, p=0.006) were independently associated with higher parent anxiety (F(5, 99)=6.77, p=0.004). CONCLUSION Over 40% of parents sampled endorsed clinically significant anxiety in the paediatric ED. Child temperament, specifically lower activity temperament, and poorer parental mental health were identified as contributors to parent anxiety, whereas clinical condition or severity did not influence parent anxiety. Current results may help identify families in need of additional intervention and may improve patient outcomes.
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Affiliation(s)
- Sarah R Martin
- Anesthesiology & Perioperative Care, University of California Irvine, Irvine, California, USA
- Center on Stress & Health, University of California, Irvine, Orange, California, USA
- Emergency Medicine, Children's Hospital of Orange County, Orange, California, USA
| | - Isaac Hung
- Center on Stress & Health, University of California, Irvine, Orange, California, USA
- School of Medicine, University of California Irvine, Irvine, California, USA
| | - Theodore W Heyming
- Emergency Medicine, Children's Hospital of Orange County, Orange, California, USA
- Department of Emergency Medicine, University of California Irvine, Irvine, California, USA
| | - Michelle A Fortier
- Center on Stress & Health, University of California, Irvine, Orange, California, USA
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
- Children's Hospital of Orange County, Orange, California, USA
| | - Zeev N Kain
- Anesthesiology & Perioperative Care, University of California Irvine, Irvine, California, USA
- Center on Stress & Health, University of California, Irvine, Orange, California, USA
- Children's Hospital of Orange County, Orange, California, USA
- Child Study Center, Yale University, New Haven, Connecticut, USA
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15
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Overhage L, Hailu R, Busch AB, Mehrotra A, Michelson KA, Huskamp HA. Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic. JAMA Psychiatry 2023; 80:924-932. [PMID: 37436733 PMCID: PMC10339224 DOI: 10.1001/jamapsychiatry.2023.2195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/21/2023] [Indexed: 07/13/2023]
Abstract
Importance Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources. Objective To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic. Design, Setting, and Participants This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively. Exposure The COVID-19 pandemic. Main outcomes and measures The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit. Results Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%). Conclusions and relevance Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.
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Affiliation(s)
- Lindsay Overhage
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ruth Hailu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alisa B. Busch
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- McLean Hospital, Belmont, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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16
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Miller KA, Cavallaro S, Hirsch A, Hudgins J, Levy J, Li J, Lipton G, Marchese A, Mannix RC, Monuteaux MC, Schutzman S, Miller AF. Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where. AEM Educ Train 2023; 7:e10903. [PMID: 37600855 PMCID: PMC10436031 DOI: 10.1002/aet2.10903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Abstract
Objectives Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions. Methods This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods. Results Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods. Conclusions Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.
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Affiliation(s)
- Kelsey A. Miller
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Sarah Cavallaro
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Alexander Hirsch
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Joel Hudgins
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Jason Levy
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Joyce Li
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Galina Lipton
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Ashley Marchese
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Rebekah C. Mannix
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | | | - Sara Schutzman
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Andrew F. Miller
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
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17
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Remick KE, Hewes HA, Ely M, Schmuhl P, Crady R, Cook LJ, Ludwig L, Gausche-Hill M. National Assessment of Pediatric Readiness of US Emergency Departments During the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2321707. [PMID: 37418265 PMCID: PMC10329204 DOI: 10.1001/jamanetworkopen.2023.21707] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 07/08/2023] Open
Abstract
Importance The National Pediatric Readiness Project assessment provides a comprehensive evaluation of the readiness of US emergency departments (EDs) to care for children. Increased pediatric readiness has been shown to improve survival for children with critical illness and injury. Objectives To complete a third assessment of pediatric readiness of US EDs during the COVID-19 pandemic, to examine changes in pediatric readiness from 2013 to 2021, and to evaluate factors associated with current pediatric readiness. Design, Setting, and Participants In this survey study, a 92-question web-based open assessment of ED leadership in US hospitals (excluding EDs not open 24 h/d and 7 d/wk) was sent via email. Data were collected from May to August 2021. Main Outcomes and Measures Weighted pediatric readiness score (WPRS) (range, 0-100, with higher scores indicating higher readiness); adjusted WPRS (ie, normalized to 100 points), calculated excluding points received for presence of a pediatric emergency care coordinator (PECC) and quality improvement (QI) plan. Results Of the 5150 assessments sent to ED leadership, 3647 (70.8%) responded, representing 14.1 million annual pediatric ED visits. A total of 3557 responses (97.5%) contained all scored items and were included in the analysis. The majority of EDs (2895 [81.4%]) treated fewer than 10 children per day. The median (IQR) WPRS was 69.5 (59.0-84.0). Comparing common data elements from the 2013 and 2021 NPRP assessments demonstrated a reduction in median WPRS (72.1 vs 70.5), yet improvements across all domains of readiness were noted except in the administration and coordination domain (ie, PECCs), which significantly decreased. The presence of both PECCs was associated with a higher adjusted median (IQR) WPRS (90.5 [81.4-96.4]) compared with no PECC (74.2 [66.2-82.5]) across all pediatric volume categories (P < .001). Other factors associated with higher pediatric readiness included a full pediatric QI plan vs no plan (adjusted median [IQR] WPRS: 89.8 [76.9-96.7] vs 65.1 [57.7-72.8]; P < .001) and staffing with board-certified emergency medicine and/or pediatric emergency medicine physicians vs none (median [IQR] WPRS: 71.5 [61.0-85.1] vs 62.0 [54.3-76.0; P < .001). Conclusions and Relevance These data demonstrate improvements in key domains of pediatric readiness despite losses in the health care workforce, including PECCs, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness.
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Affiliation(s)
- Katherine E. Remick
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin
- National Emergency Medical Services for Children Innovation and Improvement Center, Austin, Texas
| | - Hilary A. Hewes
- Emergency Medical Services (EMS) for Children Data Center, Salt Lake City, Utah
- University of Utah, Department of Pediatrics, Salt Lake City
| | - Michael Ely
- Emergency Medical Services (EMS) for Children Data Center, Salt Lake City, Utah
- University of Utah, Department of Pediatrics, Salt Lake City
| | - Patricia Schmuhl
- Emergency Medical Services (EMS) for Children Data Center, Salt Lake City, Utah
- University of Utah, Department of Pediatrics, Salt Lake City
| | - Rachel Crady
- Emergency Medical Services (EMS) for Children Data Center, Salt Lake City, Utah
- University of Utah, Department of Pediatrics, Salt Lake City
| | - Lawrence J. Cook
- Emergency Medical Services (EMS) for Children Data Center, Salt Lake City, Utah
- University of Utah, Department of Pediatrics, Salt Lake City
| | - Lorah Ludwig
- EMS for Children Branch, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics, Harbor-UCLA Medical Center, Torrance, California
- The Lundquist Institute at Harbor-UCLA, Torrance, California
- Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
- The Los Angeles County EMS Agency, Los Angeles, California
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18
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Nash KA, Olfson M, Rothenberg C, Anderson BR, Pincus HA, Venkatesh AK. Psychotropic Medication Use in United States Pediatric Emergency Department Visits. Acad Pediatr 2023; 23:971-979. [PMID: 36494030 PMCID: PMC10241984 DOI: 10.1016/j.acap.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE AND BACKGROUND Little is known about pediatric psychotropic medication use in the emergency department (ED), despite a rise in mental and behavioral health visits. This study describes psychotropic medication use in a nationally representative sample of pediatric mental and behavioral health ED visits over a 14-year period. METHODS We conducted a cross-sectional analysis of pediatric (6-17 years) mental and behavioral health ED visits using the National Hospital Ambulatory Medical Care Survey, 2006-2019. We describe administration of psychotropic medications by medication type, diagnosis, and over time. Using multivariable survey-weighted logistic regression, we examine associations between medication administration and sociodemographics. RESULTS A psychotropic medication was administered in 11.4% of the estimated 11,792,860 pediatric mental and behavioral health ED visits in our sample. Benzodiazepines were administered most frequently (4.9% of visits). Visits with anxiety disorders had the highest frequency of psychotropic medication use (26.7%). Visits by Black non-Hispanic patients had a 60% decreased odds of medication administration compared to visits for White non-Hispanic patients. Visits with public compared to private insurance had a 3.5 times increased odds of psychotropic polypharmacy. The proportion of visits in which a psychotropic medication was administered did not change statistically over time. CONCLUSIONS A psychotropic medication was administered in 1 in 10 pediatric mental and behavioral health ED visits. Use differed by sociodemographics but did not change over time. As more youth seek mental and behavioral health care in the ED, we must better understand appropriate medication use to ensure quality and equitable care.
