Discriminating Multisystem Inflammatory Syndrome in Children Requiring Treatment from Common Febrile Conditions in Outpatient Settings.

OBJECTIVES: To examine whether patients with multisystem inflammatory syndrome in children (MIS-C) demonstrated well-defined clinical features distinct from other febrile outpatients, given the difficulties of seeing acute care visits during the severe acute respiratory syndrome coronavirus 2 pandemic and the risks associated with both over- and underdiagnosis of MIS-C. STUDY DESIGN: This case-controlled study compared patients diagnosed with and treated for MIS-C at a large urban children's hospital with patients evaluated for fever at outpatient acute care visits during the peak period of MIS-C. Symptomatology and available objective data were extracted. Comparisons were performed using t tests with corrections for multiple comparisons, and multivariable logistic regression to obtain ORs. RESULTS: We identified 44 patients with MIS-C between April 16 and June 10, 2020. During the same period, 181 pediatric patients were evaluated for febrile illnesses in participating outpatient clinics. Patients with MIS-C reported greater median maximum reported temperature height (40°C vs 38.9, P < .0001), and increased frequency of abdominal pain (OR 12.5, 95% CI [1.65-33.24]), neck pain (536.5, [2.23-129,029]), conjunctivitis (31.3, [4.6-212.8]), oral mucosal irritation (11.8, [1.4-99.4]), extremity swelling or rash (99.9, [5-1960]), and generalized rash (7.42, [1.6-33.2]). Patients with MIS-C demonstrated lower absolute lymphocyte (P < .0001) and platelet counts (P < .05) and greater C-reactive protein concentrations (P < .001). CONCLUSIONS: Patients treated for MIS-C due to concern for potential cardiac injury show combinations of features distinct from other febrile patients seen in outpatient clinics during the same period.

Improving Utilization of an After-Hours Phone Triage Service: A Resident Quality Improvement Initiative.

BACKGROUND/OBJECTIVE: Phone triage systems are increasingly used by primary care clinics to improve patient satisfaction and direct low-acuity patients to appropriate care settings. Despite the prevalence of telephone triage, the majority of pediatric training programs do not include this practice in their curricula. Our aim was to increase the volume of after-hours patient phone calls per week by 25% and to secondarily reduce "treat and release" emergency department (ED) visits by 5% over the course of a 9-month quality improvement (QI) study. METHODS: A resident-led QI project was conducted from 2017 to 2019 at a mixed faculty-resident pediatric primary care practice providing care for an urban, primarily immigrant, underserved population. Eight Plan-Do-Study-Act cycles were developed on the basis of identified key drivers and included efforts to increase the visibility of the call service to patient families. After-hours calls were tracked and compared with similar practices, and ED visits for the first week of each month were reviewed using the electronic medical record system. RESULTS: After promoting the service via various modalities, the number of after-hours calls increased by 30%, from an average of 6.5 calls per week to 8.5. Treat and release ED visits decreased by 6%, from a baseline of 64.3 to 60.3 visits per week. CONCLUSIONS: The increased patient awareness of and availability of a reliable after-hours call service in pediatric practices are promising tools for reducing unnecessary ED visits, leveraging resident direction and implementation to promote the service through varying modalities.

Mental Health in the Medical Home: A Longitudinal Curriculum for Pediatric Residents on Behavioral and Mental Health Care.

Introduction: Currently, a pediatric mental and behavioral health crisis exists, driven by increasing stressors among children coupled with a paucity of psychiatric providers who treat children. Pediatric primary care providers can play a critical role in filling this gap, yet trainees feel uncomfortable screening for, identifying, and managing mental and behavioral health conditions among their patients. Thus, expanding training for pediatricians in this domain is critical. Methods: We created a longitudinal integrated mental and behavioral health curriculum for pediatric residents at NewYork-Presbyterian/Columbia University Irving Medical Center with a logic model contextualizing outpatient pediatric care as a framework for the development and planned evaluation. We devised a comprehensive set of materials, with presentations on topics including attention deficit hyperactivity disorder and anxiety disorders. Workflows and escalation pathways promoting collaboration among interdisciplinary providers were implemented. We evaluated residents' and faculty members' participation in the curriculum and their perception of curricular gaps. Results: Approximately 155 pediatric residents participated in the curriculum from 2017 to 2021, reflecting robust curricular exposure. Few residents and no preceptors perceived mental and behavioral health as a curricular gap. Discussion: Our curriculum is feasible and can be adapted to a variety of educational settings. Its use of a logic model for development, implementation, and ongoing evaluation grounds the curriculum in educational theory and can address curricular gaps. The framework can be adapted to suit the needs of other institutions' educational and practice settings and equip pediatric trainees with the skills to promote patient mental health and well-being.

Improving Screening for Social Determinants of Health in a Pediatric Resident Clinic: A Quality Improvement Initiative.

INTRODUCTION: Social determinants of health (SDOH) account for 80% of modifiable factors in a population's health. Addressing SDOH in a healthcare setting can improve care, patient experience, health outcomes, and decrease cost. Therefore, screening for SODH in the pediatric setting has become an essential and evidence-based component of pediatric preventative care. Multiple barriers exist for its implementation, particularly for trainees. METHODS: Using resident-driven quality improvement (QI) methodology, we aimed to increase SDOH screening to >90% for 9 individual questions at newborn and 1-year well visits and completely screen for all 9 questions at more than 40% of visits. Parents were provided with a paper screening form upon arrival to be completed before visits. We performed tests of change to improve distribution, documentation, and quality of interventions. RESULTS: The primary outcome of complete screening for all 9 questions increased from 24% to 43% at newborn visits and 28% to 83% at 1-year visits. Screenings that identified at least 1 need increased from 8% to 19%, with provider response to an identified need increasing from 20% to 40%. These metrics were the secondary outcome measures. CONCLUSIONS: The use of parent completed paper screening forms improved SDOH screening, documentation, and interventions by residents and faculty.

Managing the COVID-19 Pandemic Using Quality Improvement Principles: A New York City Pediatric Primary Care Experience.

In the setting of COVID-19, pediatric primary care in New York City faced multiple challenges, requiring large-scale practice reorganization. We used quality improvement principles to implement changes to care delivery rapidly. METHODS: Plan-do-study-act cycles were used, based on primary drivers of consolidation, reorganization of in-person and urgent care, telehealth expansion, patient outreach, mental health linkages, team communication, and safety. RESULTS: The average visit volume in pediatrics decreased from 662 per week to 370. Telehealth visits increased from 2 to 140 per week, whereas urgent in-person visits decreased from 350 to 8 per week. Adolescent visits decreased from 57 to 46 per week. Newborn Clinic visits increased from 37 per week to 54. Show rates increased significantly for pediatrics and adolescent (P = 0.003 and P = 0.038, respectively). CONCLUSIONS: Quality improvement methodology allowed for the consolidation of pediatric primary care practices during the first wave of the COVID-19 pandemic, ensuring care for patients while prioritizing safety, evidence-based practices, and available resources.