A Community Emergency Department Rotation for Pediatric Emergency Medicine Fellows: Development and Evaluation.

OBJECTIVE: There have been increasing job opportunities for pediatric emergency medicine (PEM) specialists within community emergency departments (CEDs), where 90% of children receive emergency care. The majority of training for PEM fellows occurs in academic children's hospitals, which may expose fellows to different resources than CEDs. Our goals were to develop and to evaluate a CED rotation aimed at improving exposure to this care environment for PEM fellows. METHODS: Kern's 6 steps of curriculum development served as our framework to identify the problem, conduct a needs assessment, develop goals and objectives, formulate an educational strategy, and then plan the implementation and evaluation. Discussion and buy-in among trainees and hospital leadership took place during rotation development. Informal and web-based surveys of PEM fellows and CED attendings evaluated the rotation and assessed participants' reactions, changes in knowledge, and changes in behavior. RESULTS: The CED rotation was piloted at 1 PEM fellowship program over 2 years. Nine PEM fellows participated in the month-long rotation. The majority of participants reported that the rotation goals and objectives were met and that they acquired new skills and rated the CED rotation as good or excellent. Challenges to the CED rotation included lower patient acuity and distance to the CED. CONCLUSIONS: A new CED rotation was developed, piloted, and well received by participants. Given the potential differences in practice between tertiary care children's emergency departments and CEDs, as well as increasing job opportunities in CEDs, program directors should consider incorporating a CED rotation for their PEM fellows.

Baclofen Pumps: Uses and Complications.

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

Hospital readmissions: physician awareness and communication practices.

BACKGROUND: Patients requiring early hospital readmission may be readmitted to different physicians, potentially without the knowledge of the prior caregivers. This lost opportunity to share information about readmitted patients may be detrimental to quality of care and resident education. OBJECTIVE: To measure physician awareness of and communication about readmissions. DESIGN: Cross-sectional study. SETTING: Two academic medical centers. PARTICIPANTS: A total of 432 patients discharged from the general medicine services and readmitted within 14 days. MEASUREMENTS: We identified patients discharged from the general medicine services and readmitted within 14 days, excluding patients readmitted to the same physician(s) and planned readmissions. We surveyed discharging and readmitting physicians 48 h after the time of readmission. RESULTS: Discharging physician teams were aware of 48.5% (95% CI 41.5%-55.5%) of patient readmissions. Communication between teams occurred on 43.7% (95% CI 37.1%-50.3%). Higher medical complexity was associated with an increased likelihood of physician communication (adjusted OR 1.12, 95% CI 1.06-1.19). When communication occurred, readmitting physicians received information about the discharging team's overall assessment (61.9%, 95% CI 51.9%-71.9%), psychosocial issues (52.6%, 95% CI 42.4%-62.8%), pending tests (34.0%, 95% CI 24.2%-43.8%), and discharge medications (30.9%, 95% CI 21.5%-40.3%). When communication did not occur, most physicians (60.8%, 95% CI 56.7%-64.9%) responded it would have been desirable to communicate. CONCLUSIONS: Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.

Oral injuries in children less than 24 months of age in a pediatric emergency department.

BACKGROUND: Oral injuries in young children may indicate physical abuse. The prevalence of oral injuries in young children presenting to the emergency department is unknown. These data would assist providers in making decisions about the need for further abuse evaluation. OBJECTIVE: To determine the prevalence of oral injuries, associated chief complaints and characteristics, and frequency of abuse evaluations in children younger than 24 months presenting to a pediatric emergency department (PED). PARTICIPANTS AND SETTING: Twelve pediatric emergency medicine physicians consecutively enrolled children younger than 24 months in a tertiary care PED. METHODS: We performed a prospective observational study. Enrolled patients underwent a complete oral examination. Providers recorded patient demographics, type of chief complaint, oral injury details, developmental ability, and the presence of an abuse evaluation. RESULTS: Oral injuries occurred in 36/1303 (2.8%, 95% CI 1.9-3.8%) and were more common in patients with traumatic (26/200, 13%) versus medical chief complaints (10/1,103, 0.9%) (p < .001). Of patients with oral injuries (36), 78% were mobile and 72% had traumatic chief complaints. Nine (25%) children with oral injuries were evaluated for abuse. Oral injuries in children 0-11 months old were more likely to be evaluated for abuse than children 12-24 months old (70.0% vs. 7.7%, p < .001). CONCLUSIONS: The prevalence of oral injuries in children <24 months old presenting to a PED was low. Most occurred in mobile children and in children with traumatic chief complaints. Younger, non-mobile children with oral injuries had a higher likelihood of having an abuse evaluation.

A controlled trial of a rapid response system in an academic medical center.

A medical emergency team composed of house staff and existing float-pool nurses was successfully implemented on the general medical floor of an academic medical center without increasing personnel. The intervention had little noticeable impact, although the number of cardiac arrests and deaths were low both before and after the intervention.

