Triage Accuracy in Pediatrics Using the Emergency Severity Index.

INTRODUCTION: Although the Emergency Severity Index is the most widely used tool in the United States to prioritize care for patients who seek emergency care, including children, there are significant deficiencies in the tool's performance. Inaccurate triage has been associated with delayed treatment, unnecessary diagnostic testing, and bias in clinical care. We evaluated the accuracy of the Emergency Severity Index to stratify patient priority based on predicted resource utilization in pediatric emergency department patients and identified covariates influencing performance. METHODS: This cross-sectional, retrospective study used a data platform that links clinical and research data sets from a single freestanding pediatric hospital in the United States. Chi-square analysis was used to describes rates of over- and undertriage. Mixed effects ordinal logistic regression identified associations between Emergency Severity Index categories assigned at triage and key emergency department resources using discrete data elements and natural language processing of text notes. RESULTS: We analyzed 304,422 emergency department visits by 153,984 unique individuals in the final analysis; 80% of visits were triaged as lower acuity Emergency Severity Index levels 3 to 5, with the most common level being Emergency Severity Index 4 (43%). Emergency department visits scored Emergency Severity Index levels 3 and 4 were triaged accurately 46% and 38%, respectively. We noted racial differences in overall triage accuracy. DISCUSSION: Although the plurality of patients was scored as Emergency Severity Index 4, 50% were mistriaged, and there were disparities based on race indicating Emergency Severity Index mistriages pediatric patients. Further study is needed to elucidate the application of the Emergency Severity Indices in pediatrics using a multicenter emergency department population with diverse clinical and demographic characteristics.

Return visit rates after an emergency department discharge for children with sickle cell pain episodes.

BACKGROUND: High return visit rates after hospitalization for people with sickle cell disease (SCD) have been previously established. Due to a lack of multicenter emergency department (ED) return visit rate data, the return visit rate following ED discharge for pediatric SCD pain treatment is currently unknown. PROCEDURE: A seven-site retrospective cohort study of discharged ED visits for pain by children with SCD was conducted using the Pediatric Emergency Care Applied Research Network Registry. Visits between January 2017 and November 2021 were identified using previously validated criteria. The primary outcome was the 14-day return visit rate, with 3- and 7-day rates also calculated. Modified Poisson regression was used to analyze associations for age, sex, initial hospitalization rate, and a visit during the COVID-19 pandemic with return visit rates. RESULTS: Of 2548 eligible ED visits, approximately 52% were patients less than 12 years old, 50% were female, and over 95% were non-Hispanic Black. The overall 14-day return visit rate was 29.1% (95% confidence interval [CI]: 27.4%-30.9%; site range 22.7%-31.7%); the 7- and 3-day return visit rates were 23.0% (95% CI: 21.3%-24.6%) and 16.7% (95% CI: 15.3%-18.2%), respectively. Younger children had slightly lower 14-day return visit rates (27.3% vs. 31.1%); there were no associations for site hospitalization rate, sex, and a visit occurring during the pandemic with 14-day returns. CONCLUSION: Nearly 30% of ED discharged visits after SCD pain treatment had a return visit within 14 days. Increased efforts are needed to identify causes for high ED return visit rates and ensure optimal ED and post-ED care.

Children's falls inside the inpatient setting: A qualitative study of parent perceptions and the implications for falls prevention messaging.

PURPOSE: To explore how parents understand their children's falls during hospitalization and how they perceive hospital interventions and messaging related to fall risk and prevention. DESIGN AND METHODS: Semi-structured interviews were conducted to explore parent-caregiver descriptions of their children's falls during hospitalization. Prospective purposive sampling was used to identify eligible participants. Interviews were conducted with the parent-caregiver who was present at the time of the fall event. Themes were coded both inductively and deductively using a constant comparative method. RESULTS: Twelve parent-child groupings participated. Three themes emerged: parental knowledge of risk, parent sense of threat to the identity of the child, and age differences in perception of level of controllability of risk. CONCLUSIONS: Falls prevention education is usually delivered as a straightforward presentation of generic factual information about risk factors, with the assumption that families need more information. Findings from this study challenge this approach. This study indicates that parent-caregivers have fairly high levels of knowledge about children's fall risks; parent-caregiver beliefs about the controllability of falls may differ based on age of the child; finally, as has been found in previous studies of adult falls, parent-caregivers may perceive hospital falls prevention measures as a source of potential threat to their child''s already vulnerable social identity. PRACTICE IMPLICATIONS: Involving the parent-caregiver in the fall risk assessment and collaborative development of falls prevention interventions may increase family alliance with health advice and reduce the incidence of falls in hospitalized children.

