Improving Turnaround Time of Transabdominal Pelvic Ultrasounds with Ovarian Doppler in a Pediatric Emergency Department.

Introduction: Adnexal torsion is an emergent surgical condition. Transabdominal pelvic ultrasound (US) with ovarian Doppler is used to diagnose adnexal torsion and requires a sufficient bladder volume. Reduce the turnaround time for US by 25% in girls 8-18 years of age who present to the emergency department (ED) for 24 months. Methods: Our baseline period was from January 2020 to June 2021, and the intervention period was from July 2021 to June 2023. Patients 8-18 years old who required an US in the ED were included. There are two key drivers: early identification of US readiness and expeditious bladder filling. Interventions were (1) bladder volume screening; (2) utilization of bladder volume nomogram to identify US readiness; (3) epic order panels; and (4) rapid intravenous fluid method. The primary outcome was US turnaround time. Secondary outcomes were percentage of patients requiring invasive interventions to fill the bladder and patients with an US study duration of ≤45 minutes. The percent of patients screened by bladder scan was used as a process measure. Balancing measures used episodes of fluid overload and ED length of stay. Results: Turnaround time for USs improved from 112.4 to 101.6 minutes. The percentage of patients who had successful USs without invasive bladder filling improved from 32.1% to 42.6%. Bladder volume screening using a bladder scan increased from 40.3% to 82.9%. The successful first-pass US completion rate improved from 77% to 90% consistently. Conclusions: Through quality improvement methodology, we have identified pelvic US readiness earlier, eliminated some invasive bladder-filling measures, and implemented a rapid fluid protocol. We have sustained these successful results for 2 years. This study can be generalized to any ED with similar patients.

Vaccine Confidence as Critical to Pandemic Preparedness and Response.

Vaccine confidence is a belief that vaccines work, are safe, and are part of a trustworthy medical system. The COVID-19 pandemic exposed the fragility of the public's confidence in vaccines and the vaccine enterprise, limiting the public health impact of vaccination. In this review, we examine the critical nature of vaccine confidence to pandemic preparedness and response.

Emergency departments: An underutilized resource to address pediatric influenza vaccine coverage.

BACKGROUND: Emergency department (ED) based influenza vaccine (IV) programs have been successful in adults; however, little is known about pediatric ED IV programs in terms of prevalence, feasibility, or successful implementation. AIMS: To describe the reach and effectiveness of IV practices in pediatric EDs, and identify IV facilitators and barriers. METHODS: We assessed, via cross-sectional survey of pediatric ED physicians, number of EDs offering IV to children, vaccines administered annually, and perceived facilitators/barriers to vaccination. The proportion of EDs offering IV is reported. Chi-square tests compared facilitators and barriers among high performers (≥50 IV/year), low performers (<50 IV/yr), and non-vaccinators. We calculated an area of missed effect for the number of children who could be vaccinated if non-vaccinating EDs offered IV. RESULTS: Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3 %) EDs). Most EDs were in large, urban, academic, freestanding children's hospitals (Table 1). Only twenty-six EDs (44.3 %) offer ≥ 1 IV/yr. Seventeen (65.4 %) were low performers, five (19.2 %) high performers, and four (15.4 %) were model programs. High/model performers used establish workflows more commonly than lower performers (78 % vs. 33 %), although this was not statistically significant (p = 0.077). Common facilitators included: strong provider and administration buy-in, electronic health record facilitation, storage/accessibility, and having a leadership team/champion (Fig. 1). Non-vaccinators commonly perceived lack of these factors as barriers. Many (24/61, 39.3 %) EDs expressed interested in establishing or growing IV programs. Up to 18,250 unvaccinated children could receive IV annually if non-vaccinating EDs offered IV during influenza season. CONCLUSIONS: Over half of EDs participating in the Pediatric Emergency Medicine Collaborative Research Committee do not currently offer pediatric IV. Addressing identified barriers/facilitators to develop IV programs in EDs has potential to improve vaccination rates, especially among minority and underserved children.

Emergency Departments: An Underutilized Resource for Expanding COVID-19 Vaccine Coverage in Children.

