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BACKGROUND: Minoritized patients are disproportionately represented in low-acuity emergency department (ED) visits in the United States in part caused by lack of timely access to primary and urgent care. However, there is also the possibility that implicit bias during triage could contribute to disproportionate representation of minority groups in low-acuity ED visits. Triage discordance, defined as when ED resources used are different from initial triage score predictions, can be used as a proxy for triage accuracy. Recent data suggest that discordant triage may be common, although little is known about the interaction with race, ethnicity, and language for care. OBJECTIVES: This study aims to determine the prevalence of discordant triage among moderate- and low-acuity pediatric ED encounters and the interaction with patient race, ethnicity, and language for care. METHODS: We performed a retrospective analysis of pediatric ED encounters from 2019 with Emergency Severity Index (ESI) scores of 3, 4, or 5 at an academic referral hospital. The primary outcome was triage discordance, encompassing overtriage (ESI 3 and 4) and undertriage (ESI 4 and 5). Logistic and multinomial regressions were used to assess discordant triage by race, ethnicity, and language group. RESULTS: Triage discordance occurred in 47% (n = 18,040) of encounters. Black and Hispanic patients had higher likelihood of undertriage for ESI 5 (adjusted odds ratio 1.21, 95% confidence interval [CI] 1.01-1.46 and 1.27, 95% CI 1.07-1.52, respectively), and Black patients were more likely to be overtriaged in ESI 3 (1.18, 95% CI 1.09-1.27). Those with a language other than English for care had higher proportions of overtriage for ESI 3 (1.08, 95% CI 1.04-1.12) and undertriage for ESI 5 (1.23, 95% CI 1.11-1.37). CONCLUSIONS: We found high rates of triage discordance in our pediatric ED, with significant associations with race, ethnicity, and language for care. Future research should evaluate the source of triage discordance and develop quality improvement efforts to improve equitable care.
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Disparities in health care delivery and health outcomes for patients in the emergency department (ED) by race, ethnicity, and language for care (REaL) are common and well documented. Addressing inequities from structural racism, implicit bias, and language barriers can be challenging, and there is a lack of data on effective interventions. We describe the implementation of a multifaceted equity improvement strategy in a pediatric ED using Kotter's model for change as a framework to identify the key drivers. The main elements included a data dashboard with quality metrics stratified by patient self-reported REaL to visualize disparities, a staff workshop on implicit bias and microaggressions, and several clinical and operational tools that highlight equity. Our next steps include refining and repeating interventions and tracking important patient outcomes, including timely pain treatment, triage assessment, diagnostic evaluations, and interpreter use, with the overall goal of improving patient equity by REaL over time. This article presents a roadmap for a disparity reduction intervention, which can be part of a multifaceted approach to address health equity in EDs.
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Atención a la Salud , Equidad en Salud , Niño , Humanos , Triaje , Servicio de Urgencia en Hospital , Técnicos Medios en SaludRESUMEN
The Neuroscience Learning Community (LC) that Stonehill introduced to its curriculum grew out of the Great Recession of 2008 and the need for our students to gain hands-on, high-impact learning experiences, despite limited resources. This learning model was first reported in 2013, and since then it has undergone changes that were necessary due to the number of credits and amount of time required for that model. Curriculum changes are common, and Stonehill College changed its credit requirements for LCs to meet students' needs. As a result, the new Neuroscience LC model that we describe here reduced credit hours while leveraging new faculty expertise, collaborations, and new community partnerships. This paper reports student evaluations of an LC model adapted to demand fewer credits and less time, but to retain the community-based learning aspect and to increase faculty collaboration, while maintaining a high standard of learning fundamental neuroscience topics. Evaluations suggest that students valued the updated Neuroscience LC because it helped them understand neuroscience concepts and the impact of neuroscience in our world.
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Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.
