Retrospective Review for Medication Dose Errors in Pediatric Emergency Department Medication Orders That Bypassed Pharmacist Review.

OBJECTIVE: To identify and evaluate dose errors on medication orders that bypassed pharmacist verification in a pediatric emergency department (PED). METHODS: Descriptive, retrospective study about dose errors in an academic PED over 1 year. A report of automatically verified orders (those that bypassed pharmacist verification) was obtained from the electronic medical record. Potential medication dose errors were defined as those greater than 20% above or below standard dose ranges by age or weight. A retrospective chart review was performed for all identified dose errors. For orders deemed erroneous, additional metrics collected included order time of day and day of week and provider training level. RESULTS: A total of 46,185 medication orders were placed; 32,928 (71%) bypassed pharmacist review. Altogether, 676 orders (2%) were outside standard dose ranges. Ondansetron represented 569 of the 676 orders; most were doses rounded down to 4 mg and technically qualifying as underdoses, but were attributed to practice variance and not further analyzed. The number of orders deemed potentially erroneous was 107: most were wrong dose (75 overdose and 21 underdose), 5 were wrong patient, and 6 were wrong formulation. Ibuprofen, benzodiazepine, and corticosteroid orders had the most errors. No errors resulted in identifiable harm to the patient: 49 were near misses, and 47 reached the patient with no evident harm. CONCLUSIONS: The overall number of dose errors in autoverified orders was low. Certain medications or ordering modalities may be targeted to enhance patient safety and satisfaction.

Offspring Self-Disclosure Predicts Substance-Related Outcomes in an Emergency Department Sample of Young Adults with Traumatic Injury.

BACKGROUND: Hundreds of thousands of individuals visit the emergency department (ED) every year, with many visits occurring following alcohol misuse. Parent-child relationship factors are associated with alcohol-related outcomes. For example, offspring choice to self-disclose information about their lives to parents, rather than parents actively soliciting this information, is associated with substance use. However, it is unclear whether self-disclosure uniquely predicts alcohol-related outcomes in a young adult ED sample. METHODS: Data were collected from young adults (age 18-30 years) visiting an ED for a traumatic injury (n=79). Participants were about 24.4 years old, majority male (53.7%), and Caucasian (76%; 24% African-American). A bifactor model within a structural equation model tested unique effects of self-disclosure on age at first drink, propensity for risky drinking, and likelihood of consuming substances prior to ED visit, over and above parental solicitation and a general factor and gender. RESULTS: Those who shared more information with their caregivers reported an older age at first drink, lower propensity for risky drinking and lower propensity to consume substances prior to their ED visit. CONCLUSIONS: These findings suggest that self-disclosure may be a unique risk factor in the initiation of alcohol use, development of problem use, and consequences following use.

Management of Pediatric Isolated Skull Fractures: A Decision Tree and Cost Analysis on Emergency Department Disposition Strategies.

OBJECTIVE: Pediatric isolated skull fractures (ISFs) are common injuries that represent challenging disposition decisions for clinicians. The purpose of this study is to use a decision analysis to compare the clinical and cost-effectiveness of 3 emergency department (ED)-based disposition scenarios for a pediatric patient presenting with ISF. METHODS: We conducted a cost-effectiveness analysis comparing ED disposition scenarios that included current practice, increased at-home surveillance, and observation unit utilization. Current rates of admission, deterioration after initial diagnosis, and ED return after discharge, as well as cost of observation-only status, were obtained through literature review. Cost calculations using Healthcare Cost and Utilization Project data included total ED cost, admission without complication, and admission with deterioration. RESULTS: In current practice, 76% of subjects with ISF are admitted and 2.5% of those develop persistent or new symptoms. No patient diagnosed with ISF required neurosurgical intervention. Of those discharged home from the ED, 2.8% return with a new concern with 7.4% having new findings on imaging leading to admission. Total cost per 100 patients by current practice was US $583,587. Increasing at-home surveillance by 20% resulted in a total cost saving of US $113,176 per 100 patients while increasing returns to the ED from less than 1% to 1.1%. Admitting at the current rate to an observation unit resulted in a US $205,395 cost saving per 100 patients. CONCLUSIONS: Decreased inpatient utilization through home surveillance or observation unit use reduced cost associated with pediatric ISF management without increasing clinical risk owing to the low probability of clinical deterioration after initial diagnosis.