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Affiliation(s)
- Katherine A Nash
- Division of Pediatric Critical Care and Hospital Medicine, New York-Presbyterian/Columbia University Irving Medical Center (KA Nash), New York, NY.
| | - Mark Olfson
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute (M Olfson), New York, NY
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine (C Rothenberg and AK Venkatesh), New Haven, Conn
| | - Brett R Anderson
- Division of Pediatric Cardiology; New York-Presbyterian/Columbia University Irving Medical Center (BR Anderson), New York, NY
| | - Harold Alan Pincus
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute (HA Pincus), New York, NY
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine (C Rothenberg and AK Venkatesh), New Haven, Conn
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19
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Leung JS, Foohey S, Burns R, Bank I, Nemeth J, Sanseau E, Auerbach M. Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room. AEM Educ Train 2023; 7:e10868. [PMID: 37215281 PMCID: PMC10199309 DOI: 10.1002/aet2.10868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 05/24/2023]
Abstract
Background Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum. Methods EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues. Results Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively. Conclusions Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.
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Affiliation(s)
| | - Sarah Foohey
- University of TorontoTorontoOntarioCanada
- Present address:
Queen's UniversityKingstonOntarioCanada
| | | | | | | | | | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale UniversityNew HavenConnecticutUSA
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Waddell K, Gaither SL, Rockwell N, Tofil NM, Rutledge C. The Impact of a Multifaceted Simulation Education and Feedback Program for Community Emergency Departments on Pediatric Diabetic Ketoacidosis Management. Pediatr Emerg Care 2023; 39:413-417. [PMID: 37163689 DOI: 10.1097/pec.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES We sought to determine if general emergency departments (GEDs) were managing pediatric diabetic ketoacidosis (DKA) correctly and if management could be improved using a multilayered educational initiative. We hypothesized that a multifaceted program of in situ simulation education and formal feedback on actual patient management would improve community GED management of pediatric DKA. METHODS This study combined a prospective simulation-based performance evaluation and a retrospective chart review. A community outreach simulation education initiative was developed followed by a formal patient feedback process. RESULTS Fifteen hospitals participated in simulation sessions and the feedback process. All hospitals were scored for readiness to provide care for critically ill pediatric patients using the Emergency Medical Services for Children (EMSC) Pediatric Readiness Assessment. Six of the 15 have had a second hospital visit that included a DKA scenario with an average performance score of 60.3%. A total of 158 pediatric patients with DKA were included in the chart review. The GEDs with higher patient volumes provided best practice DKA management more often (63%) than those with lower patient volumes (40%). Participating in a DKA simulated scenario showed a trend toward improved care, with 47.2% before participation and 68.2% after participation ( P = 0.091). Participating in the formal feedback process improved best practice management provided to 68.6%. Best practice management was further improved to 70.3% if the GED participated in both a DKA simulation and the feedback process ( P = 0.04). CONCLUSIONS A multifaceted program of in situ simulation education and formal feedback on patient management can improve community GED management of pediatric patients with DKA.
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Affiliation(s)
- Kristen Waddell
- From the Pediatric Intensive Care Unit, Children's of Alabama, Birmingham, AL
| | - Stacy L Gaither
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nicholas Rockwell
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nancy M Tofil
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Chrystal Rutledge
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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21
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Nickerson J, Ghatak-Roy A, Donnelly KA, Thomas AA, Robinson D, Roszczynialski KN, Zhao X. The Current State of Pediatric Emergency Medicine Training in Emergency Medicine Residencies. Pediatr Emerg Care 2023; 39:167-172. [PMID: 36018727 DOI: 10.1097/pec.0000000000002819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies show that emergency medicine (EM) physicians are less comfortable caring for pediatric patients than adults. The state of pediatric training has not been comprehensively evaluated since 2000. OBJECTIVES We sought to describe current pediatric education in EM residencies and to evaluate EM Program Director (PD) confidence in graduating trainees' abilities to care for pediatric patients. METHODS We conducted an anonymous, cross-sectional survey study of EM PDs in August 2020. We collected program demographics, clinical rotations, and didactic methods. We used Likert scales to measure PD confidence in graduating residents' competence to care for pediatric and adult patients. RESULTS We found e-mail addresses for 249 (93%) of 268 EM programs. One hundred nineteen (48%) PDs completed the survey. We include denominators to account for unanswered questions. Sixty-eight (59%) of 116 programs spend 10% to 20% of clinical time seeing pediatric patients. One hundred ten (91%) of 119 require a pediatric emergency medicine (PEM) rotation, 88/119 (83%) require pediatric intensive care, and 34/119 (29%) require neonatal intensive care. Seventy (62%) of 113 have curricula designed by PEM-trained faculty, 96/113 (85%) have PEM attendings teach lectures, and 77/113 (68%) spend 10% to 20% of didactic time on pediatric topics. Twenty-three (23%) of 106 PDs stated not all residents graduate with competence in pediatric resuscitation compared with 2/106 (2%) for adult resuscitation ( P < 0.05). CONCLUSIONS Program directors report less confidence in graduating residents' competence in caring for pediatric patients compared with adult patients. We propose ideas to strengthen the quality of pediatric education in EM residencies.
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Affiliation(s)
- Jillian Nickerson
- From the Division of Emergency Medicine and Trauma Services, Children's National Hospital, Washington, DC
| | - Aditi Ghatak-Roy
- Department of Emergency Medicine, Inova Fairfax Hospital, Falls Church, VA
| | - Katie A Donnelly
- From the Division of Emergency Medicine and Trauma Services, Children's National Hospital, Washington, DC
| | - Anita A Thomas
- Division of Emergency Medicine, Department of Pediatrics, Seattle Children's Hospital/University of Washington
| | | | | | - Xian Zhao
- From the Division of Emergency Medicine and Trauma Services, Children's National Hospital, Washington, DC
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Masrani AS, Nik Husain NR, Musa KI, Moraga P, Ismail MT. The Changing Trend of Paediatric Emergency Department Visits in Malaysia Following the COVID-19 Pandemic. Cureus 2023; 15:e36512. [PMID: 36968682 PMCID: PMC10038692 DOI: 10.7759/cureus.36512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has impacted the emergency department (ED) due to the surge in medical demand and changes in the characteristics of paediatric visits. Additionally, the trend for paediatric ED visits has decreased globally, secondary to implementing lockdowns to stop the spread of COVID-19. We aim to study the trend and characteristics of paediatric ED visits following Malaysia's primary timeline of the COVID-19 pandemic. Methods and materials A five-year time series observational study of paediatric ED patients from two tertiary hospitals in Malaysia was conducted from March 17, 2017 (week 11 2017) to March 17, 2022 (week 12 2022). Aggregated weekly data were analysed using R statistical software version 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria) against significant events during the COVID-19 pandemic to detect influential changepoints in the trend. The data collected were the number of ED visits, triage severity, visit outcomes and ED discharge diagnosis. Results Overall, 175,737 paediatric ED visits were recorded with a median age of three years and predominantly males (56.8%). A 57.57% (p<0.00) reduction in the average weekly ED visits was observed during the Movement Control Order (MCO) period. Despite the increase in the proportion of urgent (odds ratio (OR): 1.23, p<0.00) and emergent or life-threatening (OR: 1.79, p<0.00) cases, the proportion of admissions decreased. Whilst the changepoints during the MCO indicated a rise in respiratory, fever or other infectious diseases, or gastrointestinal conditions, diagnosis of complications originating from the perinatal period declined from July 19, 2021 (week 29 2021). Conclusion The incongruent change in disease severity and hospital admission reflects the potential effects of the healthcare system reform and socioeconomic impact as the pandemic evolves. Future studies on parental motivation to seek emergency medical attention may provide insight into the timing and choice of healthcare service utilisation.
