CHaMP: A Model for Building a Center to Support Health Care Worker Well-Being After Experiencing an Adverse Event.

BACKGROUND: With an already distressed health care workforce demonstrating high levels of burnout, depression, and suicide, access to behavioral health care, particularly after an adverse event, is critical. Unfortunately, clinicians identify multiple barriers to seeking behavioral support. In 2022 the National Academy of Medicine, in its National Plan for Health Workforce Well-Being, established "Support Mental Health and Reduce Stigma" as one of its seven priority areas. FRAMEWORK: The authors developed a program called CHaMP (Center for Healthy Minds and Practice) guided by a multidisciplinary task force that developed the vision, plan, and algorithms to improve crisis response; build a peer support program; and remove barriers to accessing mental health care by establishing an on-campus behavioral health support center. This program was implemented using Kotter's 8-step Model of Change. RESULTS: Within the first months of establishing this program, the support team responded to multiple activations of the crisis response plan, built a peer support program, and provided counseling services to 631 employees. During the COVID-19 pandemic, CHaMP played a central role in the support of all employees. CONCLUSION: This program and its implementation based on Kotter's 8-Step Model of Change was a powerful and practical methodology to design and implement interventions to address system and individual factors that affect clinician well-being and resilience after an adverse event.

Using an Online Vaccination Registry to Confirm Tetanus Status in Children with Tetanus-prone Wounds.

INTRODUCTION: Tetanus vaccination status is an important consideration for emergency physicians managing patients with tetanus-prone wounds. Physicians must identify at-risk patients, but vaccination histories are often unknown and commonly lack documentation. The study objective was to determine the potential impact of an online immunization registry (Florida SHOTS - State Health Online Tracking System) on the appropriate administration of tetanus prophylaxis for pediatric patients managed in the emergency department (ED). METHODS: We conducted a retrospective review of all patients less than 18 years old who received ED tetanus prophylaxis at two separate sites between January 2011-May 2015. The Florida SHOTS database was accessed to determine vaccination status for each patient in the study group at the time of the encounter. We compared vaccination status for each patient, as documented in the electronic health record (EHR), with Florida SHOTS data to determine whether tetanus prophylaxis was indicated. The proportion of patients receiving tetanus prophylaxis in the ED, who were subsequently identified as up to date with tetanus vaccination per Florida SHOTS, was determined. RESULTS: We identified 743 patients who received ED tetanus prophylaxis. Forty-three (6%) were listed as "up to date" on the EHR and 656 (93%) were listed as "not up to date." In comparison, 209 (30%) of the study group were identified as "up to date" via Florida SHOTS, and 477 (70%) were not. We accessed the Florida SHOTS record retrospectively to determine whether the vaccine was required. It was determined that 174 (25%) of the patients received tetanus prophylaxis unnecessarily as they were already up to date per Florida SHOTS documentation. CONCLUSION: Twenty-five percent of patients vaccinated for tetanus in the ED could have been spared if Florida SHOTS data had been used by providers at the time of the encounter. Access to Florida SHOTS provides valuable information regarding vaccination status that impacts patient care and resource utilization in the ED.

Naloxone Triggering the RRT: A Human Antidote?

OBJECTIVES: At our institution, we observed an increase in opioid-related adverse events after instituting a new pain treatment protocol. To prevent this, we programmed the Omnicell drug dispensing system to page the RRT whenever naloxone was withdrawn on the general wards. METHODS: Retrospective review of a prospectively collected database with a before and after design. RESULTS: When comparing the two 12-month periods, there was a decrease in monthly opioid-related cardiac arrests from 0.75 to 0.25 per month (difference = 0.5; 95% CI, 0.04-0.96, P = 0.03) and a nearly significant decrease in code deaths from 0.25 to 0 per month (difference = -0.25; 95% CI, -0.02-0.52, P = 0.07) without a significant decrease in pain satisfaction scores (difference = -2.3; 95% CI, -4.4 to 9.0, P = 0.48) over the study period. There were also decreased RRT interventions from 7.3 to 5.6 per month (difference = -1.7; 95% CI, -0.31 to -3.03, P = 0.02) and decreased inpatient transfers from 2.9 to 1.8 transfers per month (difference = -1.2; 95% CI, -0.38 to -1.96, P = 0.005). When adjusting for inpatient admissions and inpatient days, there was a decrease in opioid-related cardiac arrests from 2.9 to 0.1 per 10,000 admissions (difference = -2.0; 95% CI, -0.2 to -3.8, P = 0.03) and a decrease in cardiac arrests from 0.5 to 0.2 per 10,000 patients (difference = -0.34; 95% CI, -.02 to -0.65, P = 0.04). CONCLUSION: Naloxone-triggered activation of the RRT resulted in reduced opioid-related inpatient cardiac arrests without adversely affecting pain satisfaction scores.