COVID-19 vaccine (CV) acceptance rates remain suboptimal in children. Emergency departments (EDs) represent a unique opportunity to improve vaccination rates, particularly in underserved children. Little is known about the presence or reach of CV programs in US EDs. We assessed, via a cross-sectional survey of pediatric ED physicians, the number of EDs offering CVs to children, the approximate numbers of vaccines administered annually, and the perceived facilitators/barriers to vaccination. The proportion of EDs offering CVs is reported. Chi-square tests compared facilitators and barriers among frequent vaccinators (≥50 CVs/year), infrequent vaccinators (<50 CVs/year), and non-vaccinators. Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3%) EDs). Most EDs were in large, urban, academic, freestanding children's hospitals. Only 11 EDs (18.0%) offer ≥1 CV/year, and only two (18.2%) of these gave ≥50 CVs. Common facilitators of vaccination included the electronic health record facilitation of vaccination, a strong provider/staff buy-in, storage/accessibility, and having a leadership team or champion. Barriers included patient/caregiver refusal, forgetting to offer vaccines, and, less commonly, a lack of buy-in/support and the inaccessibility of vaccines. Many (28/47, 59.6%) EDs expressed interest in establishing a CV program.

The Influence of Racism in Healthcare: COVID-19 Vaccine Hesitancy Among Black Mothers in Chicago.

Black mothers and children experience significant health disparities in the USA. These health disparities have been attributed, in part, to experiencing racism in healthcare. This study aimed to explore how experiences of healthcare discrimination and mistreatment experienced by Black mothers may influence COVID-19 vaccine beliefs and decision-making for themselves and their families. From April 2021 to November 2021, we conducted 50 semi-structured interviews among Chicago residents. Ten participants self-identified as female and with reported children; these data were extracted from the larger sample for data analysis. Interview content included perceptions and experiences with the COVID-19 vaccine and experiences with healthcare discrimination, mistreatment, and medical mistrust. Interview transcripts were transcribed verbatim and coded using the MAXQDA 2022 qualitative software. Themes were identified using a team-based thematic analysis to understand how experiences of racism in healthcare may influence COVID-19 vaccine decision-making. Four themes were generated from the data: (1) experiences of healthcare discrimination and mistreatment, (2) distrust and fears of experimentation, (3) the influence of discrimination and distrust on COVID-19 vaccine decision-making, and (4) overcoming vaccine hesitancy. The results of this study highlight the current literature; Black mothers experience racism and discrimination in healthcare when seeking care for themselves and their children. It is evident in their stories that medical racism and historical medical abuse influence vaccine decision-making. Therefore, healthcare and public health initiatives should be intentional in addressing past and present racism in healthcare to improve vaccine distrust.

Factors associated with US caregivers' uptake of pediatric COVID-19 vaccine by race and ethnicity.

OBJECTIVES: To assess differences in willingness to vaccinate children against COVID-19, and factors that may be associated with increased acceptance, among US caregivers of various racial and ethnic identities who presented with their child to the Emergency Department (ED) after emergency use authorization of vaccines for children ages 5-11. STUDY DESIGN: A multicenter, cross-sectional survey of caregivers presenting to 11 pediatric EDs in the United States in November-December 2021. Caregivers were asked about their identified race and ethnicity and if they planned to vaccinate their child. We collected demographic data and inquired about caregiver concerns related to COVID-19. We compared responses by race/ethnicity. Multivariable logistic regression models served to determine factors that were independently associated with increased vaccine acceptance overall and among racial/ethnic groups. RESULTS: Among 1916 caregivers responding, 54.67% planned to vaccinate their child against COVID-19. Large differences in acceptance were noted by race/ethnicity, with highest acceptance among Asian caregivers (61.1%) and those who did not specify a listed racial identity (61.1%); caregivers identifying as Black (44.7%) or Multi-racial (44.4%) had lower acceptance rates. Factors associated with intent to vaccinate differed by racial/ethnic group, and included caregiver COVID-19 vaccine receipt (all groups), caregiver concerns about COVID-19 (White caregivers), and having a trusted primary provider (Black caregivers). CONCLUSIONS: Caregiver intent to vaccinate children against COVID-19 varied by race/ethnicity, but race/ethnicity did not independently account for these differences. Caregiver COVID-19 vaccination status, concerns about COVID-19, and presence of a trusted primary provider are important in vaccination decisions.

