The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

SECM Investigation of Carbon Composite Thermoplastic Electrodes.

Thermoplastic electrodes (TPEs) are carbon composite electrodes consisting of graphite and thermoplastic polymer binder. TPE production is a solvent-based method, which makes it easy to fabricate and pattern into complex geometries, contrary to classical carbon composite electrodes. Depending on the composition (carbon type, binder, and composition ratio), TPEs can give excellent electrochemical performance and high conductivity. However, these TPEs are relatively new electrode materials, and thorough electrochemical characterization is still missing to understand and predict why large differences between TPEs exist. We used scanning electrochemical microscopy (SECM) as a screening tool to characterize TPEs. SECM data treatment based on scanning probe microscopy imaging allows a fast and easy comparison of the numerous images, as well as the optimization of the preparation. Experiments suggest that TPEs behave as a network of interacting microelectrodes made by electrochemically active islands isolated between less active areas. Higher carbon content in TPEs is not always indicative of more uniform electrodes with better electrochemical performances. Using various SECM redox probes, it is possible to select a specific graphite or polymer type for the analyte of interest. For example, TPEs made with COC:3569 are the best compromise for general detection, whereas PMMA:11 µm is better suited for catechol-like polyphenol analysis.

The Administration of Postintubation Sedation in the Pediatric Emergency Department.

BACKGROUND: The administration of postintubation sedation (PIS) is an essential component of postintubation care. Recent studies in the adult emergency medicine literature have highlighted both delays in time to administration of PIS and subtherapeutic dosing of sedative agents in the emergency department. We aimed to investigate the administration of PIS in the pediatric population as this has not been adequately reviewed to date. OBJECTIVES: The aim of this study was to determine the percentage of pediatric emergency department patients who received PIS within an adequate time frame. We also investigated the relationship between this primary outcome and the rapid sequence intubation (RSI) agents used, the reason for intubation, and individual patient characteristics. METHODS: This was a retrospective cohort analysis of all pediatric patients who underwent RSI at a tertiary care pediatric emergency department from July 2007 to January 2016. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-RSI sedative administration that was shorter than the duration of action of the RSI sedative agent used. Logistic regression was performed to identify predictors of adequate sedation. RESULTS: A total of 240 patients were included in the analysis. Of these, 28% (95% confidence interval, 22.7%-34.1%) met the primary outcome of sedation within an adequate time frame; 72.8% (95% confidence interval, 66.8%-78.1%) of patients received some form of PIS during their emergency department stay. Patients receiving long-acting paralytic agents were much less likely to receive PIS with an odds ratio (OR) of 0.16 for meeting the primary outcome (P < 0.001, adjusted OR [AOR] = 0.13, P < 0.001). Children with higher systolic blood pressure were more likely to receive appropriate PIS with an OR of 1.02 for every mm Hg increase in systolic blood pressure (P = 0.006, AOR = 1.02, P = 0.021). Finally, patients who were ultimately admitted to the pediatric intensive care unit (vs the operating room, transfer, or neonatal intensive care unit) were less likely to receive PIS as evidenced by an OR of 0.37 (P = 0.009, AOR = 0.27, P = 0.004). CONCLUSIONS: Most pediatric patients do not receive PIS within an adequate time frame. Patients who receive long-acting paralytic agents are much less likely to be adequately sedated after RSI compared with those receiving succinylcholine.

Variations in Alarm Burden, Source, and Cause Across Inpatient Units at a Children's Hospital.

BACKGROUND AND OBJECTIVES: Alarms at hospitals are frequent and can lead to alarm fatigue posing patient safety risks. We aimed to describe alarm burden over a 1-year period and explored variations in alarm rates stratified by unit type, alarm source, and cause. METHODS: A retrospective study of inpatient alarm and patient census data at 1 children's hospital from January 1, 2019, to December 31, 2019, including 8 inpatient units: 6 medical/surgical unit (MSU), 1 PICU, and 1 NICU. Rates of alarms per patient day (appd) were calculated overall and by unit type, alarm source, and cause. Poisson regression was used for comparisons. RESULTS: There were 7 934 997 alarms over 84 077 patient days (94.4 appd). Significant differences in alarm rates existed across inpatient unit types (MSU 81.3 appd, PICU 90.7, NICU 117.5). Pulse oximetry (POx) probes were the alarm source with highest rate, followed by cardiorespiratory leads (54.4 appd versus 31). PICU had lowest rate of POx alarms (33.3 appd, MSU 37.6, NICU 92.6), whereas NICU had lowest rate of cardiorespiratory lead alarms (16.2 appd, MSU 40.1, PICU 31.4). Alarms stratified by cause displayed variation across unit types where "low oxygen saturation" had the highest overall rate, followed by "technical" alarms (43.4 appp versus 16.3). ICUs had higher rates of low oxygenation saturation alarms, but lower rates of technical alarms than MSUs. CONCLUSIONS: Clinical alarms are frequent and vary across unit types, sources, and causes. Unit-level alarm rates and frequent alarm sources (eg, POx) should be considered when implementing alarm reduction strategies.

