Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway.

OBJECTIVES: Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization. DESIGN: A quality improvement study using a prospective cohort design with historical controls. SETTING: Four hundred seven-bed free standing quaternary care academic children's hospital. PATIENTS: All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022. INTERVENTIONS: Unit-specific standard approaches to iNO initiation and weaning. MEASUREMENTS AND MAIN RESULTS: Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (-24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings. CONCLUSIONS: Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.

Toward Improving Patient Equity in a Pediatric Emergency Department: A Framework for Implementation.

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.

The Impact of an Emergency Department Bruising Pathway on Disparities in Child Abuse Evaluation.

OBJECTIVES: Previous research has shown racial, ethnic, and socioeconomic disparities in provider medical evaluations and reporting to child protective services (CPS) and law enforcement (LE) for cases of suspected child physical abuse. Our hospital standardized evaluation and reporting of high-risk bruising using a clinical pathway. We aimed to assess whether standardization impacted disparity. METHODS: We performed a retrospective observational study including children evaluated in the emergency department who had a social work consult for concern for child abuse or neglect between June 2012 and December 2019. From this group, we identified children with high-risk bruising. We compared outcomes (receipt of skeletal survey, CPS report, or LE report) before and after implementation of a standard bruising evaluation pathway to determine how the intervention changed practice among various racial, ethnic, and socioeconomic groups. RESULTS: During the study period, 2129 children presented to the ED and received a social work consult for child abuse or neglect. Of these, 333 had high-risk bruising. Children without private insurance had a higher risk of having a CPS (adjusted relative risk, 1.32; 95% confidence interval, 1.09-1.60) or LE (adjusted relative risk, 1.48; 95% confidence interval, 1.11-1.97) report prepathway, but not after pathway implementation. No significant associations were seen for race or ethnicity. CONCLUSIONS: A standardized clinical pathway for identification and evaluation of high-risk bruising may help to decrease socioeconomic disparities in reporting high-risk bruising. Larger studies are needed to fully evaluate disparities in assessment and reporting of child abuse.

Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock.

STUDY OBJECTIVE: To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock. METHODS: This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure. RESULTS: Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

Screening for Mental Health Comorbidities in a Pediatric Diabetes Clinic Setting.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve mental health screening of patients at a pediatric diabetes clinic in Seattle, WA.

Improving Antibiotic Prescribing for Children With Urinary Tract Infection in Emergency and Urgent Care Settings.

OBJECTIVES: Children with urinary tract infection (UTI) are often diagnosed in emergency and urgent care settings and increasingly are unnecessarily treated with broad-spectrum antibiotics. This study evaluated the effect of a quality improvement intervention on empiric antibiotic prescribing for the treatment of uncomplicated UTI in children. METHODS: A local clinical pathway for uncomplicated UTI, introduced in June 2010, recommended empiric treatment with cephalexin, a narrow-spectrum (first-generation) cephalosporin antibiotic. A retrospective quasi-experimental study of pediatric patients older than 1 month presenting to emergency and urgent care settings from January 1, 2009, to December 31, 2014, with uncomplicated UTI was conducted. Hospitalized patients and those with chronic conditions or urogenital abnormalities were excluded. Control charts and interrupted time-series analysis were used to analyze the primary outcome of narrow-spectrum antibiotic prescribing rates and the balancing measures of 72-hour revisits, resistant bacterial isolates, and subsequent inpatient admissions for UTI. RESULTS: A total of 2134 patients were included. There was an immediate and sustained significant increase in cephalexin prescribing before (19.2%) versus after (79.6%) pathway implementation and a concurrent significant decline in oral third-generation cephalosporin (cefixime) prescribing from 50.3% to 4.0%. There was no significant increase in 72-hour revisits, resistant bacterial isolates, or inpatient admissions for UTI. CONCLUSIONS: A clinical pathway produced a significant and sustained increase in narrow-spectrum empiric antibiotic prescribing for pediatric UTI. Increased empiric cephalexin prescribing did not result in increased treatment failures or adverse patient outcomes. Future studies on implementing clinical pathways for children outside a pediatric hospital network are needed.

Waterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department.

STUDY OBJECTIVE: Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs. METHODS: A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping "waterfall" shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change. RESULTS: A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction. CONCLUSION: This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.

Inotropic Therapy for Sepsis.

Sepsis, severe sepsis, and septic shock represent a dynamic clinical syndrome involving a systemic inflammatory response, circulatory changes, and end-organ dysfunction from an infection. Early aggressive management to restore perfusion and/or improve hypotension is critical to improving outcomes. Although the basic management principles of early goal-directed therapy for sepsis have not undergone significant changes, there has been a recent shift in recommendations related to the timing and type of inotropic support. The purpose of this article is to review fluid management along with previous and current inotrope recommendations in pediatric sepsis and septic shock.

