Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge.

Importance: Pediatric readiness is essential for all emergency departments (EDs). Children's experience of care may differ according to operational challenges in children's hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges. Objective: To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022. Design, Setting, and Participants: This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children's hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs. Exposures: Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022. Main Outcomes and Measures: Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours). Results: A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children's hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites. Conclusions and Relevance: In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC).

STUDY OBJECTIVE: Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. METHODS: MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. RESULTS: From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). CONCLUSION: Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

INTRODUCTION: Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions. METHODS: A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins. RESULTS: Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality. CONCLUSION: While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.

Michigan Emergency Department Leader Attitudes Toward and Experiences With Clinical Pathways to Guide Admission Decisions: A Mixed-methods Study.

OBJECTIVES: The objective was to characterize emergency department (ED) leader's attitudes toward potentially avoidable admissions and experiences with the use of clinical pathways to guide admission decisions, including the challenges and successes with implementation of these pathways. METHODS: A mixed-methods study of Michigan ED leaders was conducted. First, a cross-sectional Web-based survey was distributed via e-mail to all 135 hospital-based EDs in the state. Descriptive statistics were calculated. Survey participants who provided contact information were considered eligible for follow-up. Semistructured interviews were conducted by telephone until thematic saturation was reached. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and thematically coded. Representative quotes were extracted for reporting. RESULTS: Survey responses were received from 64 ED leaders (48% eligible response rate). Semistructured interviews were conducted with a purposeful sample of 11 of the 29 representatives willing to be contacted. Eight sites implemented clinical care pathways as a strategy to reduce avoidable admissions. Pathways were developed for high-frequency conditions. Many pathways were multidisciplinary, incorporating case managers and outpatient care providers, which was thought to improve acceptability. Five models of care emerged 1) standardized care, 2) observation medicine, 3) enhanced follow-up, 4) care coordination, and 5) comprehensive programs. We identified barriers to and facilitators of discharging a patient from the ED when an admission otherwise could be avoided. Barriers included limited access to follow-up, lack of care coordination, and lack of trust in patient's ability to provide self-care or navigate the system. Facilitators included strong relationships with outpatient providers, care coordination, and shared decision making. CONCLUSIONS: Potential solutions to help avoid hospitalization from the ED include multidisciplinary clinical care pathways. Successful pathways emerged from bringing stakeholders from the ED, hospital, and health care community together. Additionally, emergency providers need systems and supports in place to help their patients navigate follow-up care in a timely fashion.

Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department?

OBJECTIVES: Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA. METHODS: This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis. RESULTS: There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods. CONCLUSIONS: Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.

Simulation in Pediatric Emergency Medicine Fellowships.

BACKGROUND AND OBJECTIVES: Graduate medical education faces challenges as programs transition to the next accreditation system. Evidence supports the effectiveness of simulation for training and assessment. This study aims to describe the current use of simulation and barriers to its implementation in pediatric emergency medicine (PEM) fellowship programs. METHODS: A survey was developed by consensus methods and distributed to PEM program directors via an anonymous online survey. RESULTS: Sixty-nine (95%) fellowship programs responded. Simulation-based training is provided by 97% of PEM fellowship programs; the remainder plan to within 2 years. Thirty-seven percent incorporate >20 simulation hours per year. Barriers include the following: lack of faculty time (49%) and faculty simulation experience (39%); limited support for learner attendance (35%); and lack of established curricula (32%). Of those with written simulation curricula, most focus on resuscitation (71%), procedures (63%), and teamwork/communication (38%). Thirty-seven percent use simulation to evaluate procedural competency and resuscitation management. PEM fellows use simulation to teach (77%) and have conducted simulation-based research (33%). Thirty percent participate in a fellows' "boot camp"; however, finances (27%) and availability (15%) limit attendance. Programs receive simulation funding from hospitals (47%), academic institutions (22%), and PEM revenue (17%), with 22% reporting no direct simulation funding. CONCLUSIONS: PEM fellowships have rapidly integrated simulation into their curricula over the past 5 years. Current limitations primarily involve faculty and funding, with equipment and dedicated space less significant than previously reported. Shared curricula and assessment tools, increased faculty and financial support, and regionalization could ameliorate barriers to incorporating simulation into PEM fellowships.

The role of high-fidelity simulation in training pediatric emergency medicine fellows in the United States and Canada.

OBJECTIVES: The American Academy of Pediatrics Section on Emergency Medicine's Simulation Interest Group developed a survey targeting pediatric emergency medicine (PEM) fellowship program directors to assess the use of high-fidelity simulation (HFS) in PEM fellow training. METHODS: Content experts in simulation and in PEM developed a 38-item Internet-based questionnaire that was distributed to PEM program directors via e-mail though www.surveymonkey.com. RESULTS: Seventy-seven percent (51/66) of PEM program directors in the United States and Canada responded to the survey. Sixty-three percent of programs incorporate HFS in PEM fellowship training. For programs with HFS, the most frequent uses of HFS include (1) decision making for trauma resuscitations (97%, 31/32) and medical emergencies (91%, 29/32), and for the application of advanced life support (84%, 27/32); (2) technical skills: intubation (100%, 31/31), bag-mask ventilation (94%, 29/31), cardioversion/defibrillation (90%, 28/31), and difficult airway management (84%, 26/31). Of program directors without simulation, a majority valued simulation for PEM fellow training, and 59% (11/19) plan on expanding efforts. Perceived barriers to an active simulation program exist: lack of financial support (79%, 15/19), lack of simulator equipment (74%, 14/19), lack of a dedicated physical space (68%, 13/19), and insufficiently experienced simulation faculty (58% 11/19). CONCLUSIONS: Sixty-three percent of PEM fellowship programs integrate HFS-based activities. The majority of PEM fellowship program directors value the role of HFS in augmenting clinical experience and documenting procedural skills. Regional simulation centers are one possible solution to offer HFS training to fellowships with limited financial support and/or lack of experienced simulation faculty.

