Reminders, but not monetary incentives, increase COVID-19 booster uptake.

Despite substantially decreasing the risk of hospitalization and death from COVID-19, COVID-19 booster vaccination rates remain low around the world. A key question for public health agencies is how to increase booster vaccination rates, particularly among high-risk groups. We conducted a large preregistered randomized controlled trial (with 57,893 study subjects) in a county health system in northern California to test the impact of personal reminder messages and small financial incentives of $25 on booster vaccination rates. We found that reminders increased booster vaccination rates within 2 wk by 0.86 percentage points (P = 0.000) or nearly 33% off the control mean of 2.65%. Monetary incentives had no additional impact on vaccination rates. The results highlight the potential of low-cost targeted messages, but not small financial incentives, to increase booster vaccination rates.

The association between timely opioid administration and hospitalization in children with sickle cell disease presenting to the emergency department in acute pain.

INTRODUCTION: The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) pain crisis management recommend opioids within 60 minutes of emergency department (ED) registration and every 30 minutes thereafter until acute pain is managed. These guidelines are based on expert opinion without published, supporting data. OBJECTIVE: To evaluate the association between timely ED opioid administration and hospitalization rates in children with SCD. METHODS: Retrospective cohort of children presenting to a children's hospital ED with SCD pain between January 1, 2014, and April 30, 2018. Visits were extracted using ICD codes, chief complaints, and receipt of at least one opioid, and then reviewed to confirm the visit was an uncomplicated pain crisis. The primary outcome was hospitalization, yes or no. Generalized estimating equations were used to determine adjusted odds of hospitalization for the timely administration of initial and second doses of opioids. RESULTS: Of the 902 eligible visits, 368 (40.8%) resulted in hospitalization. The mean (SD) age was 11.9 (± 5.2) years. The first opioid was administered within 60 minutes of arrival in 601 (66.6%) visits. The second opioid was administered within 30 minutes of the first in 84 (12.3%) visits. Receipt of the first opioid within 60 minutes of arrival was not associated with decreased hospitalization (1.30 [0.96-1.76]). However, receipt of the second dose within 30 minutes of the first was associated with decreased hospitalization (0.56 [0.33-0.94]). CONCLUSION: This study suggests an association between children with SCD receiving a second dose within 30 minutes of the first opioid dose and decreased hospitalizations.

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

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

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

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

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

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

RFID in the blood supply chain--increasing productivity, quality and patient safety.

As part of an overall design of a new, standardized RFID-enabled blood transfusion medicine supply chain, an assessment was conducted for two hospitals: the University of Iowa Hospital and Clinics (UIHC) and Mississippi Baptist Health System (MBHS). The main objectives of the study were to assess RFID technological and economic feasibility, along with possible impacts to productivity, quality and patient safety. A step-by-step process analysis focused on the factors contributing to process "pain points" (errors, inefficiency, product losses). A process re-engineering exercise produced blueprints of RFID-enabled processes to alleviate or eliminate those pain-points. In addition, an innovative model quantifying the potential reduction in adverse patient effects as a result of RFID implementation was created, allowing improvement initiatives to focus on process areas with the greatest potential impact to patient safety. The study concluded that it is feasible to implement RFID-enabled processes, with tangible improvements to productivity and safety expected. Based on a comprehensive cost/benefit model, it is estimated for a large hospital (UIHC) to recover investment from implementation within two to three years, while smaller hospitals may need longer to realize ROI. More importantly, the study estimated that RFID technology could reduce morbidity and mortality effects substantially among patients receiving transfusions.

Improving Emergency Department Management of Diabetic Ketoacidosis in Children.

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