Improving Time to Antibiotics for Pediatric Oncology Patients With Suspected Infections: An Emergency Department-Based Quality Improvement Intervention.

OBJECTIVE: Studies in pediatric patients with fever and neutropenia demonstrate that shorter time to antibiotics is associated with a decrease in pediatric intensive care unit admissions and in-hospital mortality. In 2012, a 2-phase quality improvement intervention was implemented in a pediatric emergency department (ED) to improve care for this high-risk patient population.The objective was to determine if the introduction of (1) a rapid absolute neutrophil count (ANC) test and (2) a standardized prearrival process decreased time to antibiotics for febrile hematology/oncology(heme/onc) patients presenting to the ED. METHODS: The rapid ANC test introduced in February 2012 decreased turn-around-times in the laboratory from 60 to 10 minutes. The standardization of the prearrival communication between the heme/onc team and ED was implemented in August 2012 as part of a clinical standard work pathway for heme/onc patients who presented to the ED with fever and possible neutropenia. Time from arrival to the ED to administration of first antibiotic was measured.Data from January 2011 to December 2013 were analyzed using statistical process control. RESULTS: Seven hundred eighteen encounters for 327 patients were included. After the rapid ANC test, the proportion of patients who received antibiotics within 60 minutes of arrival increased from 47% to 60%. There was further improvement to 69% with implementation of the clinical standard work pathway. Mean time to antibiotics decreased from 83 to 65 minutes (21% decrease). CONCLUSION: This 2-phase quality improvement intervention increased the proportion of patients who received antibiotics within 60 minutes of arrival to the ED. Similar processes may be implemented in other pediatric EDs to improve timeliness of antibiotic administration.

Improving Timeliness of ß-Agonist and Corticosteroid Administration in Patients With Acute Wheezing.

OBJECTIVE: Timely delivery of ß-agonists and steroids to patients with acute recurrent wheezing is a key component of the National Heart, Lung, and Blood Institute recommended emergency department (ED) asthma care. We conducted an ED improvement initiative to standardize asthma care and improve time to treatments. METHODS: Our multidisciplinary team identified key contributing factors to timeliness, developed key driver diagrams, implemented and refined a management pathway, designed and executed rapid cycle improvements, and implemented interventions. A time series design was used to analyze outcomes with baseline data and continuous monitoring during active intervention steps. The primary outcomes analyzed were the times to first ß-agonist and steroid administration. Secondary outcomes included admission rate, ED length of stay, and ED revisits. RESULTS: Assignment of the Pediatric Asthma Score, our initial pathway step, occurred in most patients within the first several months. Time to first ß-agonist administration decreased from the baseline mean of 76 minutes to 27 minutes. Time to steroid administration decreased from the baseline mean of 108 minutes to 49 minutes. Mean monthly admission rate remained at 22% with no special cause variation identified. The ED revisit rate was not negatively impacted and, in most months, was 0%. CONCLUSIONS: By standardizing asthma care in our ED and redesigning care delivery processes, care variation decreased and significant improvements in timeliness of ß-agonist and steroid administration occurred.

Rapid Electronic Provider Documentation Design and Implementation in an Academic Pediatric Emergency Department.

BACKGROUND: Many emergency departments are transitioning from paper charting to full electronic health records, which include both computerized provider order entry and provider documentation. Implementation of electronic provider documentation (EPD), in particular, has been challenging. Known benefits include legibility, medicolegal and compliance safeguards, and improved access to patient charts. Offsetting these benefits may be reductions in efficiency, patient throughput, and less provider-patient interaction. METHODS: We used a rapid design process coupled with Lean principles, simulation, aggressive training, and continuous process improvement to design and implement a novel EPD system with real-time voice recognition dictation in the pediatric emergency department (PED). We used statistical process control methodologies to compare mean PED lengths of stay (LOSs) for admitted and discharged patients before and after EPD GoLive. RESULTS: We were able to design, test, train, and implement a novel EPD to the PED within 7 months. There was special cause variation, with a 2.7% (5-minute) increase in overall LOS after EPD implementation. There was a temporary 9.3% (15-minute) increase in discharge LOS for 6 weeks after GoLive, with a subsequent return to a new baseline of 4.3% (7-minute) increase. There were no significant changes in admission LOS. There was overall consistent use of the voice recognition system several months after EPD rollout. There have been improving rates of compliance with chart completion over time, as a result of easier tracking and electronic reminders to complete. CONCLUSION: Despite the inherent challenges involved in transitioning from paper charting to EPD, our study showed that an academic ED, EPD, can be rapidly designed and implemented while not significantly negatively impacting ED metrics such as LOS. We had consistent use of the voice dictation system after implementation. Time spent documenting after clinical shift was not reliably captured and is an important area of future research for successful EPD implementation.

