Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

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.

Blueprint for community emergency department pediatric simulation

Background

Gaps in quality of pediatric emergency care have been noted in community emergency departments (CEDs), where >85% of children receive care. In situ simulation provides opportunities for hands-on experiences and can help close these gaps. We aimed to develop, implement, and evaluate an innovative, replicable, and scalable pediatric in situ simulation-based CED curriculum, under the leadership of a local colleague, through collaborative approach with a regional academic medical center (AMC).

Methods

Kern's model was used as follows: problem identification and general needs assessment-pediatric readiness assessment and discussions with CED physician and nursing leadership; targeted needs assessment-review of recent pediatric transfer cases; goals and objectives-enhance pediatric knowledge and skills of interprofessional teams and detect latent safety threats; educational strategies-codeveloped by CED and AMC, included prelearning using podcasts and videos, simulation and facilitated debriefing, resource sharing after simulations; implementation-3-h simulation sessions facilitated in person by the CED team and remotely by AMC (leadership required participation and paid staff); and evaluation and feedback-retrospective pre-post survey, Simulation Effectiveness Tool-Modified (SET-M), Net Promoter Score (NPS), and review/feedback meetings.

Results

Based on needs assessment, the selected cases included newborn resuscitation, seizure, asthma, and tetrahydrocannabinol ingestion causing altered mental sensorium in a child. Twenty-four 3-h simulation sessions were conducted over 1 year. A total of 168 participants completed the sessions, while 75 participants (54.7% nurses, 22.7% physicians, and others) completed feedback surveys. Seventy-six percent of participants reported completing presimulation education material. Participants reported improved skills at appropriately evaluating a critically ill newborn and critically ill infant/toddler and improved teamwork during the care of a pediatric patient. The majority agreed that simulation was effective in teaching pediatric resuscitation. The NPS was 84% (excellent).

Conclusions

A locally facilitated CED in situ simulation curriculum was successfully developed and implemented under local leadership, with remote collaboration by AMC. The curriculum was well received and effective.

A QI Partnership to Decrease CT Use for Pediatric Appendicitis in the Community Hospital Setting

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.