Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative.

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these gaps using quality improvement (QI) methodology. Project champion from a community hospital network identified the use of safe pharmacological and non-pharmacological anxiolysis and analgesia (A&A) as one such gap and partnered with EMSC to address it. Our primary Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) aim was to increase intranasal midazolam (INM) use for common, anxiety-provoking procedures on children <8 years of age from 2% to 25% in a year.EMSC facilitated a QI team with representation from the CED and regional children's hospitals. Following the model for improvement, we initiated a process analysis of this CED A&A practice. Review of all paediatric procedural data identified common anxiety-provoking simple procedures as laceration repairs, abscess drainage and foreign body removal. Our SMART aims were benchmarked to two regional PEDs and tracked through statistical process control. A balancing metric was ED length of stay (ED LOS) for patients <8 years of age requiring a laceration repair. Additionally, we surveyed CED frontline staff and report perceptions of changes in A&A knowledge, attitudes and practice patterns. These data prioritised and informed our key driver diagram which guided the Plan-Do-Study-Act (PDSA) cycles, including guideline development, staff training and cognitive aids.Anxiety-provoking simple procedures occurred on average 10 times per month in children <8 years of age. Through PDSA cycles, the monthly average INM use increased from 2% to 42%. ED LOS was unchanged, and the perceptions of provider's A&A knowledge, attitudes and practice patterns improved.A CED-initiated QI project increased paediatric A&A use in a CED network. An A&A toolkit outlines our approach and may simplify spread from academic children's hospitals to the community.

Clinical decision rule for obtaining peripheral blood cultures in febrile oncology patients.

BACKGROUND: The utility of peripheral blood cultures in pediatric oncology patients presenting with fever is controversial. A recent systematic review showed that about one in 40 bloodstream infections (BSIs) would be missed if only central venous line (CVL) cultures are obtained. OBJECTIVE: To derive a clinical decision rule for obtaining peripheral blood cultures in pediatric oncology patients presenting to a pediatric emergency department (PED) with fever and a CVL. DESIGN/METHOD: A retrospective chart review was performed on pediatric oncology patients referred to the PED for fever while on therapy. Logistic regression with a random intercept was used to determine independent predictors of BSI and generate a prediction model for obtaining peripheral blood cultures. The decision rule was generated from the best performance as measured by a receiver operator curve. Bootstrapping analysis was performed for internal validation. RESULTS: Predictors that were significant and independently associated with positive peripheral blood cultures included vasopressor support (odds ratio [OR] 16.5, 95% confidence interval [CI]: 2.80-97.71), acute myeloid leukemia (AML) diagnosis (OR 6.9, 95% CI: 1.81-25.98), hypotension (OR 4.0, 95% CI: 1.05-15.17), mucositis (OR 8.2, 95% CI: 2.48-27.01), and maximum temperature in PED ≥39°C (OR 6.6, 95% CI: 2.36-18.20). The area under the curve (AUC) for this model was 0.90 (95% CI: 0.82-0.97) in the derivation cohort and 0.90 (95% CI: 0.81-0.98) after the internal validation. CONCLUSIONS: We derived a clinical prediction model for deciding when to obtain peripheral blood cultures in febrile oncology patients with CVLs on active therapy. Future studies should focus on prospective and external validation of this diagnostic prediction tool.

An initiative to improve pneumococcal immunization counseling in children with nephrotic syndrome.

BACKGROUND: Immunization is essential in preventing life-threatening pneumococcal infections in children with nephrotic syndrome. An additional 23-valent pneumococcal polysaccharide vaccine (PPSV23) series is required for children with nephrotic syndrome. Despite current practice guidelines, many children with nephrotic syndrome do not receive PPSV23. METHODS: Our nephrology clinic conducted a quality improvement project to improve the overall rate of PPSV23 counseling to more than 70% within a 12-month period by applying several targeted interventions to raise providers' awareness, improve communication with primary care providers, and increase provider adherence. Data was collected from the electronic health record (EHR), and monthly performance was tracked via monthly control charts and overall immunization counseling rate charts. RESULTS: We increased adherence to PPSV23 vaccination counseling from a baseline of 12 to 86%. The first intervention that effectively increased the vaccine counseling rate from 12 to 30% was improving a provider's awareness of the PPSV23 literature and vaccine guidelines. Other interventions included regular performance reviews at division meetings, creating an immunization protocol, posting performance charts on the office bulletin board, and unifying vaccine recommendation templates. Lastly, specific and timely EHR reminders improved the total counseling rate from 52 to 86% and maintained adherence until the completion of the project. CONCLUSION: Bridging the knowledge gap in provider awareness and using specific EHR reminders can improve adherence to PPSV23 counseling in children with nephrotic syndrome. Such interventions could be applied to similar groups of immunocompromised patients in whom additional vaccines are indicated. A higher resolution version of the Graphical abstract is available as Supplementary information.

