Pediatric early warning score at time of emergency department disposition is associated with level of care.

OBJECTIVE: The objective of this study was to determine the association between the Pediatric Early Warning Score (PEWS) at time of emergency department (ED) disposition and level of care. METHODS: We conducted a prospective observational study with a convenience sample of patients aged 0 to 21 years in the ED of an urban, tertiary care children's hospital between November 2010 and July 2011. Pediatric Early Warning Score data were obtained at time of ED disposition, and the disposition decision was collected from the electronic medical record. Multinomial logistic regression was used to determine the association between PEWS and disposition. RESULTS: The sample of 383 patients included 239 (62%) who were discharged, 126 (33%) admitted to acute care, and 18 (5%) admitted to intensive care. Assigned scores ranged from 0 to 9. Adjusting for triage level, a 1-point increase in PEWS increased the odds of acute care admission 48% relative to the odds of discharge (odds ratio, 1.48; 95% confidence interval, 1.25-1.76) and increased the odds of intensive care admission 41% relative to the odds of acute care admission (odds ratio, 1.41; 95% confidence interval, 1.13-1.76). Pediatric Early Warning Score of 1 or more had maximum discriminant ability for admission, and PEWS of 3 or greater had maximum discriminant ability for intensive care. Area under the receiver operator characteristic curve was 0.68 to detect need for admission for the entire sample and 0.80 among the 97 patients with respiratory complaints. CONCLUSIONS: Pediatric Early Warning Score is associated with the level of care at ED disposition but does not provide adequate sensitivity and specificity to be used in isolation. Performance characteristics are better for patients with respiratory complaints.

Qualitative Study Exploring Implementation of a Point-of-Care Competency-Based Lumbar Puncture Program Across Institutions.

OBJECTIVE: To explore the factors that facilitated or hindered successful implementation of a multi-centered infant lumbar puncture (LP) competency-based education program that required interns to demonstrate skills readiness on a task trainer before performing their first clinical LP. METHODS: In 2013, investigators conducted a qualitative study utilizing semistructured interviews and focus groups of site directors (SDs) from the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) who were responsible for implementing the LP competency-based education program. Transcripts were analyzed using grounded theory to identify and verify emergent themes and subthemes. RESULTS: Thematic saturation was attained after interviewing 19 SDs in 12 interviews and 3 focus groups. The most significant strategies and barriers were organized into 4 main themes: 1) alignment of different visions to obtain buy-in, 2) balance between providing education versus patient care, 3) acceptance of novel teaching paradigms, and 4) communication logistics. The ability to overcome barriers was influenced by institutional culture on trainee education, patient safety and research; the level of relational coordination between different groups of stakeholders; and the ability of SDs to identify and diversify entrepreneurial strategies. CONCLUSIONS: INSPIRE SDs reveal the challenges of implementing a network-wide competency-based educational initiative that determines interns' readiness to perform LPs in clinical settings. Strategizing to align the common goals of graduate medical training, patient care and research instructs clinician educators and leaders on how to successfully change educational culture in academic medicine.