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Study objective Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs. Methods A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping "waterfall" shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change. Results A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction. Conclusion This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.

Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.

Emergency department (ED) crowding is a significant and growing patient safety issue. Delays in the inpatient admission process are a significant contributor to ED crowding. We describe a systematic and comprehensive effort to decrease ED length of stay using lean manufacturing techniques derived from the Toyota Production System. Through a combination of projects, we describe how we were able to meet a hospital goal to reduce the length of time that admitted patients remain in the ED.

The focus was to examine the educational structure and curricular planning involved in current pediatric emergency interhospital transport teams that use resident physicians as members of the team and to compare these current results with the findings from 2 previous, similar surveys complete during the past 2 decades.: A 33-item questionnaire, assessing curricular components of the transport experience, was sent to a chief resident at all the officially listed nonmilitary pediatric residency program in contiguous United States. Comparisons were done for each similar item on all 3 questionnaires.: After 3 rounds of mailing and telephone follow-up to nonresponders, the overall response rates for the 2006 and 1998 surveys were 81% (n = 156) and 89% (n = 173), respectively. A similar survey on a smaller sample, published in 1990, used for comparison, had a response rate of 99% (n = 75). When asked about training provided to residents before going on transport, respondents varied in the specific experiences and skills required of the residents. In addition, programs reported variation in team backup during the pediatric emergency transport. The most common method of evaluation for the resident on completion of the transport was "no specific method" as reported by 62% of respondents in 2006 compared with 50% in 1998 and 55% in 1990 (P = not significant). The percentage of programs providing informal verbal feedback was reduced significantly in 2006 as compared with that in 1998 (P = 0.011).: The educational structure for residents serving in pediatric emergency interhospital transport teams remains variable, and the full educational value of pediatric transports continues to be somewhat unrealized particularly in the area of posttransport performance feedback and evaluation. Having medical command available has consistently been a strong point of the residents' experience on the transport team.

Protocol development between radiology and pediatric emergency medicine requires a multidisciplinary approach to manage straightforward as well as complex and time-sensitive needs for emergency department patients. Imaging evaluation requires coordination of radiologic technologists, radiologists, transporters, nurses and coordinators, among others, and might require accelerated routines or occur at sub-optimal times. Standardized protocol development enables providers to design a best practice in all of these situations and should be predicated on evidence, mission, and service expectations. As in any new process, constructive feedback channels are imperative for evaluation and modification.

Many emergency departments are transitioning from paper charting to full electronic health records, which include both computerized provider order entry and provider documentation. Implementation of electronic provider documentation (EPD), in particular, has been challenging. Known benefits include legibility, medicolegal and compliance safeguards, and improved access to patient charts. Offsetting these benefits may be reductions in efficiency, patient throughput, and less provider-patient interaction.We used a rapid design process coupled with Lean principles, simulation, aggressive training, and continuous process improvement to design and implement a novel EPD system with real-time voice recognition dictation in the pediatric emergency department (PED). We used statistical process control methodologies to compare mean PED lengths of stay (LOSs) for admitted and discharged patients before and after EPD GoLive.We were able to design, test, train, and implement a novel EPD to the PED within 7 months. There was special cause variation, with a 2.7% (5-minute) increase in overall LOS after EPD implementation. There was a temporary 9.3% (15-minute) increase in discharge LOS for 6 weeks after GoLive, with a subsequent return to a new baseline of 4.3% (7-minute) increase. There were no significant changes in admission LOS. There was overall consistent use of the voice recognition system several months after EPD rollout. There have been improving rates of compliance with chart completion over time, as a result of easier tracking and electronic reminders to complete.Despite the inherent challenges involved in transitioning from paper charting to EPD, our study showed that an academic ED, EPD, can be rapidly designed and implemented while not significantly negatively impacting ED metrics such as LOS. We had consistent use of the voice dictation system after implementation. Time spent documenting after clinical shift was not reliably captured and is an important area of future research for successful EPD implementation.

To use Lean methodologies and the Model for Improvement to rapidly redesign and pilot test a new pediatric emergency department (ED) front-end model that reduces time to a licensed independent provider to 30 minutes or less.Lean improvement methodologies were applied during a 5-day multidisciplinary model of care redesign event. The new ED front-end model of care included: (1) placement of a registered nurse in the lobby; (2) direct patient rooming with elimination of traditional triage; 3) early documentation of home medications; 4) Team-based immediate assessment; 5) "early Initiation" providers to place orders when a team was not available. An observational, cohort controlled before-and-after study design was used. The new model was tested over 2 pilot periods and compared to a similar period of control days, defined as the "current state."The ED census and patient acuity were similar during both pilot periods. Eighteen patients were included in pilot 1, and 80 patients were included in the expanded second pilot. Patients seen within 30 minutes improved from a baseline of 33% to 93% in pilot 2. Time to a licensed independent provider, to a room, and to visual assessment by a nurse all decreased. The largest decrease was in median time to provider, from 43 minutes in the current state to 7 minutes during pilot 2.Rapid process improvement methodology was used to design and test a front-end model that reduced patient waiting time. Our experience demonstrates the feasibility of employing Lean principles and the Model for Improvement in actual practice environments to rapidly improve care delivery processes in pediatric emergency departments.