Disaster medicine and public health preparedness of health professions students: a multidisciplinary assessment of knowledge, confidence, and attitudes.

OBJECTIVE: This study assessed disaster medicine knowledge and competence and perceived self-efficacy and motivation for disaster response among medical, nursing, and dental students. METHODS: Survey methodology was used to evaluate knowledge, comfort, perceived competency, and motivation. Also, a nonresponder survey was used to control for responder bias. RESULTS: A total of 136 responses were received across all 3 schools. A nonresponder survey showed no statistical differences with regard to age, gender, previous presence at a disaster, and previous emergency response training. In spite of good performance on many knowledge items, respondent confidence was low in knowledge and in comfort to perform in disaster situations. Knowledge was strong in areas of infection control, decontamination, and biological and chemical terrorism but weak in areas of general emergency management, role of government agencies, and radiologic events. Variations in knowledge among the different health professions were slight, but overall the students believed that they required additional education. Finally, students were motivated not only to acquire more knowledge but to respond to disaster situations. CONCLUSIONS: Health care students must be adequately educated to assume roles in disasters that are a required part of their professions. This education also is necessary for further disaster medicine education in either postgraduate or occupational education. As students' performance on knowledge items was better than their perceived knowledge, it appears that a majority of this education can be achieved with the use of existing curricula, with minor modification, and the addition of a few focused subjects, which may be delivered through novel educational approaches.

Medication errors in paediatric outpatients.

BACKGROUND: Medication errors are common in many settings and have important ramifications. Although there is growing research on rates and characteristics of medication errors in adult ambulatory settings, less is known about the paediatric ambulatory setting. OBJECTIVE: To assess medication error rates in paediatric patients in ambulatory settings. METHODS: The authors conducted a prospective cohort study of paediatric patients in six outpatient offices in Massachusetts. Data were collected using duplicate prescription review, two parental surveys and chart review. A research nurse classified all medication errors by stage and type of error. RESULTS: The authors identified 1205 medication errors with minimal potential for harm (rate: 68% of patients, 95% CI 64 to 72%; 53% of Rx, 95% CI 50 to 56%) and 464 potentially harmful medication errors (ie, near misses) (rate: 26% of patients, 95% CI 24 to 28%; 21% of Rx, 95% CI 19 to 22%). Overall, 94% of the medication errors with minimal potential for harm and 60% of the near misses occurred at the prescribing stage. The most common types of errors were inappropriate abbreviations followed by dosing errors. The most frequent cause of errors was illegibility. CONCLUSION: With paper prescribing, half the prescriptions had medication errors, and one in five had a potentially harmful error. These rates are very high. Interventions targeting the ordering and administration stages have the greatest potential benefit.

Single-parameter early warning criteria to predict life-threatening adverse events.

OBJECTIVES: Early warning criteria ("criteria"), used to activate rapid response system (RRS) teams, may improve patient outcomes by predicting life-threatening adverse events--urgent intensive care unit (ICU) transfers and cardiac arrests. METHODS: We conducted a case-control study on medicine patients in an academic medical center from May 2005 to June 2006. Controls were matched to RRS activation patients by admission date and unit. Rapid response system activation patients were then excluded from analysis. Chart reviews identified positive criteria on non-RRS patients. For controls, physiologic data were collected from admission until the day of matched RRS activations. Data were collected in patients with adverse events for the 8 hours preceding events. RESULTS: A total of 262 patients (2.8%) had 271 adverse events including 245 ICU transfers and 26 arrests. Positive criteria were found during 21.1% of control admissions (68/323). Positive criteria preceded 60.8% of the ICU transfers (158/260; 95% confidence interval, 54.8%-66.7%). However, 76.9% of patients with an arrest did not have previous positive criteria (20/26; 95% confidence interval, 60.7%-93.1%). Intensive care unit transfers with positive criteria were more likely to die than patients without criteria (35.4% versus 20.6%; odds ratio [OR], 2.1). Positive criteria most strongly associated with life-threatening adverse events were tachypnea (OR, 31.1) and 100% supplemental oxygen (OR, 13.7). CONCLUSIONS: The early warning conditions used to activate RRS teams were only fair predictors of acute deterioration, although early signs of respiratory failure during routine monitoring were strongly associated with future life-threatening adverse events. Improved respiratory monitoring may improve outcomes from RRS interventions.

Quantifying nursing workflow in medication administration.

New medication administration systems are showing promise in improving patient safety at the point of care, but adoption of these systems requires significant changes in nursing workflow. To prepare for these changes, the authors report on a time-motion study that measured the proportion of time that nurses spend on various patient care activities, focusing on medication administration-related activities. Implications of their findings are discussed.

Impact of barcode medication administration technology on how nurses spend their time on clinical care.

In a time-motion study conducted in a hospital that recently implemented barcode medication administration (BCMA) technology, we found that the BCMA system did not increase the amount of time nurses spend on medication administration activities, and did not compromise the amount of time nurses spent on direct care of patients. Our results should allay concerns regarding the impact of BCMA on nursing workflow.