Documentation of Shared Decisionmaking in the Emergency Department.

STUDY OBJECTIVE: While patient-centered communication and shared decisionmaking are increasingly recognized as vital aspects of clinical practice, little is known about their characteristics in real-world emergency department (ED) settings. We constructed a natural language processing tool to identify patient-centered communication as documented in ED notes and to describe visit-level, site-level, and temporal patterns within a large health system. METHODS: This was a 2-part study involving (1) the development and validation of an natural language processing tool using regular expressions to identify shared decisionmaking and (2) a retrospective analysis using mixed effects logistic regression and trend analysis of shared decisionmaking and general patient discussion using the natural language processing tool to assess ED physician and advanced practice provider notes from 2013 to 2020. RESULTS: Compared to chart review of 600 ED notes, the accuracy rates of the natural language processing tool for identification of shared decisionmaking and general patient discussion were 96.7% (95% CI 94.9% to 97.9%) and 88.9% (95% confidence interval [CI] 86.1% to 91.3%), respectively. The natural language processing tool identified shared decisionmaking in 58,246 (2.2%) and general patient discussion in 590,933 (22%) notes. From 2013 to 2020, natural language processing-detected shared decisionmaking increased 300% and general patient discussion increased 50%. We observed higher odds of shared decisionmaking documentation among physicians versus advanced practice providers (odds ratio [OR] 1.14, 95% CI 1.07 to 1.23) and among female versus male patients (OR 1.13, 95% CI 1.11 to 1.15). Black patients had lower odds of shared decisionmaking (OR 0.8, 95% CI 0.84 to 0.88) compared with White patients. Shared decisionmaking and general patient discussion were also associated with higher levels of triage and commercial insurance status. CONCLUSION: In this study, we developed and validated an natural language processing tool using regular expressions to extract shared decisionmaking from ED notes and found multiple potential factors contributing to variation, including social, demographic, temporal, and presentation characteristics.

Evaluation of a Focused Cardiac Ultrasound Protocol in a Pediatric Emergency Department.

OBJECTIVES: The objective of this study was to evaluate the implementation of a focused cardiac ultrasound (FoCUS) protocol in a pediatric emergency department (PED). METHODS: We conducted a cross-sectional, observational, quality improvement project in a PED of an urban tertiary care children's hospital. A FoCUS protocol was collaboratively developed by pediatric cardiology and pediatric emergency medicine. This included a reference document with definitions, indications, image acquisition guidelines, and interpretation expectations. We measured physician-sonographer performance against pediatric cardiologist interpretation of stored cine clips as our reference standard. Focused cardiac ultrasound interpretation was dichotomized for the presence or absence of pericardial effusion, depressed left ventricular function, and chamber size abnormalities. Run charts were used to compare the number FoCUS performed each month and the quality of captured cine clips with those from the previous year. RESULTS: Ninety-two FoCUSs were performed by 34 different physician-sonographers from January to December 2016. The prevalence of FoCUS abnormalities was 18.5%. For pericardial effusion, sensitivity was 100% (95% confidence interval [CI], 48%-100%) and specificity was 99% (95% CI, 94%-100%). For depressed function, sensitivity was 100% (95% CI, 54%-100%) and specificity was 99% (95% CI, 94%-100%). For chamber size abnormalities, sensitivity was 100% (95% CI, 54%-100%) and specificity was 95% (95% CI, 89%-99%). The median number of monthly FoCUS increased from 1 (preprotocol) to 5 (postprotocol), and the median rate of adequate studies increased from 0% to 55%. CONCLUSIONS: We report the collaborative development and successful implementation of a PED FoCUS protocol. Physician-sonographer interpretation of FoCUS yielded acceptable results. Improvements in FoCUS utilization and cine clip adequacy were observed.

Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program.

OBJECTIVES: Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program. METHODS: We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes. RESULTS: Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends. CONCLUSIONS: Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry.

OBJECTIVE: Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events. DESIGN: A multicenter retrospective cohort study. SETTING: Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative. PATIENTS: Primary tracheal intubation in children younger than 18 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics. CONCLUSIONS: Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service.

OBJECTIVE: Overcrowding in the emergency department (ED) has been associated with patient harm, yet little is known about the association between ED boarding and adverse hospitalization outcomes. We sought to examine the association between ED boarding and three common adverse hospitalization outcomes: rapid response team activation (RRT), escalation in care, and mortality. METHOD: We conducted an observational analysis of consecutive patient encounters admitted from the ED to the general medical service between February 2013 and June 2015. This study was conducted in an urban, academic hospital with an annual adult ED census over 90,000. We defined boarding as patients with greater than 4h from ED bed order to ED departure to hospital ward. The primary outcome was a composite of adverse outcomes in the first 24h of admission, including RRT activation, care escalation to intensive care, or in-hospital mortality. RESULTS: A total of 31,426 patient encounters were included of which 3978 (12.7%) boarded in the ED for 4h or more. Adverse outcomes occurred in 1.92% of all encounters. Comparing boarded vs. non-boarded patients, 41 (1.03%) vs. 244 (0.90%) patients experienced a RRT activation, 53 (1.33%) vs. 387 (1.42%) experienced a care escalation, and 1 (0.03%) vs.12 (0.04%) experienced unanticipated in-hospital death, within 24h of ED admission. In unadjusted analysis, there was no difference in the composite outcome between boarding and non-boarding patients (1.91% vs. 1.91%, p=0.994). Regression analysis adjusted for patient demographics, acuity, and comorbidities also showed no association between boarding and the primary outcome. A sensitivity analysis showed an association between ED boarding and the composite outcome inclusive of the entire inpatient hospital stay (5.8% vs. 4.7%, p=0.003). CONCLUSION: Within the first 24h of hospital admission to a general medicine service, adverse hospitalization outcomes are rare and not associated with ED boarding.

An Initiative to Reduce Routine Viral Diagnostic Testing in Pediatric Patients Admitted with Bronchiolitis.

BACKGROUND: Bronchiolitis is a viral lower respiratory tract infection that causes significant morbidity and mortality in the pediatric population. Viral diagnostic testing (VDT) has been used to identify specific viral pathogens. However, current guidelines suggest that routine use of this testing is not advisable. For children admitted to a children's hospital from the pediatric emergency department (PED), the rate of VDT was 63%, which was higher than the national rate. A quality improvement project was conducted to reduce the use of routine VDT. METHODS: Key drivers of VDT were identified, and interventions, which included staff education about the cost and use of VDT and dissemination of a simplified cohorting policy aimed to eliminate VDT without medical necessity, were implemented through the PED and inpatient unit settings. RESULTS: Between January 2017 and April 2017, VDT use in all non-ICU patients admitted from the PED with bronchiolitis decreased from 63% to 12%. In the same time period, patients with VDT sent from the PED fell from 53% to 14%. A reduction in VDT for patients admitted with asthma exacerbation was also observed-from 24% to 0%-demonstrating early spread of these effects. Cost savings of approximately $8,584 per year in direct supply costs alone was documented. CONCLUSION: Using simple, low-cost interventions, including education and guideline refinement, the rate of VDT use for bronchiolitis was significantly reduced. Further directions for this project include the reduction of routine testing for patients with bronchiolitis who are admitted to the ICU or discharged for outpatient care.

A taxonomy and cultural analysis of intra-hospital patient transfers.