To determine the frequency and consequences of vehicular crashes among dedicated pediatric and neonatal transport teams.A three-page questionnaire was sent to the transport teams of National Association of Children's Hospitals and Related Institutions (NACHRI) member hospitals. The survey instrument consisted of three sections. The first section requested demographic information about the team and asked the team to report any vehicular collisions or incidents in the previous five years. The second section was directed at teams that did not report collisions or incidents and asked the team to identify potential reasons for their safety record. The third section was directed to those teams reporting collisions or incidents and asked about the causes and consequences of these events.Ninety of 153 (59%) surveys were returned. Thirty-eight of the 90 teams (42%) reported at least one collision in the previous five years. A total of 66 collisions were reported (nine aircraft crashes and 57 ambulance collisions). The number of collisions was not related to the total number of transports performed by the team. Most teams attributed the collisions to errors on the part of a team member or to the actions of a third party. Collisions resulted in eight deaths, ten cases of moderate to severe injury, and 28 minor injuries to patients, health care workers, and/or the ambulance crew. All deaths resulted from aircraft crashes. Additionally, there were operational impacts upon the teams. These included missed workdays and disability on the part of team members and changes in team practices. Collision-free teams attributed their safety record to specific policies of the team and/or the vehicle owner or vendor and to luck.Collisions/crashes among pediatric transport teams are unusual. However, they have resulted in deaths, injuries, and disability. Collisions/crashes appear to be caused by the actions of a team member and/or those of third parties. Specific safety policies on the part of the team and/or vehicle owner or provider may prevent or decrease collisions/crashes.

INTRODUCTION: Pediatric interfacility transport teams often rely on advanced practice nurses as primary care providers. These individuals may be required to transport patients without the presence of a physician. There is, however, little information in the medical literature regarding how frequently advanced practice transport nurses perform advanced procedures, how often these procedures are successfully performed, and the rate of complications associated with nurse-performed procedures. PURPOSE: The purpose of this study was to determine how frequently advanced practice transport nurses were called on to perform advanced procedures and to determine the nurses' procedural success and complication rates. DESIGN: Prospective convenience sample of consecutive pediatric interfacility transports. METHODS: Transport nurses collected data on 336 pediatric interfacility transports that were performed during a 4-month period beginning in May 1997. All patient transports occurring during the study period were included. Data regarding procedures were recorded on data collection sheets. This data included the type of procedure performed, the outcome of the procedure, and the complications associated with the procedure. The number of attempts required to successfully complete the procedure was not recorded. During or after the patient's hospitalization, the medical record was reviewed to identify potential complications related to the transport that may not have been recorded on the data collection sheet. RESULTS: Nurses performed 95.2% of transports without the presence of a physician. Twenty-six patients (8.8%) required advanced procedures. Nurses performed eight tracheal intubations. Personnel at the referring hospital performed the remaining procedures. All tracheal intubations by transport nurses were successful. There were no complications related to these procedures. All patients were transported to the receiving hospital without incident. CONCLUSIONS: Although they had considerable training for advanced procedures, the transport nurses rarely used these skills. All tracheal intubations performed by transport nurses were successful, and there were no adverse consequences related to intubation by a transport nurse. Language: en