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Affiliation(s)
- Afiqah Syamimi Masrani
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
| | - Nik Rosmawati Nik Husain
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
| | - Kamarul Imran Musa
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
| | - Paula Moraga
- Division of Computer, Electrical and Mathematical Science and Engineering, King Abdullah University of Science and Technology, Thuwal, SAU
| | - Mohd Tahir Ismail
- School of Mathematical Sciences, Universiti Sains Malaysia, Pulau Pinang, MYS
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Marcin JP, Sauers-Ford HS, Mouzoon JL, Haynes SC, Dayal P, Sigal I, Tancredi D, Lieng MK, Kuppermann N. Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers: A Cluster-Randomized Crossover Trial. JAMA Netw Open 2023; 6:e2255770. [PMID: 36780158 PMCID: PMC9926323 DOI: 10.1001/jamanetworkopen.2022.55770] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
IMPORTANCE Pediatric referral centers are increasingly using telemedicine to provide consultations to help care for acutely ill children presenting to rural and community emergency departments (EDs). These pediatric telemedicine consultations may help improve physician decision-making and may reduce the frequency of overtriage and interfacility transfers. OBJECTIVE To examine the use of pediatric critical care telemedicine vs telephone consultations associated with risk-adjusted transfer rates of acutely ill children from community and rural EDs. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized crossover trial was conducted between November 18, 2015, and March 26, 2018. Analyses were conducted from January 19, 2018, to July 23, 2022, 2022. Participants included acutely ill children aged 14 years and younger presenting to a participating ED in 15 rural and community EDs in northern California. INTERVENTIONS Participating EDs were randomized to use telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine:1 telephone) crossover treatment assignment sequences. MAIN OUTCOMES AND MEASURES Intention-to-treat, treatment-received, and per-protocol analyses were performed to determine the risk of transfer using mixed effects Poisson regression analyses with random intercepts for presenting EDs to account for hospital-level clustering. RESULTS A total of 696 children (392 boys [56.3%]; mean [SD] age, 4.2 [4.6] years) were enrolled. Of the 537 children (77.2%) assigned to telemedicine, 251 (46.7%) received the intervention. In the intention-to-treat analysis, patients assigned to the telemedicine arm were less likely to be transferred compared with patients assigned to the telephone arm after adjusting for patient age, severity of illness, and hospital study period (risk rate [RR], 0.93; 95% CI, 0.88-0.99). The adjusted risk of transfer was significantly lower in the telemedicine arm compared with the telephone arm in both the treatment-received analysis (RR, 0.81; 95% CI, 0.71-0.94) and the per-protocol analysis (RR, 0.79; 95% CI, 0.68-0.92). CONCLUSIONS AND RELEVANCE In this randomized trial, the use of telemedicine to conduct consultations for acutely ill children in rural and community EDs resulted in less frequent overall interfacility transfers than consultations done by telephone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02877810.
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Affiliation(s)
- James P. Marcin
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Hadley S. Sauers-Ford
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jamie L. Mouzoon
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Sarah C. Haynes
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Parul Dayal
- Genentech Inc, South San Francisco, California
| | - Ilana Sigal
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Daniel Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Monica K. Lieng
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
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Workman JK, Keenan HT, Weir CR. Pediatric Septic Shock Care Pathways in General Emergency Departments: A Qualitative Study Targeting How to Really Make it Work. Pediatr Emerg Care 2023. [PMID: 36688499 DOI: 10.1097/PEC.0000000000002910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Many academic pediatric emergency departments (PEDs) have successfully implemented pediatric septic shock care pathways. However, many general emergency departments (GEDs), who see the majority of pediatric ED visits, have not. This study aims to compare the workflow, resources, communication, and decision making across these 2 settings to inform the future implementation of a standardized care pathway for children with septic shock in the GED. METHODS We used the critical incident technique to conduct semistructured interviews with 24 ED physicians, nurses, and technicians at one PED and 2 GEDs regarding pediatric septic shock care. We performed a thematic analysis using the Framework Method to develop our coding schema through inductive and deductive analyses. We continued an iterative process of revising the schema until we reached consensus agreement and thematic saturation. RESULTS We identified the following 6 themes: (1) functioning like a "well-oiled machine" may be key to high performance; (2) experiencing the sequence of care for children with sepsis as invariant and predictable may be essential to high-quality performance; (3) resilience and flexibility are characteristic of high levels of performance; (4) believing that "the buck stops here" may contribute to more accountability; (5) continuous system learning is essential; and (6) computerized clinical decision support may not be optimized to drive decision-making at the point of care. Commentary from GED and PED participants differed across the 6 themes, providing insight into the approach for standardized care pathway implementation in GEDs. CONCLUSIONS Pediatric septic shock workflow, decision making, and system performance differ between the PED and GEDs. Implementation of a standardized care pathway in GEDs will require a tailored approach. Specific recommendations include (1) improving shared situation awareness; (2) simulation for knowledge, skill, and team-based training; and (3) promoting a culture of continuous learning.
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Ghirardo S, Trevisan M, Ronfani L, Zanon D, Maestro A, Barbieri F, De Nardi L, Amaddeo A, Barbi E, Cozzi G. Oral ibuprofen versus oral ketorolac for children with moderate and severe acute traumatic pain: a randomized comparative study. Eur J Pediatr 2023; 182:929-935. [PMID: 36526794 PMCID: PMC9758024 DOI: 10.1007/s00431-022-04759-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/28/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4-6) and severe (NRS 7-10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0-4.0) for ibuprofen and 1.0 (IQR 1.0-3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623.
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Affiliation(s)
- Sergio Ghirardo
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy.
