Scheduling doesn't matter! A noninferiority study of block versus longitudinal scheduling for emergency medicine resident pediatric procedural training experience.

Background: Emergency medicine (EM) residencies offer a wide variety of scheduling models for pediatric patient experience, including blocked weeks in pediatric emergency departments and longitudinal models with pediatric emergency pod/department shifts integrated within other clinical experiences. Concerns with autonomy, attending entrustment, and resident comfort imply that these different scheduling models may impact EM residents' pediatric procedure volumes. The purpose of this study is to quantitatively compare EM residents' pediatric procedure experience and volumes between block versus longitudinal scheduling models. We hypothesize noninferiority between the scheduling models. Methods: A retrospective review characterized the numbers and types of procedures performed by The Ohio State Emergency Medicine residents at the tertiary care pediatric hospital where residents' receive their pediatric emergency medicine clinical experience. Procedure numbers and variety were compared across six academic years: four with a block model, one reorganization year, and one integrated longitudinal year. Results: 2552 procedures were performed by 266 resident academic years over the 6-year period. Overall, no statistically significant differences in the number of procedures performed per year or the variety of types of procedures performed per year were found when comparing the block and longitudinal models. Differences were seen in experience of PGY1 versus PGY3 residents between scheduling models and the overall experience and volumes of the PGY2 residents during the reorganization year. Conclusions: Our study quantitatively concluded that the longitudinal scheduling model is noninferior to the more traditional block scheduling model for emergency medicine residents' pediatric emergency medicine clinical experience when reviewing volumes and types of procedures performed in a pediatric emergency department. This suggests that procedural opportunities do not need to dictate scheduling models.

Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department.

INTRODUCTION: Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. METHODS: The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. RESULTS: Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. DISCUSSION: The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.

Yield of skeletal survey by age in children referred to abuse specialists.

OBJECTIVE: To determine rates of skeletal survey completion and injury identification as a function of age among children who underwent subspecialty evaluation for concerns of physical abuse. STUDY DESIGN: This was a retrospective secondary analysis of an observational study of 2609 children <60 months of age who underwent evaluation for possible physical abuse. We measured rates of skeletal survey completion and fracture identification for children separated by age into 6-month cohorts. RESULTS: Among 2609 subjects, 2036 (78%) had skeletal survey and 458 (18%) had at least one new fracture identified. For all age groups up to 36 months, skeletal survey was obtained in >50% of subjects, but rates decreased to less than 35% for subjects >36 months. New fracture identification rates for skeletal survey were similar between children 24-36 months of age (10.3%, 95% CI 7.2-14.2) and children 12-24 months of age (12.0%, 95% CI 9.2-15.3) CONCLUSIONS: Skeletal surveys identify new fractures in an important fraction of children referred for subspecialty consultation with concerns of physical abuse. These data support guidelines that consider skeletal survey mandatory for all such children <24 months of age and support a low threshold to obtain skeletal survey in children as old as 36 months.