Ultrasound-Guided Peripheral Intravenous Catheter Training Results in Physician-Level Success for Emergency Department Technicians.

OBJECTIVES: To report our success and complication rates with emergency department (ED) technician-performed ultrasound (US)-guided peripheral intravenous (IV) catheter placement and to compare our results to similar studies in the literature. METHODS: We conducted a retrospective review of a prospective database of patients who underwent US-guided peripheral IV catheter placement attempts for clinical care in the ED. All patients meeting difficult IV access criteria who had a US-guided peripheral IV catheter placement attempted by a trained ED technician were included. Average attempts per success and overall success rates were compared to similar published studies. RESULTS: There were 830 participants, with an overall success rate of ED technician- performed US-guided peripheral IV catheter placement of 97.5%. Clinicians categorized 82.6% of participants as having difficult IV access and reported that in 46.5%, a central venous catheter would have been necessary if the US-guided peripheral IV catheter failed. Of successful catheter attempts, 86.8% were placed on the first attempt; 11.6% were placed on the second attempt; and 1.6% were placed on the third attempt. For this study, the average number of attempts per success was 1.15 (95% confidence interval, 1.12-1.18), which was lower than in 6 other published studies, ranging from 1.27 to 1.70. The overall success rate of our ED technician-performed attempts was 0.970 (95% confidence interval, 0.956-0.983), which was higher than that reported in previous ED technician studies (0.79-0.80), and closer to that reported for physicians or nurses (0.87-0.97). The arterial puncture complication rate was 0.8%, which was also lower than in other published studies (1.25%-9.80%). CONCLUSIONS: With brief but comprehensive training, ED technicians can successfully obtain US-guided peripheral IV catheter access in patients with difficult IV access.

The long-term burden of severe sepsis and septic shock: Sepsis recidivism and organ dysfunction.

BACKGROUND: Severe sepsis and septic shock mortality has improved; however, rates of persistent (28-90 days) and long-term (>90 day) organ dysfunction in sepsis survivors are unknown. METHODS: Secondary analysis of a prospective cohort of adult emergency department patients with severe sepsis. RESULTS: Of 110 sepsis admissions, we obtained follow-up on 51 of 78 survivors of whom 41% (21 of 51) had persistent organ dysfunction: pulmonary, 18% (9 of 51); renal, 22% (11 of 51); coagulopathy, 10% (5 of 51); cardiovascular, 6% (3 of 51); hepatic, 2% (1 of 51); and neurologic, 3% (3 of 51). We obtained follow-up on 40 of 73 survivors at more than 90 days of whom 38% (15 of 40) had long-term organ dysfunction: pulmonary, 13% (5 of 40); renal, 18% (7 of 40); coagulopathy, 3% (1 of 40); cardiovascular, 5% (2 of 40); hepatic, 0%; and neurologic, 5% (2 of 40). Readmission rate within 90 days was 32% (25 of 78), and recurrent sepsis was the cause of readmission in 52% (13 of 25). Baseline SOFA scores from the index sepsis admission were compared using Wilcoxon rank-sum test and were significantly different in participants with organ dysfunction versus those without organ dysfunction at less than 90 days (z, -2.51; p = 0.01). CONCLUSION: Readmission with recurrent sepsis and organ dysfunction occurs frequently in sepsis survivors. Baseline SOFA score may be predictive of sepsis recidivism and persistent or recurrent organ dysfunction. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV.