| | - Matteo Trevisan
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy
| | - Luca Ronfani
- Department Servizio di Epidemiologia e Biostatistica, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Davide Zanon
- Department of Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Alessandra Maestro
- Department of Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Francesca Barbieri
- Department: Pediatria e Neonatologia, AAS 5 Ospedale di Santa Maria degli Angeli di Pordenone, Pordenone, Italy
| | - Laura De Nardi
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy
| | - Alessandro Amaddeo
- Pediatric Emergency Department, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy ,Department of Pediatrics, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Giorgio Cozzi
- Pediatric Emergency Department, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Janke AT, Nash KA, Goyal P, Auerbach M, Venkatesh AK. Pediatric mental health visits with prolonged length of stay in community emergency departments during COVID-19. J Am Coll Emerg Physicians Open 2022; 3:e12869. [PMID: 36570374 PMCID: PMC9767857 DOI: 10.1002/emp2.12869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/14/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives To characterize trends in pediatric mental health visit counts, including visits for prolonged length of stay (LOS), in a sample of emergency departments (EDs) from 29 states during COVID-19. Methods We performed a secondary analysis of the Clinical Emergency Data Registry from January 2020 through December 2021. We reported trends in pediatric mental health visit counts overall and for those with prolonged ED LOS. We reported incident rate ratios (IRRs) for monthly counts compared to January 2020. Among visits with LOS >24 hours, we reported on the most common diagnostic categories. Results There were 107 EDs from 29 states with available complete data in 2020 and 2021. Pediatric mental health visit counts resulting in a LOS greater than 6, 12, and 24 hours were higher for much of 2021. At their peak, there were 604 visits with LOS >12 hours (IRR, 2.14; 95% confidence interval [CI], 1.86-2.47) and 262 visits (IRR, 2.46; 95% CI, 1.97-3.09) with LOS >24 hours in April 2021. Pediatric mental health visits with LOS >12 hours and >24 hours made up 20.9% and 7.3% of pediatric mental health visits overall, respectively. For visits with ED LOS >24 hours, the most common diagnostic categories were suicide or self-injury, depressive disorders, and mental health syndrome. Conclusions In this sample of 107 EDs in 29 states, visit counts with prolonged LOS >24 hours more than doubled in some months since the arrival of COVID-19. These findings are indicative of an increasingly strained emergency and mental health system.
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Affiliation(s)
- Alexander T. Janke
- Institute for Healthcare Policy and InnovationVA Ann Arbor/University of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Katherine A. Nash
- Department of PediatricsNewYork‐Presbyterian/Columbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Pawan Goyal
- American College of Emergency PhysiciansDallasTexasUSA
| | - Marc Auerbach
- Departments of Emergency Medicine and PediatricsYale University School of MedicineNew HavenConnecticutUSA
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
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Abstract
BACKGROUND Pediatric emergency care coordinators (PECCs) are associated with pediatric readiness of emergency departments (EDs). National organizations have called for PECCs in all EDs. Although the National Pediatric Readiness Program provides a list of suggested tasks for each PECC, little is known about implementation. Our objective was to describe the role of PECCs in EDs. METHODS We analyzed data from the 2019 National ED Inventory-USA to identify EDs with PECCs in 8 states (Arkansas, Florida, Iowa, Maryland, Nebraska, New York, Vermont, and Wisconsin). We called each ED that reported having a PECC to administer a standardized survey assessing NRPP tasks, specifically quality improvement (QI), education provision, skill verification, equipment responsibilities, and how many hours the PECC devoted to the role. RESULTS Of the 201 of 830 EDs (24%) that reported a PECC, 167 (83%) completed the survey, with >80% response rate in each state. Of these, 153 EDs (92%) confirmed a PECC, and during the past year, 81% participated in QI initiatives, 93% provided pediatric education, 90% verified staff skills, and 90% were responsible for ensuring medications, equipment, supplies, and resources for children. The median number of hours per week that PECCs devoted to this role was 12 (interquartile range, 5-40). There was wide variation between states (eg, 50% of PECCs in Vermont participating in QI activities, as compared with 100% in Nebraska). CONCLUSIONS Most PECCs report participating in the suggested National Pediatric Readiness Program tasks, although there was variation by state. Future directions for this work include assessing the association between PECC tasks and patient outcomes.
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Affiliation(s)
- Margaret E Samuels-Kalow
- From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School Boston, MA
| | - Krislyn M Boggs
- From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School Boston, MA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Carlos A Camargo
- From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School Boston, MA
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Thomas AA, Montgomery EE, Abulebda K, Whitfill T, Chapman J, Leung J, Fayyaz J, Auerbach M. The feasibility of a pediatric distance learning curriculum for emergency department nurses during the COVID-19 pandemic: An Improving Pediatric Acute Care Through Simulation (ImPACTS) collaboration. J Emerg Nurs 2022. [PMCID: PMC9458703 DOI: 10.1016/j.jen.2022.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction To develop and evaluate the feasibility and effectiveness of a longitudinal pediatric distance learning curriculum for general emergency nurses, facilitated by nurse educators, with central support through the Improving Acute Care Through Simulation collaborative. Methods Kern’s 6-step curriculum development framework was used with pediatric status epilepticus aimed at maintaining physical distancing, resulting in a 12-week curriculum bookended by 1-hour telesimulations, with weekly 30-minute online asynchronous distance learning. Recruited nurse educators recruited a minimum of 2 local nurses. Nurse educators facilitated the intervention, completed implementation surveys, and engaged with other educators with the Improving Pediatric Acute Care through Simulation project coordinator. Feasibility data included nurse educator project engagement and curriculum engagement by nurses with each activity. Efficacy data were collected through satisfaction surveys, pre-post knowledge surveys, and pre-post telesimulation performance checklists. Results Thirteen of 17 pediatric nurse educators recruited staff to complete both telesimulations, and 38 of 110 enrolled nurses completed pre-post knowledge surveys. Knowledge scores improved from a median of 70 of 100 (interquartile range: 66-78) to 88 (interquartile range: 79-94) (P = .018), and telesimulation performance improved from a median of 60 of 100 (interquartile range: 45-60) to 100 (interquartile range: 85-100) (P = .016). Feedback included a shortened intervention and including physician participants. Discussion A longitudinal pediatric distance learning curriculum for emergency nurses collaboratively developed and implemented by nurse educators and Improving Pediatric Acute Care through Simulation was feasible for nurse educators to implement, led to modest engagement in all activities by nurses, and resulted in improvement in nurses’ knowledge and skills. Future directions include shortening intervention time and broadening interprofessional scope.
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Cutler GJ, Bergmann KR, Doupnik SK, Hoffmann JA, Neuman MI, Rodean J, Zagel AL, Zima BT. Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic. Acad Pediatr 2022; 22:889-891. [PMID: 35351651 PMCID: PMC8957359 DOI: 10.1016/j.acap.2022.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Gretchen J Cutler
- Children's Minnesota Research Institute, Children's Minnesota (GJ Cutler), Minneapolis, Minn.
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota (KR Bergmann), Minneapolis, Minn
| | - Stephanie K Doupnik
- Division of General Pediatrics, PolicyLab, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia (SK Doupnik), Philadelphia, Pa
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (JA Hoffmann), Chicago, Ill
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School (MI Neuman), Boston, Mass
| | | | - Alicia L Zagel
- Fairview Pharmacy Services (AL Zagel), Minneapolis, Minn
| | - Bonnie T Zima
- UCLA Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles (BT Zima), Los Angeles, Calif
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Lin MY, Kim J, Sheldrick RC, Bair-Merritt MH, Durham MP, Feinberg E, Cole MB. Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study. J Pediatr 2022; 246:199-206.e17. [PMID: 35301021 DOI: 10.1016/j.jpeds.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits. STUDY DESIGN This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter. RESULTS Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively. CONCLUSIONS Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.