Management of youth with suicidal ideation: Challenges and best practices for emergency departments.

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

Strategies for optimal management of pediatric acute agitation in emergency settings.

Acute agitation in youth is a challenging presentation to the emergency department. In many cases, however, youth can be behaviorally de-escalated using a combination of environmental modification and verbal de-escalation. In cases where additional strategies such as pharmacologic de-escalation or physical restraint are needed, using the least restrictive means possible, including the youth in the decision-making process, and providing options are important. This paper reviews specific considerations on the approach to a youth with acute agitation and strategies and techniques to successfully de-escalate agitated youth who pose a danger to themselves and/or others.

Reducing the Frequency of Pulse Oximetry Alarms at a Children's Hospital.

BACKGROUND AND OBJECTIVES: Alarm fatigue is exacerbated by frequent, nonactionable physiologic monitor alarms. Overutilization of pulse oximetry (SpO2) compounds this alarm burden. Narrow default alarm limits and overutilization of continuous (CSpO2) rather than intermittent monitoring contribute to nonactionable alarms. There were 1.12 million SpO2 alarms on included units during the baseline period, of which 41.0% were for SpO2 ≥ 88%. We aimed to decrease SpO2 alarms per patient day by 20% within 12 months. METHODS: This quality improvement study included patients admitted January 2019 to June 2022. Intensive care and cardiology units were excluded. Interventions included (1) changing default alarm SpO2 limits on monitors from <90% to <88%, (2) changing SpO2 order default from continuous to intermittent, and (3) adding indication requirements for CSpO2. Outcome measures were total SpO2 alarms and alarms for SpO2 ≥ 88% per patient day. Balancing measures were high acuity transfers and code blues without CSpO2 ordered. Control charts were used for each. RESULTS: Our study included 120 408 patient days with 2.98 million SpO2 alarms. Total SpO2 alarms and alarms for SpO2 ≥ 88% per patient day decreased by 5.48 (30.57 to 25.09; 17.9%) and 4.48 (12.50 to 8.02; 35.8%), respectively. Special cause improvement was associated with changing default monitor alarm parameters. Balancing measures remained stable. CONCLUSIONS: SpO2 monitors alarm frequently at our children's hospital. Widening default alarm limits was associated with decreased SpO2 alarms, particularly nonactionable alarms (≥88%). This high-reliability intervention may be applied, when appropriate, to other monitor alarm parameters to further mitigate alarm burden.

Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS. METHODS: In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors. RESULTS: Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively. CONCLUSIONS: We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.

The role of telehealth in pediatric emergency care.

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Initiative to Improve Postintubation Sedation in a Pediatric Emergency Department.

BACKGROUND: Previous research has shown that appropriate pediatric postintubation sedation (PIS) after rapid sequence intubation only occurs 28% of the time. Factors such as high provider variability, cognitive overload, and errors of omission can delay time to PIS in a paralyzed patient. PURPOSE: To increase the proportion of children receiving timely PIS by 20% within 6 months. METHODS: A multidisciplinary team identified key drivers and targeted interventions to improve timeliness of PIS. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-Rapid Sequence Intubation sedative administration less than the duration of action of the RSI sedative agent. Secondary outcomes included the proportion of patients receiving any sedation and time to PIS administration. RESULTS: Pediatric postintubation sedation in an adequate time was improved from 27.9% of intubated patients to 55.6% after intervention (p = .001). The number of patients receiving any PIS improved from 74% to 94% (p = .006). The median time from RSI to PIS was reduced from 13 to 9 minutes (p < .001). Process control charts showed a reduction in PIS variability and a centerline reduction from 19 to 10 minutes. CONCLUSIONS: Implementation of an intubation checklist and a multidisciplinary approach improved the rate of adequate pediatric PIS.

