Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area.

OBJECTIVES: Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area. METHODS: This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status. RESULTS: A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status. CONCLUSIONS: One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Improving Wait Times for Children with Caregivers with Limited English Proficiency in the Emergency Department.

Introduction: In our pediatric emergency department (ED), children triaged as low acuity who presented with Spanish-speaking caregivers with limited English proficiency (SSLEP) experienced disparately longer wait times than similarly triaged children with English-proficient caretakers. Although inequities in ED care based on language preference exist, little is known about effective interventions to eliminate the disparity. This quality improvement study aimed to eliminate the disparity in wait times and share effective interventions. Methods: A multidisciplinary team incorporating clinicians, professional interpreters, and data analysts utilized quality improvement methodology to introduce early identification of SSLEP children, standardize physician workflow, and optimize the interpreter process. The primary outcome was the length of stay. The secondary outcome was time to the provider. The balancing measures were revisits and non-LEP length of stay and time to the provider. Secondary analyses distinguished between the effect of our QI intervention and secular trends. Results: The mean length of stay for SSLEP children decreased from a mean of 178 to 142 minutes, a 36-minute (20%) decrease. Mean time to provider for SSLEP decreased from 92.8 to 55.5 minutes, a 37-minute improvement (40%). The 72-hour-revisit rates did not increase for SSLEP children throughout the project. Conclusions: We identified feasible interventions to improve wait times for children with SSLEP. Future directions include addressing components of the entire ED visit to decrease the length of stay discrepancies between populations. We hope to extend our findings to benefit all LEP communities.

Improving Adherence to Evidence-based Practice for Uncomplicated UTI in a Pediatric Emergency Department.

Introduction: Uncomplicated urinary tract infections (uUTIs) are among the more common pediatric bacterial infections. Despite their prevalence, significant variability exists in the treatment duration and antibiotic selection for uUTI. Our first aim was to improve adherence to a three-day course of antibiotic treatment for uUTI in children over 24 months old. Our second aim was to increase the selection of cephalexin in this population. Methods: We conducted a single-center quality improvement study from March 2021 to March 2022. One thousand four hundred thirty-five patients were included across our baseline and intervention periods. We created an order set with embedded discharge prescriptions and followed this with education and provider feedback. The outcome measures for this study were percent of children receiving 3 days of antibiotic treatment and percent of children prescribed cephalexin. In addition, we tracked order set use as a process measure, and 7-day emergency department revisit as a balancing measure. Results: Rates of 3-day prescriptions for uUTI demonstrated special cause variation with an increase from 3% to 44%. Prescription rates of cephalexin for uUTI demonstrated special cause variation with an increase from 49% to 74%. The process measure of order set use improved from 0% to 49% after implementation. No change occurred in 7-day emergency department revisits. Conclusion: We demonstrated improved use of shorter course therapy for uUTI with a first-generation cephalosporin throughout this project without adverse events. We leveraged an order set with embedded discharge prescriptions to achieve our goals.