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Antibacterianos/uso terapéutico , Apendicectomía , Apendicitis/tratamiento farmacológico , Apendicitis/cirugía , Toma de Decisiones , Niño , Medicina Basada en la Evidencia , Humanos , RecurrenciaRESUMEN
OBJECTIVES: Delivery of pediatric critical care in low-income countries is limited by a lack of infrastructure, resources, and providers. Few studies have analyzed the epidemiology of disease associated with a PICU in a low-income country. The aim of this study was to document the primary diagnoses and the associated mortality rates of patients presenting to a tertiary PICU in Mozambique in order to formulate quality improvement projects through an international academic partnership. We hypothesized that the PICU mortality rate would be high and that sepsis would be a common cause of death. DESIGN: Retrospective, observational study. SETTING: Tertiary academic PICU. PATIENTS: All admitted PICU patients. INTERVENTIONS: All available data collection forms containing demographic and clinical data of patients admitted to the PICU at Hospital Central de Maputo, Mozambique from January 2013 to December 2013 were analyzed retrospectively. MEASUREMENTS AND MAIN RESULTS: The patient median age was 2 years (57% male). The most common primary diagnoses were malaria (22%), sepsis (18%), respiratory tract infections (12%), and trauma (6%). The mortality rate was 25%. Mortality rates were highest among patients with sepsis (59%), encephalopathy (56%), noninfectious CNS pathologies (33%), neoplastic diseases (33%), meningitis/encephalitis (29%), burns (26%), and cardiovascular pathologies (26%). The median length of PICU stay was 2 days. HIV exposure/infection had a nonstatistically significant association with mortality. Patients admitted for burns had the highest median length of PICU stay (4 d). Most trauma admissions were male (75%), and approximately half of all trauma admissions had an associated head injury (55%). CONCLUSIONS: Infectious disease and trauma were highly represented in this Mozambican PICU, and overall mortality was high compared with high-income countries. With this knowledge, targeted collaborative projects in Mozambique can now be created and modified. Further research is needed to monitor the potential benefits of such interventions.
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Mortalidad del Niño , Mortalidad Hospitalaria , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Adolescente , Causas de Muerte , Niño , Preescolar , Cuidados Críticos/estadística & datos numéricos , Femenino , Infecciones por VIH/epidemiología , Humanos , Lactante , Recién Nacido , Tiempo de Internación , Malaria/epidemiología , Masculino , Mozambique/epidemiología , Pobreza , Estudios Retrospectivos , Sepsis/mortalidadRESUMEN
BACKGROUND: In Mozambique, there is a limited supply of blood and elevated risks for transmission of infections. Prior studies have documented that many transfusions in Mozambique are potentially avoidable. Transfusion training workshops with a survey and exam were held for providers to understand their perceptions and to improve knowledge and clinical practice. STUDY DESIGN AND METHODS: Health care providers completed a survey and a knowledge assessment. The Wilcoxon signed rank test was utilized to compare the relative importance of each factor in the survey, and pre- and posttraining exam scores were compared using Fisher's exact test. RESULTS: A total of 216 health care providers participated; the majority worked in a referral hospital (74%) and reported transfusing blood at least once per week (56%). Most acknowledged the limited blood supply and transfusion risks. Providers rated low hemoglobin (Hb) levels and pallor as significantly important indications for transfusion (p < 0.001). They were more likely to transfuse with age under 5 years when compared to other ages (p < 0.01). The three most potentially influential factors for transfusion practice were increased reliability of the blood supply, education about transfusion indications, and assessment of perfusion. Before training, the majority of participants identified an incorrect Hb threshold for preoperative or critically ill patients. Overall exam scores improved from a mean of 58% to 74% (p < 0.001). CONCLUSIONS: Mozambican providers were knowledgeable about the risks of blood transfusions. Preoperative patients, the critically ill, and children appear to be at highest risk for receiving an avoidable blood transfusion. These results will help guide planning for future provider training.
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Donantes de Sangre/provisión & distribución , Transfusión Sanguínea/normas , Educación Médica Continua/normas , Encuestas y Cuestionarios , Femenino , Humanos , Masculino , MozambiqueRESUMEN
BACKGROUND: Acute pediatric respiratory illness is one of the most common reasons for emergency department(ED) transfer however few studies have examined predictors of potentially avoidable ED transfer(PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness. METHODS: Cross-sectional analysis of 8,402,577 visits for patients <17 years from 2018-2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a three-level generalized linear mixed model with adjustment for patient and hospital covariates. RESULTS: Among 4,409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits(n=472, 42.0%). In the multivariable model, likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09 -3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes(OR 0.48 95% CI 0.26-0.88). CONCLUSIONS: Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower three quartiles of pediatric volume.
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Understanding and addressing health care disparities relies on collecting and reporting accurate data in clinical care and research. Data regarding a child's race, ethnicity, and language; sexual orientation and gender identity; and socioeconomic and geographic characteristics are important to ensure equity in research practices and reported outcomes. Disparities are known to exist across these sociodemographic categories. More consistent, accurate data collection could improve understanding of study results and inform approaches to resolve disparities in child health. However, published guidance on standardized collection of these data in children is limited, and given the evolving nature of sociocultural identities, requires frequent updates. The Pediatric Emergency Care Applied Research Network, a multi-institutional network dedicated to pediatric emergency research, developed a Health Disparities Working Group in 2021 to support and advance equitable pediatric emergency research. The working group, which includes clinicians involved in pediatric emergency medical care and researchers with expertise in pediatric disparities and the conduct of pediatric research, prioritized creating a guide for approaches to collecting race, ethnicity, and language; sexual orientation and gender identity; and socioeconomic and geographic data during the conduct of research in pediatric emergency care settings. Our aims with this guide are to summarize existing barriers to sociodemographic data collection in pediatric emergency research, highlight approaches to support the consistent and reproducible collection of these data, and provide rationale for suggested approaches. These approaches may help investigators collect data through a process that is inclusive, consistent across studies, and better informs efforts to reduce disparities in child health.
