Imaging of acute appendicitis in children: EU versus U.S. ... or US versus CT? A North American perspective.

The timing, type, and technique of imaging evaluation of suspected appendicitis in children are all debated. This debate is both local and international. The fact is that choices in imaging evaluation will depend on both local and national influences, which are reasonable and to be expected. There still is a responsibility, though, for those involved with evaluation of patients with possible appendicitis to come to agreement about an appropriate diagnostic pathway that considers standards of care and available resources.

Simulated pediatric trauma team management: assessment of an educational intervention.

OBJECTIVES: Trauma is the leading cause of death in children. The quality of initial medical care received by injured children contributes to outcomes. Our objective was to assess effectiveness of an educational intervention on performance of emergency department (ED) teams during simulated pediatric trauma resuscitations. METHODS: A prospective, preinterventional and postinterventional study was performed on a random, convenience sample of 17% of EDs in North Carolina. An unannounced simulated pediatric trauma resuscitation was conducted at each site, followed by an educational intervention and a second visit 6 months later. The key outcome measure was team performance on a clinical assessment tool previously described that included 44 resuscitation tasks deemed critical to appropriate management of pediatric trauma resuscitation. RESULTS: All 18 sites consented and completed the study. Interrater reliability was excellent, weighted kappa = 0.80 (95% confidence interval, 0.76-0.84). After the educational intervention, the mean (+/- SD) number of the 44 tasks passed by each ED team increased from 17.7 +/- 4.3 to 26.6 +/- 5.8 (P < 0.001). At the individual task level, the scores on 37 (84%) of the 44 tasks improved, of which 11 (25%) of the 44 tasks improved significantly. CONCLUSIONS: This study demonstrated that an on-site educational intervention was effective in improving the performance of ED teams during simulated pediatric trauma resuscitations. Postintervention performance was more consistent with the Pediatric Advanced Life Support and Advanced Trauma Life Support guidelines. Further studies are needed to determine if improved performance in a simulated scenario leads to improved performance and better clinical outcomes of critically injured children.

Evaluation of a method to reduce over-the-counter medication dosing error.

OBJECTIVES: To introduce a simple method of dosing over-the-counter medication in a home setting using a color-coding concept and to compare dosing deviation from recommended dosage using the color-coded method with dosing deviation using conventional package labeling. DESIGN: Randomized controlled clinical trial. SETTING: Pediatric emergency center at a tertiary care medical center. PARTICIPANTS: A sample of 101 caregivers of children with nonemergent complaints separated into 2 groups. One group used a conventional dosing method and the other group used a color-coded method to determine and measure a dose of acetaminophen for their child. MAIN OUTCOME MEASURES: For both dose determination and dose measuring, percentage of deviation from recommended acetaminophen dosage was calculated and compared between the 2 groups. RESULTS: There was no significant difference in sociodemographic characteristics between the 2 groups. How-ever, for dose determination, the average deviation (25.8% vs 1.7%) and median deviation (1% vs 0%) from recommended dosage were both higher for the group using conventional methods compared with the group using the color-coded method. The Wilcoxon rank sum test indicated that the median deviation was significantly different between the 2 groups (P<.001). Similar results were obtained for dose measuring. The average deviation (29% vs 0.5%) and the median deviation (17.2% vs 0%) from recommended dosage were higher for the group using conventional methods compared with the group using the color-coded method. The median deviation was also significantly different between the 2 groups (P<.001). CONCLUSION: This study suggests a marked improvement in caregivers' ability to correctly determine and measure an over-the-counter medication for their child using a color-coded method compared with conventional methods.

Fundamentals of a patient safety program.

Thousands of people are injured or die from medical errors and adverse events each year, despite being cared for by hard-working, intelligent and well-intended health care professionals, working in the highly complex and high-risk environment of the American health care system. Patient safety leaders have described a need for health care organizations to make error prevention a major strategic objective while at the same time recognizing the importance of transforming the traditional health care culture. In response, comprehensive patient safety programs have been developed with the aim of reducing medical errors and adverse events and acting as a catalyst in the development of a culture of safety. Components of these programs are described, with an emphasis on strategies to improve pediatric patient safety. Physicians, as leaders of the health care team, have a unique opportunity to foster the culture and commitment required to address the underlying systems causes of medical error and harm.

'Sleeping with the enemy?' Expectations and reality in imaging children in the emergency setting.

As an introduction to the ALARA conference titled "Building Bridges between Radiology and Emergency Medicine: Consensus Conference on Imaging Safety and Quality for Children in the Emergency Setting," it is important for us to understand the landscapes of both the pediatric radiology and emergency medicine subspecialties. Recognizing potentially different practice patterns, including perspectives on pediatric care, as well as shared and sometimes unique professional pressures, can help us identify common concerns and problems and facilitate the development of strategies aimed at correcting these issues.

Enhancing pediatric safety: using simulation to assess radiology resident preparedness for anaphylaxis from intravenous contrast media.

