Effect of an Evaluation Algorithm on CT Utilization in Identifying Appendicitis in Children.

OBJECTIVE: Our objective was to determine if there was a significant change in computed tomography (CT) utilization or length of stay (LOS) among patients evaluated for acute appendicitis after implementation of an appendicitis evaluation algorithm. METHODS: We conducted a retrospective chart review of patients aged 3-18 years in an urban, tertiary pediatric emergency department with acute abdominal pain, evaluated for appendicitis. Data were collected for 6 months preimplementation and postimplementation of the evaluation algorithm with a 3-month washout period between September 2018 and November 2019. Main outcomes were rate of CT utilization and LOS preimplementation and postimplementation and were analyzed using χ 2 test and Mann-Whitney U test, respectively. Descriptive analysis of demographics was performed, in addition to logistic regression to assess differences between the 2 study periods. RESULTS: A total of 2872 charts were identified with a chief complaint inclusive of "abdominal pain." Of these, 1510 met age requirements but did not meet at least 1 inclusion criteria; 229 more were excluded upon chart review for a final study sample of 1133 patients. Of these, 648 (57.2%) were female, 747 (65.9%) were White, and 988 (87.2%) were non-Hispanic. The majority of patients (770, 68%) were discharged home from the emergency department without a diagnosis of acute appendicitis. Neither CT (25.7% to 24.8%; P = 0.794) nor ultrasound (59.5% to 59.7%; P = 1.000) utilization significantly changed postimplementation. Total ED median LOS increased significantly (333.50 to 362.00 minutes; P = 0.011). Significant factors associated with CT utilization included fever, migration of pain, and right lower quadrant tenderness. Significant factors associated with appendicitis diagnosis included right lower quadrant pain, nausea/vomiting, migration of pain, and peritoneal signs. CONCLUSIONS: Overall, the appendicitis evaluation algorithm did not significantly decrease CT utilization or LOS. Equivocal grade 2 or 3 ultrasound finding rates were high, likely leading to higher rates of CT utilization and increasing LOS.

Improving Discharge Instructions Following a Concussion Diagnosis in the Pediatric Emergency Department: A Pre-post Intervention Study.

INTRODUCTION: Many children are discharged from the pediatric emergency department (PED) with incomplete or inappropriate instructions following a concussion. Our objective was to evaluate the effectiveness of a simple intervention in improving discharge instruction disbursement and completeness following PED diagnosis of concussion. METHODS: A pre/post intervention study of 935 patients (375 preintervention and 560 postintervention) ages 5-19, diagnosed with a concussion and discharged from the PED between July 2016 and November 2019, was performed at a single United States pediatric tertiary-care center. Dedicated provider education sessions were held, and a consensus guideline-based set of discharge instructions were implemented in the electronic health record. Primary outcomes included the presence of return-to-play (RTP) instructions, return-to-learn (RTL) instructions, follow-up recommendations, and "complete" discharge (ie, all 3 components present). Statistical process control charts were generated and tested for special cause variation. RESULTS: More patients received instructions for RTP (87% versus 59%) and RTL (60% versus 3%), and a complete discharge was more frequent (45% versus 2%), following the conclusion of the intervention. Only the improvement in RTP instructions was completely sustained into the following academic year, whereas RTL and complete discharge rates declined to 27% and 20%, respectively. CONCLUSIONS: A simple, low-cost intervention such as peer-to-peer education and consensus guideline-based discharge instruction templates can significantly improve discharge readiness after pediatric concussion. Further work is needed to maintain progress and continue improvements, at our large academic trauma center.

Development of an interprofessional clinical learning environment report card.

Multiple factors in the learning environment can encourage or impede student learning. Unanswered questions regarding the shared learning environment for graduate nursing and medical education and the desire for an ongoing improvement process drove creation of an interprofessional collaborative and development of an Interprofessional Clinical Learning Environment Report Card (I-CLERC) at one U.S. academic medical center. The I-CLERC offers a process and a product for institutionalizing a shared assessment tool to inform improvement efforts, track progress and promote accountability. In addition, it enhances interprofessional collaboration, with students and faculty from both nursing and medicine working together to define excellence, monitor performance, and identify areas for improvement in the shared clinical learning environment. The purpose of this manuscript is to describe development and implementation of an interdisciplinary, institutional collaborative for ongoing evaluation of the shared clinical learning environment.

Fractures in the Pediatric Emergency Department: Are We Considering Abuse?

Approximately one fourths of infant fractures are due to abuse. Recognition of abuse is important to avoid further morbidity/mortality. There is limited knowledge regarding how frequently pediatric emergency department clinicians consider abuse in infants with fractures. Our primary objective was to estimate the percentage of infants with fractures for whom abuse was considered, and to examine characteristics associated with abuse consideration. We performed a retrospective review of infants <1 year of age presenting to a pediatric emergency department. Our primary outcome variable was consideration of abuse. Our secondary outcome measures were identification of predictor variables associated with consideration of abuse. We identified 509 infants meeting study criteria. Pediatric emergency physicians considered abuse in approximately two thirds of infants with fractures. Consideration was more likely to occur in younger infants, in the presence of no history or unwitnessed injury mechanism, when evaluated by male physicians, and emergency department encounters from 12 am to 6 am.

Radiology in Medical Education: A Pediatric Radiology Elective as a Template for Other Radiology Courses.

PURPOSE: Traditionally, the pediatric radiology elective for medical students and pediatric residents constituted a morning teaching session focused mainly on radiography and fluoroscopy. A more structured elective was desired to broaden the exposure to more imaging modalities, create a more uniform educational experience, and include assessment tools. METHODS: In 2012, an introductory e-mail and formal syllabus, including required reading assignments, were sent to participants before the start date. A rotating weekly schedule was expanded to include cross-sectional imaging (ultrasound, CT, MR) and nuclear medicine. The schedule could accommodate specific goals of the pediatric resident or medical student, as requested. Starting in 2013, an online pre-test and post-test were developed, as well as an online end-of-rotation survey specific to the pediatric radiology elective. Taking the Image Gently pledge was required. A scavenger hunt tool, cue cards, and electronic modules were added. RESULTS: Pre-test and post-test scores, averaged over 2 years, showed improvement in radiology knowledge, with scores increasing by 27% for medical students and 21% for pediatric residents. Surveys at the end of the elective were overwhelmingly positive, with constructive criticism and complimentary comments. CONCLUSIONS: We have successfully created an elective experience in radiology that dedicates time to education while preserving the workflow of radiologists. We have developed tools to provide a customized experience with many self-directed learning opportunities. Our tools and techniques are easily translatable to a general or adult radiology elective.