Using Dry-Erase Boards to Share Information in a Pediatric Emergency Department to Improve Family Experience of Care.

OBJECTIVES: To determine whether the use of dry-erase boards for communicating the plan of care of children evaluated in the pediatric emergency department (PED) improves the family experience of care. METHODS: Dry-erase boards were mounted at eye level in patient examination rooms. The study was conducted during a 4-week period during which physicians were instructed to use the boards on alternating weeks. During the 2 intervention weeks, they were instructed to write their name and plan of care in addition to their standard verbal communication. A questionnaire was administered to a convenience sample of caregivers that measured their perceptions of physician listening skills, time spent with the physician, their understanding of the care plan, their willingness to ask questions, likelihood to recommend the PED, and overall physician care. Differences between intervention and nonintervention weeks were analyzed using adjusted multivariable modeling taking into account clustered observations within physician. RESULTS: Surveys were completed by 672 caregivers. There were no significant differences in reported experience of care between the intervention and nonintervention weeks. During the intervention weeks, 59% of caregivers recalled use of the dry-erase boards, whereas 10% of caregivers recalled use during nonintervention weeks. Caregivers who recalled the use of dry-erase boards were more likely to report better physician listening skills, better understanding of the plan of care, and higher overall physician ratings. CONCLUSIONS: Recommending use of dry-erase boards in pediatric emergency department rooms did not increase overall measures of experience of care, although patients who recalled dry-erase board use did report higher performance. Further study could explore how to effectively and efficiently use these boards.

Investigating the Feasibility and Utility of Bedside Balance Technology Acutely After Pediatric Concussion: A Pilot Study.

OBJECTIVE: To examine postural instability in children acutely after concussion, using the Wii Balance Board (WBB). We hypothesized that children with traumatic brain injury would have significantly worse balance relative to children without brain injury. DESIGN: Prospective case-control pilot study. SETTING: Emergency department of a tertiary urban pediatric hospital. PARTICIPANTS: Cases were a convenience sample 11-16 years old who presented within 6 hours of sustaining concussion. Two controls, matched on gender, height, and age, were enrolled for each case that completed study procedures. Controls were children who presented for a minor complaint that was unlikely to affect balance. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The participant's postural sway expressed as the displacement in centimeters of the center of pressure during a timed balance task. Balance testing was performed using 4 stances (single or double limb, eyes open or closed). RESULTS: Three of the 17 (17.6%) cases were too dizzy to complete testing. One stance, double limbs eyes open, was significantly higher in cases versus controls (85.6 vs 64.3 cm, P = 0.04). CONCLUSIONS: A simple test on the WBB consisting of a 2-legged standing balance task with eyes open discriminated children with concussion from non-head-injured controls. The low cost and feasibility of this device make it a potentially viable tool for assessing postural stability in children with concussion for both longitudinal research studies and clinical care. CLINICAL RELEVANCE: These pilot data suggest that the WBB is an inexpensive tool that can be used on the sideline or in the outpatient setting to objectively identify and quantify postural instability.

A comprehensive view of parental satisfaction with pediatric emergency department visits.

STUDY OBJECTIVE: We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data. METHODS: This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview-style question. RESULTS: Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview-style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their child's diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care. CONCLUSION: Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.

Development of a motivation-based tool to facilitate individualized self-management interventions for adolescents with asthma.

OBJECTIVE: To develop a questionnaire for segmenting adolescents with asthma into archetypes based on their motivations for individualized self-management interventions. METHODS: A prospective observational study using segmentation methodology. First, adolescents created photo diaries followed by in-person semi-structured interviews to develop a pool of candidate items for identifying and describing archetypes. Second, quantitative methods were used to test the pool of items to determine which ones best identified each archetype. RESULTS: Six archetypes based on motivations were identified and described: goal oriented visionaries; mentors and helpers; influencers; discouraged adolescents; dependent adolescents; and shame avoiders. A questionnaire with 63 candidate items was administered to 201 adolescents. Confirmatory factor analysis resulted in a 17-item questionnaire that identified the archetypes. CONCLUSION: This study is the first step towards applying a segmentation methodology to facilitate the application of interventions during a clinic visit to increase adherence. It has shown that a relatively short questionnaire can be used to identify archetypes based on motivations. PRACTICE IMPLICATIONS: The 17-item questionnaire could provide a framework and direction for healthcare professionals to customize existing adherence interventions, such as motivational interviewing, to different segments of adolescents. It would be especially helpful in primary care settings where time is limited.

