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STUDY OBJECTIVE: The epidemiology of children who present to the emergency department (ED) and leave without being seen has not been well characterized. We evaluate rates and secular trends of children who leave without being seen, identify factors associated with pediatric leave without being seen cases, and determine whether there are differences in leaving patterns between children and adults seeking emergency care. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey, which collects information on patient visits to EDs throughout the United States. We examined data for children (less than or equal to 18 years of age) and adults who presented to EDs during the 6-year period ending in 2005. RESULTS: During the study period, there were an estimated 11,848,351 leave without being seen visits nationally, accounting for 1.79% of all ED visits. The prevalence of leaving without being seen was 2.46% (95% confidence interval [CI] 1.71% to 3.55%) for pediatric patients presenting to pediatric EDs, 1.86% (95% CI 1.65% to 2.10%) for pediatric patients presenting to general EDs, and 1.73% (95% CI 1.57% to 1.91%) for adults presenting to general EDs. The leave without being seen rates did not increase significantly during the study period. Factors associated with leave without being seen visits included hospital urban location, self-pay insurance status, and less acute triage level for children and adults, as well as race/ethnicity and arrival time for adult patients. CONCLUSION: In this national sample of patients, leave without being seen rates were similar for pediatric and adult patients and did not increase during the 6-year study period, although some variation in rates was observed for specific patient and ED characteristics. These national estimates provide an important reference for institutions to assess their ED performance. [ABSTRACT FROM AUTHOR]

Background: Frontline healthcare safety leaders require expertise and confidence to manage local safety programs effectively yet are confronted with substantial challenges in identifying risk and reducing harm., Methods: We convened a multidisciplinary safety learning collaborative in a children's hospital pediatric department and used the Institute for Healthcare Improvement's Breakthrough Series model. Participants attended four virtual education sessions over 13 months (September 2020-September 2021) focused on identifying harm and using tools to improve safety. We analyzed departmental safety data monthly throughout the collaborative. The primary outcome was the development of improvement projects using direct application of the session content. The secondary outcome was participant confidence in improving safety via pre- and postsurveys., Results: Seventy clinicians and quality consultants participated. Fifteen divisional safety improvement projects were initiated. The percentage of survey respondents who reported feeling "completely confident" in their ability to improve safety increased from 26% (n = 39) to 58% (n = 26) from September 2020 to September 2021 ( P = 0.01) and maintained at 65% 1 year after the end of the collaborative. We observed a decrease in the mean rate of reported inpatient preventable and possibly preventable moderate/serious/catastrophic events per 1000 bedded days from 1.10 (baseline) to 0.71 (intervention period)., Conclusions: Through a collaborative effort in a virtual learning environment, we facilitated the development of fifteen safety projects, increased leaders' confidence in improving safety, and saw improved inpatient safety. This approach, which involves healthcare professionals from various disciplines, may be effectively adapted to other settings., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care., Methods: We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition., Results: There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022)., Conclusions: A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives: Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement., Methods: At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates., Results: Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates., Conclusions: The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits., (Copyright © 2022 by the American Academy of Pediatrics.)

Structured handoffs at transitions of care are vital components of patient safety. A safety culture survey showed that "handoffs and transitions" were among the lowest scoring dimensions at our hospital. We sought to improve physician handoffs and safety culture scores by implementing standardized handoff communication across multiple divisions of an academic pediatric department., Methods: We used a modified learning collaborative model to implement an I-PASS program, including training, standardized verbal handoff processes, observation and feedback, and sustainment. The setting was the Department of Pediatrics (DoP) within a tertiary academic children's hospital encompassing 13 clinical divisions. The primary outcome was a change in the DoP staff physician "handoffs and transitions" score on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture. Process measures included handoff duration and proportion of handoffs using the complete I-PASS mnemonic., Results: Five hundred sixty-seven physicians from clinical divisions participated over 14 months. One hundred percent of eligible physicians completed an introductory online I-PASS training module. The "handoffs and transitions" score improved from 46% to 54% from 2018 to 2020. From May 2019 to February 2020, the proportion of observed handoffs with all five elements of the I-PASS mnemonic improved from 62% to 100%, and the duration of handoffs per patient did not change., Conclusions: We successfully implemented an I-PASS program across an academic department of pediatrics. The departmental staff physician safety culture "handoff and transitions" score improved. The adherence to the I-PASS mnemonic improved. The duration of handoffs did not change over the study period., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019., Methods: A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System., Results: Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time., Conclusions: We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management., Competing Interests: FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Objective: Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits., Methods: This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted., Results: There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results., Conclusions: These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED., (© 2021 Society for Academic Emergency Medicine.)