Improving Duration of Antibiotics for Skin and Soft-tissue Infections in Pediatric Urgent Cares.

BACKGROUND AND OBJECTIVES: National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021. METHODS: We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers' concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations. RESULTS: After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days. CONCLUSIONS: By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.

The ratio between positive and negative affect and flourishing mental health across adulthood.

Using data from a 30-day diary study with 239 adults (81 young, 81 middle-aged, and 77 older adults), this study examined whether a specific ratio between positive and negative affect distinguished individuals with different mental health status and especially flourishing from non-flourishing individuals. In addition, the study addressed whether there were age differences in the positivity ratio when daily affect data were used, and whether the proposed critical positivity ratio of 2.9 discriminated equally well between individuals with different mental health status across the adult lifespan. Findings showed that the ratio of positive to negative affect differed across adulthood such that age was associated with an increasing preponderance of positive to negative affect. The positivity ratio was also associated with mental health status in the hypothesized direction; higher positivity ratios were associated with better mental health. Finally, although the data supported the notion of a positivity ratio of 2.9 as a 'critical value' in young adulthood, this value did not equally well discriminate the mental health status of middle-aged and older adults.

Improving Communication for Admissions From Urgent Care to Inpatient Using a Structured Handoff.

BACKGROUND: Previous studies reveal that ineffective communication contributes to patient-safety events. Structured handoffs improve communication during shift change and transfers from outpatient clinics to emergency departments. We aimed to improve the perceived quality of admission handoffs from a baseline of 22.2% to 50% by the end of the study period through use of a standardized template between urgent care (UC) and inpatient providers. METHODS: We used quality improvement methodology to identify key themes (clarity in illness severity, organization, completeness, and pace) that contribute to decreased quality communication. A survey to evaluate the perception of communication and key themes between the groups was administered. During the 15-month quality improvement study at a tertiary pediatric institution, we implemented a handoff tool with visual aids. Givers of information received formal training. Participants received iterative performance feedback. A control chart was used to monitor fidelity to the handoff tool. We used statistical analyses to compare changes in perceived communication between provider types before and after implementation of the handoff tool. RESULTS: Both UC and inpatient providers had an increased rate of positive perceptions in the overall quality of communication after 12 months of using the admission handoff tool (22% vs 67.3%; P = .01). Complete fidelity to the admission handoff tool increased over time. There was no change in mean duration of handoff (4 minutes) after implementing the structured handoff. CONCLUSIONS: A structured handoff during admission of pediatric patients from an off-site UC to inpatient setting improved the perception of the quality of admission handoff communication.

Impact of High Flow Nasal Cannula on Resource Utilization in Bronchiolitis.

OBJECTIVES: High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC. METHODS: In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes. RESULTS: The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups. CONCLUSIONS: Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC.

Barriers to Tobacco Cessation for Caregivers of Hospitalized Children: Perspectives of Pediatric Hospitalists.

OBJECTIVES: Secondhand smoke exposure is associated with adverse health outcomes in children, yet tobacco cessation efforts for caregivers of hospitalized children are lacking. We sought to explore pediatric hospitalists' attitudes and barriers to providing tobacco cessation for caregivers of hospitalized children. METHODS: We conducted a cross-sectional survey of pediatric hospitalists and fellows at 7 hospitals from November 1, 2018, to November 30, 2019. A 70-question anonymous survey was used to assess participants' perceptions of current practices, attitudes, and barriers to providing tobacco cessation support for caregivers of hospitalized children. We used descriptive statistics to summarize the data. RESULTS: Of 207 eligible participants, 100 responded (48%). A majority (79%) agreed that offering tobacco cessation counseling for caregivers is an important part of their role in caring for hospitalized children, but 79% never received tobacco cessation training. Only half of the participants were comfortable providing brief advice and few were comfortable prescribing nicotine replacement therapy. Identified barriers included lack of time (74%), perceived lack of interest from patients' caregivers (71%), and other medical conditions of the patient taking priority (70%). The majority of participants were interested in further training in tobacco cessation support. CONCLUSIONS: In this survey of 100 pediatric hospitalists, we found overall agreement that tobacco cessation support for caregivers of hospitalized children is important. However, most participants did not feel comfortable with provision of evidence-based counseling or pharmacotherapy because of identified barriers. Future work should target actionable barriers to improve provision of tobacco cessation support in this clinical setting.