Creating a leaner pediatric emergency department: how rapid design and testing of a front-end model led to decreased wait time.

OBJECTIVE: To use Lean methodologies and the Model for Improvement to rapidly redesign and pilot test a new pediatric emergency department (ED) front-end model that reduces time to a licensed independent provider to 30 minutes or less. METHODS: Lean improvement methodologies were applied during a 5-day multidisciplinary model of care redesign event. The new ED front-end model of care included: (1) placement of a registered nurse in the lobby; (2) direct patient rooming with elimination of traditional triage; 3) early documentation of home medications; 4) Team-based immediate assessment; 5) "early Initiation" providers to place orders when a team was not available. An observational, cohort controlled before-and-after study design was used. The new model was tested over 2 pilot periods and compared to a similar period of control days, defined as the "current state." RESULTS: The ED census and patient acuity were similar during both pilot periods. Eighteen patients were included in pilot 1, and 80 patients were included in the expanded second pilot. Patients seen within 30 minutes improved from a baseline of 33% to 93% in pilot 2. Time to a licensed independent provider, to a room, and to visual assessment by a nurse all decreased. The largest decrease was in median time to provider, from 43 minutes in the current state to 7 minutes during pilot 2. CONCLUSIONS: Rapid process improvement methodology was used to design and test a front-end model that reduced patient waiting time. Our experience demonstrates the feasibility of employing Lean principles and the Model for Improvement in actual practice environments to rapidly improve care delivery processes in pediatric emergency departments.

Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization?

OBJECTIVES: Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS: We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS: Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS: Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

Improving Identification of Firearm Access in Children With Mental Health Complaints.

OBJECTIVE: To determine if electronic medical record (EMR) changes and implementation of a study on firearm storage practices changed identification of firearm exposure in children presenting to a pediatric emergency department (PED) with mental health complaints. We also sought to determine the accuracy of information collected on firearm storage practices. METHODS: Retrospective study of EMR documentation of firearm exposure in PED patients with mental health complaints from January 20, 2015 until November 20, 2017. EMR changes occurred on January 20, 2016 and the firearms study began on February 13, 2016. The primary outcome was documentation of firearm exposure. Secondary outcomes were documentation of unsafe firearm storage practices. We also examined differences between clinical and research documentation of unsafe firearm storage practices post-intervention. We compared groups using descriptive statistics and chi-squared tests. We used statistical process control to examine the relationship between interventions and changes in outcomes. RESULTS: 5582 encounters were examined. Identification of firearm exposure increased from 11 to 17% postintervention. Identification of unsafe storage practices increased from 1.9% to 4.4% across all encounters. Special cause variation in both metrics occurred concurrently with the interventions. Postintervention, unsafe firearms storage practices in firearm owning families were under-identified (39% identified as not triple-safe in clinical data vs 75% in research data). CONCLUSIONS: EMR changes and implementation of a firearms study improved identification of firearm exposure and unsafe storage practices in families of PED patients being evaluated for mental health complaints. However, unsafe storage practices continued to be under-identified in firearm-owning families.

Improving Pediatric Ovarian Torsion Evaluation in the Pediatric Emergency Department: A Quality Improvement Initiative.

Background: Transabdominal pelvic ultrasound (TPUS) is the diagnostic test of choice for the evaluation of ovarian torsion, a time-sensitive surgical emergency. A full bladder is required to visualize the ovaries. Bladder filling is a time-consuming process leading to delays to TPUS, poor visualization of ovaries requiring repeat studies, and prolonged emergency department length of stay (ED LOS). The primary objective was to decrease the time to TPUS by standardizing the bladder filling process. Methods: This quality improvement initiative occurred at a single, academic, quaternary-care children's hospital ED and utilized the Institute for Healthcare Improvement Model for Improvement with sequential plan-do-study-act cycles. The first set of interventions implemented in August 2021 included a new electronic order set and bladder scan by ED nurses. Subsequent plan-do-study-act cycles aimed to decrease the time to intravenous fluid, decrease fluid requirement, and decrease the need for intravenous fluid. The primary outcome measure was the monthly mean time to TPUS. Secondary outcome measures included monthly mean ED LOS and percentage of repeat TPUS. We performed data analysis with statistical process control charts to assess for system change over time. Results: The preintervention baseline included 292 ED encounters more than 10 months, and postintervention analysis included 526 ED encounters more than 16 months. Time to TPUS decreased (138-120 min), ED LOS decreased (372-335 min), and repeat TPUS decreased (18% to 4%). All changes met the rules for special cause variation. Conclusions: Standardizing the bladder filling process was associated with decreased time to TPUS, ED LOS, and repeat TPUS.

Improving and Sustaining Interpreter Use Over 5 Years in a Pediatric Emergency Department.

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.

Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative.

OBJECTIVES: We sought to improve utilization of a sepsis care bundle and decrease 3- and 30- day sepsis-attributable mortality, as well as determine which care elements of a sepsis bundle are associated with improved outcomes. METHODS: Children's Hospital Association formed a QI collaborative to Improve Pediatric Sepsis Outcomes (IPSO) (January 2017-March 2020 analyzed here). IPSO Suspected Sepsis (ISS) patients were those without organ dysfunction where the provider "intended to treat" sepsis. IPSO Critical Sepsis (ICS) patients approximated those with septic shock. Process (bundle adherence), outcome (mortality), and balancing measures were quantified over time using statistical process control. An original bundle (recognition method, fluid bolus < 20 min, antibiotics < 60 min) was retrospectively compared with varying bundle time-points, including a modified evidence-based care bundle, (recognition method, fluid bolus < 60 min, antibiotics < 180 min). We compared outcomes using Pearson χ-square and Kruskal Wallis tests and adjusted analysis. RESULTS: Reported are 24 518 ISS and 12 821 ICS cases from 40 children's hospitals (January 2017-March 2020). Modified bundle compliance demonstrated special cause variation (40.1% to 45.8% in ISS; 52.3% to 57.4% in ICS). The ISS cohort's 30-day, sepsis-attributable mortality dropped from 1.4% to 0.9%, a 35.7% relative reduction over time (P < .001). In the ICS cohort, compliance with the original bundle was not associated with a decrease in 30-day sepsis-attributable mortality, whereas compliance with the modified bundle decreased mortality from 4.75% to 2.4% (P < .01). CONCLUSIONS: Timely treatment of pediatric sepsis is associated with reduced mortality. A time-liberalized care bundle was associated with greater mortality reductions.

Impact of the COVID-19 Pandemic on the Severity of Diabetic Ketoacidosis Presentations in a Tertiary Pediatric Emergency Department.

More severe presentations of diabetic ketoacidosis (DKA) have been reported during the coronavirus disease 2019 (COVID-19) pandemic, possibly due to avoidance of healthcare settings or reduced access to care. To date, no studies have utilized statistical process control to relate temporal COVID-19 events with DKA severity. Our objectives were (1) to determine whether the severity of pediatric DKA presentations changed during COVID-19 and (2) to temporally relate changes in severity with regional pandemic events. Methods: This study was a retrospective chart review of 175 patients younger than 18 years with DKA presenting to a pediatric emergency department in the United States between 5/1/2019 and 8/15/2020. As part of our ongoing clinical standard work in ED management of DKA, DKA severity measures, including presenting pH, the proportion of PICU admissions, and admission length of stay, were analyzed using statistical process control. Results: During COVID-19, we found special cause variation with a downward shift in the mean pH on DKA presentation from 7.2 to 7.1 for all patients. The proportion of DKA patients requiring PICU admission increased from 34.2% to 54.6%. Changes temporally corresponded to the statewide bans on large events (3/11/2020), school closures (3/13/2020), and a reduction in our institution's emergency department volumes. Admission length of stay was unchanged. Conclusions: Pediatric DKA presentations were more severe from March to June 2020, correlating with regional COVID-19 events. Future quality improvement interventions to reduce delayed presentations during COVID-19 surges or other natural disasters should target accessibility of care and public education regarding the importance of timely care for symptoms.

Implementation of Standardized Care for the Medical Stabilization of Patients With Anorexia Nervosa.

Approaches to refeeding patients with anorexia nervosa for medical stabilization vary across institutions, and there is no established standard of care. This study assessed the impact of a refeeding pathway on hospital length of stay and transfer to the psychiatry unit. Methods: This quality improvement intervention sought to standardize care for adolescents with anorexia nervosa at a tertiary care, free-standing children's hospital from Spring 2017 to Fall 2018. The pathway specified admission criteria, nutritional advancement, activity restriction, laboratory monitoring, readiness to transfer to the psychiatry unit, and discharge criteria. Statistical process control analysis was utilized to identify system-level changes over time. We used linear regression to assess pre- and postpathway differences in length of stay and transfer to the psychiatry unit. Results: There were 161 patient encounters for anorexia nervosa admitted for medical stabilization. 84% of the sample were female with median age of 15.2 (IQR 14.0-17.0) years. There was no difference in hospital length of stay between the pre- and postpathway groups. There was a statistically significant increase in the proportion of patients transferred to the psychiatry unit over the study period. Conclusion: Clinical pathway use to deliver standardized care to achieve medical stability for patients with anorexia nervosa did not shorten hospital length of stay. Multiple potentially confounding medical and psychosocial factors may have contributed to this lack of improvement.

Changes in Rates and Modality of Interpreter Use for Pediatric Emergency Department Patients in the COVID-19 Era.

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.