Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022.

OBJECTIVES: Boarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics. METHODS: We performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018-02/2020), early pandemic (II, 03/2020-06/2021), COVID-19 variants (III, 07/2021-06/2022), and non-COVID respiratory viruses (IV, 07/2022-12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions. RESULTS: Median PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report. CONCLUSIONS: Since July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.

Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline.

BACKGROUND: Left without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended. OBJECTIVE: We assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS. METHODS: We performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively. RESULTS: Mean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am. CONCLUSIONS: LWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.

Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents.

ABSTRACT: Hyperglycemic hyperosmolar syndrome (HHS) is an indolent process characterized by significantly increased levels of serum glucose, high osmolality, and electrolyte abnormalities. The incidence of HHS has steadily risen in the pediatric population over the past several years. Patients with HHS often present with profound dehydration, fatigue, and early mental status changes. Primary emergency management of HHS involves fluid replacement, hemodynamic support, correcting electrolyte derangements, and addressing complications and underlying illnesses. Insulin is not an initial therapy in HHS and should be considered only after the patient's fluids and electrolytes have been repleted. Unlike in diabetic ketoacidosis, HHS patients are not acidotic, although children may present with mixed HHS/diabetic ketoacidosis syndromes. Complications of HHS include thrombosis, rhabdomyolysis, and, rarely, malignant hyperthermia.

Pediatric-Specific Hazard Vulnerability Analysis: The Missing Component of Regional and Hospital-Based Preparedness.

Though children comprise a large percentage of the population and are uniquely vulnerable to disasters, pediatric considerations are often omitted from regional and hospital-based emergency preparedness. Children's absence is particularly notable in hazard vulnerability analyses (HVAs), a commonly used tool that allows emergency managers to identify a hazard's impact, probability of occurrence, and previous mitigation efforts. This paper introduces a new pediatric-specific HVA that provides emergency managers with a quantifiable means to determine how a hazard might affect children within a given region, taking into account existing preparedness most relevant to children's safety. Impact and preparedness categories within the pediatric-specific HVA incorporate age-based equipment and care needs, long-term developmental and mental health consequences, and the hospital and community functions most necessary for supporting children during disasters. The HVA allows emergency managers to create a more comprehensive assessment of their pediatric populations and preparatory requirements.

Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction.

OBJECTIVES: Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death. METHODS: We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID. RESULTS: Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3. CONCLUSIONS: Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.

Coaching the Fundamentals: Exploring the Applicability and Usefulness of a Novel Skills-Based Feedback Modality.

OBJECTIVE: Receiving and integrating feedback is a key to medical trainee development. To assist trainees seeking improvement through daily formative feedback and deliberate practice, the authors created a new skills-based framework called microskills, derived from the Accreditation Council for Graduate Medical Education (ACMGE) milestones and entrustable professional activities. The authors then explored pediatric resident perceptions around the applicability and usefulness of microskills. METHODS: The authors conducted 4 qualitative semistructured focus groups of 28 pediatric residents. Focus group prompts asked participants to reflect on microskills as a new feedback modality and microskills in relation to existing feedback and assessment approaches. Focus group transcripts were analyzed through inductive thematic analysis through an iterative process until theoretical saturation was reached. RESULTS: Participants felt microskills could facilitate skill-building and improvement, allow for consistent, targeted feedback, and establish a practice of coaching. Participants also perceived microskills' future success to be dependent on how the modality is adopted and utilized alongside existing assessment tools. CONCLUSIONS: Trainees found microskills to be a granular, context-based, coaching tool that could improve skill-building and the feedback process. Microskills' emphasis on feedback and their delineation of clinical skills that can be repeatedly practiced has the potential to provide a roadmap for trainee growth. Though microskills could fill a current need in the medical training landscape, they are not a substitute for existing assessment frameworks.

Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality.

The Accreditation Council for Graduate Medical Education milestones and entrustable professional activities (EPAs) are important assessment approaches but may lack specificity for learners seeking improvement through daily feedback. As in other professions, clinicians grow best when they engage in deliberate practice of well-defined skills in familiar contexts. This growth is augmented by specific, actionable coaching from supervisors. This article proposes a new feedback modality called microskills, which are derived from the psychology, negotiation, and business literature, and are unique in their ability to elicit targeted feedback for trainee development. These microskills are grounded in both clinical and situational contexts, thereby mirroring learners' cognitive schemas and allowing for more natural skill selection and adoption. When taken as a whole, microskills are granular actions that map to larger milestones, competencies, and EPAs. This article outlines the theoretical justification for this new skills-based feedback modality, the methodology behind the creation of clinical microskills, and provides a worked example of microskills for a pediatric resident on a hospital medicine rotation. Ultimately, microskills have the potential to complement milestones and EPAs and inform feedback that is specific, actionable, and relevant to medical learners.

Accelerated Idioventricular Rhythm: A Rare Case of Wide-Complex Dysrhythmia in a Teenager.

BACKGROUND: Accelerated idioventricular rhythm (AIVR) is an uncommon and typically benign dysrhythmia with similarities to more malignant forms of ventricular tachycardia (VT). It is often seen in adults after myocardial infarctions, although it also arises in the newborn period, as well as in children with and without congenital heart disease. CASE REPORT: We describe a presentation of AIVR in an otherwise healthy 13-year-old girl, discovered on arrival to the pediatric emergency department in the setting of post-tonsillectomy bleeding. The case reviews the diagnostic criteria of AIVR, associated symptoms, the pathophysiologic origin of AIVR, and potential treatment strategies. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given its morphologic similarities to life-threatening forms of VT, AIVR can be misdiagnosed in the emergency department or primary care settings. With an understanding of the dysrhythmia's unique features, emergency physicians can avoid unnecessary interventions and provide the correct diagnosis, workup, and management of AIVR for pediatric patients.