Experience of burnout among pediatric inpatient nurse preceptors.

BACKGROUND: There is a paucity of research describing burnout among nurses who work in the role of a preceptor, in the inpatient setting. In 2017, precepting nurses at an academic children's hospital were surveyed using the Oldenburg Burnout Inventory (OBI). Results of the survey inspired leadership to further explore this phenomenon using key informant interviews. METHODS: Prospective qualitative description with individual interviews analyzed using conventional content analysis. RESULTS: In regard to burnout, five themes illustrated the experiences of precepting nurses. "Feeling the Responsibility" reflected the cognitive stain of precepting. "An Obligation to the Role," reflected the dimensions of the OBI that addressed distancing and decreased interest in the work. However, preceptors described positive experiences "It Challenges Me Every Day," awareness of resources "Nursing Response," and insights for improving the preceptor program, "Future Strategies." CONCLUSIONS: While elements of the OBI were salient in the data, three inductive themes highlighted the balance of positive challenges and learning opportunities that inspire preceptors.

Predictors of specialty certification among paediatric hospital nurses.

AIMS AND OBJECTIVES: To evaluate differences in hospitals' proportion of specialty certified nurses and to determine whether and to what extent individual nurse characteristics and organisational hospital characteristics are associated with a nurse's likelihood of having specialty certification. BACKGROUND: Prior research has shown that patients in hospitals with high proportions of specialty certified nurses have better outcomes including lower mortality and fewer adverse events, yet less is known about what motivates nurses to obtain specialty certification. METHODS AND DESIGN: Cross-sectional study of paediatric nurses in 119 acute care hospitals. Multivariate logistic regression models were used to determine the association between individual nurse characteristics, organisational hospital characteristics and an individual nurses' likelihood of holding a specialty certification. STROBE was followed. RESULTS: The proportion of certified nurses varies substantially among hospitals, with Magnet® hospitals being significantly more likely, on average, to have higher proportions of certified nurses. Nurses in children's hospitals were no more likely than paediatric nurses in general hospitals to be certified. A nurse's years of experience and bachelors-preparation were significantly associated with higher odds of having certification. The strongest predictors of certification were favourable nurse work environments and Magnet® -designation of the hospital. CONCLUSIONS: While individual attributes of the nurse were associated with a nurse's likelihood of having a specialty certification, the strongest predictors of certification were modifiable attributes of the hospital-a favourable nurse work environment and Magnet® -designation. RELEVANCE TO CLINICAL PRACTICE: Hospital administrators seeking to increase the proportion of specialty certified nurses in their organisation should look to improvements in the organisation's nurse work environment as a possible mechanism.

The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care.

OBJECTIVES: Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture. METHODS: An observational cross-sectional study used 2015-2016 survey data on 177 hospitals in four U.S. states, including pediatric care in general hospitals and freestanding children's hospitals. Pediatric registered nurses providing direct patient care assessed hospital safety and the clinical work environment. Safety was measured by items from the Agency for Healthcare Research and Quality's Culture of Patient Safety survey. Hospital clinical work environment was measured by the National Quality Forum-endorsed Practice Environment Scale. RESULTS: A total of 1875 pediatric nurses provided an assessment of safety in their hospitals. Sixty percent of pediatric nurses gave their hospitals less than an excellent grade on patient safety; significant variation across hospitals was observed. In the average hospital, 46% of nurses report that mistakes are held against them and 28% do not feel safe questioning authority regarding unsafe practices. Hospitals with better clinical work environments received better patient safety grades. CONCLUSIONS: The culture of patient safety varies across U.S. hospital pediatric settings. In better clinical work environments, nurses report more positive safety culture and higher safety grades.

