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To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock.This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure.Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

OBJECTIVE: Pediatric mental health emergency department (ED) visits that involve restraints for agitation are increasing. Quality measures are used to assess and improve healthcare quality. Our objective was to develop quality measures for pediatric ED agitation management informed by multidisciplinary perspectives. METHODS: A multidisciplinary panel developed quality measures for pediatric ED agitation management through the modified Delphi method. Panelists ranked measures in importance and feasibility on a 9-point scale during two survey rounds, with a teleconference discussion between surveys. Consensus was defined by >75% of panelists ranking a quality measure highly (≥7) in importance and a median feasibility score ≥4. RESULTS: Panelists included 36 physicians, nurses, social workers, security, child life specialists, hospital data analysts, and parents. The panel reached consensus on 20 quality measures. Measures with the highest percentage of scores with importance ≥7 were related to adverse medication events, patients restrained, staff/patient injuries, re-escalation plans, presence of an algorithm to standardize care, formal staff training on de-escalation techniques, time to medication administration, and room safety. CONCLUSIONS: Twenty quality measures that incorporate multidisciplinary perspectives were developed for pediatric ED agitation management. Once operationalized and field-tested, these measures may be used to assess and improve healthcare quality for pediatric agitation.

Since the Institute of Medicine's initial report on medical error was published in 1999, understanding of the magnitude of this problem within health care continues to grow. Although medical error is a broad category that includes both system and human factors, diagnostic error, with significant consequences for patients and their families, bias is a common and often overlooked contributor. This type of error is complex, as it is rooted in clinicians' use of heuristics and their inherent or cognitive biases. The objective of this review is to define medical error and to explore the methods that can be used to reduce error in clinical practice. Using a case-based discussion, cognitive bias resulting in diagnostic error will be reviewed.

* Abbreviations: EMR — : electronic medical record QI — : quality improvement Since the early 1990s, the United States has been fighting the epidemic of opioid addiction. Increases in the prescription of over-the-counter opioid pain medications were correlated with a notable rise in overdose deaths as early as 1999.1 These trends may have been driven in part by national efforts to improve the assessment and management of pain among patients and the “pain as a fifth vital sign” culture.2 In this issue of Pediatrics , Bryl et al3 describe their quality improvement (QI) initiative to decrease prescription of opioid medications at discharge from their urban pediatric emergency department. Evaluation of data showing that nearly half of the opioid-related deaths among patients 0 to 21 years in the San Diego area involved patients seen at their institution prompted a call to action. As the largest pediatric provider in that region, achieving a decrease in the group’s prescription of opioid medications could have a significant impact on this population. The team used rigorous QI methods to guide their initiative. These included developing a specific … Address correspondence to Jacqueline B. Corboy, MD, MS, Division of Emergency Medicine, Ann & Robert H Lurie Children’s Hospital of Chicago, 225 East Chicago Ave, Box 62, Chicago, IL 60611-2991. E-mail: jcorboy{at}luriechildrens.org

Supplemental Digital Content is available in the text., Introduction: Since 2015, the Ann and Robert H. Lurie Children’s Hospital Emergency Department (ED) has improved the recognition and treatment of pediatric sepsis and septic shock. Despite existing clinical care guidelines, the ED had not yet achieved the Surviving Sepsis Campaign timeliness goals for fluid and antibiotic administration. Methods: The team conducted a multidisciplinary Kaizen event to evaluate clinical workflows and identify opportunities to improve sepsis care adherence. Using rigorous quality improvement methodology, frontline providers mapped workflows to identify barriers and prioritize emerging solutions. Results: Thirty-seven staff members across 17 disciplines participated. Nurses and physicians identified communication gaps at pathway initiation. Access to supplies, inadequate task delegation, and a lack of urgency for a subset of pathway patients delayed treatment. Prioritized interventions included scripted communication tools, a delineated response plan, and standardized reassessment processes. Revisions to the key driver diagram were made after the improvement event, guiding future plan-do-study-act cycles. Conclusions: Frontline provider participation in the Kaizen event uncovered barriers to care and identified the root causes of ineffective communication and system process inefficiencies. Engaging key stakeholders from multiple care areas in a candid context was a novel approach to process improvement within our department. The Kaizen methodology is fundamental to developing sustainable quality improvement practices, creating momentum for a continuous improvement culture to engrain quality improvement in practice. The success of Kaizen will shape the format of future ED improvement projects.

Emergency departments are a primary site for evaluation of pediatric patients presenting with fever. Part of this evaluation may include the collection of blood cultures to rule out infection from a bacterial pathogen. Many of these samples, however, yield results that are not representative of a true bacterial infection, causing undue burden on patients and their families and adding considerable costs for the health care system. Reducing the rate of false-positive blood cultures may be achieved through quality improvement methodology. Strategies for the reduction of blood culture contamination, including process improvement and targeted education, are discussed in this review.