Impact of risk mapping as a strategy for monitoring and improving patient safety in paediatric emergency care.

OBJECTIVE: To design a risk map (RM) as a tool for identifying and managing risks in the paediatric emergency department and to assess the impact of the improvement actions developed based on the identified risks in terms of the level of risk to patient safety. METHODOLOGY: A multidisciplinary working group reviewed the entire care process by applying the Failure Mode and Effects Analysis (FMEA) tool. Project phases: (1) RM 2017 and planning of improvement actions; (2) Development and implementation of improvement actions; (3) RM 2019; (4) Analysis: evolution of the RM and impact of improvement actions. RESULTS: A total of 106 failure modes (FMs) were identified in the 2017 RM (54.7% high- or very high risk). We applied prioritization criteria to select the improvement actions to plan. Nineteen improvement actions were planned, with assigned responsible parties and deadlines, to address 46 priority FMs. One hundred percent were implemented. In the 2019 RM, we identified 110 FMs (48.2% high risk) and found an overall reduction of the risk level of 20%. Analysing the 46 priority FMs that had been addressed by the 19 planned improvement actions, we found that 60% had changed from high to medium risk level and that the risk level had decreased, both overall (-27.8%) and by process. CONCLUSION: The FMEA is a useful tool to identify risks, analyse the impact of improvement strategies and monitor the risk level of a complex clinical care department. The improvement actions developed succeeded in reducing the level of risk in the processes in our unit, improving patient safety.

Risk Factors of Serious Bacterial Infection in Previously Healthy Children Older Than 90 Days Old With Fever and Neutropenia.

BACKGROUND: The main objective was to determine the clinical or analytical factors that independently predict risk of serious bacterial infection (RSBI) in immunocompetent patients older than 90 days given a diagnosis of fever and for whom neutropenia was an incidental finding. The secondary objective was to describe the prevalence of serious bacterial infections (SBIs). METHODS: This is a 3-year-long, multicenter, prospective analytical and observational study carried out at 6 pediatric emergency departments. Data for epidemiological, clinical, and analytical variables were collected. RESULTS: One hundred forty patients with febrile neutropenia (60.7% mild, 39.3% moderate to severe) were recruited. Serious bacterial infection incidence was 15.0% (95% confidence interval [CI], 9-21): 1 Invasive Bacterial Infection (Staphylococcus epidermidis bacteremia), 10 urinary tract infections, 8 pneumonias, and 2 cellulitis. Median total neutrophil counts per microliter showed no statistically significant differences (P = 0.512; 1000 [750-1200] in SBI patients vs 1100 [800-1300] in non-SBI patients). Higher RSBI was observed in patients with neutrophils less than 20% relative to total leukocytes (SBI, 15, 26.3%) than in those with neutrophils of 20% or greater (SBI, 6, 7.2%) (odds ratio, 4.6; 95% CI, 1.7-12.7). In patients with greater than 5000 leukocytes/µL, a percentage of neutrophils less than 20% was related to a greater RSBI with a trend toward statistical significance (odds ratio, 6.1; 95% CI, 0.7-51.1; P = 0.066). The clinical variables did not show a significant association with RSBI. CONCLUSIONS: None of the clinical or analytical variables assessed were associated with the RSBI. However, according to a post hoc analysis, in patients with greater than 5000 leukocytes/µL, a neutrophil percentage less than 20% could be an independent risk factor for SBI. A thorough physical examination and basic diagnostic tests (urinalysis and chest x-ray) may help to establish a diagnosis of SBI in the vast majority of cases.

[Management and serious risk factors associated with unintentional injuries in paediatric emergencies in Spain]. / Manejo y factores de riesgo de gravedad asociados a lesiones no intencionadas en urgencias de pediatría en España.

INTRODUCTION: Thirty-eight million patients with injuries are treated in Emergency Departments every year, 90% of them being in the form of unintentional injuries (UIs). There are currently no global records of its management in Spain, or the risk factors that may be associated with them. The objective of this study is to describe the management of UIs in Spanish paediatric emergency departments, and to analyse factors related to the presence of serious injuries. MATERIAL AND METHODS: A sub-study of a prospective multicentre observational study conducted over 12months in 11hospitals of the Spanish Paediatric Emergency Research Group (RiSEUP-SPERG), including children from 0 to 16years of age consulting for UIs. Epidemiological data, circumstances of the injury, and data on emergency care and discharge destination were recorded on the 13th day of each month. RESULTS: A total of 10,175 episodes were recorded, of which 1,941 were UIs (19.1%), including 1,673, of which 257 (15.4%) were severe. The most frequent complementary test was simple radiography (60.0%), and the most frequent procedure was limb immobilisation (38.6%). A significant relationship was found between presenting with a severe UI and age >5 years (OR2.24; 95%CI: 1.61-3.16), history of fracture (OR2.05; 95%CI: 1.22-3.43), or sports activity as a mechanism of injury (OR1.76; 95%CI: 1.29-2.38), among others. CONCLUSION: In Spain, most UIs are not serious. X-rays and immobilisation of extremities are the most frequently performed tests and procedures. Severe UIs were associated with individual factors, such as age >5years or history of fracture, and with sports activity as a mechanism associated with severity. It is vital to implement measures to improve the prevention of these injuries and to support the training of caregivers through educational programmes.