Advancing Opportunities for Clinical Inquiry and Professional Development During a Pandemic.

A notable challenge faced by pediatric hospitals during the COVID-19 pandemic included the need to decrease inpatient census and socially distant non-clinical hospital employees to alternative work arrangements. In doing so, nurses and other clinical care services employees were reassigned to new roles, while others continue to work from home. This paper aims to describe how during the COVID-19 pandemic, a pediatric hospital-based center for nursing research and evidence-based practice used this opportunity to virtually engage staff across the department in topics of clinical inquiry through education sessions, office hours, and individualized/team consultation. Therefore, elevating and increasing the presence of nursing research and evidence-based practice while providing opportunities for the continued professional development of nurses, respiratory therapists, clinical dietitians, child life specialists and employees in neurodiagnostics.

Traumatic stress in emergency nurses: Does your work environment feel like a war zone?

INTRODUCTION: Emergency nurses are exposed to both primary and secondary trauma with attendant sequelae in both work and personal spheres. The purpose of the study was to investigate the prevalence of traumatic stress, measured by the secondary traumatic stress scale (STSS) in a sample of emergency nurses and describe the impact of traumatic stress on nursing practice and workplace environment. METHODS: Mixed methods approach using survey instrument data from the Secondary Traumatic Stress Scale (STSS) (N = 125) and focus group data (N = 53). RESULTS: The average total score on the STSS was 51.83 for nurses who attended one of the focus groups 48.42 for nurses who did not attend (clinical cutoff for STS = 39). Focus group data aligned with elements of the STSS; thematic categories of cumulative trauma, mental health sequelae, bullying and organizational violence, coping mechanisms, relationship damage, and solutions were described. Although we measured only STS, participants often used the terms "PTSD" and "STS" interchangeably. CONCLUSIONS: The nurses in this study demonstrated high levels of STS and described in detail how chronic, cumulative trauma affected relational nursing care and social connections. Participants discussed high levels of suicidality in the profession, and the compounding trauma of relational and organizational violence. The pervasiveness of traumatic stress and the extent to which it affects all areas of nurses' lives is a cause for great concern.

Safety and Quality of Pediatric Care in Freestanding Children's and General Hospitals.

OBJECTIVES: The purpose of this study was to evaluate quality and safety of care in acute pediatric settings from the perspectives of nurses working at the bedside and to investigate hospital-level factors associated with more favorable quality and safety. METHODS: Using data from a large survey of registered nurses in 330 acute care hospitals, we described nurses' assessments of safety and quality of care in inpatient pediatric settings, including freestanding children's hospitals (FCHs) (n = 21) and general hospitals with pediatric units (n = 309). Multivariate logistic regression models were used to estimate the effects of being a FCH on favorable reports on safety and quality before and after adjusting for hospital-level and nurse characteristics and Magnet status. RESULTS: Nurses in FCHs were more likely to report favorably on quality and safety after we accounted for hospital-level and individual nurse characteristics; however, adjusting for a hospital's Magnet status rendered associations between FCHs and quality and safety insignificant. Nurses in Magnet hospitals were more likely to report favorably on quality and safety. CONCLUSIONS: Quality and safety of pediatric care remain uneven; however, the organizational attributes of Magnet hospitals explain, in large part, more favorable quality and safety in FCHs compared with pediatric units in general acute care hospitals. Modifiable features of the nurse work environment common to Magnet hospitals hold promise for improving quality and safety of care. Transforming nurse work environments to keep patients safe, as recommended by the National Academy of Medicine 20 years ago, remains an unfinished agenda in pediatric inpatient settings.

The perceived impact of legalized cannabis on nursing workload in adult and pediatric emergency department visits: A qualitative exploratory study.