Poisonings with Suicidal Intent Aged 0-21 Years Reported to Poison Centers 2003-12.

INTRODUCTION: Few studies explore the clinical features of youth suicide by poisoning. The use of both social and clinical features of self-poisoning with suicidal intent could be helpful in enhancing existing and creating new prevention strategies. We sought to characterize self-poisonings with suicide intent in ages 0 to 21 years reported to three regional poison control centers from 2003-2012. METHODS: This study was a blinded retrospective review of intentional self-poisonings by those age 21 or younger captured by the Poison Information Control Network. Age, sex, substance(s) used, medical outcome, management site, clinical effects, and therapies were described using counts and percentages and analyzed using chi-square tests. We analyzed the medical outcome ranging from no effect to death using the Wilcoxon rank-sum test. Serious medical outcome was defined as death or major outcome. RESULTS: We analyzed a total of 29,737 cases. The majority were females (20,945;70.5%), of whom 274 (1.3%) were pregnant. Most cases were 15-18 year olds (15,520;52.2%). Many experienced no effects (9,068;30.5%) or minor medical outcomes (8,612;29%). Males had more serious medical outcomes (p<0.0001), but females were more likely to be admitted to a critical care unit (p<0.0001). There were 17 deaths (0.06%), most in males (10;p=0.008). Of the 52 substances reported in the death cases, 12 (23.1%) were analgesics. In eight (47.1%) of the deaths, over two substances were used. Overall, drowsiness/lethargy (7,097;19.3%) and single-dose charcoal (8,815;16.3%) were frequently reported. Nearly 20% were admitted to critical care units (5,727;19.3%) and 28.7% went to psychiatric facilities (8,523). Of those admitted to hospitals (8,203), nearly 70% (5,727) required critical care units. Almost half <10 years old were evaluated and released (43;47.2%). Of the 114 reported substances for this population, 22.8% involved psychotropic medications, 15.8% analgesics, and 14% Attention Deficit-Hyperactive Disorder (ADHD) medications. Analgesics (13,539;33.6%) were the most common medication category used by all age groups. Typically only one substance (20,549;69.1%) was used. CONCLUSION: Undiagnosed ADHD may be a potential underlying cause for self-harming behaviors in the very young. Gender-specific suicide prevention strategies may be more effective at identifying those at risk than traditional measures alone. Further study into admitting practices by emergency physicians is needed to understand the difference in critical care admission rates based on gender. Once identified to be at-risk for suicidal behavior, access to analgesics and psychotropics should be monitored by care-givers especially in those between the ages of 15-18.

The relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock.

BACKGROUND: Previous studies suggest a relationship between chloride-rich intravenous fluids and acute kidney injury in critically ill patients. OBJECTIVES: The aim of this study was to evaluate the relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock. METHODS: A retrospective chart review was performed to determine (1) quantity and type of bolus intravenous fluids, (2) serum creatinine (Cr) at presentation and upon discharge, and (3) need for emergent hemodialysis (HD) or renal replacement therapy (RRT). Linear regression was used for continuous outcomes, and logistic regression was used for binary outcomes and results were controlled for initial Cr. The primary outcome was change in Cr from admission to discharge. Secondary outcomes were need for HD/RRT, length of stay (LOS), mortality, and organ dysfunction. RESULTS: There were 95 patients included in the final analysis; 48% (46) of patients presented with acute kidney injury, 8% (8) required first-time HD or RRT, 61% (58) were culture positive, 55% (52) were in shock, and overall mortality was 20% (19). There was no significant relationship between quantity of chloride administered in the first 24 hours with change in Cr (ß = -0.0001, t = -0.86, R(2) = 0.92, P = .39), need for HD or RRT (odds ratio [OR] = 0.999; 95% confidence interval [CI], 0.999-1.000; P = .77), LOS >14 days (OR = 1.000; 95% CI, 0.999-1.000; P = .68), mortality (OR = 0.999; 95% CI, 0.999-1.000; P = .88), or any type of organ dysfunction. CONCLUSION: Chloride administered in the first 24 hours did not influence kidney function in this cohort with severe sepsis or septic shock.