The Role of Limited Head Computed Tomography in the Evaluation of Pediatric Ventriculoperitoneal Shunt Malfunction.

BACKGROUND: The evaluation of children with suspected ventriculoperitoneal shunt (VPS) malfunction has evolved into a diagnostic dilemma. This patient population is vulnerable not only to the medical risks of hydrocephalus and surgical complications but also to silent but harmful effects of ionizing radiation secondary to imaging used to evaluate shunt efficacy and patency. The combination of increased medical awareness regarding ionizing radiation and public concern has generated desire to reduce the reliance on head computed tomography (CT) for the evaluation of VPS malfunction. Many centers have started to investigate the utility of low-dose CT scans and alternatives, such as fast magnetic resonance imaging for the investigation of VP shunt malfunction in order to keep radiation exposure as low as reasonably achievable. This pilot study hopes to add to the armamentarium available to the clinician charged with evaluating this challenging patient population by testing the feasibility of a limited CT protocol as an alternative to a full head CT examination. OBJECTIVE: To evaluate the efficacy of a limited head CT protocol compared with a complete head CT for the evaluation of children presenting to the pediatric emergency department with suspected shunt malfunction. METHODS: We retrospectively reviewed all pediatric patients who received a head CT for suspected VPS malfunction evaluation at a tertiary care children's hospital from January 2001 through January 2013. Children were included in the pilot study if they had at least 2 CT scans in this study period interpreted by a specific senior attending neuroradiologist. For each patient enrolled, a limited series was generated from the most recent CT scan by selecting four representative axial slices based on the sagittal scout image. These 4 slices where selected at the level of the fourth ventricle, third ventricle, basal ganglia level, and lateral ventricles, respectively. A blinded, senior attending neuroradiologist first reviewed the limited 4-slice CT data set and was asked to determine if the ventricular system had increased, decreased, or remained stable. Subsequently, the neuroradiologist compared their interpretation of the limited examination with the official report from the full CT data set as the standard of reference as well as the interpretation of the most recent prior scan. RESULTS: Forty-six patients (age range, 2 months to 18 years; average age, 6.4 years (SD, 4.2), 54% male) were included in the study. Forty-four of 46 (95.7%) limited CT scans matched the official report of the full CT scan. No cases of increased ventricular size were missed (100% positive predictive value for increased ventricular size). The use of a limited head CT (4 axial images) instead of a complete head CT (average of 31 axial images in our studied patients) confers a radiation dose reduction of approximately 87%. CONCLUSIONS: Our pilot study demonstrates that utilization of limited head CT scan in the evaluation of children with suspected VP shunt malfunction is a feasible strategy for the evaluation of the ventricular size. Further prospective and multidisciplinary studies are needed to evaluate the reliability of limited head CT for the clinical evaluation of VP shunt malfunction.

Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up.

BACKGROUND: Anaphylaxis is a systemic life-threatening allergic reaction that presents unique challenges for emergency care practitioners. Allergists and emergency physicians have a history of collaborating to promote an evidence-based, multidisciplinary approach to improve the emergency management and follow-up of patients with or at risk of anaphylaxis. OBJECTIVES: To review recent scientific literature about anaphylaxis, discuss barriers to care, and recommend strategies to support improvement in emergency anaphylaxis care. METHODS: An expert panel of allergists and emergency physicians was convened by the American College of Allergy, Asthma and Immunology in November 2014 to discuss current knowledge about anaphylaxis, identify opportunities for emergency practitioners and allergists to partner to address barriers to care, and recommend strategies to improve medical management of anaphylaxis along the continuum of care: from emergency medical systems and emergency department practitioners for acute management through appropriate outpatient follow-up with allergists to confirm diagnosis, identify triggers, and plan long-term care. RESULTS: The panel identified key barriers to anaphylaxis care, including difficulties in making an accurate diagnosis, low rates of epinephrine administration during acute management, and inadequate follow-up. Strategies to overcome these barriers were discussed and recommendations made for future allergist/emergency physician collaborations, and key messages to be communicated to emergency practitioners were proposed. CONCLUSION: The panel recommended that allergists and emergency physicians continue to work in partnership, that allergists be proactive in outreach to emergency care practitioners, and that easy-to-access educational programs and materials be developed for use by emergency medical systems and emergency department practitioners in the training environment and in practice.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department.