Background: Many institutions track early ICU transfers (transfer from an inpatient floor to an ICU within 24 hours of admission) as a marker of quality of emergency department (ED) care. There are limited data evaluating whether patient characteristics or clinical outcomes differ on the basis of timing of ICU transfer within this 24-hour window., Methods: We conducted a retrospective cohort study examining all patients ≤21 years old admitted to an inpatient pediatric floor from the ED and subsequently transferred to an ICU within 24 hours of hospitalization. Patient characteristics and clinical outcomes were compared on the basis of timing (0-6 hours, 6-12 hours, 12-24 hours) of ICU transfer. Outcomes assessed included receipt of critical intervention, timing of intervention with respect to transfer, type of intervention received, hospital and ICU length of stay, and mortality at 72 hours and during hospitalization., Results: A total of 841 patients were transferred to an ICU within 24 hours from admission to a pediatric ward from the ED; 266 patients (32%) transferred within 6 hours of admission, 269 patients (32%) transferred between 6 and 12 hours, and 306 patients (36%) transferred between 12 and 24 hours. Patient characteristics did not materially differ on the basis of timing of ICU transfer, nor did clinical outcomes., Conclusions: Among children transferred to an ICU within 24 hours of hospitalization, patient characteristics and clinical outcomes did not materially differ based on the timing of transfer relative to admission from the ED., Competing Interests: POTENTIAL CONFLICTS OF INTEREST: The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency., Methods: We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process., Results: Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention., Conclusions: Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED., Competing Interests: Competing interests: NS, AJS and DCW have consulted with and hold equity in the I-PASS Patient Safety Institute, which seeks to train institutions in best handoff practices and aid in their implementation. NS, AJS and DCW also reported receiving honoraria and travel reimbursement from multiple academic and professional organisations for delivering lectures on handoffs and patient safety., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine demographic and clinical risk factors associated with boarding (length of stay ≥24 h) for pediatric mental health emergency department (ED) visits., Methods: This is a retrospective cross-sectional analysis of mental health visits identified by diagnosis codes for children 5-18 years old presenting to a tertiary pediatric ED in 2016. We performed multivariate logistic regression to identify demographic and clinical factors associated with boarding., Results: There were 1746 mental health visits and 386 (22%) visits had length of stay ≥24 h. In the multivariate logistic regression model, factors associated with boarding included: private insurance (OR 1.59, 95% CI 1.15, 2.19) and having both private and public insurance (OR 1.68, 95% CI 1.16, 2.43) relative to public insurance; presentation during a school month (OR 2.17, 95% CI 1.30, 3.63); physical or chemical restraint use (OR 4.80, 95% CI 2.61, 8.84); comorbid autism or developmental delay (OR 1.82, 95% CI 1.35, 2.46); prior psychiatric hospitalization (OR 2.55, 95% CI 1.93, 3.36); and reasons for presentation of agitation, aggression, or homicidal ideation (OR 2.76, 95% CI 1.40, 5.45), depression, self-injury, or suicidal ideation (OR 2.79, 95% CI 1.45, 5.40), and bipolar, mania, or psychosis (OR 5.78, 95% CI 2.36, 14.09) relative to anxiety., Conclusions: Insurance status, presentation month, restraint use, autism or developmental delay comorbidity, prior psychiatric hospitalization, and reason for presentation are associated with pediatric mental health ED boarding. Resources should be directed to improve the mental health care system for children with identified risk factors for boarding., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Analyze trends in visit numbers, length of stay (LOS), and costs of pediatric mental health emergency department (ED) visits over time., Methods: We conducted a cross-sectional, time-series analysis from 2010 to 2016 of mental health visits, identified by billing diagnosis codes, among children 5 to 18years old in a tertiary pediatric ED. We used Poisson regression to analyze trends in rates of mental health visits, patient-hours, and visits with LOS ≥ 24hours. We used time-series analysis to trend median costs per visit., Results: From 2010 to 2016, there were 197,982 ED visits and 13,367 (6.7%) mental health visits. Mental health visits increased by 45% (from 1462 to 2119), compared to a 13% increase in non-mental health visits. The rate of mental health visits increased from 5.6 to 7.1 per 100 ED visits and increased 5.5% annually, compared to -0.4% annually for non-mental health visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.05-1.07). Mental health patient-hours increased 186%, compared to an 18% increase in non-mental health patient-hours. The rate of mental health visits with LOS ≥ 24hours increased from 4.3 to 18.8 per 100 mental health visits and increased 22% annually (IRR, 1.22; 95% CI, 1.19-1.26). Median costs per visit increased by $38 per quarter (95% CI, $28-$48)., Conclusions: Rates of mental health visits, patient-hours, visits with LOS ≥ 24hours, and visit costs are increasing over time. Additional hospital and community resources are needed to address rising ED utilization for mental illness in children., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: There is a paucity of data describing pediatric patients transferred to an ICU within 24 hours of hospital admission from the emergency department (ED)., Methods: We conducted a retrospective cohort study of patients ≤21 years old transferred from an inpatient floor to an ICU within 24 hours of ED disposition from 2007 to 2016 in a tertiary children's hospital. Patients transferred to an ICU after planned operative procedures were excluded. Rate of transfer, clinical course, and baseline demographic and/or clinical characteristics of these patients are described., Results: The study cohort consisted of 841 children, representing 1% of 82 397 non-ICU ED admissions over the 10-year period. Median age was 5.1 years, 43% had ≥1 complex chronic condition, and 47% were hospitalized within the previous year (27% in the ICU). The majority of transfers were for respiratory conditions (65%) and cardiovascular compromise (18%). Median time from hospitalization to ICU transfer was 9.1 hours (interquartile range 5.1-14.9 hours). Thirty-eight percent of transfers received 1 or more critical interventions within 72 hours of hospitalization, most commonly positive pressure ventilation (29%) and vasoactive infusion (9%). Median time to intervention from hospitalization was 13.6 hours (interquartile range 7.5-21.6 hours), 0.8% of children died within 72 hours of hospitalization, and 2.4% died overall., Conclusions: In this single pediatric academic center, 1% of hospitalized children were transferred to an ICU within 24 hours of ED disposition. One-third of patients received a critical intervention, and 2.4% died. Although most ED dispositions are appropriate, future efforts to identify patients at the highest risk of deterioration are warranted., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objective: Efforts to reduce the rate of computerized cranial tomography (CT) in pediatric patients with minor head trauma (MHT) have focused on academic medical centers. However, community hospitals deliver the majority of pediatric emergency care. We aimed to reduce cranial CT utilization in patients presenting with MHT at 3 community hospital emergency departments (EDs)., Methods: Multidisciplinary stakeholder teams at each site oversaw the quality improvement effort, which included education about an evidence-based guideline for MHT and individual provider feedback on CT rates. Given the variation in hospital structure, we tailored the specifics of the intervention to each site. We used statistical process control methodology to measure CT rates over time. The primary balancing measure was returned to the ED within 72 hours with clinically important traumatic brain injury., Results: We included 3,215 pediatric ED visits for MHT: 1,253 in the baseline period and 1,962 in the intervention period. The CT rate dropped from 18% in the baseline period to 13% in the intervention period, a 28% relative reduction. Pediatric providers saw 72% of the intervention period encounters and drove this reduction. There was no increase in the number of children who returned to their local ED within 72 hours with clinically important traumatic brain injury., Conclusions: We safely reduced the proportion of children with MHT who received a cranial CT through a multicenter community ED quality improvement initiative. We did not see an increase in missed clinically important traumatic brain injury.