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Remick KE, Bartley KA, Gonzales L, MacRae KS, Edgerton EA. Consensus-driven model to establish paediatric emergency care measures for low-volume emergency departments. BMJ Open Qual 2022; 11:bmjoq-2021-001803. [PMID: 35803615 PMCID: PMC9272131 DOI: 10.1136/bmjoq-2021-001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/19/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Katherine E Remick
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Krystle A Bartley
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Louis Gonzales
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kate S MacRae
- Gonzaga University College of Arts and Sciences, Spokane, Washington, USA
| | - Elizabeth A Edgerton
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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Goldman MP, Palladino LE, Malik RN, Powers EM, Rudd AV, Aronson PL, Auerbach MA. A Workplace Procedure Training Cart to Augment Pediatric Resident Procedural Learning. Pediatr Emerg Care 2022; 38:e816-e820. [PMID: 35100781 DOI: 10.1097/pec.0000000000002397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Our primary aim was to describe pediatric residents' use of a workplace procedural training cart. An exploratory aim was to examine if the cart associated with increased resident procedural experiences with real patients. METHODS Guided by the procedural training construct of "Learn, See, Practice, Prove, Do, Maintain," we created a novel workplace procedural training cart with videos (learn and see) and simulation equipment (practice and prove). An electronic logbook recorded resident use data, and a brief survey solicited residents' perceptions of the cart's educational impact. We queried our electronic medical record to compare the proportion of real procedures completed by residents before and after the intervention. RESULTS From August 1 to December 31, 2019, 24 pediatric residents (10 interns and 14 seniors) rotated in the pediatric emergency department. Twenty-one cart encounters were logged, mostly by interns (67% [14/21]). The 21 cart encounters yielded 32 learning activities (8 videos watched and 24 procedures practiced), reflecting the residents' interest in laceration repair (50% [4/8], 54% [13/24]) and lumbar puncture (38% [3/8], 33% [8/24]). All users agreed (29% [6/21]) or strongly agreed (71% [15/21]) the cart encouraged practice and improved confidence in independently performing procedures. No changes were observed in the proportion of actual procedures completed by residents. CONCLUSIONS A workplace procedural training cart was used mostly by pediatric interns. The cart cultivated residents' perceived confidence in real procedures but was not used by all residents or influenced residents' procedural behaviors in the pediatric emergency department.
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Affiliation(s)
- Michael P Goldman
- From the Section of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Lauren E Palladino
- Department of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rabia N Malik
- From the Section of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Emily M Powers
- From the Section of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Alexis V Rudd
- From the Section of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Paul L Aronson
- From the Section of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Marc A Auerbach
- From the Section of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
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Abstract
OBJECTIVE Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.
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Merianos AL, Fiser KA, Mahabee-Gittens EM, Lyons MS, Gordon JS. Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework. Implement Sci Commun 2022; 3:3. [PMID: 35022066 PMCID: PMC8754362 DOI: 10.1186/s43058-021-00251-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors. Methods Semi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles. Results Fifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling. Conclusions Study findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.
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Affiliation(s)
- Ashley L Merianos
- School of Human Services, University of Cincinnati, P.O. Box 210068, Cincinnati, OH, 45221-0068, USA. .,Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Kayleigh A Fiser
- School of Human Services, University of Cincinnati, P.O. Box 210068, Cincinnati, OH, 45221-0068, USA
| | - E Melinda Mahabee-Gittens
- Division of Emergency Medicine, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Michael S Lyons
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Emergency Medicine, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267-0769, USA
| | - Judith S Gordon
- College of Nursing, The University of Arizona, 1305 N Martin Avenue, PO Box 210203, Tucson, AZ, 85721-0203, USA
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Alsaedi H, Lutfi R, Abu-Sultaneh S, Montgomery EE, Pearson KJ, Weinstein E, Whitfill T, Auerbach MA, Abulebda K. Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center. J Pediatr 2022; 240:235-240.e1. [PMID: 34481806 DOI: 10.1016/j.jpeds.2021.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. STUDY DESIGN A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18 years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected. RESULTS A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted. CONCLUSIONS Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.
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Affiliation(s)
- Hani Alsaedi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Riad Lutfi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Kellie J Pearson
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Elizabeth Weinstein
- Division of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Marc A Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
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Abulebda K, Whitfill T, Mustafa M, Montgomery EE, Lutfi R, Abu-Sultaneh S, Nitu ME, Auerbach MA. Improving Pediatric Readiness and Clinical Care in General Emergency Departments: A Multicenter Retrospective Cohort Study. J Pediatr 2022; 240:241-248.e1. [PMID: 34499944 DOI: 10.1016/j.jpeds.2021.08.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the impact of a collaborative initiative between general emergency departments (EDs) and the pediatric academic medical center on the process of clinical care in a group of general EDs. STUDY DESIGN This retrospective cohort study assessed the process of clinical care delivered to critically ill children presenting to 3 general EDs. Our previous multifaceted intervention included the following components: postsimulation debriefing, designation of a pediatric champion, customized performance reports, pediatric resources toolkit, and ongoing interactions. Five pediatric emergency care physicians conducted chart reviews and scored encounters using the Pediatric Emergency Care Research Network's Quality of Care Implicit Review Instrument, which assigns scores between 5 and 35 across 5 domains. In addition, safety metrics were collected for medication, imaging, and laboratory orders. RESULTS A total of 179 ED encounters were reviewed, including 103 preintervention and 76 postintervention encounters, with an improvement in mean total quality score from 23.30 (SD 5.1) to 24.80 (4.0). In the domain of physician initial treatment plan and initial orders, scores increased from a mean of 4.18 (0.13) to 4.61 (0.15). In the category of safety, administration of wrong medications decreased from 28.2% to 11.8% after the intervention. CONCLUSION A multifaceted collaborative initiative involving simulation and enhanced pediatric readiness was associated with improvement in the processes of care in general EDs. This work provides evidence that innovative collaborations between academic medical centers and general EDs may serve as an effective strategy to improve pediatric care.
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Affiliation(s)
- Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Manahil Mustafa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Riad Lutfi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Mara E Nitu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Marc A Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
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Lutfi R, Berrens ZJ, Ackerman LL, Montgomery EE, Mustafa M, Kirby ML, Pearson KJ, Abu-Sultaneh S, Abulebda K. Quality of Resuscitative Care Provided to an Infant With Abusive Head Trauma in Community Emergency Departments: An In Situ, Prospective, Simulation-Based Study. Pediatr Emerg Care 2022; 38:e337-e342. [PMID: 33148953 DOI: 10.1097/pec.0000000000002277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Abusive head trauma (AHT) is a very common and serious form of physical abuse, and a major cause of mortality and morbidity for young children. Early Recognition and supportive care of children with AHT is a common challenge in community emergency department (CEDs). We hypothesized that standardized, in situ simulation can be used to measure and compare the quality of resuscitative measures provided to children with AHT in a diverse set of CEDs. METHODS This prospective, simulation-based study measured teams' performance across CEDs. The primary outcome was overall adherence to AHT using a 15-item performance assessment checklist based on the number of tasks performed correctly on the checklist. RESULTS Fifty-three multiprofessional teams from 18 CEDs participated in the study. Of 270 participants, 20.7% were physicians, 65.2% registered nurses, and 14.1% were other providers. Out of all tasks, assessment of airway/breathing was the most successfully conducted task by 53/53 teams (100%). Although 43/53 teams (81%) verbalized the suspicion for AHT, only 21 (39.6%) of 53 teams used hyperosmolar agent, 4 (7.5%) of 53 teams applied cervical spine collar stabilization, and 6 (11.3%) of 53 teams raised the head of the bed. No significant difference in adherence to the checklist was found in the CEDs with an inpatient pediatric service or these with designated adult trauma centers compared with CEDs without. Community emergency departments closer to the main academic center outperformed CEDs these that are further away. CONCLUSIONS This study used in situ simulation to describe quality of resuscitative care provided to an infant presenting with AHT across a diverse set of CEDs, revealing variability in the initial recognition and stabilizing efforts and provided and targets for improvement. Future interventions focusing on reducing these gaps could improve the performance of CED providers and lead to improved patient outcomes.