Overestimation of impairment-related asthma control by adolescents.

We investigated the concordance between adolescents' perceived and impairment-related asthma control. Based on self-reported medication use, symptoms, and activity limitations, most overestimated their impairment-related control (73.8%). Providers should ask detailed, structured questions to get the most comprehensive picture of a patient's impairment-related control so they can ultimately improve disease outcomes.

End-of-life care for the dying child: what matters most to parents.

OBJECTIVE: To identify and define the dimensions of pediatric end-of-life (EOL) care that are important to parents. POPULATION: Parents of children who died as a result of an illness, chronic condition, or birth defect while receiving EOL care in hospital or at home in 2004 and 2005. DESIGN: Qualitative data derived from semi-structured and focus group interviews were analyzed using content analysis. SETTING: A large pediatric hospital located in the Midwestern United States. RESULTS: Seven dimensions of pediatric EOL care were identified--respect for the family's role, comfort, spiritual care, access to care and resources, communication, support for parental decision making, and caring/ humanism. CONCLUSION: There are clear dimensions of pediatric EOL care that are important to parents; these can be defined in terms of health care provider behaviours, some of which require balancing seemingly conflicting objectives. Developing a measurement tool based on these dimensions would help to improve the quality of pediatric EOL care.

A Pilot Study of a Measure of Parental Trust in Pediatric Emergency Department Care Teams.

OBJECTIVE: To modify and test an existing measure of trust validated in a primary care setting for use in a pediatric emergency department (PED). METHODS: The study population was parents/guardians who brought their child to an urban PED with a chief complaint of abdominal pain or head injury. We used a 2-phase design with modifications resulting from cognitive interviews with 15 participants followed by a field test with 150 participants. We measured usefulness by percent missing responses and ceiling effects. Cronbach's alpha and greatest lower bound measured reliability. As evidence of validity, we calculated a total trust score by summing the item scale values and correlating the score with measures of constructs shown to be positively associated with trust in other settings. We conducted a similar analysis to test a published shortened version of the same scale. RESULTS: Four items were modified prior to field testing. Ceiling effects for each item ranged from 53% to 67%. Missing data were minimal affecting only 2 items. The modified measure exhibited high reliability (Cronbach's alpha = .88, greatest lower bound = 0.93). Total trust scores ranged from 27 to 50 with mean (standard deviation) = 45.1 (4.9). The trust score exhibited a high positive correlation with communication and overall satisfaction, and moderate correlation with intent to adhere to physician recommendations. The short version of the scale performed similarly. CONCLUSIONS: This study provides evidence that the modified Wake Forest measure of trust is applicable and useful in the PED setting for this patient population.

Resident-Sensitive Quality Measures in the Pediatric Emergency Department: Exploring Relationships With Supervisor Entrustment and Patient Acuity and Complexity.

PURPOSE: This study explores the associations between resident-sensitive quality measures (RSQMs) and supervisor entrustment as well as between RSQMs and patient acuity and complexity for encounters in the pediatric emergency department (PED) in which residents are caring for patients. METHOD: Pediatric residents rotating through Cincinnati Children's Hospital Medical Center PED as well as supervising pediatric emergency medicine faculty and fellows were recruited during the 2017-2018 academic year for the purpose of collecting the following data from the residents' patient encounters for 3 illnesses (acute asthma exacerbation, bronchiolitis, and closed head injury [CHI]): supervisor entrustment decision rating, RSQMs relevant to the care provided, and supervisor patient acuity and complexity ratings. To measure the association of RSQM composite scores with the other variables of interest, mixed models were used. RESULTS: A total of 83 residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with CHI. Entrustment decision ratings were positively associated with asthma RSQM composite scores (beta coefficient = 0.03; P < .001). There was no significant association between RSQM composite scores and entrustment decision ratings for bronchiolitis or CHI. RSQM composite scores were significantly higher when acuity was also higher and significantly lower when acuity was also lower for both asthma (P < .001) and bronchiolitis (P = .01). However, RSQM composite scores were almost identical between levels of acuity for CHI (P = .94). There were no significant differences in RSQM composite scores when complexity varied. CONCLUSION: This study found limited associations between RSQM composite scores and entrustment decision ratings but offers insight into how RSQMs could be used for the purposes of resident assessment and feedback.

Initial Implementation of Resident-Sensitive Quality Measures in the Pediatric Emergency Department: A Wide Range of Performance.

PURPOSE: A lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment. METHOD: During academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed. RESULTS: Eighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89. CONCLUSIONS: Individually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.