Introduction: Use of Evidence-based Guidelines (EBGs) has been shown to improve and standardize care. After implementation and maturation of a guideline program, next steps include incorporating new evidence, sustaining adherence, minimizing measurement burden and fostering scaling of the program. We propose a framework for maintenance and dissemination of an EBG program., Methods: Using a program of 28 EBGs developed for use in a pediatric emergency department (ED) in 2010, we developed: a framework for iterative review and revision, a strategy to measure ongoing use in practice and an approach for minimizing repeated measurement sufficient to evaluate outcomes. Also, we created a process to spread the EBG program to the hospital's Department of Pediatrics., Results: The framework for maintenance and spread of a program of EBGs resulted in an annual review of individual guidelines with 14 revisions warranted by new evidence, some leading to decreased medication utilization and hospitalization rates. We demonstrated adherence to key quality measures, and decreased the number of measures from 89 to 43, retiring 46 measures with stable peformance. We spread the process for program development to the hospital pediatric department resulting in 36 new EBGs., Conclusions: We developed a framework for maintenance and scale of a program of EBGs. Our key learning points were that regular incorporation of new evidence, assessment and feedback on performance and leadership with administrative support are necessary to maintain improvement. This framework may assure sustainability and inform other guideline programs. We offer processes to promote guideline dissemination within an academic hospital.

Objective: Opportunity exists to reduce unnecessary hospitalizations for children with anaphylaxis given wide variation in admission rates across U.S. emergency departments (EDs). We sought to identify children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies, as these patients may be candidates for ED discharge rather than inpatient hospitalization., Methods: We conducted a single-center retrospective cohort study of children 1-21 years of age hospitalized with anaphylaxis from 2009 to 2016. Acute inpatient therapies included intramuscular (IM) or racemic epinephrine, bronchodilators, fluid boluses, vasopressors, non-invasive ventilation, or intubation. We derived age-specific (pre-verbal [<36 months] vs. verbal [≥ 36 months]) prediction rules using recursive partitioning to identify children at low risk of receiving acute inpatient therapies., Results: During the study period 665 children were hospitalized for anaphylaxis, of whom 108 (16.2%) received acute inpatient therapies. The prediction rule for patients < 36 months (no wheezing, no cardiac involvement [hypotension or wide pulse pressure]) had a sensitivity of 90.5% (CI 69.6-98.8%) and a negative predictive value of 98.3% (CI 94.1-99.8%) for identifying children at low risk of receipt of acute inpatient therapies during hospitalization. For children ≥ 36 months, the prediction rule (no wheezing, no cardiac involvement, presence of gastrointestinal symptoms) had a sensitivity of 90.8% (CI 82.7-96.0%) and a negative predictive value of 92.4% (CI 85.6-96.7%)., Conclusions: We derived age specific prediction rules for children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies. These children may be candidates for ED discharge rather than inpatient hospitalization., Competing Interests: The authors have declared that no competing interests exist.

Background: Miscommunication during patient transfers is a leading cause of medical errors. Inpatient standardization of handoff communication has been associated with reduced medical errors, but less is known about best practices for handoffs from referring providers to the emergency department (ED). The study aims were to identify (1) stakeholder perceptions of current handoff processes and (2) key handoff elements and strategies to optimize patient care on transfer., Methods: A mixed-methods needs assessment study was conducted at a tertiary care children's hospital with a communication center that receives verbal handoff via telephone from referring providers and provides written summary to the ED. ED, primary care providers, and communication center staff were surveyed to understand perceptions of handoff processes and ideal handoff elements. Focus groups were conducted to refine concepts. Descriptive statistics, chi-square analysis, and qualitative content analysis were used to analyze responses., Results: The survey response rate was 129/152 providers (85%). Forty-two percent of respondents described the quality of the handoff process as "very good" or "excellent"; 43% reported miscommunication occurring "sometimes" or "frequently." Within the I-PASS framework-Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver-respondents identified 10 key elements to obtain through a receiver-driven process to optimize care on transfer. Free-text responses revealed a perceived need to standardize communication., Conclusion: A minority of providers perceived handoff quality between outpatient practices and the ED as "very good" or "excellent"; almost half perceived regular miscommunication. A receiver-driven process is a novel approach that may help ensure standardized communication of key handoff elements in this context., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review., Methods: Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance., Results: Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis., Conclusions: We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.

Objective: Return visits to the emergency department (ED) are used as a marker of quality of care. Limited English proficiency, along with other demographic and disease-specific factors, has been associated with increased risk of return visit, but the relationship between language, short-term return visits, and overall ED use has not been well characterized., Methods: This is a planned secondary analysis of a prospective cohort examining the ED discharge process for English- or Spanish-speaking parents of children aged 2 months to 2 years with fever and/or respiratory illness. At 1 year after the index visit, a standardized chart review was performed. The primary outcome was the number of ED visits within 72 hours of the index visit. Multivariable logistic regression was used to examine the relative importance of predictor variables and adjust for confounders., Results: There were 202 parents eligible for inclusion, of whom 23% were Spanish speaking. In addition, 6.9% of the sample had a return visit within 72 hours. After adjustment for confounders, Spanish language was associated with return visit within 72 hours (odds ratio, 3.49; 95% confidence interval, 1.02-11.90) but decreased risk of a second visit within the year (odds ratio, 0.28; 95% confidence interval, 0.12-0.66)., Conclusion: Spanish-speaking parents are at an increased risk of 72-hour return ED visit but do not seem to be at increased risk of ED use during the year after their ED visit.

