Implementing a Standardized Constipation-Management Pathway to Reduce Resource Utilization.

OBJECTIVE: Constipation is commonly diagnosed in our pediatric emergency department (ED). Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for the diagnosis of and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical examination, less reliance on AR, and standardized home management. METHODS: Using quality improvement (QI) methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management "gift basket" containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and length of stay, and ED admission rate for constipation. RESULTS: Within 3 months, >90% of patients discharged home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and gift basket changes, and a higher threshold for inpatient management led to significant decreases in AR rate (73.3%-24.6%, P < .001), average per-patient cost ($637.42-$538.85), length of stay (223-196 minutes, P < .001), and ED admission rate (15.3%-5.4%, P < .001), with no concerning missed diagnoses or increases in ED revisit rate. CONCLUSIONS: An ED QI project standardizing the care of pediatric constipation was implemented successfully, leading to a sustainable decrease in resource utilization. The next phase of the project will focus on collaborating with community providers to reduce ED utilization.

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis.

OBJECTIVE: The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS: This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS: Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS: Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.

Patient-level Factors and the Quality of Care Delivered in Pediatric Emergency Departments.

OBJECTIVE: Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient-level factors. METHODS: This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect. RESULTS: In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (-0.65 points in quality, 95% confidence interval [CI] = -1.24 to -0.06) and upper respiratory symptoms (-0.68 points in quality, 95% CI = -1.30 to -0.07). CONCLUSION: We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.

Implicit Review Instrument to Evaluate Quality of Care Delivered by Physicians to Children in Emergency Departments.

OBJECTIVE: To evaluate the consistency, reliability, and validity of an implicit review instrument that measures the quality of care provided to children in the emergency department (ED). DATA SOURCES/STUDY SETTING: Medical records of randomly selected children from 12 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). STUDY DESIGN: Eight pediatric emergency medicine physicians applied the instrument to 620 medical records. DATA COLLECTION/EXTRACTION METHODS: We determined internal consistency using Cronbach's alpha and inter-rater reliability using the intraclass correlation coefficient (ICC). We evaluated the validity of the instrument by correlating scores with four condition-specific explicit review instruments. PRINCIPAL FINDINGS: Individual reviewers' Cronbach's alpha had a mean of 0.85 with a range of 0.76-0.97; overall Cronbach's alpha was 0.90. The ICC was 0.49 for the summary score with a range from 0.40 to 0.46. Correlations between the quality of care score and the four condition-specific explicit review scores ranged from 0.24 to 0.38. CONCLUSIONS: The quality of care instrument demonstrated good internal consistency, moderate inter-rater reliability, high inter-rater agreement, and evidence supporting validity. The instrument could be useful for systems' assessment and research in evaluating the care delivered to children in the ED.

Dispensing medications at the hospital upon discharge from an emergency department.

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED's outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.

A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit.

OBJECTIVES: The aim of the study was to assess the impact of an observation unit (OU) on hospital resource utilization for patients with croup. METHODS: A retrospective review with the use of a historical control was performed for 2 years of nondischargeable emergency department (ED) patients with croup. RESULTS: The total number of ED patients with croup was 694 in the first year and 789 in the second year. Hundred seventy patients were enrolled, 66 in the first year and 104 in the second year (76 admitted to the OU and 33 admitted to the ward). There was a reduction in the ward admission rate from 9.5% to 4.2% (P < .0001) from the first to the second year. The median length of stay for the pre-OU group was 27.2 vs 21.3 hours for the post-OU group (P = .03). The median charge for the pre-OU group was $1685 vs $1327 for the post-OU group (P = .03). CONCLUSIONS: After the introduction of the OU, hospitalization was reduced, and the overall resource utilization for the care of nondischargeable ED patients with croup was reduced.