The bubble study: ultrasound confirmation of central venous catheter placement.

STUDY OBJECTIVE: The objective was to determine if ultrasound (US) can more rapidly confirm central venous catheter (CVC) position in comparison to chest radiography (CXR) in the emergency department. METHODS: The study included a convenience sample of emergency department patients with supradiaphragmatic CVCs and a CXR for confirmation. Ultrasound was used for CVC confirmation by visualizing microbubble artifact in the right atrium after injection of saline through the distal port. To evaluate for pneumothorax (PTX), "sliding sign" of the pleura was noted on US of the anterior chest. Blinded chart review was performed to assess CXR timing, catheter position and CVC complications. Student's t test was used to compare US time to CXR performance time and radiologist reading time. RESULTS: Fifty patients were enrolled; 4 were excluded because of inadequate views. Forty-six patients were included in the final analysis. Mean total US time was 5.0 minutes (95% confidence interval [CI], 4.2-5.9) compared to 28.2 minutes (95% CI, 16.8-39.4) for CXR performance with a mean difference of 23.1 minutes (95% CI, -34.5 to -11.8; P < .0002). When comparing only US CVC confirmation time to CXR time, US was an average of 24.0 minutes (95% CI, -35.4 to -12.7; P < .0001) faster. Comparing total US time to radiologist CXR reading time, US was an average of 294 minutes faster (95% CI, -384.5 to -203.5; P < .0000). There were a total of 3 misplaced lines and 2 patients with PTX, all of which were identified correctly on US. CONCLUSION: Ultrasound can confirm CVC placement and rule out PTX significantly faster than CXR, expediting the use of CVCs in the critically ill.

End-tidal carbon dioxide as a goal of early sepsis therapy.

OBJECTIVE: To determine the use of end-tidal carbon dioxide (etco2) as an end point of sepsis resuscitation. METHODS: This was a prospective, observational, single-center cohort study of emergency department patients receiving treatment for severe sepsis with a quantitative resuscitation protocol. Three etco2 readings were taken during a 1-minute time frame at 0, 3, and 6 hours of treatment. Linear regression was used to characterize the association between etco2 and central venous oxygen saturation (SCVo2) and lactate and also to determine the relationship between their change. Analysis of variance was used to determine the relationship between etco2 and disposition. RESULTS: Sixty-nine patients were included in our final analysis. For baseline values, linear regression failed to show a relationship between etco2 and SCVo2 (ß = -0.04, t(70) = -0.53, P = .60) but showed a nearly significant relationship (ß = -0.51, t(70) = -1.90, P = .06) with lactate. There was no significant relationship between etco2 and SCVo2 at 3 hours (ß = 0.12, t(70) = 1.43, P = .16) or 6 hours (ß = 0.05, t(64) = 0.82, P = .67). There was also no significant relationship between 6-hour change in etco2 and change in SCVo2 (ß = 0.04, t(64) = 0.43, P = .67) or lactate (ß = 0.04, t(59) = 0.52, P = .60) or disposition (F(4) = 0.78, P = .54). CONCLUSION: End-tidal carbon dioxide is unlikely to be a useful clinical end point for sepsis resuscitation, although it may be useful as a triage tool in suspected sepsis because baseline values may reflect initial lactate.

A 6-year retrospective review of pediatric firearm injuries: do patients < 14 years of age differ from those 15-18 years of age?