Background and Objectives: Most children with anaphylaxis in the emergency department (ED) are hospitalized. Opportunities exist to safely reduce the hospitalization rate for children with anaphylaxis by decreasing unnecessary hospitalizations. A quality improvement (QI) intervention was conducted to improve care and reduce hospitalization rates for children with anaphylaxis., Methods: We used the Model for Improvement and began with development and implementation in 2011 of a locally developed evidence-based guideline based on national recommendations for the management of anaphylaxis. Guideline adoption and adherence were supported by interval reminders and feedback to providers. Patients from 2008 to 2014 diagnosed with anaphylaxis were identified, and statistical process control methods were used to evaluate change in hospitalization rates over time. The balancing measure was any return visit to the ED within 72 hours. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children's hospitals over the same time period were analyzed., Results: Over the study period, there were 1169 visits for children with anaphylaxis, of which 731 (62%) occurred after the QI implementation. The proportion of children hospitalized decreased from 54% to 36%, with no increase in the 72-hour ED revisit rate. The hospitalization rate across 34 other US pediatric hospitals remained static at 52% over the study period., Conclusions: We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To improve oral rehydration therapy (ORT) after discharge for children presenting to the emergency department (ED) with acute gastroenteritis (AGE)., Methods: We designed and implemented a quality improvement initiative to improve caregiver adherence to ORT in children 6 months to 21 years old with AGE. The intervention consisted of ORT "kits" with rehydration supplies and caregiver instructions. In the preintervention period we monitored patient/caregiver adherence to ORT recommendations and additionally monitored ORT kit and educational material distribution during the intervention phase via a caregiver survey after discharge. We utilized statistical process control methodology to assess responses to the intervention. As a balancing measure, we monitored the ED length of stay for patients with AGE., Results: Over the study period from November 2013 to April 2015, we included 174 encounters during the preintervention period and 256 encounters during the intervention period. More than 9 of 10 children received ORT kits in the intervention period. Self-reported adherence to ORT between the 2 time periods remained constant. The ED length of stay did not change between the preintervention and intervention period., Conclusions: Despite successful distribution of novel ORT materials and education for caregivers of children with AGE in a pediatric ED, caregiver self-reported adherence to ORT postdischarge visit was unchanged. An unexpected high baseline adherence to ORT practices may have limited improvement.

Background: The optimal staffing model for emergency departments (EDs) is not known. Improving staffing could lead to more timely, efficient, and effective care. We created a model of staffing to identify times of staffing limitation by provider type., Methods: We analyzed data from an academic pediatric ED with 60,000 visits per year. Each 10-minute interval from January 1, 2011, through December 31, 2012, was categorized as nonlimited (no staffing limitation), space limited (≥2 patients in the waiting room with wait times > 30 minutes and ≥ 80% ED bed occupancy), nurse limited (≥2 patients in the waiting room with wait times > 30 min and < 80% ED bed occupancy), or physician limited (≥2 patients in examination rooms who have waited > 30 minutes for a physician) using computer modeling. We calculated the percentage of time each type of limitation was in effect and the median lengths of stay for patients presenting during times of each category of limitation., Results: The ED was space limited 5.0% of the time, nurse limited 16.1% of the time, and physician limited 0.1% of the time. In nonlimited times, length of stay was 201 minutes (interquartile range, 128-301), whereas patients presenting during space-limited, nurse-limited, and physician-limited times had statistically significantly higher LOS of 265 (187-360), 244 (169-337), and 247 (174-334) minutes, respectively., Conclusions: Times identified as space and staffing limited were associated with longer LOS. This computer model could be used to rapidly identify targeted staffing needs and then measure the effect of modifying staffing.

Background and Objective: Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures., Methods: We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database., Results: We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%., Conclusions: We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions., (Copyright © 2016 by the American Academy of Pediatrics.)

Introduction: Care guidelines can improve the quality of care by making current evidence available in a concise format. Emergency departments (EDs) are an ideal site for guidelines given the wide variety of presenting conditions and treating providers, and the need for timely decision making. We designed a programme for guideline development and implementation and evaluated its impact in an ED., Methods: The setting was an urban paediatric ED with an annual volume of 60 000. Common and/or high-risk conditions were identified for guideline development. Following implementation of the guidelines, their impact on effectiveness of care, patient outcomes, efficiency and equitability of care was assessed using a web-based provider survey and performance on identified metrics. Variation in clinical care between providers was assessed using funnel plots., Results: Eleven (11) guidelines were developed and implemented. 3 years after the initiation of the programme, self-reported adherence to recommendations was high (95% for physicians and 89% for nurses). 97% of physicians and 92% of nurses stated that the programme improved the quality of care in the ED. For some guidelines, provider-to-provider care practice variation was reduced significantly. We found reduced disparity in imaging when assessing one guideline. There were also reductions in utilisation of diagnostic tests or therapies. As a balancing measure, the percentage of patients with any of the guideline conditions who returned to the ED within 72 h of discharge did not change from before to after guideline initiation. Overall, 80% of physician and 56% of nurse respondents rated the guideline programme at the highest value., Conclusions: A programme for guideline development and implementation helped to improve efficiency, and standardise and eliminate disparities in emergency care without jeopardising patient outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Emergency department (ED) utilization by children is common and growing more expensive. Tracking trends and variability in ED charges is essential for policymakers who strive to improve the efficiency of the health care system and for payers who prepare health care budget forecasts. Our objective was to examine trends and variability in ED charges for pediatric patients across Massachusetts., Methods: This was a comprehensive analysis of the statewide database containing all the visits of children aged 0 to 18 years evaluated in any of the state's EDs from 2000 to 2011, excluding patients with chronic medical conditions and those whose visits resulted in hospital admission. A validated system designed to specifically classify pediatric emergency patients into major diagnostic groups was used. Mean charges as well as interhospital variability of charges over time were examined for the most common diagnostic groups., Results: Seventy-six hospitals provided emergency care in Massachusetts during the study period, with 6,249,923 pediatric patients treated and discharged. Statewide charges significantly increased from 2000 until 2007/2008, before plateauing or decreasing through 2011. There was no evidence that interhospital variability changed over time. With the exception of academic teaching status, no hospital-level factors emerged as consistent predictors of charges., Conclusions: Charges for common pediatric emergency conditions varied widely across Massachusetts EDs, and hospital-level factors by and large could not consistently explain the variability. Although a plateau (and in some cases decrease) of statewide pediatric emergency health care charges was observed after 2007, no evidence was found that interhospital variability decreased. These data may be useful in the ongoing effort to reform the economics of health care delivery systems., (© 2015 by the Society for Academic Emergency Medicine.)