Improving access to pediatric subspecialty care: initial failures and lessons learned.

OBJECTIVES: We originally examined the effectiveness of strategies, proven successful in improving appointment availability in primary care, at a large tertiary-care academic medical center. We then sought to describe the reasons for the initial failure of these strategies. METHODS: Clinics participating in an access improvement initiative were matched to control clinics. Intervention clinics used a variety of techniques to improve access. Run charts were used to determine the impact of the interventions on appointment availability. Linear models, control charts, and other graphic displays were used to understand the relationship among supply, demand, and appointment availability. RESULTS: Access did not improve in intervention clinics. Neither a linear models approach nor the use of control charts resulted in a simple tool to help clinics better understand the relationship among supply, demand, and days to third next available appointment. However, the development of a single clinic chart that incorporated supply and demand, plus estimates of future supply and demand, made it clear that current supply would not be able to meet demand. This helped teams focus their efforts on improving supply. CONCLUSIONS: Use of detailed data-based tools to guide choices of interventions, coupled with new and explicit institutional expectations for physician attendance at clinics, appears to be a promising strategy for enhancing access.

A Validation Argument for a Simulation-Based Training Course Centered on Assessment, Recognition, and Early Management of Pediatric Sepsis.

INTRODUCTION: Early recognition of sepsis remains one of the greatest challenges in medicine. Novice clinicians are often responsible for the recognition of sepsis and the initiation of urgent management. The aim of this study was to create a validity argument for the use of a simulation-based training course centered on assessment, recognition, and early management of sepsis in a laboratory-based setting. METHODS: Five unique simulation scenarios were developed integrating critical sepsis cues identified through qualitative interviewing. Scenarios were piloted with groups of novice, intermediate, and expert pediatric physicians. The primary outcome was physician recognition of sepsis, measured with an adapted situation awareness global assessment tool. Secondary outcomes were physician compliance with pediatric advanced life support (PALS) guidelines and early sepsis management (ESM) recommendations, measured by two internally derived tools. Analysis compared recognition of sepsis by levels of expertise and measured association of sepsis recognition with the secondary outcomes. RESULTS: Eighteen physicians were recruited, six per study group. Each physician completed three sepsis simulations. Sepsis was recognized in 19 (35%) of 54 simulations. The odds that experts recognized sepsis was 2.6 [95% confidence interval (CI) = 0.5-13.8] times greater than novices. Adjusted for severity, for every point increase in the PALS global performance score, the odds that sepsis was recognized increased by 11.3 (95% CI = 3.1-41.4). Similarly, the odds ratio for the PALS checklist score was 1.5 (95% CI = 0.8-2.6). Adjusted for severity and level of expertise, the odds of recognizing sepsis was associated with an increase in the ESM checklist score of 1.8 (95% CI = 0.9-3.6) and an increase in ESM global performance score of 4.1 (95% CI = 1.7-10.0). CONCLUSIONS: Although incomplete, evidence from initial testing suggests that the simulations of pediatric sepsis were sufficiently valid to justify their use in training novice pediatric physicians in the assessment, recognition, and management of pediatric sepsis.

Financial impact of failing to prevent surgical site infections.

BACKGROUND: Despite advances in infection-control practices, surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, and increased costs among hospitalized patients. METHODS: We used a matched cohort design to compare costs and length of stay for 16 pediatric patients with an SSI with those of 16 matched control patients who had a similar operative procedure during the same time period but in whom an SSI did not develop. RESULTS: On average, length of stay was increased by 10.6 days (P = .02) and costs were increased by $27,288 (P = .01) for each patient with a potentially preventable SSI. On the day of the surgical procedure, costs between study patients and matched controls differed by only 1.4%. By day 3, however, costs were 36% higher for patients with an SSI. CONCLUSIONS: While matching study patients and control patients requires significant time from financial and clinical staff, this approach and the resulting data analysis strengthened and focused our efforts to prevent future SSIs and aligned initiatives to reduce SSIs with the business case for quality.

Long-Term Sustainability of Timely Emergency Department Analgesia for Fractures: A Time Series Study.