These cases demonstrate a few of the presentations that may occur with new onset oncologic problems. While the transport phase of these children's care was not extraordinary, the development and management of the clinical issues might have been influenced by earlier interventions. Would the outcome of Case 1 have been different if the abnormal hematologic parameters demonstrated on the preoperative laboratory results had been further investigated? Would the institution of cerebral resuscitative measures before and during transport have offered this child a better chance of survival? Would the involvement of a specialized pediatric team earlier in the process have addressed some of those issues and would it have made a difference? Should the patient in case two have had cerebral resuscitative measures instituted at the referring hospital or during transport? In hindsight, this clearly would not have been useful or beneficial to the patient. But what if the initial CT interpretation of a brain tumor and increased intracranial pressure with ventricular ablation and midline shift had been correct? Should the transport team have suggested or instituted a different level of therapy with the information that was available at the time of transport? The patient in Case 3 had a dramatic presentation of his ALL. Were there signs and symptoms that should have alerted the referring hospital, transport command physician or transport team to the likely deterioration of that patient? If this patient had presented to a hospital a further distance away, would the impending cardiovascular collapse and respiratory failure have been anticipated or occurred during the transport? Would or should the mode of transport or team configuration have been altered? If this patient had deteriorated during the transport, would the transport team have had the skills to manage this potentially difficult airway? Should the patient in Case 4 have had antihypertensive medication started at the referring hospital or during the transport process? What are the guidelines for antihypertensive intervention in this situation? If antihypertensive therapy were instituted by the transport team, should this have affected time or mode of transport, or was it more prudent not to rock the boat by instituting interventional therapy? Is hypertension a different issue with a liver mass, as suspected at the time of referral, or with a nephrogenic tumor? These cases afford us the ability to review several presentations of oncologic emergencies. The questions above are but a few of the potential areas of discussion that can arise from these cases. We should use these cases as an opportunity to review and refresh our transport teams on the many faces of oncology and potential pitfalls in the care of those patients.

Transport medicine offers the challenge of patient diagnosis based only on the relayed history an the impressions of referring medical personnel. A thorough pretransport review of the patient's history, physical examination, radiographs, laboratory values, and other supporting information can help avoid surprises upon arrival at the patient's bedside and lead to an appropriate diagnosis and management plan. One must approach the transported child with an open mind, however, to avoid misdiagnosis and inadequate or inappropriate intervention and management. One of the advantages of pediatric specialty transport services is the ability to critically assess a referred patient and offer diagnostic and therapeutic guidance in addition to transportation to the receiving center. These above two examples illustrate difficult cases where the diagnostic skills of the transport medical personnel enabled the patients to receive appropriate acute interventional and specific disease-related therapy.

Objective. To define the frequency and nature of delayed diagnosis of injury (DDI) in pediatric trauma. Design. Retrospective review. Setting. Tertiary pediatric trauma center. Methods. Medical records of 1175 pediatric trauma admissions from July 1, 1989, through June 30, 1992, were reviewed. Results. Fifty (4.3%) patients had 53 DDI. Fractures accounted for 38 DDI, most commonly of the extremities (total, 16). The delay until injury diagnosis ranged from 1 to 55 (median, 3) days. Patients with DDI had lower scores on the Glasgow Coma Scale, higher injury severity scores, and longer pediatric intensive care unit and hospital stays than patients without DDI. Patients with DDI more frequently required medical transport, emergent intubation, admission to the pediatric intensive care unit, and surgery. The DDI altered treatment for 68% of patients; 10 required surgery, including second operations for 6 children. Conclusions. DDI represents a failure of pediatric trauma care at all levels. The severely injured child is at the greatest risk of DDI. All pediatric patients with trauma warrant ongoing evaluation to identify initially unrecognized injuries.

I am pleased to be able to offer the Transport Case Section for Pediatric Emergency Care. In every other issue, a case will be presented, reviewed, and discussed with goals of : 1) stimulating our thought processes regarding transport medicine ; 2) educating us with respect to pediatric transport medicine, and 3) discussing specific medical issues which one might encounter in the transport arena. Cases are solicited from the readership and should be submitted to George A. Woodward, MD, Section Editor Transport Cases, Pediatric Emergency Care, The Children's Hospital of Philadelphia, Room 2418, Main Building, 34th St and Civic Center Blvd, Philadelphia, PA 19104 ; Fax : 215-590-1394. Cases will be reviewed, and those selected will be published in a future issue. The presentation should follow the journal's instructions for author's guidelines. Visual aids such as x-rays, computed tomography scans, patient photographs, electrocardiograms, and other related documentation are encouraged.-Editor

This article describes some of the miscellaneous etiologies of pediatric chest pain that are important to recognize early and diagnose. Up to 45% of pediatric chest pain cases may elude definitive diagnosis. Serious morbidity or mortality is infrequent. Accurate diagnosis of more obscure causes may help to avoid unnecessary emergency department evaluation and cardiology referral, while also alleviating the concern and stress families and patients experience when dealing with chest pain.

The most important principles of initial management of the head-injured patient are rapid transport to an institution capable of providing the sophisticated evaluation, neurosurgical services, and monitoring necessary to improve outcome because definitive management of the head-injured patient is not possible in the field. The emphasis of care during stabilization and transport should be on the prevention of secondary central nervous system injury, primarily by prompt stabilization of the airway and assurance of proper ventilation and oxygenation, and by control of bleeding and provision of adequate circulation.