PURPOSE: To prospectively develop and test a simulation model for assessing radiology resident preparedness for pediatric life-threatening events in the radiology environment. MATERIALS AND METHODS: This study was institutional review board approved. Nineteen radiology residents (10 men, nine women; mean age, 28.5 years) participated in two simulated contrast material reaction scenarios: one with and one without resuscitation aids available. Each resident examined and managed two mannequins-simulating a 1-2-year-old patient and an 8-9-year-old patient-for type, sequence, dose, and administration route for any intervention, including administering medication, calling a code team, and providing oxygen. The time to order each intervention was documented. Resident responses (time to order intervention, appropriateness of intervention, and intervention route) were evaluated. The paired t test was used to compare the time to intervention between the resuscitation-aid-available and resuscitation-aid-not-available scenarios and between the scenario performed first and the scenario performed second. The McNemar test was performed to compare the percentage of appropriate interventions between the two resuscitation aid scenarios. RESULTS: The average time to call the code team was shorter when no resuscitation aids were available than when resuscitation aids were available (98 vs 149 seconds, P=.08). The average times to request oxygen and epinephrine were shorter when resuscitation aids were available (40 vs 89 seconds to request oxygen, P=.016; 121 vs 163 seconds to request epinephrine, P=.21). Appropriate medication dosing was not significantly different between the two scenarios. In only five of the 38 simulated scenarios was calling the code team the first intervention. The correct sequence of interventions (calling code team, providing oxygen, and then providing epinephrine) was performed by only one resident in one scenario. Only five residents recognized that they were encountering a contrast material reaction. CONCLUSION: Simulation training for radiology residents is valuable and suggests that resident preparedness for pediatric anaphylaxis from intravenous contrast media is insufficient. Clear step-by-step resuscitation aids are needed in the radiology environment.

Development and implementation of a hospital-based patient safety program.

Evidence from numerous studies indicates that large numbers of patients are harmed by medical errors while receiving health-care services in the United States today. The 1999 Institute of Medicine report on medical errors recommended that hospitals and health-care agencies "establish safety programs to act as a catalyst for the development of a culture of safety" [1]. In this article, we describe one approach to successful implementation of a hospital-based patient safety program. Although our experience at Duke University Health System will be used as an example, the needs, principles, and solutions can apply to a variety of other health-care practices. Key components include the development of safety teams, provision of tools that teams can use to support an environment of safety, and ongoing program modification to meet patient and staff needs and respond to changing priorities. By moving patient safety to the forefront of all that we do as health-care providers, we can continue to improve our delivery of health care to children and adults alike. This improvement is fostered when we enhance the culture of safety, develop a constant awareness of the possibility of human and system errors in the delivery of care, and establish additional safeguards to intercept medical errors in order to prevent harm to patients.

Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: identification of targets for performance improvement.

OBJECTIVE: Trauma is the leading cause of death in children. Most children present to community hospital emergency departments (EDs) for initial stabilization. Thus, all EDs must be prepared to care for injured children. The objectives of this study were to (1) characterize the quality of trauma stabilization efforts in EDs and (2) identify targets for educational interventions. METHODS: This was a prospective observational study of simulated trauma stabilizations, that is, "mock codes," at 35 North Carolina EDs. An evaluation tool was created to score each mock code on 44 stabilization tasks. Primary outcomes were (1) interrater reliability of tool, (2) overall performance by each ED, and (3) performance per stabilization task. RESULTS: Evaluation-tool interrater reliability was excellent. The median number of stabilization tasks that needed improvement by the EDs was 25 (57%) of 44 tasks. Although problems were numerous and varied, many EDs need improvement in tasks uniquely important and/or complicated in pediatric resuscitations, including (1) estimating a child's weight (17 of 35 EDs [49%]), (2) preparing for intraosseous needle placement (24 of 35 [69%]), (3) ordering intravenous fluid boluses (31 of 35 [89%]), (4) applying warming measures (34 of 35 [97%]), and (5) ordering dextrose for hypoglycemia (34 of 35 [97%]). CONCLUSIONS: This study used simulation to identify deficiencies in stabilization of children presenting to EDs, revealing that mistakes are ubiquitous. ED personnel were universally receptive to feedback. Future research should investigate whether interventions aimed at improving identified deficiencies can improve trauma stabilization performance and, ultimately, the outcomes of children who present to EDs.

Improved pediatric multidetector body CT using a size-based color-coded format.

OBJECTIVE: CT technique should be adjusted while scanning infants and children. One format that has proven successful in simplifying pediatric care and reducing medical error is the size-based, color-coded Broselow-Luten pediatric system. This color-coded system can serve as a format for CT protocols. The purpose of this investigation was to compare variation (or error) occurrence and technologist preference for conventional and color-coded formats for pediatric multidetector body CT protocols. MATERIALS AND METHODS: Multidetector CT examinations were set up using either a conventional or a color-coded format for a period of 6 weeks each. Variations (errors) from protocol parameters (including tube current, detector configuration, table speed, and IV contrast media dose) were tabulated. Qualitative assessment consisted of a survey of CT technologists (n = 20) for preference in six areas related to ease of use and clarity of the formats. RESULTS: There were 44 CT examinations (n = 30 infants and children) in the conventional group and 55 CT examinations (n = 31 infants and children) in the color-coded protocol format group. Overall, the number of errors was significantly less in the color-coded group (p < 0.01), with a significantly lower error percentage in individual parameters affecting radiation dose, including tube current, detector configuration, and table speed (p < 0.05). In all areas, the color-coded format was preferred over the conventional format (p < 0.0003). CONCLUSION: Color-coded CT formatting is an extension of a clinical color-coded system. This system provides an easy, expeditious, consistent, and preferable format for general pediatric body CT protocols. Most importantly, the color-coded system can reduce variations (errors) in the radiology department.