BACKGROUND: Pediatric firearm injuries are an increasing source of morbidity. Firearm injuries in adolescents are common but not well studied in younger children. The aims were to describe the epidemiology of firearm injuries in patients 0 year to 18 years old, with a case study of patients 14 years or younger for determining shooting characteristics and epidemiologic trends. METHODS: Part 1 obtained data from hospital trauma registry. Inclusion criteria were patients 0 year to 18 years of age presenting from 2005 to 2010 with firearm injury and registry inclusion. Demographic and injury data were extracted. Part 2 included a retrospective review of patients 14 years or younger including hospital and emergency medical services records. Data from the group 0 year to 14 years included shooting and treatment details. Categorical variables were described using counts and percentages. Differences between the groups were assessed using odds ratios (ORs), along with 95%confidence intervals (CIs), extracted from logistic regression models. RESULTS: Registry query resulted in 456 patients (0-18 years), including 78 patients who are 14 years or younger. In the group of 0 to 18 years, 86% were male; 83% were black in the group of 15 to 18 years and 64% in the group 0 to 14 years. Overall death rate was 7%. Patients in the group of 15 years to 18 years were twice more likely (23% vs. 11%) to arrive via car or walk-in compared with the patients in the group of 0 year to 14 years (OR, 2.32;95% CI, 1.07-5.03). Patients in the group of 0 year to 14 years were almost four times more likely to be shot at home compared with those who are 15 years to 18 years (OR, 3.76; 95% CI, 2.29-6.19). Patients in the group of 5 years to 9 years were six times more likely to have multiple injury sites compared with those who are 10 years to 14 years (OR, 6.26; 95% CI, 1.26-31.09). Only 13% had documented child protective services notification. CONCLUSION: Results from this study suggest that firearm injuries differ in younger patients compared with adolescents. The younger subset was more likely to be shot at home versus public settings. Hospital and emergency medical services records lacked important shooting details often found in crime scene reports, which are necessary for the development of effective crime and prevention strategies.

Impact of an abbreviated cardiac enzyme protocol to aid rapid discharge of patients with cocaine-associated chest pain in the clinical decision unit.

INTRODUCTION: In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. METHODS: We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. RESULTS: There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%). CONCLUSION: Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.

Persistent organ dysfunction after severe sepsis: a systematic review.

OBJECTIVE: Sepsis is a prevalent disease with high mortality. Survivors of sepsis often suffer significant resultant morbidity, including organ dysfunction. However, little is known about persistent or long-term organ dysfunction in this patient population. Our objective was to systematically review original research studies evaluating organ-specific outcomes at 28 days or greater in patients surviving severe sepsis. METHODS: We performed a systematic review of studies reporting organ-specific outcomes at 28 days or greater in survivors of severe sepsis. RESULTS: We identified 1,173 articles and five met our inclusion criteria. No study reported on organ dysfunction at greater than 30 days. Two studies contributed the majority of patients and had consistent rates of 1 month organ dysfunction for adult respiratory distress syndrome (ARDS) (8%-9%), renal (7%-8%), hepatic (3%-7%), and central nervous system (2%-5%). Another study reported higher rates of dysfunction for pulmonary (non-ARDS and ARDS), hepatic and renal but similar rates for central nervous system and disseminated intravascular coagulation when compared to the first two studies. The most recent study had the highest rates of dysfunction (>47%) across all organ systems. For organ failure resolution the rates were highly variable. CONCLUSIONS: Our review found variable rates of organ dysfunction at 1 month after severe sepsis. Future studies should attempt to characterize organ dysfunction at greater than 1 month after an acute severe sepsis episode to determine the true prevalence long-term organ dysfunction and treatments for prevention. Additionally, standardized objective measures of organ dysfunction are needed so that future studies can be directly compared.

Proactive rounding by the rapid response team reduces inpatient cardiac arrests.