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Affiliation(s)
- Riad Lutfi
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics
| | - Zachary J Berrens
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics
| | - Laurie L Ackerman
- Department of Neurosurgery, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Manahil Mustafa
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics
| | - Michele L Kirby
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Kellie J Pearson
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics
| | - Kamal Abulebda
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics
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Mangus CW, Canares T, Klein BL, Costabile P, Monroe D, Noje C, Stevens MW. Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment. Pediatr Emerg Care 2022; 38:e105-e110. [PMID: 32925174 DOI: 10.1097/pec.0000000000002167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many children seeking emergency care at community hospitals require transport to tertiary centers for definitive management. Interhospital transport via ambulance versus patient's own vehicle (POV) are 2 possible modes of transport; however, presence of a peripheral venous catheter (PIV) can determine transport by ambulance. Caregiver satisfaction, patient comfort, and PIV complications related to POV transport have not been described. OBJECTIVE The aims of the study were to examine caregivers' satisfaction and perceptions of POV transport in children with/without PIVs and to assess PIV-related complications during transport. METHODS We performed a mixed-methods, prospective cohort study of children who presented with low-acuity conditions to a community hospital and subsequently required transfer to a pediatric tertiary center. Caregivers of patients with/without PIVs were given the choice of transport by POV or ambulance. Surveys completed after transport used dichotomous, 5-point Likert scale, and open-ended responses to assess satisfaction, perceptions, and PIV-related complications. Responses were quantitatively and qualitatively analyzed accordingly. The receiving hospital assessed PIV integrity. RESULTS Sixty-nine of 78 eligible patients were enrolled; of those, 67 (97%) elected transport by POV and 55 (82%) completed surveys. Most caregivers had positive responses related to satisfaction, comfort, and safety. Results did not differ significantly between those with/without PIVs. The majority (96%) would choose POV transport again. There were no reported PIV complications; all PIVs were functional upon arrival. Qualitative analysis identified themes of comfort, convenience, and efficiency. CONCLUSIONS In select scenarios, interfacility transport by POV is preferred by families and doing so with a saline-locked PIV does not result in complications.
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Affiliation(s)
- Courtney W Mangus
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Therese Canares
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Bruce L Klein
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | | | - David Monroe
- Department of Emergency Medicine, Howard County General Hospital, Columbia
| | - Corina Noje
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martha W Stevens
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
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Goldman MP, Query LA, Wong AH, Gross IT, Emerson BL, Auerbach MA, Tiyyagura GK. Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program. Pediatr Emerg Care 2021; 37:e1535-e1543. [PMID: 33009320 PMCID: PMC8012401 DOI: 10.1097/pec.0000000000002108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program. METHODS We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes. RESULTS Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends. CONCLUSIONS Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.
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Affiliation(s)
- Michael P Goldman
- From the Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME, Auerbach MA, Lutfi R, Abu-Sultaneh S. Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program. Pediatr Emerg Care 2021; 37:543-549. [PMID: 30870337 DOI: 10.1097/pec.0000000000001751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. METHODS This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. RESULTS A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. CONCLUSIONS This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.
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Affiliation(s)
- Kamal Abulebda
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | | | | | - Rami A Ahmed
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Mara E Nitu
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | - Riad Lutfi
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
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Alsaedi H, Berrens ZJ, Lutfi R, Weinstein E, Montgomery EE, Pearson KJ, Kirby ML, Abu-Sultaneh S, Abulebda K, Thammasitboon S. Simulation-based assessment of care for infant cardiogenic shock in the emergency department. Nurs Crit Care 2021; 28:353-361. [PMID: 34699685 DOI: 10.1111/nicc.12716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 08/17/2021] [Accepted: 09/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) is the leading cause of infant deaths associated with birth defects. Neonates with undiagnosed CHD often present to general emergency departments (GEDs) for initial resuscitation that are less prepared than paediatric centres, resulting in disparities in the quality of care. Neonates with undiagnosed CHD represent a challenge; thus, it is necessary for GEDs to be prepared for this population. AIM To evaluate the process of resuscitative care provided to a neonate in cardiogenic shock due to CHD in the GEDs in a simulated setting and to describe the impact of teams and GED variables on the process of care. METHODS This is a prospective simulation-based assessment of the process of care provided to a neonate with coarctation of the aorta in cardiogenic shock. Simulation sessions were conducted at participating GEDs utilizing each GED's interdisciplinary team and resources. The primary outcome was adherence to best practice, as measured by a 15-item overall composite adherence score (CAS). In addition, we stratified the overall CAS into CHD-critical items and the general resuscitation items CAS. The secondary outcome was the impact of the team's and GED's characteristics on the scores. FINDINGS This study enrolled 32 teams from 12 GEDs. Among 161 participants, 103 (63.97%) were registered nurses, 33 (20.50%) were physicians, 17 (10.56%) were respiratory therapists, and 8 (4.97%) were other medical professionals. The overall median CAS was 84, with the CHD-critical items having a median CAS of 34.5. The most underperformed tasks are checking pulses on the upper and lower extremities (44%), obtaining blood pressure in the upper and lower extremities (25%), and administering prostaglandin E1 (22%). CONCLUSIONS Using in situ simulation in a set of GEDs, we revealed gaps in the resuscitation care of neonates with CHD in cardiogenic shock. RELEVANCE TO CLINICAL PRACTICE These findings highlight the importance of targeted improvement programs for high-stakes illnesses in GED.
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Affiliation(s)
- Hani Alsaedi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Zachary J Berrens
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Riad Lutfi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Elizabeth Weinstein
- Department of Emergency Medicine, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, Indiana, USA
| | - Kellie J Pearson
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, Indiana, USA
| | - Michelle L Kirby
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, Indiana, USA
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Satid Thammasitboon
- Associate Professor of Pediatrics, Critical Care Medicine Section, Director, Center for Research, Innovation and Scholarship in Medical Education (CRIS), Chair, Resident Scholarship Program Executive Committee, Texas Children's Hospital Baylor College of Medicine, Houston, Texas, USA
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Goldman MP, Lynders W, Crain M, Nocera Kelley M, Solomon DM, Bokhari SAJ, Tiyyagura G, Auerbach MA, Emerson BL. A QI Partnership to Decrease CT Use for Pediatric Appendicitis in the Community Hospital Setting. Pediatr Qual Saf 2021; 6:e479. [PMID: 34589653 DOI: 10.1097/pq9.0000000000000479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/09/2021] [Indexed: 10/29/2022] Open
Abstract
The primary aim of this quality improvement initiative was to decrease the use of computerized tomography (CT) in the evaluation of pediatric appendicitis in a community general emergency department (GED) system by 50% (from 32% to 16%) in 1 year. Methods Colleagues within a State Emergency Medical Service for Children (EMSC) community of practice formed the quality improvement team, representing multiple stakeholders across 3 independent institutions. The team generated project aims by reviewing baseline practice trends and implemented changes using the Model for Improvement. Ultrasound (US) use and nondiagnostic US rates served as process measures. Transfer and "over-transfer" rates served as balancing measures. Interventions included a GED pediatric appendicitis clinical pathway, US report templates, and case audit and feedback. Statistical process control tracked the main outcomes. Additionally, frontline GED providers shared perceptions of knowledge gains, practice changes, and teamwork. Results The 12-month baseline revealed a GED CT scan rate of 32%, a US rate of 63%, a nondiagnostic US rate of 77%, a transfer to a children's hospital rate of 23.5%, and an "over-transfer" rate of 0%. Project interventions achieved and sustained the primary aim by decreasing the CT scan rate to 4.5%. Frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. Conclusions Engaging regional colleagues in a pediatric-specific quality improvement initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on the community of practice facilitated by Emergency Medical Service for Children may guide future improvement work in the state and beyond.