A 20-year-old man presented to the emergency department (ED) with an injured right hand, fever, and a history of dog exposure. This splenectomized individual developed hypotension less than 90 minutes after arriving in the ED with normal vital signs. He later developed overwhelming sepsis, gangrene, disseminated intravascular coagulation (DIC), respiratory insufficiency, retroperitoneal hematoma, and renal insufficiency. Blood cultures grew Capnocytophaga canimorsus sp nov (formerly Dysgonic Fermenter-2). Sepsis, gangrene, and DIC are more likely to occur in asplenic individuals exposed to this organism. Many physicians use prophylactic outpatient penicillin therapy in asplenic or functionally asplenic victims of dog and cat bites. However, a brief admission or stay in an observation unit may be indicated for these high-risk individuals.

Objective: To evaluate the effectiveness of a pediatric trauma course taught in a developing country. Study design: A pediatric trauma course was designed with didactic presentations and reinforced with small group case discussions. Subjects included a general trauma overview, head trauma, airway/chest trauma, cervical spine trauma, abdominal trauma, shock, burns, and orthopedic injuries. Evaluation consisted of a pre- and post-course test and questionnaire assessing the participants' knowledge and level of comfort in managing trauma. Nine months after the course, the participants were evaluated with the same post-course test. Also a questionnaire was given to physician and nurse co-workers from the participating institutions, who themselves had not participated in the course, to assess the perceptual and attitudinal impact of the pediatric trauma course. Setting: Guatemala City, Guatemala. Participants: Forty-three physicians from Central America. Results: Initial and nine-month post-test scores showed uniform improvement (P value < 0.05) when compared to pretest results using the Wilcoxon signed-ranks test. Analysis of the pre- and post-course questionnaires indicated that all participants felt more comfortable (scale 1 to 5) after the course managing pediatric trauma patients. All participants strongly agreed the course provided information that would improve their management of the pediatric trauma victim. Nine months after the course, 100% of their medical co-workers perceived physicians who participated in the pediatric trauma course to have better resuscitative skills, and 92% perceived these physicians to have a higher level of confidence. Conclusion: This course, when presented to physicians in a developing country, appears to be effective in improving their knowledge base regarding pediatric trauma and increasing their comfort level in managing major pediatric trauma.

Head injury is a frequent cause of morbidity and mortality in pediatric trauma. Guidelines for obtaining computed tomographic (CT) scans in the child with mild head injury are poorly defined. This study investigated the utility of head CT scanning in the pediatric patient presenting with normal neurologic examination. All patients undergoing head CT scanning for trauma in the emergency department (ED) at a tertiary care pediatric trauma center during 1992 were identified (508). Charts were reviewed for historical and physical examination findings, CT results, and need for neurosurgical intervention. Patients were excluded if they had an abnormal neurologic examination (179), known depressed skull fracture (11), bleeding diathesis (3), age older than 18 years (1), or developmental delay (1). Included were 313 patients (median 5.5 years) who presented with clinical variables including sleepiness (38%), vomiting (34%), headache (30%), loss of consciousness (LOC) (25%), irritability (22%), amnesia (20%), and seizures (8%). An abnormal head CT was noted in 88 cases (28%); 79 (25%) were traumatic abnormalities involving the skull and/or contents. Thirteen patients (4%) had intracranial injuries (ICI); all had either a linear (10), basilar (2), or depressed (1) skull fracture noted on CT. Four patients required neurosurgery, three for epidural hematoma, and one for a complicated orbital fracture (without ICI). No clinical variables (seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, amnesia) were associated with ICI (P > 0.05). In pediatric head trauma patients, with normal neurologic examinations in the ED, ICI occurs < 5% of the time and neurosurgery is needed in 1% of the cases. Commonly used clinical variables are not associated with ICI in these children.

A potential etiology of anxiety and agitation in the posthead trauma patient is cortical blindness. Cortical blindness can be seen after both mild and severe head trauma. Early recognition and understanding of this syndrome can lead to a decreased anxiety level, not only for the patient, but for the parents as well. Two cases of posttraumatic cortical blindness are presented. The signs and symptoms of cortical blindness, its presentation, diagnosis, and outcome are discussed. The available literature is reviewed and discussed.

Chest pain in adolescents and younger children is most often benign, and cardiac causes are rare. We present a 16-year-old with chest pain temporally related to cocaine use and discuss the relationship between cocaine use and acute myocardial infarction that has been seen in the adult population. Pediatricians and emergency physicians should consider cocaine abuse in the evaluation of an adolescent with chest pain.

The toxic effects of oral diphenhydramine are well documented and include central nervous system and anticholinergic symptomatology. We present a case of diphenhydramine intoxication from combined oral/percutaneous medication. Overzealous application of a commercially available topical diphenhydramine preparation resulted in hallucinations and other side effects in a five-year-old child with varicella.