Understanding Influenza and SARS-CoV-2 Vaccine Hesitancy in Racial and Ethnic Minority Caregivers.

(1) Background: We compared influenza and SARS-CoV-2 vaccine hesitancy levels in Black, Hispanic, and White parents/caregivers and identified barriers and facilitators to vaccine acceptance. (2) Methods: This was a mixed methods study. A cross-sectional survey of ED caregivers presenting with children 6mo−18yo compared vaccine hesitancy levels among diverse caregivers. Six focus groups of survey participants, stratified by caregiver race/ethnicity and caregiver intent to receive SARS-CoV-2 vaccine, assessed facilitators and barriers of vaccination, with thematic coding using the Consolidated Framework for Implementation Research (CFIR). (3) Results: Surveys (n = 589) revealed Black caregivers had significantly higher vaccine hesitancy rates than White caregivers for pediatric influenza (42% versus 21%) and SARS-CoV-2 (63% versus 36%; both p < 0.05). Hispanic caregivers were more hesitant than White caregivers (37% flu and 58% SARS-CoV-2), but this was not significant. Qualitative analysis (n = 23 caregivers) identified barriers including vaccine side effects, lack of necessity, inadequate data/science, and distrust. Facilitators included vaccine convenience, fear of illness, and desire to protect others. (4) Conclusions: Minority caregivers reported higher levels of vaccine hesitancy for influenza and SARS-CoV-2. We identified vaccine facilitators and barriers inclusive of Black and Hispanic caregivers, which may guide interventions designed to equitably improve acceptance of pediatric vaccines.

Should COVID-19 vaccines be mandated in schools? - an international caregiver perspective.

OBJECTIVES: Caregiver attitudes toward mandating COVID-19 vaccines for their children are poorly understood. We aimed to determine caregiver acceptability of COVID-19 vaccine mandates for schools/daycares and assess if opposition to mandates would result in removal of children from the educational system. STUDY DESIGN: Perform a cross-sectional, anonymous survey of adult caregivers with children ≤ 18 years presenting to 21 pediatric emergency departments in the United States, Canada, Israel, and Switzerland, November 1st through December 31st, 2021. The primary outcome was caregiver acceptance rates for school vaccine mandates, and the secondary outcomes included factors associated with mandate acceptance and caregiver intention to remove the child from school. RESULTS: Of 4,393 completed surveys, 37% of caregivers were opposed to any school vaccine mandate. Caregiver acceptance was lowest for daycare settings (33%) and increased as the child's level of education increased, college (55%). 26% of caregivers report a high likelihood (score of 8-10 on 0-10 scale) to remove their child from school if the vaccine became mandatory. Child safety was caregivers' greatest concern over vaccine mandates. A multivariable model demonstrated intent to vaccinate their child for COVID-19 (OR = 8.9, 95% CI 7.3 to 10.8; P < 0.001) and prior COVID-19 vaccination for the caregiver (OR = 3.8, 95% CI 3.0 to 4.9; P < 0.001) had the greatest odds of increasing mandate acceptance for any school level. CONCLUSIONS: Many caregivers are resistant to COVID-19 vaccine mandates for schools, and acceptance varies with school level. One-fourth of caregivers plan to remove their child from the educational system if vaccines become mandated.

Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes.

OBJECTIVE: In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months. RESEARCH DESIGN AND METHODS: Plan-do-study-act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two-bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO3 ) <15 mEq/L. PRIMARY OUTCOME: the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO3 ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts. RESULTS: From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures. CONCLUSIONS: Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA.

Quality Improvement Project to Improve the Timeliness of Care for Children With Testicular Torsion in the Emergency Department.