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Recolección de Datos , Humanos , Niño , Recolección de Datos/métodos , Disparidades en Atención de Salud , Etnicidad , Factores Sociodemográficos , Medicina de Urgencia Pediátrica , Factores Socioeconómicos , Identidad de Género , ConsensoRESUMEN
Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.
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Infecciones Bacterianas , Etnicidad , Lactante , Niño , Recién Nacido , Humanos , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Estudios Transversales , Lenguaje , Barreras de Comunicación , Antibacterianos/uso terapéuticoRESUMEN
BACKGROUND: Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment. METHODS: We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits. RESULTS: A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges. CONCLUSIONS: IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.
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Trastornos Migrañosos , Sumatriptán , Humanos , Femenino , Niño , Masculino , Sumatriptán/uso terapéutico , Sumatriptán/efectos adversos , Estudios Retrospectivos , Cefalea/tratamiento farmacológico , Trastornos Migrañosos/tratamiento farmacológico , Servicio de Urgencia en Hospital , Resultado del TratamientoRESUMEN
Individuals with intellectual and developmental disabilities (IDD) face several barriers to healthcare, making them less likely to receive numerous routine preventive health screenings. Preventive healthcare is a critical aspect to maintaining health and wellness, particularly for people with complex health needs. This study examines individual- and state-level factors associated with mammogram and colonoscopy screenings in mid- and later-life foradults with IDD receiving state services. Multilevel logistic regression models analyzed data from the 2012-2013 and 2018-2019 waves of the National Core Indicators In-Person Survey (NCI-IPS). Results indicated that factors such as age, living situation, transportation access, and community involvement were associated with completion of both preventive screenings. Medicaid expansion was associated with a significantly greater likelihood of completing a colonoscopy screening only among younger persons in the sample (i.e., in their 50s). These findings may have implications for completion of preventive health screenings for adults with IDD.
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Discapacidades del Desarrollo , Medicaid , Estados Unidos , Humanos , Anciano , Niño , Discapacidades del Desarrollo/diagnóstico , Servicios Preventivos de Salud , Modelos Logísticos , Atención a la SaludRESUMEN
BACKGROUND: Patients with a language for care other than English (LOE) face communication barriers and inequitable outcomes in health care. Professional interpretation can improve outcomes but is underutilized. Our pediatric emergency department (ED) implemented quality improvement (QI) interventions over a 5-year period with an aim to increase interpreter use to 80% of patient encounters with LOE. METHODS: Overall interpreter use for ED encounters was measured over time, with a baseline period of October 2015 to December 2016 and during 5 years of QI interventions from January 2017 to August 2021. Interventions included staff education, data feedback, reducing barriers to interpreter use, and improving identification of language for care with plan-do-study-act cycles. Outcomes were analyzed by using statistical process control charts and standard rules for special cause variation. RESULTS: We analyzed a total of 277 309 ED encounters during the study period, 12.2% with LOE. The overall use of interpretation increased from a baseline of 53% to 82% of encounters. Interpretation throughout the ED visit and the number of interpreted interactions per hour also increased. There was improvement across language types, patient age groups, acuity levels, and during different times of day. Special cause variation was associated with multiple QI interventions. CONCLUSION: We reached our primary aim of providing professional interpretation for 80% of patient encounters with LOE. There were several QI interventions associated with improvements, including staff education, data feedback, improved access to interpretation, and improved identification and visualization of language for care. Efforts to improve interpreter use may benefit from a similar multifaceted approach.
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Lenguaje , Traducción , Niño , Humanos , Barreras de Comunicación , Mejoramiento de la Calidad , Servicio de Urgencia en HospitalRESUMEN
The prolonged COVID-19 pandemic has created unique and complex challenges in operational and capacity planning for pediatric emergency departments, as initial low pediatric patient volumes gave way to unpredictable patient surges during Delta and Omicron variants. Compounded by widespread hospital supply chain issues, staffing shortages due to infection and attrition, and a concurrent pediatric mental health crisis, the surges have pushed pediatric emergency department leaders to re-examine traditionally defined clinical processes, and adopt innovative operational strategies. This study describes the strategic surge response and lessons learned by 3 major freestanding academic pediatric emergency departments in the western United States to help inform current and future pediatric pandemic preparedness.