OBJECTIVE: Rapid response teams (RRTs) are frequently employed to respond to deteriorating inpatients. Proactive rounding (PR) consists of the RRT nurse rounding through the inpatient wards identifying high risk patients and intervening preemptively. At our institution, PR began in July of 2007. Our objective was to determine the effect of PR by the RRT at our institution on non-ICU cardiac arrests, code deaths, RRT interventions, and transfers to a higher level of care. Also, to report ICU transfer survival and survival to discharge rates after the start of PR. DESIGN: Retrospective review of a prospectively collected database. SETTING: A tertiary, academic, level 1 trauma center with 696 beds and a rapid response system. PATIENTS: 1253 Non-ICU cardiac arrests from 2005 through June of 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The total study period included 223,267 inpatient admissions (70,129 pre-PR and 153,138 post-PR) and 1,250,814 patient days (391,088 pre-PR and 859,726 post-PR). The quarterly code rate before PR was 66 and the code rate after the institution of PR was 30 (difference=36.8, 95% CI 25.6-48.0, p<.001). Quarterly code deaths decreased from 29 to 7 (difference=21.95, 95% CI 16.3-27.6, p<.001). This decrease in floor codes and code deaths was still present after adjusting for inpatient admission and inpatient days. Average quarterly RRT interventions increased from 141 in the pre-PR period to 690 in the post-PR period (difference=549, 95% CI 360-738, p<.001). Average quarterly transfers to HLC went up from 38 pre-PR to 164 post-PR (difference=126, 95% CI 79-172, p<.001). CONCLUSIONS: The institution of proactive rounding at a tertiary care, academic, level 1 trauma center results in reduced floor codes and code deaths as well as increased RRT interventions and transfers to a higher level of care.

Ultrasound evaluation of cranial and long bone fractures in a cadaver model.

BACKGROUND: Ultrasound has been utilized in various settings for evaluation and treatment of skeletal injuries. Bone has different tissue acoustic impedance than soft tissue allowing visualization of the cortical disruption found in fractures. OBJECTIVE: To determine emergency physicians' accuracy in diagnosing cranial and long bone fractures using ultrasound. METHODS: This multi-center prospective double-blinded study used high-frequency linear ultrasound to detect induced fractures among eight test locations from eight cadaver models. After a standard orientation, blinded emergency physicians interpreted real-time sonographic images of test locations. RESULTS: Proximal tibia combined sensitivity (SE)/specificity (SP) was 87.3/69.8% with a combined positive predictive value (PPV)/negative predictive value (NPV) of 84.6/74.3%. Distal radius combined SE/SP was 93.7/93.5% with a combined PPV/NPV of 93.4/90.8%. Frontal combined SE/SP was 84.1/88.9% with a PPV/NPV of 84.9/88.3%. Temporal-parietal combined SE/SP was 95.2/87.9% with a PPV/NPV of 94.8/88.2%. Time to decision varied from less than 10 seconds to 357 seconds. Mean time to decision was 43 to 63 seconds depending on fracture site. CONCLUSION: Ultrasound by trained emergency medicine physicians can reliably identify fractures in the radius, tibia, frontal, and temporal bones in a very short amount of time, allowing for triage, treatment, and resource management.

Reduced use of occult bacteremia blood screens by emergency medicine physicians using immunization registry for children presenting with fever without a source.

OBJECTIVES: This study examined whether utilization of the Florida State Health Online Tracking System (SHOTS) immunization registry to determine Haemophilus influenzae type B and heptavalent pneumococcal conjugate (PCV7) vaccine status impacts the protocolized decision to perform a screening blood draw for occult bacteremia (OB) in young children. METHODS: A convenience sample of children 6 to 24 months of age presenting to the pediatric emergency department with fever of greater than 39°C without a source was enrolled. Physicians were trained to use the SHOTS immunization registry and reviewed the emergency department's fever protocol. A "preregistry" workup plan was documented for each patient based on clinical history, immunization status before accessing SHOTS, and physical examination. A "postregistry" workup plan was then documented based on the SHOTS record. Demographic and registry data were recorded. RESULTS: Preregistry workup plans indicated OB screening blood draws for 100% (n = 91; 95% confidence interval [CI], 96-100) of patients with unconfirmed immunization status. Of those 91 children, 58% (n = 53; 95% CI, 55-61) were documented in SHOTS as having received their primary conjugate vaccine series at ages 2, 4, and 6 months. Registry access reduced the percentage of screening blood draws from 100% (n = 91) to 42% (n = 38; 95% CI, 37-53; P < 0.001). CONCLUSIONS: The state immunization registry is an adjunctive tool to caregiver recall, which can be used by emergency medicine practitioners to confirm completion of the primary conjugate vaccine series before making the decision to perform blood screens for OB in children aged 6 to 24 months who present with fever without a source.