OBJECTIVE: Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge. METHODS: Within the Pediatric ED (PED) at a tertiary children's hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart. RESULTS: Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%. CONCLUSIONS: This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.

Abusive head trauma in young children: a population-based study.

OBJECTIVE: The objectives of this study were to provide population-based incidence estimate of abusive head trauma (AHT) in children aged 0 to 5 years from inpatient and emergency department (ED) and identify risk characteristics for recognizing high-risk children to improve public health surveillance. METHODS: This was a retrospective cohort study based on children's first encounter in ED or hospital admission with a diagnosis of head trauma (HT), 2000-2010. The relationship between clinical markers and AHT was examined controlling for covariables in the model using Cox hazards regression. Kaplan-Meier incidence probability was plotted, and the number of weeks elapsing from date of birth to the first encounter with HT established the survival time (T). RESULTS: Twenty-six thousand six hundred eighty-one children had HT, 502 (1.8%) resulted from abuse; 42.4% was captured from ED. Incidence varied from 28.9 (95% confidence interval [CI], 27.9-37.4) in infants to 4.1 (95% CI, 2.4-5.7) in 5-year-olds per 100,000 per year. Adjusted hazard ratio was 20.3 (95% CI, 10.9-38.0) for intracranial bleeding and 11.4 (95% CI, 8.57-15.21) for retinal hemorrhage. CONCLUSIONS: Incidence estimates of AHT are incomplete without including ED. Intracranial bleeding is a cardinal feature of AHT to be considered in case ascertainment to improve public health surveillance.

Customizing anaphylaxis guidelines for emergency medicine.

BACKGROUND: Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition. OBJECTIVE: Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements. DISCUSSION: Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode--regardless of severity--is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as "possible anaphylaxis," it is generally better to err on the side of caution and administer epinephrine. CONCLUSION: We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.

Abusive head trauma in young children: a population-based study.

OBJECTIVE: The objectives of this study were to provide population-based incidence estimate of abusive head trauma (AHT) in children aged 0 to 5 years from inpatient and emergency department (ED) and identify risk characteristics for recognizing high-risk children to improve public health surveillance. METHODS: This was a retrospective cohort study based on children's first encounter in ED or hospital admission with a diagnosis of head trauma (HT), 2000-2010. The relationship between clinical markers and AHT was examined controlling for covariables in the model using Cox hazards regression. Kaplan-Meier incidence probability was plotted, and the number of weeks elapsing from date of birth to the first encounter with HT established the survival time (T). RESULTS: Twenty-six thousand six hundred eighty-one children had HT, 502 (1.8%) resulted from abuse; 42.4% was captured from ED. Incidence varied from 28.9 (95% confidence interval [CI], 27.9-37.4) in infants to 4.1 (95% CI, 2.4-5.7) in 5-year-olds per 100,000 per year. Adjusted hazard ratio was 20.3 (95% CI, 10.9-38.0) for intracranial bleeding and 11.4 (95% CI, 8.57-15.21) for retinal hemorrhage. CONCLUSIONS: Incidence estimates of AHT are incomplete without including ED. Intracranial bleeding is a cardinal feature of AHT to be considered in case ascertainment to improve public health surveillance.

Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy.

OBJECTIVES: The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging. METHODS: A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation. RESULTS: Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation. CONCLUSIONS: Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.

To Give Epinephrine or Not to Give Epinephrine-That Is (No Longer) The Question!

