Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value.

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department?

OBJECTIVES: Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA. METHODS: This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis. RESULTS: There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods. CONCLUSIONS: Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.

Successful emergency department interventions that reduce time to antibiotics in febrile pediatric cancer patients.

Children with cancer and fever are at high risk for sepsis related death. Rapid antibiotic delivery (< 60 minutes) has been shown to reduce mortality. We compared patient outcomes and describe interventions from three separate quality improvement (QI) projects conducted in three United States (US) tertiary care pediatric emergency departments (EDs) with the shared aim to reduce time to antibiotic (TTA) to < 60 minutes in febrile pediatric oncology patients (Temperature > 38.0 C). A secondary objective was to identify interventions amenable to translation to other centers. We conducted a post project analysis of prospectively collected observational data from children < 18 years visiting these EDs during independently conducted QI projects. Comparisons were made pre to post intervention periods within each institution. All interventions were derived independently using QI methods by each institution. Successful as well as unsuccessful interventions were described and common interventions adopted by all sites identified. A total of 1032 ED patient visits were identified from the three projects. Improvement in median TTA delivery (min) pre to post intervention(s) was 118.5-57.0 at site 1, 163.0-97.5 at site 2, and 188.0-111.5 at site 3 (p<.001 all sites). The eight common interventions were 1) Triage application of topical anesthetic 2) Rapid room placement & triage 3) Resuscitation room placement of ill appearing children 4) Close proximity to central line equipment 5) Antibiotic administration before laboratory analyses 6) Consensus clinical practice guideline establishment 7) Family pre-ED education for fever and 8) Staff project updates. This core set of eight low cost, high yield QI interventions were developed independently by the three ED's which led to substantial reduction in time to antibiotic delivery in children with cancer presenting with fever. These interventions may inform future QI initiatives in other settings caring for febrile pediatric oncology patients.