Introduction: Testicular torsion (TT) is a urologic emergency that requires timely diagnosis and surgery. We noted variation in the door-to-detorsion times for patients with TT at our institution and our orchiectomy rate was 25.8%. We aimed to decrease the mean door-to-detorsion time from 124.6 to 114.6 minutes or less over 12 months. Methods: A multidisciplinary team of pediatric emergency medicine, radiology, urology physicians, and nurses, was formed. Our key drivers were use of Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, prompt urology consultation, and efficient transfer from emergency department (ED) to operating room. Our process measures were TWIST score documentation rate and early urology consultation rate, outcome measures were door-to-detorsion time and orchiectomy rate, and balancing measure was ultrasound utilization rate. Early urology consultation occurred when the ED provider documented telephone communication with urology, immediately after placing a testicular doppler ultrasound (TDUS) order and before TDUS result. Results: Over 2 years, 45 cases of TT were diagnosed. TWIST score documentation was implemented and was sustained at 78%. This improved early urology consultations from 40% to 60%. The mean door-to-detorsion time improved from 124.6 to 114.2 minutes. There was no reduction in the orchiectomy rate or TDUS utilization rate. Conclusions: A quality improvement project to improve the timeliness of care for children with TT resulted in expedited ED care but did not impact the orchiectomy rate.

Urgent COVID-19 Vaccination of Healthcare Workers via a Quality Improvement Initiative.

The COVID-19 pandemic has posed a significant threat to US healthcare workers' mental and physical health. The US Food and Drug Administration approved the first mRNA COVID-19 vaccine for Emergency Use Authorization on December 11, 2020. High-risk healthcare workers were determined to be Phase 1a. Goal: Complete the two-dose vaccine series in all interested phase 1a staff immediately after the COVID-19 vaccine was available and distributed to our institution, December 14, 2020. METHODS: A multidisciplinary team involving key stakeholders performed process mapping to develop four key drivers for vaccination success: rapid vaccine procurement, proper storage and handling, well-defined vaccine administration and follow-up plan, and system preparation. We tested interventions using plan-do-study-act cycles. We included employees and providers with direct patient care responsibilities, age 18 years or older, employed at the children's health system, or the affiliated academic medical center. We examined the total number of dose 1 and dose 2 vaccines administered for our primary outcome, and the balancing measure included the percent of wasted vaccines. RESULTS: Three thousand nine-hundred twenty-one healthcare personnel completed the survey, and 73% reported intent to receive the COVID-19 vaccine immediately or at a later time. After 57 clinic days, we vaccinated 83% (n = 5,231) of healthcare personnel at our institution, and 99% completed the two-dose series. Due to surplus vaccines, we vaccinated an additional 1,258 community members with 99% completion of the two-dose series. Vaccine waste was minimal 0.1%. CONCLUSION: We describe the development and implementation of a successful COVID-19 employee and community vaccination program.

Assessing improvements in emergency department referrals to a hospital-based violence intervention program.

BACKGROUND: Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018-2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7-18 years who present to our Level 1 emergency department/trauma center with a violent injury. METHODS: For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts. RESULTS: The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase. CONCLUSION(S): We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

Vaccinating in the Emergency Department, a Model to Overcome Influenza Vaccine Hesitancy.

INTRODUCTION: Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018-2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019-2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients. METHODS: Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months-18 years old, emergency severity index score 2-5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure. RESULTS: We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2. CONCLUSIONS: This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

Vaccinating in the Emergency Department, a Novel Approach to Improve Influenza Vaccination Rates via a Quality Improvement Initiative.

INTRODUCTION: Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017-2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s. METHODS: Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution. RESULTS: We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital. CONCLUSIONS: We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.

Improving Emergency Department Management of Diabetic Ketoacidosis in Children.

BACKGROUND: Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months. METHODS: Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts. RESULTS: Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P < .001). In patients without DKA, IV placement decreased from 85% to 36% (P < .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively. CONCLUSIONS: Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.

Identifying Pediatric Severe Sepsis and Septic Shock: Accuracy of Diagnosis Codes.

OBJECTIVES: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.