OBJECTIVES: To determine the long-term sustainability and unintended consequences of a quality improvement project to improve the timeliness of intravenous (IV) opioid administration to patients with long-bone extremity fractures within a dynamic pediatric emergency department. METHODS: A retrospective study of patients with long-bone extremity fractures was conducted using electronic medical record data from 2007 to 2014. The primary outcome was the percentage of patients receiving timely IV opioids. Control charts and time series models were used to determine if changes in the clinical microenvironment were associated with shifts in the outcome measure. Unintended consequences included patients receiving potentially avoidable IVs and use of the quality improvement process for patients without long-bone extremity fractures. RESULTS: Improved timeliness of IV opioids was sustained. The type of physician who staffed the process and optimization of faculty staffing hours were associated with a 9.6% decrease and 11.8% increase in timely IV opioids, respectively. Implementation of the IV opioid process was not associated with increased placement of potentially avoidable IVs. Of patients receiving the IV opioid process, 22% did not have a long-bone extremity fracture, of whom 91% were diagnosed with a different painful injury. CONCLUSION: Sustainability of IV opioid timeliness was robust, despite changes in the clinical microenvironment. Changes in physician staffing and responsibilities in a pediatric emergency department may be especially important to consider when planning future improvement initiatives. Our findings support the importance of higher reliability interventions, such as identification and utilization of existing patterns of behavior, as high yield for sustaining outcomes.

A Randomized Trial of User-Controlled Text Messaging to Improve Asthma Outcomes: A Pilot Study.

We enrolled 64 patients age 12 to 22 years with a diagnosis of poorly controlled persistent asthma in a 6-month longitudinal crossover study. During the 3 intervention months, participants created personalized text messages to be sent to their phones. Adherence was objectively monitored in 22 of the participants. The adolescent participants gave high ratings on the acceptability of the text messaging system. Asthma control improved from baseline to month 1 regardless of whether teens were in the texting or control group. While participants were in the texting group, their quality of life improved and worry about their asthma decreased. Receiving the text intervention resulted in an increase in adherence of 2.75% each month relative to no intervention, but the improvements were not sustained. There was modest improvement in asthma control and quality of life outcomes, as well as improved adherence during the texting intervention.

Worker, workplace, and community/environmental risk factors for workplace violence in emergency departments.

Workplace violence committed by patients and visitors has high propensity to occur against emergency department employees. This article reports the association of worker, workplace, and community/environmental factors with violence risks. A cross-sectional research design was used with 280 employees from six emergency departments in the Midwest United States. Respondents completed the Survey of Violence Experienced by Staff and a 10-item demographic questionnaire. Data were analyzed using frequencies, percentages, Chi-square tests, and adjusted relative risks with 95% confidence intervals. Over 80% of respondents experienced at least one type of workplace violence with their current employer and approximately 40% experienced all three types. Risks for workplace violence were significantly higher for registered nurses and hospital-based emergency departments. Workplace violence can impact all employees in the emergency department regardless of worker, workplace, and community/environmental factors.

Family-Centered Pediatric Emergency Care: A Framework for Measuring What Parents Want and Value.

OBJECTIVE: To identify and describe dimensions of family-centered care important to parents in pediatric emergency care and compare them to those currently defined in the literature. METHODS: A qualitative study was conducted involving 8 focus groups with parents who accompanied their child to an emergency department visit at a large tertiary-care pediatric health system. Participants were identified using purposive sampling to achieve representation across demographic characteristics including child's race, insurance status, severity, and participant's relationship to child. Focus groups were segmented by patient age and presence of a chronic condition. They were moderated by a facilitator experienced in health-related topics. A 6-member multidisciplinary team completed a content analysis. RESULTS: Sixty-eight parents participated. They were female (77%); aged 20 to 29 years (19%), 30 to 39 years (47%), more than 40 years (31%); black (44%), white (52%); and married (50%). Their child's characteristics were: public insurance (52%); black (46%), white (46%); and admitted as an inpatient (46%). The analysis resulted in 8 dimensions: 1) emotional support; 2) coordination; 3) elicit and respect preferences, and involve the patient and family in care decisions; 4) timely and attentive care; 5) information, communication, and education; 6) pain management; 7) safe and child-focused environment; and 8) continuity and transition. Compared to those published in the literature, the most notable differences were combining involving family and respect for preferences into a single dimension, and separating physical comfort into 2 dimensions: pain management and safe/child-focused environment. CONCLUSIONS: The resulting dimensions provide a framework for measuring and improving the delivery of family-centered pediatric emergency care.

Perceptions of value of routine care among patients with cystic fibrosis and their families.