It is vital that school nurses be able to assess students who are at risk for anaphylaxis and that nurses train school staff to identify the symptoms of a life-threatening allergic reaction. When a reaction occurs, school nurses and staff must be prepared to administer epinephrine immediately.

"Beat the Shock Clock": An Interprofessional Team Improves Pediatric Septic Shock Care.

Ideal care for septic shock (SS) is difficult. This interprofessional quality improvement intervention in a mid-volume pediatric emergency department aimed to reduce time to vascular access, fluid resuscitation, and antibiotics for SS. Intensive education, a care pathway, and an order set were applied. Outcome measures for patients with criteria for SS before and after intervention were compared. There were 43 patients pre-intervention (January 2009 to June 2011) and 63 post-intervention (June 2012 to June 2013). Median time to vascular access decreased from 37 minutes pre-intervention to 24 minutes post-intervention (p = 0.05). Median time to first fluid bolus decreased from 35 to 26 minutes (p = 0.08). Percentage of boluses delivered rapidly by pressure method increased from 21% to 74% (p < 0.0001). Median time to antibiotics decreased from 92 to 55 minutes (p = 0.02). In conclusion, a multimodal, interprofessional quality improvement intervention in a mid-sized pediatric emergency department improved the time to critical interventions for SS.

Parental preference for short- versus long-course corticosteroid therapy in children with asthma presenting to the pediatric emergency department.

Asthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (ED). We aimed to determine parental preference between short- and long-term courses of oral corticosteroids for use in children with mild to moderate asthma presenting to our pediatric ED with acute asthma exacerbations. We surveyed parents of asthmatic children who presented to our pediatric ED from August 2011 to April 2012. Questions characterized each patient's asthma severity, assessed parental preference among systemic steroid and inhaled medication delivery options for acute asthma management, and inquired about compliance, medication costs, and intention to follow up. The majority of our parents prefer the use of 1 to 2 days of steroids to 5 days for acute asthma exacerbations in the ED. Thus, dexamethasone is an attractive alternative to prednisone/prednisolone and should be considered in the management of acute asthma exacerbations in the ED.

Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice.

BACKGROUND: Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations. METHODS: This was an online anonymous survey of a random sample of EM health providers in US EDs. RESULTS: Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended. CONCLUSIONS: This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.

Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model?

BACKGROUND: Blunt trauma is a leading cause of morbidity and mortality in children. Despite the potential for malignancy, increased cost, limited small bowel injury detection sensitivity, and the low incidence of injury requiring operative intervention, the use of computed tomographic (CT) scan in pediatric blunt trauma evaluation remains common. Previous studies suggest that a clinical model using examination and laboratory data may help predict intra-abdominal injuries (IAIs) and potentially limit unnecessary CT scans in children. METHODS: A retrospective chart review of all blunt "trauma alerts" for patients younger than 16 years during an 18-month period was performed at a Level I trauma center. Clinical factors, which might predict blunt IAI (hemodynamics, abdominal examination, serology, and plain radiographs), and potential limitations to performing a reliable abdominal examination (altered mental status, young age) were reviewed. A previously defined clinical prediction model based on six high-risk clinical variables for blunt IAI (hypotension, abnormal abdominal examination, elevated aspartate aminotransferase, elevated amylase, low hematocrit, and heme-positive urinalysis) was applied to each patient. RESULTS: Of the 125 "trauma alert" patients who sustained blunt trauma during the study period, 97 underwent abdominal CT scan, with only 15 identified as IAI. Our prediction rule would have identified 16 of 17 patients with IAI (SE, 94%) as high-risk and missed only 1 patient (grade I spleen laceration, which did not require operation) (negative predictive value, 99%). Of the 83 patients with no risk factors for IAI based on the prediction rule, 54 underwent a negative abdominal CT scan. Of these 54 patients, only 22 had a potential limitation to a reliable abdominal examination. Application of our prediction rule could have prevented unnecessary CT scan in at least 32 patients (33%) during an 18-month period. CONCLUSION: Use of a prediction model based on high-risk variables for IAI may decrease cost and radiation exposure by reducing the number of abdominal CT scans in children being evaluated for blunt abdominal trauma.