Objective: Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries., Methods: We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time., Results: We included 6851 ED visits of which 4242 (62%) occurred in the post-guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation., Conclusions: An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return., Design and Setting: Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System., Participants: Patients <18 years old discharged following an ED visit., Measures: The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization., Results: 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7-2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively., Conclusions: Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization., (© 2014 Society of Hospital Medicine.)

Objective: To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals., Methods: We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates., Results: A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates., Conclusions: We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission., (Copyright © 2014 by the American Academy of Pediatrics.)

Objectives: The use of ultrasound (US) has been shown to improve success rates and reduce complications of central venous catheter (CVC) placement in adult emergency department (ED) patients. The authors sought to determine if US assistance for CVC placement is associated with an increased success rate in pediatric ED patients., Methods: This was a retrospective cohort study of CVC placement in a pediatric ED from January 2003 to October 2011. Data were extracted from a procedure log created to record details entered by physicians at the time of CVC placement, including indication, location, complications, and information regarding use of US. All femoral vein and internal jugular vein CVC placement attempts performed by, assisted with, or directly supervised by pediatric emergency physicians (EPs) were included. Characteristics of procedures performed with and without US assistance were compared, controlling for patient and physician factors. The primary outcome was the success rate of CVC placement., Results: There were 168 patients undergoing CVC placement attempts. The proportion of successful placement attempts was significantly higher when using US assistance (96 of 98) compared to those without (55 of 70; 98% vs. 79%, odds ratio [OR] = 13.1, 95% confidence interval [CI] = 2.9 to 59.4). When controlling for patient- and physician-specific factors, success rates remained significantly higher., Conclusions: Ultrasound assistance was associated with greater likelihood of success in CVC placement in a pediatric ED., (© 2014 by the Society for Academic Emergency Medicine.)

Objective: Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED)., Methods: We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS)., Results: There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge., Conclusions: A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.

Background: A growing body of literature supports the use of ultrasound (US) to assist central venous catheter (CVC) placement, and in many settings, this has become the standard of care. However, this remains a relatively new and uncommonly performed procedure for pediatric emergency medicine physicians., Objectives: This study aims to describe the change over time in percentage of CVC procedures performed with US assistance per 10,000 patient visits in a pediatric emergency department., Methods: We describe the development of an emergency US program in a pediatric emergency department and investigate how US use for CVC placement in internal jugular and femoral veins changed from July 2007, when US became available, until December 2011. Data related to CVC procedures were obtained from a procedure database maintained for quality assurance purposes., Results: The percentage of CVC procedures performed with US assistance increased significantly over time (P < 0.001)., Conclusions: The development of an emergency US program was associated with significantly increased physician use of US for CVC placement.

Objectives: Safe and effective care after discharge requires parental education in the pediatric emergency department (ED). Parent-provider communication may be more difficult with parents who have limited health literacy or English-language fluency. This study examined the relationship between language and discharge comprehension regarding medication dosing., Methods: We completed a prospective observational study of the ED discharge process using a convenience sample of English- and Spanish-speaking parents of children 2 to 24 months presenting to a single tertiary care pediatric ED with fever and/or respiratory illness. A bilingual research assistant interviewed parents to ascertain their primary language and health literacy and observed the discharge process. The primary outcome was parental demonstration of an incorrect dose of acetaminophen for the weight of his or her child., Results: A total of 259 parent-child dyads were screened. There were 210 potential discharges, and 145 (69%) of 210 completed the postdischarge interview. Forty-six parents (32%) had an acetaminophen dosing error. Spanish-speaking parents were significantly more likely to have a dosing error (odds ratio, 3.7; 95% confidence interval, 1.6-8.1), even after adjustment for language of discharge, income, and parental health literacy (adjusted odds ratio, 6.7; 95% confidence interval, 1.4-31.7)., Conclusions: Current ED discharge communication results in a significant disparity between English- and Spanish-speaking parents' comprehension of a crucial aspect of medication safety. These differences were not explained purely by interpretation, suggesting that interventions to improve comprehension must address factors beyond language alone.

Background: Hospital emergency departments (ED) are confronted with triaging and managing dental emergencies of both traumatic and non-traumatic origin. However, the literature suggests that there exists inadequate knowledge of the management of traumatic dental injuries (TDI) among medical professionals who must be knowledgeable and have the appropriate resources needed to triage or treat patients presenting with TDI., Aim: The aims of this study were to (i) evaluate the resources of Massachusetts emergency departments (MEDs) for TDI, (ii) determine the knowledge of management of TDI among MED physicians, and (iii) investigate potential factors that affect their knowledge., Materials and Methods: Surveys were mailed to MED directors and their physicians. The director survey contained questions regarding institutional information for each emergency department (ED). The physician survey contained questions about physician characteristics and tested their knowledge of managing dental trauma., Results: A total of 72 surveys (16 MED directors and 56 physicians) were returned and included in the analysis. Only 50% of the MEDs had on-site dental coverage, 43.8% had 24-h off-site dental coverage, and none had a formal written dental trauma protocol. MED physician's knowledge of the appropriate management of luxations and avulsions was generally good, but poor for dental fractures. The MED physician's knowledge for the emergent nature of the various injuries was generally good with that of avulsions being the best. Physicians were more likely to have a better knowledge of managing dental trauma if they were specialists in pediatric emergency medicine (P = 0.001) or their hospitals had an academic affiliation (P = 0.05)., Conclusions: Based on the findings from this study, educational campaigns must be undertaken to improve both the resources available to the ED, and the knowledge of physicians regarding emergency management of TDI. In addition, efforts should be made by local dental organizations to provide ED with lists of dentists who are knowledgeable and willing to be available 24 h day⁻¹ to consult with and, if necessary, treat TDI. These efforts would enhance the long-term outcomes for patients sustaining dental trauma who present to hospital ED., (© 2012 John Wiley & Sons A/S.)