Existing research on intra-hospital patient transitions focuses chiefly on handoffs, or exchanges of information, between clinicians. Less is known about patient transfers within hospitals, which include but extend beyond the exchange of information. Using participant observations and interviews at a 1,541-bed, academic, tertiary medical center, we explored the ways in which staff define and understand patient transfers between units. We conducted observations of staff (n = 16) working in four hospital departments and interviewed staff (n = 29) involved in transfers to general medicine floors from either the Emergency Department or the Medical Intensive Care Unit between February and September 2015. The collected data allowed us to understand transfers in the context of several hospital cultural microsystems. Decisions were made through the lens of the specific unit identity to which staff felt they belonged; staff actively strategized to manage workload; and empty beds were treated as a scarce commodity. Staff concepts informed the development of a taxonomy of intra-hospital transfers that includes five categories of activity: disposition, or determining the right floor and bed for the patient; notification to sending and receiving staff of patient assignment, departure and arrival; preparation to send and receive the patient; communication between sending and receiving units; and coordination to ensure that transfer components occur in a timely and seamless manner. This taxonomy widens the study of intra-hospital patient transfers from a communication activity to a complex cultural phenomenon with several categories of activity and views them as part of multidimensional hospital culture, as constructed and understood by staff.

A Qualitative Study of Multidisciplinary Providers' Experiences With the Transfer Process for Injured Children and Ideas for Improvement.

OBJECTIVE: Most injured children initially present to a community hospital, and many will require transfer to a regional pediatric trauma center. The purpose of this study was 1) to explore multidisciplinary providers' experiences with the process of transferring injured children and 2) to describe proposed ideas for process improvement. METHODS: This qualitative study involved 26 semistructured interviews. Subjects were recruited from 6 community hospital emergency departments and the trauma and transport teams of a level I pediatric trauma center in New Haven, Conn. Participants (n = 34) included interprofessional providers from sending facilities, transport teams, and receiving facilities. Using the constant comparative method, a multidisciplinary team coded transcripts and collectively refined codes to generate recurrent themes across interviews until theoretical saturation was achieved. RESULTS: Participants reported that the transfer process for injured children is complex, stressful, and necessitates collaboration. The transfer process was perceived to involve numerous interrelated components, including professions, disciplines, and institutions. The 5 themes identified as areas to improve this transfer process included 1) Creation of a unified standard operating procedure that crosses institutions/teams, 2) Enhancing 'shared sense making' of all providers, 3) Improving provider confidence, expertise, and skills in caring for pediatric trauma transfer cases, 4) Addressing organization and environmental factors that may impede/delay transfer, and 5) Fostering institutional and personal relationships. CONCLUSIONS: Efforts to improve the transfer process for injured children should be guided by the experiences of and input from multidisciplinary frontline emergency providers.

Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy.

BACKGROUND: GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). PURPOSES: This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. METHODS: Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. RESULTS: Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. CONCLUSIONS: A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

Hourly rounding in the pediatric emergency department: patient and family safety and satisfaction rounds.

BACKGROUND: Methods of increasing patient and family involvement in and understanding of their medical care are plentiful, and hourly rounding specifically has shown benefit in several clinical settings. Although the approach has shown a variety of advantages in other areas, its use in urgent care pediatric settings is not well described. OBJECTIVES: This study evaluates the institution of patient satisfaction and safety rounding ("hourly rounding") in the pediatric emergency department (ED) setting. METHODS: Hourly rounding was instituted in a tertiary care, urban pediatric ED using a formal mnemonic, after staff education, training, and observation to ensure standardization of approach. Pre- and postintervention data were collected, including frequency and type of nursing call bell usage, family discharge opinion survey, and vendor-collected survey results. RESULTS: Two weeks of nursing call bell activation data and 200 pre- and postintervention family discharge opinion surveys were collected, evenly divided between pre- and postimplementation data. Call bell activations prior to and after hourly rounding institution were 102 and 150 respectively, with accidental activations comprising the majority. Additionally, vendor-collected patient satisfaction data were analyzed. There were no changes in patient scoring when pre- and postimplementation data were compared. CONCLUSIONS: This model of hourly rounding shows no measurable improvement in patient satisfaction or provider-patient communication using call bell data, family discharge opinion surveys, or vendor-collected patient satisfaction data. Further studies may be indicated to identify different methods of analyzing the effects of this method, and to examine alternative methods of improving these outcomes in the pediatric ED setting.

Postpartum depression screening in the pediatric emergency department.

