Learning From a National Quality Improvement Collaborative for Brief Resolved Unexplained Events.

OBJECTIVE: In 2016, the American Academy of Pediatrics published the Brief Resolved Unexplained Event (BRUE) Clinical Practice Guideline (CPG). A multicenter quality improvement (QI) collaborative aimed to improve CPG adherence. METHODS: A QI collaborative of 15 hospitals aimed to improve testing adherence, the hospitalization of lower-risk infants, the correct use of diagnostic criteria, and risk classification. Interventions included CPG education, documentation practices, clinical pathways, and electronic medical record integration. By using medical record review, care of emergency department (ED) and inpatient patients meeting BRUE criteria was displayed via control or run charts for 3 time periods: pre-CPG publication (October 2015 to June 2016), post-CPG publication (July 2016 to September 2018), and collaborative (April 2019 to June 2020). Collaborative learning was used to identify and mitigate barriers to iterative improvement. RESULTS: A total of 1756 infants met BRUE criteria. After CPG publication, testing adherence improved from 56% to 64% and hospitalization decreased from 49% to 27% for lower-risk infants, but additional improvements were not demonstrated during the collaborative period. During the collaborative period, correct risk classification for hospitalized infants improved from 26% to 49% (ED) and 15% to 33% (inpatient) and the documentation of BRUE risk factors for hospitalized infants improved from 84% to 91% (ED). CONCLUSIONS: A national BRUE QI collaborative enhanced BRUE-related hospital outcomes and processes. Sites did not improve testing and hospitalization beyond the gains made after CPG publication, but they did shift the BRUE definition and risk classification. The incorporation of caregiver perspectives and the use of shared decision-making tools may further improve care.

Pediatric Oncologic Emergencies.

The overall prognosis for most pediatric cancers is good. Mortality for all childhood cancers combined is approximately half what it was in 1975, and the survival rates of many malignancies continue to improve. However, the incidence of childhood cancer is significant and the related emergencies that develop acutely carry significant morbidity and mortality. Emergency providers who can identify and manage oncologic emergencies can contribute significantly to an improved prognosis. Effective care of pediatric malignancies requires an age-appropriate approach to patients and compassionate understanding of family dynamics.

Pediatric Sepsis.

Pediatric sepsis is distinct from adult sepsis in its definitions, clinical presentations, and management. Recognition of pediatric sepsis is complicated by the various pediatric-specific comorbidities that contribute to its mortality and the age- and development-specific vital sign and clinical parameters that obscure its recognition. This article outlines the clinical presentation and management of sepsis in neonates, infants, and children, and highlights some key populations who require specialized care.

Trends in emergency department management of skin abscesses.

BACKGROUND: Abscess is a distinct skin and soft tissue infection (SSTI) requiring incision and drainage (I&D). Previous national surveys combined all SSTIs to estimate abscess and evaluate management. We hypothesized that antibiotic rates are declining in response to evidence that antibiotics are unnecessary for most SSTIs requiring I&D. METHODS: Emergency department (ED) patients included in the National Hospital Ambulatory Medical Care Survey from 2007-2010 with diagnosis codes for cutaneous abscess or SSTI were filtered using a procedure code for I&D available since 2007. The number of patients with SSTI, the percentage of patients receiving I&D, and the percentage of patients receiving antibiotics were determined. Antibiotics were characterized based on efficacy to methicillin-resistant Staphylococcus aureus (MRSA). RESULTS: ED visits for SSTI increased from 3.55 million (95% confidence interval [CI], 3.24 million-3.86 million) in 2007 to 4.21 million (95% CI, 3.89 million-4.55 million) in 2010. Incidences of I&D rose from 736,000 (95% CI, 602,000-869,000) to 1.48 million (95% CI, 1.30 million-1.65 million) and comprised 32.2% of SSTI visits over the 4 years. In 2007, 85.1% (95% CI, 82.6%-87.7%) of patients received antibiotics after I&D with no change over 4 years. In 2010, 15.5% (95% CI, 12.1%-18.7%) received ≥2 antibiotics. Commonly prescribed antibiotics were trimethoprim-sulfamethoxazole (mean, 50.4%) followed by cephalexin (mean, 17.2%) and clindamycin (mean, 16.3%). CONCLUSION: ED visits for SSTIs continue to rise. Despite mounting evidence, antibiotic use in SSTIs requiring I&D is high, and many patients receive multiple antibiotics, including drugs with no efficacy on MRSA.

Pediatric oncologic emergencies.

The overall prognosis for most pediatric cancers is good. Mortality for all childhood cancers combined is approximately half what it was in 1975, and the survival rates of many malignancies continue to improve. However, the incidence of childhood cancer is significant and the related emergencies that develop acutely carry significant morbidity and mortality. Emergency providers who can identify and manage oncologic emergencies can contribute significantly to an improved prognosis. Effective care of pediatric malignancies requires an age-appropriate approach to patients and compassionate understanding of family dynamics.

Effect of depression and psychosocial stressors on cessation self-efficacy in mothers who smoke.

Motherhood offers factors that may contribute to or confound attempts to quit smoking, including social cues around pregnancy, post partum depression, financial and other pressures of child rearing, being a role model and concern that secondhand smoke might affect their child's health. We sought to characterize a population of tobacco-using mothers in order to identify barriers to quitting that both mirror the general population and are unique to motherhood. A cross-sectional survey collected information in two urban emergency departments from women who smoked and were mothers of small children. The survey asked about tobacco use, including levels of addiction, attempts to quit, readiness and self efficacy for quitting, and other psychosocial risks. We hypothesized that mothers reporting psychosocial stressors and depression would be less motivated to quit and less likely to have attempted quitting. One hundred ninety-two smoking mothers enrolled, representing 433 children exposed to secondhand smoke. Nicotine addiction was moderate. Women reporting at least one form of stress (relationship, financial, work, emotional, family-related) had similar levels of addiction (Fagerstrom score 2.8 vs. 2.9, p = 0.63) and motivation to quit (Ladder of Contemplation 6.4 vs. 6.1, p = 0.26), but reported feeling less confident in their ability to quit than non-stressed counterparts (6.6 vs. 7.6, p = 0.04). Over half (51.3%) of smoking mothers reported symptoms of depression for more than 2 weeks in a row in the last year. Depressed mothers had similar levels of addiction (Fagerstrom score 2.9 vs. 2.8, p = 0.63), and readiness to quit (6.6 vs. 6.5, p = 0.89), and had attempted to quit at similar rates (78% vs. 82%, p = 0.58). However, depressed mothers were less confident in their ability to quit (6.4 vs. 7.4, p = 0.02) and were more than twice as likely to report they are "not at all confident" (22% vs. 9%, p = 0.03). Providers who encourage mothers to quit smoking must identify and be prepared to address psychosocial stressors and co-morbid depression.