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Burns R, Madhok M, Bank I, Nguyen M, Falk M, Waseem M, Auerbach M. Creation of a standardized pediatric emergency medicine simulation curriculum for emergency medicine residents. AEM Educ Train 2021; 5:e10685. [PMID: 34632245 PMCID: PMC8489268 DOI: 10.1002/aet2.10685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/15/2021] [Accepted: 08/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The majority of children seeking care in emergency departments are seen by general emergency medicine (EM) residency program graduates. Throughout training, EM residents manage fewer critically ill pediatric patients compared to adults, and the exposure to children with illness and injury requiring emergent assessment and management is often limited and sporadic across training sites. This report describes the creation of a robust set of simulation cases for EM trainees incorporating topics identified during a previous modified Delphi study to improve their pediatric acute care knowledge and skills. METHODS All 30 pediatric EM topics and 19/26 procedures previously identified as "must be taught by simulation" to EM residents were mapped to 15 simulation case topics. Twenty-seven authors from 16 institutions created cases and supporting materials. Each case was iteratively implemented during a peer review process at two to five sites with EM residents. Feedback from learners and facilitators was collected via electronic surveys and used to revise each case before the next implementation. RESULTS Thirty-five institutions participated in the peer review process. Fifty-one facilitators and 281 participants (90% EM residents) completed surveys. Most facilitators (98%) agreed or strongly agreed with the statement "This simulation case is relevant to the field of emergency medicine." A majority of facilitators and participants agreed or strongly agreed with the statements "The simulation case was realistic" (98% of facilitators, 94% of participants) and "This simulation case was effective in teaching resuscitation skills" (92% of facilitators, 98% of participants). Most participants reported confidence in knowledge and skills addressed in the learning objectives after participation. CONCLUSIONS Facilitators and EM residents found cases from a novel simulation-based curriculum covering critical pediatric EM topics relevant, realistic, and effective. This curriculum can help provide a standardized, uniform experience for EM residents who will care for critically ill pediatric patients in their communities.
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Affiliation(s)
- Rebekah Burns
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
| | - Manu Madhok
- Department of PediatricsChildren's MinnesotaMinneapolisMinnesotaUSA
| | - Ilana Bank
- Department of PediatricsMcGill UniversityMontrealQuebecCanada
| | - Michael Nguyen
- Department of MedicineMorsani College of MedicineUniversity of South FloridaTampaFloridaUSA
| | - Michael Falk
- Department of PediatricsChildren's Hospital Medical CenterWashingtonDCUSA
| | - Muhammad Waseem
- Departments of Pediatrics and Emergency MedicineLincoln Medical CenterBronxNew YorkUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale UniversityNew HavenConnecticutUSA
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Michelson KA, Dart AH, Finkelstein JA, Bachur RG. Validation of an Automated System for Identifying Complications of Serious Pediatric Emergencies. Hosp Pediatr 2021; 11:864-878. [PMID: 34290041 PMCID: PMC8651277 DOI: 10.1542/hpeds.2020-005792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Illness complications are condition-specific adverse outcomes. Detecting complications of pediatric illness in administrative data would facilitate widespread quality measurement, however the accuracy of such detection is unclear. METHODS We conducted a cross-sectional study of patients visiting a large pediatric emergency department. We analyzed those <22 years old from 2012 to 2019 with 1 of 14 serious conditions: appendicitis, bacterial meningitis, diabetic ketoacidosis (DKA), empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. We applied a method using disposition, diagnosis codes, and procedure codes to identify complications. The automated determination was compared with the criterion standard of manual health record review by using positive predictive values (PPVs) and negative predictive values (NPVs). Interrater reliability of manual reviews used a κ. RESULTS We analyzed 1534 encounters. PPVs and NPVs for complications were >80% for 8 of 14 conditions: appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. Lower PPVs for complications were observed for DKA (57%), empyema (53%), encephalitis (78%), ovarian torsion (21%), and septic arthritis (64%). A lower NPV was observed in stroke (68%). The κ between reviewers was 0.88. CONCLUSIONS An automated method to measure complications by using administrative data can detect complications in appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. For DKA, empyema, encephalitis, ovarian torsion, septic arthritis, and stroke, the tool may be used to screen for complicated cases that may subsequently undergo manual review.
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Goldman MP, Auerbach MA, Garcia AM, Gross IT, Tiyyagura GK. Pediatric Emergency Medicine ECHO (Extension for Community Health Care Outcomes): Cultivating Connections to Improve Pediatric Emergency Care. AEM Educ Train 2021; 5:e10548. [PMID: 34141996 PMCID: PMC8164662 DOI: 10.1002/aet2.10548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/28/2020] [Accepted: 10/18/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND An Extension for Community Health Care Outcomes (ECHO) provides the opportunity for specialists at academic medical centers (AMCs) and frontline community generalists to engage in bidirectional learning. Specialists provide generalists with the current best evidence, and generalists share the local challenges applying this evidence to their practice. All ECHO participants strategize how to navigate these challenges together. Pediatric emergency medicine (PEM) may benefit from this knowledge translation strategy because most children seek emergency care from generalists in community emergency departments (CEDs) where variations in care between the AMC and the CED have been reported. METHODS Our objective was to use ECHO to cultivate a PEM community of practice that facilitated knowledge translation and generated future CED pediatric improvement initiatives. As such, we developed, implemented, and evaluated a PEM ECHO. We conducted general and targeted needs assessments to inform our curriculum and formatted the sessions to generate bidirectional learning. A postparticipation evaluation collected self-reported perceptions about knowledge translation, planned provider practice changes, and perceptions of the formation of a community of practice. Additionally, we solicited information on the implementation of any pediatric improvement activities attributed to the PEM ECHO. RESULTS Thirteen 1-hour sessions covered the chosen PEM topics. Participants represented diverse CEDs, with varied experience and roles in caring for children. All respondents (13/13) appreciated the ECHO learning format, reported improved PEM knowledge, and perceived the cultivation of a community of practice. Nine (85%) individuals attributed implementation of new pediatric improvement activities to the PEM ECHO. CONCLUSIONS Our PEM ECHO was associated with improved perceptions of PEM knowledge, cultivated a community of practice, and facilitated the implementation of CED pediatric improvement activities. The PEM ECHO's bidirectional learning format generated new initiatives and partnerships aiming to improve the emergency care of children.
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Affiliation(s)
- Michael P. Goldman
- From theDepartment of PediatricsSection of Pediatric Emergency Medicine and Department of Emergency MedicineYale University School of MedicineNew HavenCTUSA
| | - Marc A. Auerbach
- From theDepartment of PediatricsSection of Pediatric Emergency Medicine and Department of Emergency MedicineYale University School of MedicineNew HavenCTUSA
| | - Angelica M. Garcia
- and theDepartment of Emergency MedicineBoston Children’s HospitalBostonMAUSA
| | - Isabel T. Gross
- From theDepartment of PediatricsSection of Pediatric Emergency Medicine and Department of Emergency MedicineYale University School of MedicineNew HavenCTUSA
| | - Gunjan K. Tiyyagura
- From theDepartment of PediatricsSection of Pediatric Emergency Medicine and Department of Emergency MedicineYale University School of MedicineNew HavenCTUSA
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46
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Heyming TW, Knudsen-Robbins C, Feaster W, Ehwerhemuepha L. Criticality index conducted in pediatric emergency department triage. Am J Emerg Med 2021; 48:209-217. [PMID: 33975133 DOI: 10.1016/j.ajem.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/27/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To develop and analyze the performance of a machine learning model capable of predicting the disposition of patients presenting to a pediatric emergency department (ED) based on triage assessment and historical information mined from electronic health records. METHODS We retrospectively reviewed data from 585,142 ED visits at a pediatric quaternary care institution between 2013 and 2020. An extreme gradient boosting machine learning model was trained on a randomly selected training data set (50%) to stratify patients into 3 classes: (1) high criticality (patients requiring intensive care unit [ICU] care within 4 h of hospital admission, patients who died within 4 h of admission, and patients who died in the ED); (2) moderate criticality (patients requiring hospitalization without the need for ICU care); and (3) low criticality (patients discharged home). Variables considered during model development included triage vital signs, aspects of triage nursing assessment, demographics, and historical information (diagnoses, medication use, and healthcare utilization). Historical factors were limited to the 6 months preceding the index ED visit. The model was tested on a previously withheld test data set (40%), and its performance analyzed. RESULTS The distribution of criticality among high, moderate, and low was 1.5%, 7.1%, and 91.4%, respectively. The one-versus-all area under the receiver operating characteristic (AUROC) curve for high and moderate criticality was 0.982 (95% CI 0.980, 0.983) and 0.968 (0.967, 0.969). The multi-class macro average AUROC and area under the receiver operating characteristic curve were 0.976 and 0.754. The features most integral to model performance included history of intravenous medications, capillary refill, emergency severity index level, history of hospitalization, use of a supplemental oxygen device, age, and history of admission to the ICU. CONCLUSION Pediatric ED disposition can be accurately predicted using information available at triage, providing an opportunity to improve quality of care and patient outcomes.