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COVID-19 , Humanos , Niño , COVID-19/epidemiología , Pandemias/prevención & control , SARS-CoV-2 , Servicio de Urgencia en HospitalRESUMEN
Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking. Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations. Design, Setting, and Participants: In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks. Outcome: Consensus agenda of research priorities to identify and address health care disparities in PEC. Results: PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation. Conclusions and Relevance: These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.
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Servicios Médicos de Urgencia , Etnicidad , Humanos , Niño , Investigación , Lenguaje , InvestigadoresRESUMEN
BACKGROUND: As the COVID-19 pandemic continues, health care systems around the world have changed care delivery in significant ways. Racial and ethnic disparities have emerged for COVID-19 infection rates, morbidity, and mortality. Inequities in care and underutilization of interpretation for patients who use a language other than English (LOE) for care existed prior to this era. This study sought to evaluate interpreter use in a pediatric emergency department (ED) as changes associated with COVID-19 were implemented. METHODS: ED records were reviewed from December 1, 2019, to July 31, 2020. Patients were classified as having LOE if they preferred a language other than English and consented to interpretation. Statistical process control was used to analyze changes in interpreter use over time, relative to the onset of COVID-19-related operational changes. Beginning March 1, 2020, in-person interpreters were no longer available and staff were encouraged to communicate from outside the patient room when possible; this change served as the exposure of interest. Interpreter use for LOE patients, overall and by triage acuity level, was the study outcome. RESULTS: A total of 26,787 encounters were included. The weekly mean proportion of encounters that used interpretation for patients with LOE increased from 59% to 73% after the onset of COVID-19. This increase met criteria for special cause variation. Interpretation modality changed to being mostly by phone from previously by video or in-person. CONCLUSION: Operational changes in the ED related to COVID-19 were associated with increased interpreter use. Possible explanations include lower patient volumes or changes in model of care that encouraged interpreter use by a variety of modalities.
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COVID-19 , Barreras de Comunicación , Servicio de Urgencia en Hospital , Traducción , Niño , Humanos , PandemiasRESUMEN
BACKGROUND: There are disparities in pain management for children presenting to the emergency department (ED) according to their racial and ethnic backgrounds. It is not known if there are differences in the treatment of pain associated with pediatric migraines by race, ethnicity, and language for care (REaL). METHODS: We analyzed treatment patterns and outcomes in our ED for acute migraine in pediatric patients by REaL. Retrospective data on treatments, length of stay (LOS), and charges were collected from the electronic medical record for pediatric patients on the ED migraine pathway from October 2016 to February 2020. Patient race/ethnicity and language for care were self-reported at registration. We analyzed two treatment groups: receipt of oral (PO) or intranasal (IN) medications only or intravenous (IV) ± IN/PO medications. A total of 833 patients (median age 14.8 years, interquartile range [IQR] 12.3-16.5 years; 67% female, 51% non-Hispanic White (nHW), 23% Hispanic, 8.3% Black or African American, 4.3% Asian) were included. A total of 287 received PO/IN medications only and 546 received IV medications. RESULTS: Initial pain scores in the two groups were similar. Patients who were Asian, Black or African American, and Hispanic or had a language for care other than English (LOE) had significantly lower odds of receiving IV treatment, while patients who were nHW and preferred English had higher odds of receiving IV treatment. The IV treatment group had longer LOS and ED charges. Pediatric ED patients with migraine who were Black, Asian, and Hispanic or had a LOE had a decreased likelihood of receiving IV therapies while patients who were nHW were more likely to receive IV treatments, despite similar initial pain scores. CONCLUSIONS: These data align with previous studies on pain management disparities and highlight another area where we must improve equity for patients in the ED.
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Etnicidad , Trastornos Migrañosos , Adolescente , Niño , Servicio de Urgencia en Hospital , Femenino , Disparidades en Atención de Salud , Humanos , Lenguaje , Masculino , Trastornos Migrañosos/terapia , Dolor/tratamiento farmacológico , Estudios RetrospectivosRESUMEN
Pediatric Emergency and Critical Care-Kenya (PECC-Kenya) is an international collaboration between the University of Nairobi and the University of Washington (UW) supporting a combined fellowship program in pediatric emergency medicine (PEM) and pediatric critical care medicine (PCCM) in Kenya. Typically, PEM/PCCM faculty from UW travel to Kenya to support in-person simulation, which was cancelled due to COVID-19 travel restrictions. This presented a need for alternative modalities to continue simulation-based education. This technical report describes the use of virtual simulation for pediatric emergency and critical care fellow education on the management of hypovolemic and septic shock, utilizing international guidelines and being based on resource availability.