PURPOSE: This study aimed to determine the prevalence of and risk factors for postpartum depression (PPD) in mothers of young infants presenting to the pediatric emergency department (PED). METHODS: This was a prospective, observational study to evaluate the prevalence of PPD in a sample of mothers of young infants presenting to the PED of an urban, tertiary care children's hospital. A convenience sample of mothers with infants younger than 4 months who presented to our urban, tertiary care PED was surveyed in English or Spanish using the Edinburgh Postpartum Depression Scale (EPDS). Demographic information was collected. Members of the study team evaluated and counseled those mothers who screened positive on the EPDS (score ≥ 10). During the PED visit, social work consultation and mental health resources were also offered. Resource use and additional mental health needs were assessed, with a follow-up telephone call 4 weeks after the initial ED presentation. Performance characteristics of a brief, 3-question anxiety subset were compared using a positive EPDS as the reference standard. All study participants were given information about community resources for new mothers. Data were analyzed using t test or Χ (with Yates correction as necessary). RESULTS: A convenience sample of 200 mothers was enrolled; 31 (16%) of these mothers had an EPDS score of 10 or greater. Mothers had a mean age of 27 years (range, 15-41); 45% were first-time mothers; 40% got pediatric care in a state-funded clinic; and 10% were Spanish speaking. There were no statistically significant differences in baseline demographic characteristics of mothers with and without PPD. Mothers who were depressed were more likely to report that they either strongly agreed or agreed with the statement "I feel that my child is always fussy" (P = 0.004). The anxiety subscale produced a sensitivity of 0.87 (95% confidence interval [CI], 0.69-0.96), a specificity of 0.70 (95% CI, 0.63-0.77), and a negative predictive value of 0.97 (95% CI, 0.91-0.99). The majority of participants (92%) reached at follow-up reported improvement in their mood. Fifty percent reported discussing their mood with someone else, although only 33% of these women did so with a medical provider. CONCLUSIONS: Postpartum depression affects a significant number of mothers of young infants who present to the PED for medical care. There are no clear demographic identifiers of these at-risk mothers, making universal screening an advisable approach. Capture of at-risk mothers during PED visits may accelerate connection with mental health resources. Anxiety seems to be a significant contributor. Mothers with PPD often characterize their infants to have a "fussy" temperament. The most appropriate referral for these women in this setting merits further investigation.

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion.

PURPOSE: Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. MATERIALS AND METHODS: An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4 h from 64% to >90% within one year. RESULTS: We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4 h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147 min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56 min, mean time from arrival to scrotal ultrasound decreased from 70 to 36 min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80 min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. CONCLUSIONS: Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4 h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

Improving Quality and Efficiency in Pediatric Emergency Department Behavioral Health Care.

INTRODUCTION: Many children with behavioral health concerns increasingly utilize the emergency department for assessment and care. These visits are increasing in frequency, length, and cost, further stressing already limited resources. To improve the quality of care in this population, we developed a multidisciplinary improvement initiative to decrease the length of stay by 10% (from 5.2 hours), increase suicide screening to 90%, and improve patient and family experience by 10% (from 89.7). METHODS: We leveraged a multidisciplinary team to map care processes, standardize suicide risk screening, optimize staffing, and develop a brochure to demystify patients' and families' visits. We developed dashboards and a call-back system following discharge to understand engagement in post-acute care plans. We utilized run charts to identify signals of nonrandom variation. RESULTS: We reduced overall length of stay from 5.2 to 4 hours, improved patient experience scores from 89.7 to 93.2, and increased the suicidality screening rate from 0% to 94%. There was no change in the 72-hour return rate in this population. CONCLUSIONS: Engagement of a multidisciplinary team, with strategic implementation of improvements, measurably improved many aspects of care for pediatric patients with behavioral health crises in the emergency department setting. Recidivism, however, remains unchanged in this population and continues as a goal for future work.

Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS).

BACKGROUND: Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. METHODS: Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. RESULTS: A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. CONCLUSIONS: While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.

Simulated airway drills as a tool to measure and guide improvements in endotracheal intubation preparation in the paediatric emergency department.