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Affiliation(s)
- Theodore W Heyming
- Children's Hospital of Orange County, Orange, CA, United States; Department of Emergency Medicine, University of California, Irvine, United States.
| | | | - William Feaster
- Children's Hospital of Orange County, Orange, CA, United States
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47
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Schoppel KA, Stapleton S, Florian J, Whitfill T, Walsh BM. Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees? AEM Educ Train 2021; 5:e10509. [PMID: 33898912 PMCID: PMC8052997 DOI: 10.1002/aet2.10509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training. METHODS This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument. RESULTS A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%). CONCLUSIONS This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.
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Affiliation(s)
| | | | | | - Travis Whitfill
- Department of Pediatrics and Emergency MedicineYale UniversityNew HavenCTUSA
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48
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Claiborne DM, Kelekar U, Shepherd JG, Naavaal S. Emergency department use for nontraumatic dental conditions among children and adolescents: NEDS 2014-2015. Community Dent Oral Epidemiol 2021; 49:594-601. [PMID: 33755217 DOI: 10.1111/cdoe.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Despite great efforts to improve paediatric dental care access in the last two decades, the use of emergency departments (ED) for dental conditions among children that are more appropriately addressed in dental offices remains a public health concern in the United States. We examined factors associated with ED visits for nontraumatic dental conditions or NTDCs and ED visits for any other reason among children and adolescents. METHODS A retrospective secondary data analysis of ED visits was conducted using the 2014-2015 Nationwide Emergency Department Sample (NEDS) data. NTDCs were further categorized as diseases of hard tissue (eg dental caries), pulp/periapical (eg root canal infections), gingival/periodontal (eg conditions that affect the supporting tissues) and other. We included patient/socioeconomic characteristics, disposition, time of visit, and the Grouped Charlson Comorbidity Index (GRPCI) in our analysis. Bivariate associations were tested using chi-squared test (α = 0.05). RESULTS There were 70 616 194 ED visits in 2014-15, with 465 353 (0.7%) visits for NTDCs. Statistically significant differences were observed for all patient characteristics tested, except for gender when comparing children visiting the ED for NTDCs and children visiting for any other reason. Medicaid was the expected payer for nearly 60% of all ED visits, and the uninsured shared a larger proportion of NTDC visits (19.4%) than other visits (8.8%). Late adolescents (aged 18-21) accounted for over 50% of NTDC visits but only one-fifth of all other types of ED visits. Late adolescents (18-21 years old) who were uninsured had a significantly higher proportion of NTDC visits. Of all NTDC visits, 19.1% were related to hard tissue disease, 25.3% pulp/periapical, 7.9% periodontal disease, and the remaining were grouped as other dental diseases. CONCLUSIONS The ED use for NTDCs is more common among late adolescents, Medicaid and uninsured groups. Examining and implementing new approaches that improve access to routine dental care for these groups may help in reducing inefficient ED use related to NTDCs.
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Affiliation(s)
- Denise M Claiborne
- Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk, VA, USA
| | - Uma Kelekar
- School of Business, Innovation, Leadership and Technology, Marymount University, Arlington, VA, USA
| | | | - Shillpa Naavaal
- Dental Public Health and Policy, School of Dentistry, Virginia Commonwealth University, Richmond, VA, USA.,Oral Health in Childhood and Adolescence Core, Institute for Inclusion, Inquiry and Innovation, Virginia Commonwealth University, Richmond, VA, USA
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Abulebda K, Whitfill T, Montgomery EE, Thomas A, Dudas RA, Leung JS, Scherzer DJ, Aebersold M, Van Ittersum WL, Kant S, Walls TA, Sessa AK, Janofsky S, Fenster DB, Kessler DO, Chatfield J, Okada P, Arteaga GM, Berg MD, Knight LJ, Keilman A, Makharashvili A, Good G, Bingham L, Mathias EJ, Nagy K, Hamilton MF, Vora S, Mathias K, Auerbach MA. Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study. J Pediatr 2021; 230:230-237.e1. [PMID: 33137316 DOI: 10.1016/j.jpeds.2020.10.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs). STUDY DESIGN A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers. RESULTS Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P < .001) from a baseline of 62.4 (SEM = 2.2) to 78.7 (SEM = 2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol, and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline. CONCLUSIONS Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in WPRS when disseminated to a diverse group of general EDs partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.
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Affiliation(s)
- Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Anita Thomas
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Robert A Dudas
- Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - James S Leung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Daniel J Scherzer
- Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | | | - Wendy L Van Ittersum
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Northeast Ohio Medical University, Akron, OH
| | - Shruti Kant
- Department of Emergency Medicine and Pediatrics, University of California San Francisco, San Francisco, CA
| | - Theresa A Walls
- Department of Pediatrics, Division of Emergency Medicine, The Children's Hospital of Philadelphia at the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anna K Sessa
- Office of Emergency Medical Services, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Stephen Janofsky
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Daniel B Fenster
- Department of Emergency Medicine, Morgan Stanley Children's Hospital of New York Presbyterian at Columbia University Medical Center, New York, NY
| | - David O Kessler
- Department of Emergency Medicine, Morgan Stanley Children's Hospital of New York Presbyterian at Columbia University Medical Center, New York, NY
| | - Jenny Chatfield
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Pamela Okada
- Department of Pediatrics, University of Texas Southwestern School of Medicine, Dallas, TX
| | - Grace M Arteaga
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, MN
| | - Marc D Berg
- Davison of Critical Care Medicine, Lucile Packard children's Hospital Stanford, Stanford University College of Medicine, Palo Alto, CA
| | - Lynda J Knight
- Davison of Critical Care Medicine, Lucile Packard children's Hospital Stanford, Stanford University College of Medicine, Palo Alto, CA
| | - Ashley Keilman
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Ana Makharashvili
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Grace Good
- Department of Pediatrics, Division of Emergency Medicine, The Children's Hospital of Philadelphia at the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ladonna Bingham
- Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Emily J Mathias
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kristine Nagy
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Northeast Ohio Medical University, Akron, OH
| | - Melinda F Hamilton
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Marc A Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
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50
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Abstract
Most infants and children who are ill and injured are cared for in community-based settings across the emergency continuum. These settings are often less prepared for pediatric patients than dedicated pediatric settings such as academic medical centers. Disparities in health outcomes exist and are associated with gaps in community emergency preparedness. Simulation is an effective technique to enhance emergency preparedness to ensure the highest quality of care is provided to all pediatric patients. In this article, we summarize the pediatric emergency care provided across the emergency continuum and outline the key features of simulation used to measure and improve pediatric preparedness in community settings. First, we discuss the use of simulation as a training tool and as an investigative methodology to enhance emergency preparedness across the continuum. Next, we present two examples of successful simulation-based programs that have led to improved emergency preparedness. [Pediatr Ann. 2021;50(1):e19-e24.].
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