Routine quarterly visits are an integral part of effective disease management for patients with cystic fibrosis (CF), regardless of the patient's age. The objective of this study was to explore the relationship between perceptions of the value of routine visits and perceived overall quality of care. The population in this study consisted of 194 patients at a single CF center. Telephone interviews were completed with 162 parents of children or adult patients (response rate, 84%) in May-June 2000. Among other satisfaction-related questions, respondents were asked to rate: 1) overall quality of care, 2) importance of routine clinic visits in providing good preventative care, and 3) helpfulness of routine clinic visits in providing knowledge for CF care. They were also asked open-ended questions concerning the reasons for their ratings. Perceived helpfulness and importance of routine visits were negatively associated with patient age and positively associated with perceived overall quality of care, especially for parents of teenage patients. The most common reason for low importance ratings was that the patient's health is perceived to be good, making routine clinic visits unnecessary. The most common reasons for low helpfulness ratings were that the visits are too repetitive or routine, and the family learns nothing new from them. In conclusion, tailoring routine visits to respond to different age-based needs and making routine visits less repetitive may add value to routine visits, which could result in increased perceived overall quality of care, especially for parents of teenage patients.

Family perceptions of the usability and value of chronic disease web-based patient portals.

The objective of this study was to understand perceptions of the usability and value of web-based patient portals among parents of children with a chronic condition (diabetes, juvenile idiopathic arthritis, and cystic fibrosis). The design was a cross-sectional telephone survey with semistructured interviews and was conducted at a tertiary children's hospital. Parent ratings of their experiences with and the value of a web-based portal and reasons for not using the portal were ascertained. Most parents agreed that the portal information was accurate, timely, and useful. Confidentiality and seeing worrisome health-related information about their child was not a major concern, and parents felt that the portal helped to improve their understanding of and ability to manage their child's condition. In conclusion, the results of this study support the notion that web-based patient portals have the potential to be a useful tool for parents of children with a chronic disease.

The effect of emergency department crowding on reassessment of children with critically abnormal vital signs.

OBJECTIVES: The objective was to determine whether several measures of emergency department (ED) crowding are associated with an important indicator of quality and safety: time to reevaluation of children with documented critically abnormal triage vital signs. METHODS: This was a retrospective cross-sectional study of all patients with critically abnormal vital signs measured in triage over a 2.5-year period (September 1, 2006, to May 1, 2009). Cox proportional hazard analysis was used to determine rate ratios for time to critically abnormal vital sign reassessment, when controlled for potential confounders. RESULTS: In this 2.5-year sample, 9,976 patients with critically abnormal vital signs in triage (representing 3.9% of 253,408 visits) were placed in regular ED rooms with electronic alerts prompting vital sign reassessment after 1 hour. Overall, the mean time to reassessment was 84 minutes. The rate of vital sign reassessment was reduced by 31% for each additional 10 patients waiting for admission (adjusted odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.98 to 0.99), by 10% for every 10 patients in the lobby (adjusted OR = 0.94; 95% CI = 0.93 to 0.96), and by 6% for every additional 10 patients in the overall ED census (adjusted OR = 0.97; 95% CI = 0.97 to 0.98). CONCLUSIONS: Emergency department crowding was associated with delay in the reassessment of critically abnormal vital signs in children; further work is needed to develop systems to mitigate these delays.

Improving sexually transmitted infection results notification via mobile phone technology.

PURPOSE: To improve adolescent notification of positive sexually transmitted infection (STI) tests using mobile phone technology and STI information cards. METHODS: A randomized intervention among 14- to 21-year olds in a pediatric emergency department (PED). A 2 × 3 factorial design with replication was used to evaluate the effectiveness of six combinations of two factors on the proportion of STI-positive adolescents notified within 7 days of testing. Independent factors included method of notification (call, text message, or call + text message) and provision of an STI information card with or without a phone number to obtain results. Covariates for logistic regression included age, empiric STI treatment, days until first attempted notification, and documentation of confidential phone number. RESULTS: Approximately half of the 383 females and 201 males enrolled were ≥18 years of age. Texting only or type of card was not significantly associated with patient notification rates, and there was no significant interaction between card and notification method. For females, successful notification was significantly greater for call + text message (odds ratio, 3.2; 95% confidence interval, 1.4-6.9), and documenting a confidential phone number was independently associated with successful notification (odds ratio, 3.6; 95% confidence interval, 1.7-7.5). We found no significant predictors of successful notification for males. Of patients with a documented confidential phone number who received a call + text message, 94% of females and 83% of males were successfully notified. CONCLUSIONS: Obtaining a confidential phone number and using call + text message improved STI notification rates among female but not male adolescents in a pediatric emergency department.