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INTRODUCTION: Children with food insecurity (FI) experience adverse health outcomes due to inadequate quantity or quality of food. Food insecurity may be high among families seeking emergency care. The Hunger Vital Sign (HVS) is a two-question validated tool used to screen families for FI. Our goal in this study was to assess prevalence of FI among emergency department (ED) patients, patient-level risk factors for FI, and the feasibility of screening. METHODS: This was a cross-sectional analysis of FI in the ED. Parents or guardians of ED patients and adult patients (18 years or older) were approached for screening using the HVS during screening periods spanning weekdays/weekends and days/evenings. All ED patients were eligible, excluding siblings, repeat visits, critically ill patients, minors without a guardian, and families that healthcare staff asked us not to disturb. Families answered the HVS questions verbally or in writing, based on preference. Families with positive screens received information about food resources. We summarized patient and visit characteristics and defined medical complexity using a published algorithm. Multivariable logistic regression was used to assess FI risk factors. RESULTS: In July-August 2019, 527 patients presented during screening periods: 439 agreed to screening, 18 declined, 19 met exclusions, and 51 were missed. On average the screening tool required five minutes (range 3-10 minutes) to complete. Most families (328; 75%) preferred to answer in writing rather than verbally. Overall, 77 participants (17.5%) screened positive for FI. In regression analyses, FI was associated with self-reported race/ethnicity (combined variable) of African American or Black (odds ratio [OR] 5.21, 95% confidence interval [CI], 2.13-12.77), Hispanic (OR 3.47, 95% CI, 1.48-8.15), or mixed/other (OR 3.81, 95% CI, 1.54-9.39), compared to non-Hispanic white. FI was also associated with public insurance type (OR 5.74, 95% CI, 2.52-13.07, reference: private insurance), and each year of increasing patient age (OR 1.05, 95% CI, 1.01-1.09). There were no associations between FI and medical complexity or preferred language. CONCLUSION: Food insecurity was common among our ED patients. Race and ethnicity, insurance status, and increasing patient age were associated with increased odds of FI. Efforts to include universal FI screening for ED patients with immediate connection to resources will enhance overall care quality and address important health needs.
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Inseguridad Alimentaria , Tamizaje Masivo , Adulto , Niño , Estudios Transversales , Servicio de Urgencia en Hospital , Estudios de Factibilidad , HumanosRESUMEN
Asthma exacerbations are frequent in the pediatric emergency department (ED) and result in significant morbidity and costs; standardized treatment improves outcomes. In this study, we aimed to use provider adherence data and the associated patient outcomes as an intervention to change behavior and improve care. METHODS: We used a retrospective cohort design to analyze 2 years of baseline data for asthma patient encounters. Providers were classified based on guideline adherence. We compared patient outcomes by provider adherence using Mann-Whitney U and Fisher's exact test. Our intervention included education with data feedback and peer comparison. We then analyzed changes in guideline adherence, the proportion of patients admitted, length of stay (LOS), and costs for this population over time using statistical process control charts. RESULTS: In our baseline data analysis, patients seen by less adherent physicians had a higher likelihood of admission (65.1% versus 50.8%, P < 0.001), a longer ED LOS (4.7 versus 4.2 h, P = 0.007), and higher costs ($1,896.20 versus $1,728.50, P < 0.001). Using SPC analysis, there was an improvement in guideline adherence by providers (64%-77%) with a mirrored improvement in patient adherence (76%-84%) associated with our interventions. Admissions decreased 1 year after the intervention; ED LOS and returns remained unchanged. CONCLUSION: In this study, we evaluated patient outcomes according to provider adherence to a clinical guideline and used the results to change provider behavior and improve patient outcomes. Active provision of feedback with peer comparison for providers was associated with improved adherence over time.
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In the midst of a global pandemic, hospitals around the world are working to meet the demand for patients ill with the 2019 coronavirus disease (COVID-19) caused by the novel coronavirus first identified in Wuhan, China. As the crisis unfolds, several countries have reported lower numbers as well as less morbidity and mortality for pediatric patients. Thus, pediatric centers find themselves pivoting from preparing for a patient surge to finding ways to support the regional response for adults. This study describes the response from 2 West Coast freestanding academic children's hospitals that were among the first cities in the United States impacted during this pandemic.