Background: Return visits to the emergency department (ED) resulting in admission are an important marker of quality of care. Patients and families with limited English proficiency (LEP) are at risk for suboptimal care related to imprecise communication., Objective: The objective of this study was to compare the rate of return visits resulting in admission in LEP patients to the rate in the English-speaking patients., Methods: We assembled a retrospective cohort of patients cared for in a pediatric, tertiary ED. Eligible patients included those who were discharged on the first encounter, and those who returned and were admitted to the hospital within 72 hours of ED discharge were identified. A logistic regression was performed comparing the rate of return visits resulting in admission in the LEP and non-LEP populations adjusting for emergency severity index and time of day at ED visit., Results: A total of 119,782 patients were discharged from the ED during a 32-month study period. Of these patients, 11.7% (14,053) identified a language other than English as their primary language. The rate of return visits resulting in admission was 1.2% (1279/105,729) among English speakers and 1.6% (220/14,053) in the LEP population. Patients with LEP were more likely to return to the ED for admission (odds ratio, 1.30; 95% confidence interval, 1.12-1.50; P < 0.001) The increased risk of a return visit for LEP patients remained significant after controlling for age, emergency severity index, and time of day (adjusted odds ratio, 1.43; 95% confidence interval, 1.23-1.66; P < 0.001)., Conclusion: Patients with LEP are at higher risk of return visit for admission.

Objectives: Patient and parent satisfaction are important measures of quality of care. Data are lacking regarding satisfaction with emergency procedures, including laceration repair. The objective was to define the elements of care that are important to parents during a pediatric laceration repair and to determine the predictors of excellent parent satisfaction., Methods: This was a cross-sectional observational study of a convenience sample of patients younger than 18 years of age presenting for laceration repair to an urban tertiary care children's hospital emergency department (ED). At the end of the ED visit, parents completed a survey developed for this study assessing ratings of their experience and their perception of how their child experienced the repair. Exploratory factor analysis was used to derive the factors comprising parents' perception of the laceration repair process. A separate factor analysis was performed for the 0- to 4-years age subgroup. Multivariate logistic regression was used to determine which of these factors predicted excellent parent satisfaction with the visit, and also satisfaction with the procedure itself, adjusting for sociodemographic factors., Results: A total of 408 parents returned completed surveys (response rate=76%). Factor analysis revealed that three factors provided a summary of the 16 survey items. They were labeled "provider performance,""anxiety and pain," and "cosmetic appearance," based on factor loading patterns. Provider performance was the only predictor of satisfaction with the visit (adjusted odds ratio [OR]=11.6; 95% confidence interval [CI]=6.2 to 21.6). Provider performance (adjusted OR=4.7; 95% CI=3.1 to 7.2) and cosmetic appearance (adjusted OR 2.7; 95% CI=1.7 to 4.2) predicted satisfaction with the procedure. Anxiety and pain did not predict either outcome., Conclusions: Provider performance, which comprises the elements of physician communication, caring attitude, confidence, and hygiene, is the strongest predictor of excellent parent satisfaction for pediatric patients with ED visits for laceration repair., (© 2012 by the Society for Academic Emergency Medicine.)

Objectives: To determine whether insurance status is associated with the use of diagnostic testing or intervention in the emergency department (ED) care of children., Study Design: Retrospective cross-sectional analysis of ED visits using data from the National Hospital Ambulatory Medical Care Survey (1999-2008). Children <19 years old were categorized as having private insurance, public insurance, or no insurance. The main outcome measure was the adjusted odds of testing (laboratory or radiologic) or intervention (medication or procedure), controlling for demographic, clinical, and hospital specific factors. Illness severity was controlled for using triage and admission status., Results: Forty-five percent (95% CI; 44, 47) of visits were characterized as having private insurance compared with 43% with public insurance (95% CI; 42, 44) and 12% without insurance (95% CI; 11, 13). Children with public insurance and no insurance received less testing compared with those with private insurance (adjusted OR 0.78, 95% CI; 0.73, 0.84 and adjusted OR 0.78, 95% CI; 0.72, 0.84, respectively). Similar patterns were seen in the use of medications and performance of procedures., Conclusions: Non-private insurance status is associated with decreased utilization of diagnostic testing and intervention in children visiting the ED. It is unclear whether these patterns represent appropriate utilization, overutilization in patients with private insurance, or underutilization in patients without private insurance. Further studies are needed to evaluate whether these disparate care patterns impact health outcomes and could have important implications for the allocation of healthcare resources within the ED as well as the primary care setting., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes., (Copyright © 2011. Published by Mosby, Inc.)