Introduction: Emergent paediatric intubation is an infrequent but high-stakes procedure in the paediatric emergency department (PED). Successful intubations depend on efficient and accurate preparation. The aim of this study was to use airway drills (brief in-situ simulations) to identify gaps in our paediatric endotracheal intubation preparation process, to improve on our process and to demonstrate sustainability of these improvements over time in a new staff cohort. Method: This was a single-centre, simulation-based improvement study. Baseline simulated airway drills were used to identify barriers in our airway preparation process. Drills were scored for time and accuracy on an iteratively developed 16-item rubric. Interventions were identified and their impact was measured using simulated airway drills. Statistical analysis was performed using unpaired t-tests between the three data collection periods. Results: Twenty-five simulated airway drills identified gaps in our airway preparation process and served as our baseline performance. The main problem identified was that staff members had difficulty locating essential airway equipment. Therefore, we optimised and implemented a weight-based airway cart. We demonstrated significant improvement and sustainability in the accuracy of obtaining essential airway equipment from baseline to postintervention (62% vs 74%; p=0.014), and postintervention to sustainability periods (74% vs 77%; p=0.573). Similarly, we decreased and sustained the time (in seconds) required to prepare for a paediatric intubation from baseline to postintervention (173 vs 109; p=0.001) and postintervention to sustainability (109 vs 103; p=0.576). Conclusions: Simulated airway drills can be used as a tool to identify process gaps, measure and improve paediatric intubation readiness.

A longitudinal course pilot to improve surgical resident acquisition of quality improvement skills.

PROBLEM: Despite mounting evidence that incorporation of QI curricula into surgical trainee education improves morbidity and outcomes, surgery training programs lack standardized QI curricula and tools to measure QI knowledge. In the current study, we developed, implemented, and evaluated a quality improvement curriculum for surgical residents. INTERVENTION: Surgical trainees participated in a longitudinal, year-long (2019-2020) curriculum based on the Institute for Healthcare Improvement's online program. Online curriculum was supplemented with in person didactics and small group projects. Acquisition of skills was assessed pre- and post- course via self-report on a Likert scale as well as the Quality Improvement Knowledge Application Tool (QIKAT). Self-efficacy scores were assessed using the General Self-Efficacy Scale. 9 out of 18 total course participants completed the post course survey. This first course cohort was analyzed as a pilot for future work. CONTEXT: The project was developed and deployed among surgical residents during their research/lab year. Teams of surgical residents were partnered with a faculty project mentor, as well as non-physician teammates for project work. IMPACT: Participation in the QI course significantly increased skills related to studying the process (p = 0.0463), making changes in a system (p = 0.0167), identifying whether a change leads to an improvement (p = 0.0039), using small cycles of change (p = 0.0000), identifying best practices and comparing them to local practices (p = 0.0020), using PDSA model as a systematic framework for trial and learning (p = 0.0004), identifying how data is linked to specific processes (p = 0.0488), and building the next improvement cycle upon success or failure (p = 0.0316). There was also a significant improvement in aim (p = 0.037) and change (p = 0.029) responses to one QIKAT vignette. LESSONS LEARNED: We describe the effectiveness of a pilot longitudinal, multi component QI course based on the IHI online curriculum in improving surgical trainee knowledge and use of key QI skills.

Improving Patient Experience Scores in a Pediatric Emergency Department.

INTRODUCTION: Patient experience (PE) is an important aspect of the quality of medical care and is associated with positive health outcomes. In the pediatric emergency department (PED), PE is complicated due to the balance of needs between the patient and their family while receiving care. We identified an opportunity to improve our PE, as measured by a survey administered to patients and families following their visit to the PED. METHODS: Utilizing quality improvement methods, we assembled a multidisciplinary team, developed our aims, and evaluated the process. We utilized a key driver diagram and run charts to track our performance. The team additionally monitored several essential subcategories in our improvement process. We aimed to improve our overall PE score from 86.1 to 89.7 over 9 months to align with institutional objectives. RESULTS: Over 6 months, we improved our overall PE score from 86.1 to 89.8. Similarly, each of our subscores of interest (physician performance, things for patients to do in the waiting room, waiting time for radiology, staff sensitivity, and communication about delays) increased. Interventions included rounding in the waiting and examination rooms, staff training, team huddles, and a cross-department committee. All measures demonstrated sustained improvement. CONCLUSIONS: Even in this complex setting, a multidisciplinary team's careful and rigorous process evaluation and improvement work can drive measurable PE improvement. We are continuing our efforts to further improve our performance in excellent patient-centered care to this critical population.