Color coded medication safety system reduces community pediatric emergency nursing medication errors.

OBJECTIVES: To compare the performance of current systems in place for preparation and administration of pediatric medications in community emergency departments to the color-coded medication safety (CCMS) system among nurses. METHODS: Community ED nurses participated in simulated pediatric emergency scenarios using traditional dosing references then the CCMS system. We measured preintervention/postintervention: (1) time to task completion from physician order to medication administration; (2) accuracy of conversion to milliliters, dilution, and time for medication administration; and (3) recognition of 10-fold physician errors. RESULTS: A total of 320 medication and infusion orders were given to 16 nurses. The median time to task completion preintervention was 109 seconds (interquartile range, 44-626). Time to task completion was reduced to a median of 28 seconds (interquartile range, 14-43; P < 0.001) with the CCMS system. Significant error reductions were noted when nurses used the CCMS system: 25.6% of medications were converted incorrectly compared with 2.5% with the system, a 23% improvement (95% confidence interval [CI], 13-33; P < 0.001), 35.6% were diluted incorrectly compared with 0.63%, a 35% improvement (95% CI, 26-44; P < 0.001), and 54.7% were administered incorrectly compared with 3.9%, a 51% improvement (95% CI, 39-61; P < 0.001). Only 20% of 10-fold physician order errors were recognized preintervention but 93% were recognized using the CCMS system, a 73% improvement. CONCLUSIONS: The CCMS system reduces pediatric medication delay and improves nursing accuracy. This is important in the community ED setting where many children receive emergency care and where providers may lack familiarity with pediatric medication dosing.

Stabilization and treatment of dental avulsions and fractures by emergency physicians using just-in-time training.

STUDY OBJECTIVE: The objective of this investigation is to use a dental simulation model to compare splinting and bandaging methods for managing tooth avulsions and fractures, as measured by dentist evaluators for quality and time to complete each stabilization procedure. METHODS: This was a randomized crossover study comparing 3 splinting techniques for managing a traumatically avulsed tooth (periodontal pack, wire, and bondable reinforcement ribbon) and 2 bandage techniques for managing a fractured tooth (calcium hydroxide paste and light-cured composite). After viewing a Just-in-Time training video, a convenience sample of emergency physicians performed the 5 stabilization techniques on dental models containing extracted teeth embedded in clay to simulate a segment of the human dentition. Data collected included time to complete each procedure, the evaluation of dentists about whether the procedure was performed satisfactorily or unsatisfactorily, and the ranking of dentists' and participants' preferred technique. RESULTS: Twenty-five emergency physicians participated in the study: 17 residents, 2 pediatric emergency medicine fellows, and 6 attending physicians. Reported median time, as well as minimum and maximum times to complete each splinting technique for an avulsed tooth, was as follows: periodontal pack 4.4 minutes (2.5 to 6.5 minutes), wire 8.6 minutes (5.8 to 12.9 minutes), and bondable reinforcement ribbon 8.9 minutes (5.6 to 15 minutes). Median time (and minimum and maximum times) to complete each protective bandaging technique for a fractured tooth was calcium hydroxide paste 4.6 minutes (3 to 9.6 minutes) and light-cured composite 7.1 minutes (5.5 to 14.1 minutes). When asked to choose a preferred splinting and bandaging technique according to the performance of the physicians, the dentists chose the bondable reinforcement ribbon 96% (24/25) and the light-cured composite 100% (25/25) of the time. Study participants had no measurable or agreeable preference for a particular splinting or bandaging technique. CONCLUSION: The results of this study suggest that of the stabilization procedures completed by emergency physicians, dentists preferred the bondable reinforcement ribbon for managing an avulsed tooth and the light-cured composite technique for managing a fractured tooth over the commonly taught and more frequently used procedures in emergency medicine.