Objectives: Emergency department (ED) crowding may affect disposition decision-making. The objective was to measure the effect of ED crowding on probability of admission and return visit to the ED after discharge., Methods: The authors studied a historical cohort at a large pediatric ED over 40 months. Each patient was assigned a score on arrival based on the ED occupancy rate (the ratio of patients to beds). Patients were divided into quintiles by occupancy rate. The proportion admitted for each quintile was compared to the least crowded quintile adjusting for acuity, hospital occupancy, and time of arrival. The same analysis was performed for return visits to the ED within 48 hours. The analyses were repeated for the subsets of patients with asthma and with gastroenteritis and/or dehydration., Results: From the 40 months of historical data, 198,778 visits were analyzed. The adjusted odds ratio (aOR) for admission among the whole cohort was 0.85 (95% confidence interval [CI]=0.81 to 0.89) comparing the highest to the lowest crowding quintiles (occupancy rate >1.17 and <0.54, respectively). For asthma patients, aOR=0.93 (95% CI=0.72 to 1.20), and for gastroenteritis patients, aOR=0.87 (95% CI=0.65 to 1.17). The aOR of return visits comparing the highest to the lowest crowding quintiles for all patients was aOR=0.87 (95% CI=0.79 to 0.97), for asthma patients was aOR=1.52 (95% CI=0.95 to 2.46), and for gastroenteritis patients was aOR=0.83 (95% CI=0.54 to 1.28)., Conclusions: Increasing ED crowding is associated with a lower likelihood of hospital admission and lower frequency of return visits within 48 hours., (© 2012 by the Society for Academic Emergency Medicine.)

Objectives: The objective was to determine whether insurance status is associated with the care of patients presenting to the emergency department (ED)., Methods: This was a retrospective cross-sectional analysis of ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS; 1999 through 2008). Patients 19 to 64 years of age were categorized as having private insurance, public insurance, or no insurance as their primary insurance. Six components of ED care were assessed: wait time, left prior to discharge, use of diagnostic testing, treatment, instructions for follow-up, and whether the patient had been seen in the past 72 hours., Results: Nonprivate insurance status was associated with all six components of ED care, including higher proportions of leaving before discharge of patients with public insurance (4.1%, 95% confidence interval [CI]=3.8% to 4.5%) versus patients with no insurance (4.7%, 95% CI=4.2% to 5.1%) or private insurance (2.2%, 95% CI=2.0% to 2.4%; p<0.001). It was also associated with a higher proportion of return visits with 5.1% (95% CI=4.6% to 5.6%) of patients with public insurance versus 4.7% (95% CI=4.1% to 4.6%) of patients with no insurance versus 3.8% (95% CI=3.5% to 4.2%) of patients with private insurance (p<0.001). Patients with public or no insurance also had decreased odds of ED testing compared to those with private insurance (adjusted odds ratio [AOR] for public=0.84, 95% CI=0.80 to 0.88; and AOR for none=0.82, 95% CI=0.79 to 0.86)., Conclusions: Nonprivate insurance status is associated with different care patterns in adults aged 19 to 64 years visiting the ED. Further studies are needed to evaluate how these disparate care patterns affect health outcomes., (© 2012 by the Society for Academic Emergency Medicine.)

Objective: There is a high risk for morbidity and mortality in immunocompromised patients with fever if antibiotics are not received in a timely manner. We designed a quality improvement effort geared at reducing the time to antibiotic delivery for this high risk population., Methods: The setting was the emergency department in an academic pediatric tertiary care hospital that sees ~60,000 patients annually. We assembled a multidisciplinary team who set a target of 60 minutes from time of presentation to antibiotic delivery for patients with known neutropenia and 90 minutes for patients with possible neutropenia. Quality improvement methods were used to effect change and evaluate when the targets were not met. Improved communication between providers and patients and timely feedback were implemented., Results: Mean time to antibiotic delivery in febrile oncology patients with known neutropenic status dropped from 99 minutes in the preimplementation period to 49 minutes in the postimplementation period, whereas it dropped from 90 minutes to 81 minutes in possibly neutropenic patients. The percentage of patients who met the targets for time to antibiotics rose from 50% to 88.5%., Conclusions: A multidisciplinary team approach and standardization of the process of care were effective in reducing the time from arrival to antibiotic delivery for febrile neutropenic patients in the pediatric emergency department.

Study Objective: Although it has been suggested that high hospital occupancy leads to emergency department (ED) overcrowding and impedes ED throughput, there are limited data defining this relationship. The objective of this study is to examine whether high inpatient hospital occupancy negatively affects throughput in a pediatric ED., Methods: This cross-sectional analysis evaluated patient visits to an urban pediatric ED and hospital occupancy rates. Data were collected from a 347-bed pediatric tertiary care hospital in Boston, MA, between January and December 2006. Primary outcome measure was ED length of stay; secondary outcomes were percentages of patients who left without being seen or had a hallway bed used for treatment., Results: Throughout the study period, there were 56,335 patient visits to the pediatric ED; 9,687 (17%) patients were hospitalized. High hospital occupancy directly correlated with longer length of stay for all patients treated in the ED. When inpatient occupancy was at or more than 80% capacity, every 5% increase in hospital occupancy was associated with an increase in length of stay of 17.7 minutes for discharged patients (95% confidence interval [CI] 2.2 to 33.2 minutes) and 34.3 minutes for admitted patients (95% CI 11.4 to 57.2 minutes). With the same 5% increase in inpatient occupancy, there were increases in the odds of either a patient leaving without being seen (odds ratio 1.21; 95% CI 1.12 to 1.31) or being treated in a hallway bed (odds ratio 1.18; 95% CI 1.15 to 1.22)., Conclusion: High hospital occupancy has a significant and quantifiable negative influence on ED throughput, affecting patients both discharged and hospitalized.

Clostridium difficile is the leading cause of nosocomial antibiotic-associated diarrhea, and recent outbreaks of strains with increased virulence underscore the importance of identifying novel approaches to treat and prevent relapse of Clostridium difficile-associated diarrhea (CDAD). CDAD pathology is induced by two exotoxins, toxin A and toxin B, which have been shown to be cytotoxic and, in the case of toxin A, enterotoxic. In this report we describe fully human monoclonal antibodies (HuMAbs) that neutralize these toxins and prevent disease in hamsters. Transgenic mice carrying human immunoglobulin genes were used to isolate HuMAbs that neutralize the cytotoxic effects of either toxin A or toxin B in cell-based in vitro neutralization assays. Three anti-toxin A HuMAbs (3H2, CDA1, and 1B11) could all inhibit the enterotoxicity of toxin A in mouse intestinal loops and the in vivo toxicity in a systemic mouse model. Four anti-toxin B HuMAbs (MDX-1388, 103-174, 1G10, and 2A11) could neutralize cytotoxicity in vitro, although systemic toxicity in the mouse could not be neutralized. Anti-toxin A HuMAb CDA1 and anti-toxin B HuMAb MDX-1388 were tested in the well-established hamster model of C. difficile disease. CDA1 alone resulted in a statistically significant reduction of mortality in hamsters; however, the combination treatment offered enhanced protection. Compared to controls, combination therapy reduced mortality from 100% to 45% (P<0.0001) in the primary disease hamster model and from 78% to 32% (P<0.0001) in the less stringent relapse model.