The Diagnostic Performance of Early Sjögren's Syndrome Autoantibodies in Juvenile Sjögren's Syndrome: The University of Florida Pediatric Cohort Study.

Objectives: The aim of this study was to evaluate the clinical validity of early Sjögren's syndrome (SS) autoantibodies (eSjA), which were originally marketed for early diagnosis of SS, for juvenile SS (JSS) in a recently identified pediatric cohort. Methods: A total of 105 symptomatic subjects with eSjA results available were evaluated at the Center for Orphaned Autoimmune Disorders at the University of Florida and enrolled for this study. JSS diagnosis was based on the 2016 ACR/EULAR SS criteria. Demographic/clinical/laboratory parameters were compared between JSS (n = 27) and non-JSS (n = 78) for % positivity, sensitivity, and specificity of eSjA (SP1, anti-salivary protein; CA6, anti-carbonic anhydrase VI; PSP, anti-parotid secretory protein) and classic SS-autoantibodies (cSjA; ANA, SSA/SSB, RF, and others) either alone or in combination. Associations between eSjA and diagnostic/glandular parameters were also determined by Fisher's exact test. Results: Compared to non-JSS, JSS patients exhibited sicca symptoms demonstrating reduced unstimulated salivary flow rate (USFR) and abnormal glandular features revealed by salivary gland ultrasound (SGUS). Among cSjA, ANA demonstrated the highest sensitivity of 69.2%, while SSA, SSB, and RF showed around 95% specificities for JSS diagnosis. The % positive-SSA was notably higher in JSS than non-JSS (56% vs. 5%). Of eSjA, anti-CA6 IgG was the most prevalent without differentiating JSS (37%) from non-JSS (32%). Sensitivity and specificity of eSjA were 55.6 and 26.9%, respectively. Autoantibodies with potentially applicable specificity/sensitivity for JSS were seen only in cSjA without a single eSjA included. There were no associations detected between eSjA and focus score (FS), USFR, SSA, SGUS, and parotitis/glandular swelling analyzed in the entire cohort, JSS, and non-JSS. However, a negative association between anti-PSP and parotitis/glandular swelling was found in a small group of positive-SSA (n = 19, p = 0.02) whereas no such association was found between anti-PSP-positive compared to anti-PSP-negative. JSS and non-JSS groups differed in FS, USFR, and EULAR SS Patient Reported Index Dryness/Mean in CA6/PSP/ANA, SP1, and SSA-positive groups, respectively. Additionally, a higher FS was found in RF-positive than RF-negative individuals. Conclusions: eSjA underperformed cSjS in differentiating JSS from non-JSS. The discovery of clinical impact of eSjA on early diagnosis of JSS necessitates a longitudinal study.

Pegylated interferon alpha-associated optic neuropathy.

A 52-year-old man with chronic hepatitis C presented with painless, bilateral, simultaneous nonarteritic anterior ischemic optic neuropathy (NAION) and peripheral neuropathy. Symptoms began 19 weeks after starting peginterferon alpha-2a. The peripheral neuropathy and vision of the right eye improved, but the vision of the left eye worsened after stopping interferon. We identified 23 additional cases of NAION during interferon alpha therapy. At least 12 of these patients suffered bilateral NAION. Patients lost vision 1-40 weeks after initiating therapy. Of 21 eyes that had documented initial and follow-up acuities, 8 improved, 1 worsened, and the rest remained stable. One patient had a painful peripheral neuropathy. Treatment with interferon alpha may result in NAION. Discontinuation of therapy deserves consideration after weighing individual risks and benefits.

Mood enhancement persists for up to 12 hours following aerobic exercise: a pilot study.

The objective was to estimate the duration of the effects of aerobic exercise on mood. Healthy men (n = 13) and women (n = 35) ages 18 to 25 years (M = 20.2, SD = 3.4) were randomly assigned to either a control or exercise group. Participants completed the Profile of Mood States before, after, and at 1, 2, 4, 8, 12, and 24 hours following either exercise at 60% VO2 peak or quiet rest. Repeated-measures analysis of covariance was utilized with VO2 peak entered as a covariate. The exercise group showed significantly lower total mood disturbance immediately after and at 4, 8, and 12 hours following exercise.

Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings.

BACKGROUND AND OBJECTIVES: Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings. METHODS: We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages >60 days to <24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons. RESULTS: Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased (P < .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center (P < .001) and emergency department (P = .001). CONCLUSIONS: We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.