[Emergency department consultations associated with unintentional injuries: A cases series]. / Consultas relacionadas con lesiones no intencionadas en urgencias en España: serie de casos.

OBJECTIVE: To analyse the clinical and epidemiological characteristics of children who are attended in Emergency Departments (EDs) for an unintentional injury in Spain. METHODS: Multicentre case series with prospective data collection conducted during 12 months in the ED of 11 hospitals belonging to the Spanish Paediatric Emergency Research Group. Data were collected between September 2014 and January 2015, continuing for one year in all paediatric EDs, and included children between 0 and 16 years old seen for an unintentional injury. RESULTS: A total of 10,175 episodes were recorded during the study, of which 1,941 were due to unintentional injuries (19.1%, 95% CI: 18.3%-19.8%), and 1,673 of these were included in the study. Falling, direct injuries, and injuries due to sports activities represented more than 80%, with significant variations in the injuries mechanism observed in different age groups. More than occurred at home or school. About 40% of the unintentional injuries were not witnessed by an adult. The most frequent diagnosis was limb trauma (63.0%), with a fracture being observed in 242 (14.4% of unintentional injuries). As regards fractures, 34 (2.0%) were admitted to hospital, with 21 (61.8%) for surgical reduction of the fracture. No deaths were recorded in the first 24h. CONCLUSIONS: Unintentional injuries constitute a very common reason for consultation in EDs in Spain. The circumstances surrounding the unintentional injuries should be considered, in order to develop preventive measures and to improve the training of people involved in the care of these children.

[Epidemiology and risk factors in injuries due to fall in infants under one year-old]. / Epidemiología y factores de riesgo de las lesiones por caídas en niños menores de un año.

OBJECTIVES: To describe the epidemiological characteristics of unintentional injuries due to falls in children under one year and to analyse the risk factors associated with severe injuries. PATIENTS AND METHODS: This multicentre, observational and cross-sectional study included all children less than one year treated for unintentional fall in the Emergency Departments of 8 Spanish Hospitals, belonging to the «Unintentional Paediatric Injury Workshop¼ of the Spanish Paediatric Emergency Society, between March 1st, 2014 and February 28th, 2015. RESULTS: Out of 289,887 emergency department cases, 1,022 were due to unintentional falls. The median age was 8 months and 52.5% were males. Fall injuries were more frequent among children aged 9-12 months (37.6%), and 83.5% occurred at home. The most common mechanism was fall from nursery equipment (69.4%), and 47.8% occurred from a height under 50cm. More than two-thirds (68%) of falls were witnessed, but in half of the cases (329) the caregiver was not in area. Serious injuries were seen in 12% of cases. In this study, a fall height greater than 50cm, falls in the street, from the arms of the carer, and from the stairs were identified as independent risk factors for worse outcomes. CONCLUSIONS: The most serious injuries occur in children <3 months and from a height of >50cm, though not related to unwitnessed falls. Because the most common serious injury mechanism is the fall from the arms of the carer, from stairs, and falls in the street, these facts should be highlighted in order to avoid morbidity.

[Falls in less than one year-old infants: Management in the emergency department]. / Caídas en menores de un año: ¿qué hacemos en urgencias?

OBJECTIVES: A study was performed in order to describe injuries associated with falls in children aged <1 year who attended the emergency department. The approaches used were examined, as well as the factors associated with the greater use of these approaches, and the management of the patient. PATIENTS AND METHODS: This was a multicentre, descriptive and analytical study that included all patients aged <1 year who had experienced a fall for which they attended the emergency departments of one of 8 Spanish Hospitals belonging to the "Unintentional Paediatric Injury Working Group" of the Spanish Paediatric Society. A record was made of the data regarding the visit, circumstances before arrival at the hospital, injuries observed, and the diagnostic and therapeutic approaches used. RESULTS: A total of 1022 patients had experienced falls, that is, 0.35% of the emergencies attended in the study hospitals (95% CI, 0,348-0,352). The most commonly affected part was the head (58%). Cranial radiography was ordered in 31.8% of cases, and was associated with the presence of bruising or signs of fracture on examination (P<.001), falls from heights >100cm (P<.001), and age <3 months (P=.004). Minor head injury was the most common finding (85.6%), followed by fractures, especially cranial fractures (7.1%), which were associated with bruising or signs of fracture on examination (P<.001), and age <3 months (P<.001). Six percent of the patients required admission to hospital. The risk factors for hospital admission in this group were falls from heights >50cm and age <3 months. CONCLUSIONS: Injuries after falls in infants aged <1 year are commonly due to head trauma and frequently require additional diagnostic tests.