Objectives: (1) To identify the extent to which information provided by parents in the pediatric emergency department (ED) can drive the assessment and categorization of data on allergies to medications, and (2) to identify errors related to the capture and documentation of allergy data at specific process level steps during ED care., Methods: An observational study was conducted in a pediatric ED, combining direct observation at triage, a structured verbal interview with parents to ascertain a full allergy history related to medications, and chart abstraction. A comparative standard for the allergy history was established using parents' interview responses and existing guidelines for allergy. Errors associated with ED information management of allergy data were evaluated at five steps: (1) triage assessment, (2) treating physician's discussion with parent, (3) treating nurse's discussion with parent, (4) use of an allergy bracelet, and (5) documentation of allergy history on medication order sheets., Results: 256 parent-child dyads were observed at triage; 211/256 parents (82.4%) completed the structured verbal interview that served as the basis for the comparative standard (CS). Parents reported a total of 59 medications as possible allergies; 56 (94.9%) were categorized as allergy or not based on the CS. Twenty eight of 48 patient cases were true allergies by guideline based assessment. Sensitivity of triage for detecting true medication allergy was 74.1% (95% confidence interval (CI) 53.7 to 88.9). Specificity of triage personnel for correctly determining that no allergy existed was 93.2% (95% CI 88.5 to 96.5). Physician and nursing care had performance gaps related to medication allergy in 10-25% of cases., Conclusions: There are significant gaps in the quality of information management regarding medication allergies in the pediatric ED.

BACKGROUND: A recently licensed pneumococcal conjugate vaccine has been shown to be highly effective in the prevention of bacteremia in immunized children but the degree of protection against pneumonia has been difficult to determine. METHODS: We sought to develop a model of Streptococcus pneumoniae pneumonia in Sprague-Dawley rats. We challenged three-week old Sprague-Dawley pups via intrapulmonary injection of S. pneumoniae serotypes 3 and 6B. Outcomes included bacteremia, mortality as well histologic sections of the lungs. RESULTS: Pneumonia was reliably produced in animals receiving either 10 or 100 cfu of type 3 pneumococci, with 30% and 50% mortality respectively. Similarly, with type 6B, the likelihood of pneumonia increased with the inoculum, as did the mortality rate. Prophylactic administration of a preparation of high-titered anticapsular antibody prevented the development of type 3 pneumonia and death. CONCLUSION: We propose that this model may be useful for the evaluation of vaccines for the prevention of pneumococcal pneumonia.

Immunologic mechanisms are thought to contribute to the pathogenesis of respiratory syncytial virus (RSV) bronchiolitis in humans. RSV-infected BALB/c mice exhibit tachypnea and signs of outflow obstruction, similar to symptoms in humans. Interferon gamma (IFNgamma) has been found to be the predominant cytokine produced in humans and mice with RSV infection. We therefore undertook this study to evaluate the role of IFNgamma in the development of respiratory illness in RSV-infected mice. BALB/c mice were infected with RSV, and lung function was assessed by plethysmography. Bronchoalveolar lavage (BAL) fluids were analyzed for the concentration of interferon gamma (IFNgamma) and the presence of inflammatory cells, and lung tissue sections were examined for histopathologic changes. The role of IFNgamma was further addressed in studies of IFNgamma knock-out mice (IFNgamma(-/-)) and of mice depleted of IFNgamma by in vivo administration of a neutralizing antibody. After infection, mice developed respiratory symptoms that were strongly associated with the number of inflammatory cells in BAL, as well as with the concentrations of IFN-gamma. Both IFN-gamma(-/-) mice and mice treated with anti-IFNgamma developed more extensive inflammation of the airways than control mice. However mice lacking IFNgamma exhibited less severe signs of airway obstruction. Together these data suggest a protective role of IFNgamma in RSV infection in terms of limiting viral replication and inflammatory responses but also a pathogenic role in causing airway obstruction., (Copyright 2000 Wiley-Liss, Inc.)

Respiratory syncytial virus (RSV) is the primary cause of lower respiratory tract illness in young children. Vaccine development has been hampered by the experience of the formalin-inactivated vaccine tested in the 1960's. Currently, several vaccine candidates are under development and immune response to these candidate vaccines must be evaluated closely. We introduce a novel low-dose murine model of RSV infection and a new pathologic scoring system for the resultant pulmonary disease. We have also developed new sensitive methods for measuring cytokine expression. We then used this new model to test vaccine challenge strains of RSV in order to determine their pathogenicity.

Septic shock induced by lipopolysaccharide (LPS) triggering of cytokine production from monocytes/macrophages is a major cause of morbidity and mortality. The major monocyte/macrophage LPS receptor is the glycosylphosphatidylinositol (GPI)-anchored glycoprotein CD14. Here we demonstrate that CD14 coimmunoprecipitates with Gi/Go heterotrimeric G proteins. Furthermore, we demonstrate that heterotrimeric G proteins specifically regulate CD14-mediated, LPS-induced mitogen-activated protein kinase (MAPK) activation and cytokine production in normal human monocytes and cultured cells. We report here that a G protein binding peptide protects rats from LPS-induced mortality, suggesting a functional linkage between a GPI-anchored receptor and the intracellular signaling molecules with which it is physically associated.