OBJECTIVE: To investigate changes in emergency nursing workload related to cannabis ingestion or inhalation by adult and pediatric patients in states and bordering states where recreational cannabis is legal. DESIGN: Qualitative exploratory design using data collected from focus groups. SAMPLE: Twenty-four English-speaking emergency nurses over the age of 18 who provide direct care to patients and work in US emergency departments located in a state, or bordering state, where recreational cannabis use is legal. MEASUREMENTS: Qualitative data were gathered using a semi-structured interview format and analyzed using situational analysis. RESULTS: The legalization of recreational cannabis in some US states is reported as resulting in an increase in patients presenting with cyclic vomiting syndromes, and increased difficulty in managing both associated behaviors and repetitive ED presentations. New presentations also include unintentional intoxication in both pediatric and geriatric populations. An unexpected finding was the displacement of local homeless populations by younger, indigent "cannabis tourists"; social services agencies might consider this while planning for cannabis legalization in their state or territory. CONCLUSIONS: To protect public health and safety, regulatory efforts to standardize the formulation, dosing and labeling of cannabis products would be beneficial along with educational initiatives for both consumers and health care providers.

How Much Cardiopulmonary Resuscitation Does a Pediatric Emergency Provider Perform in 1 Year? A Video-Based Analysis.

OBJECTIVES: We aimed to quantify time performing chest compressions (CCs) per year of individual providers in a pediatric ED and to project a rate of opportunity for CC based on median clinical hours per provider category. METHODS: This was an observational study of video-recorded resuscitations in a pediatric ED over 1 year. Events where CCs were performed for more than 2 minutes were included. Identification of providers and duration of CCs per provider were determined by video review. Time of CCs was totaled per provider over the study period. Data were expressed as median and interquartile range (IQR). Rate of opportunity for providing CC to a child was calculated by dividing the median clinical hours per year per provider type by the number of CC events per year. RESULTS: Twenty-three CC events totaling 340 minutes of CCs were analyzed. Chest compressions were performed by 6 (13%) of 45 attending physicians, 3 (25%) of 12 fellows, 32 (22%) of 143 nurses, and 19 (59%) of 32 technicians. The median amount of time performing CC was 182 seconds (IQR, 91-396 seconds); by provider category, median amount of time was as follows: attending physicians, 83 seconds (IQR, 64-103 seconds); fellows, 45 seconds (IQR, 6-83 seconds); nurses, 128 seconds (IQR, 93-271 seconds); and technicians, 534 seconds (IQR, 217-793 seconds). The projected hours needed for an opportunity to perform CCs was 730 hours (91 shifts) for attending physicians, 243 hours (30 shifts) for fellows, and 1460 hours (121 shifts) for nurses and technicians. CONCLUSIONS: Performing CCs on children in the ED is a rare event, with a median of 3 minutes per provider per year. Future studies should determine training methods to optimize readiness for these rare occurrences.

Nursing Research Priorities in the Pediatric Emergency Care Applied Research Network (PECARN): Reaching Consensus Through the Delphi Method.

INTRODUCTION: Pediatric emergency nurses who are directly involved in clinical care are in key positions to identify the needs and concerns of patients and their families. The 2010 Institute of Medicine report on the future of nursing supports the active participation of nurses in the design and implementation of solutions to improve health outcomes. Although prior efforts have assessed the need for research education within the Pediatric Emergency Care Applied Research Network (PECARN), no systematic efforts have assessed nursing priorities for research in the pediatric ED setting. METHODS: The Delphi technique was used to reach consensus among emergency nurses in the PECARN network regarding research priorities for pediatric emergency care. The Delphi technique uses an iterative process by offering multiple rounds of data collection. Participants had the opportunity to provide feedback during each round of data collection with the goal of reaching consensus about clinical and workforce priorities. RESULTS: A total of 131 nurses participated in all 3 rounds of the survey. The participants represented the majority of the PECARN sites and all 4 regions of the United States. Through consensus 10 clinical and 8 workforce priorities were identified. DISCUSSION: The PECARN network provided an infrastructure to gain expert consensus from nurses on the most current priories that researchers should focus their efforts and resources. The results of the study will help inform further nursing research studies (for PECARN and otherwise) that address patient care and nursing practice issues for pediatric ED patients.