Prospective comparison of live evaluation and video review in the evaluation of operator performance in a pediatric emergency airway simulation.

INTRODUCTION: Real-time assessment of operator performance during procedural simulation is a common practice that requires undivided attention by 1 or more reviewers, potentially over many repetitions of the same case. OBJECTIVE: To determine whether reviewers display better interrater agreement of procedural competency when observing recorded, rather than live, performance; and to develop an assessment tool for pediatric rapid sequence intubation (pRSI). METHODS: A framework of a previously established Objective Structured Assessment of Technical Skills (OSATS) tool was modified for pRSI. Emergency medicine residents (postgraduate year 1-4) were prospectively enrolled in a pRSI simulation scenario and evaluated by 2 live raters using the modified tool. Sessions were videotaped and reviewed by the same raters at least 4 months later. Raters were blinded to their initial rating. Interrater agreement was determined by using the Krippendorff generalized concordance method. RESULTS: Overall interrater agreement for live review was 0.75 (95% confidence interval [CI], 0.72-0.78) and for video was 0.79 (95% CI, 0.73-0.82). Live review was significantly superior to video review in only 1 of the OSATS domains (Preparation) and was equivalent in the other domains. Intrarater agreement between the live and video evaluation was very good, greater than 0.75 for all raters, with a mean of 0.81 (95% CI, 0.76-0.85). CONCLUSION: The modified OSATS assessment tool demonstrated some evidence of validity in discriminating among levels of resident experience and high interreviewer reliability. With this tool, intrareviewer reliability was high between live and 4-months' delayed video review of the simulated procedure, which supports feasibility of delayed video review in resident assessment.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations.

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.

A randomized controlled trial of an emergency department-based interactive computer program to prevent alcohol misuse among injured adolescents.

STUDY OBJECTIVE: To determine whether an emergency department (ED)-based laptop computer intervention reduces the normative age-related increase in alcohol misuse compared with standard of care. METHODS: This was a randomized controlled trial conducted from October 11, 1999, to April 14, 2001, in a community teaching hospital and university medical center. Subjects were aged 14 to 18 years and with a minor injury. Controls and intervention participants completed a computer-based questionnaire. Intervention participants also completed a laptop-based interactive computer program to affect alcohol misuse. Main outcome measures were Alcohol Misuse Index (Amidx) and binge-drinking episodes. Follow-up occurred by telephone at 3 and 12 months. Analysis included repeated-measures analysis of variance (alpha=0.05; power 0.80; effect size 0.10). RESULTS: Three hundred twenty-nine participants were randomized to the intervention group, and 326 participants were randomized to the control group. Two hundred ninety-five (89.7%) intervention subjects and 285 (87.4%) control subjects completed 3- and 12-month follow-ups. For intervention and control groups, respectively, mean age was 16.0 and 15.9 years and men composed 66.8% and 66.3% of the groups; Amidx scores were 2.2 and 2.0; binge-drinking episodes were 1.2 and 1.0. Outcomes for intervention and control, respectively, were Amidx (3 months) 1.5 and 1.4; Amidx (12 months) 1.8 and 2.1; binge drinking (3 months) 0.9 and 0.8; and binge drinking (12 months) 1.4 and 1.2. Overall, there were no significant effects (effect size 0.04). No detrimental effects were noted. Subgroup analysis suggested that the intervention may have an effect among subjects with experience drinking and driving (5% of the sample). CONCLUSION: The intervention was not effective in decreasing alcohol misuse among the study population. Further research will be required to determine effectiveness among the subgroup of adolescent minor injury patients who have experience drinking and driving.

Baclofen toxicity in an 8-year-old with an intrathecal baclofen pump.

Baclofen delivered by intrathecal pumps (ITB) is increasingly being utilized in the pediatric population, however, resources and education to support problems with these devices are limited. Typical management strategies for systemic baclofen overdose include removal of baclofen from the device reservoir or removal of cerebrospinal fluid from the adjacent device catheter. Appropriate care of these patients requires awareness of the clinical patterns of toxicity and mechanics of the ITB pump delivery system. This report describes the clinical presentation, unfamiliar dilemmas, and the management of a pediatric patient with intrathecal baclofen toxicity, noting problems that may arise in the care of these patients.

Feasibility of using an interactive laptop program in the emergency department to prevent alcohol misuse among adolescents.

STUDY OBJECTIVE: Alcohol, the most commonly used substance among adolescents, is frequently associated with injury. Effective interventions to prevent adolescent alcohol use and misuse in acute care settings are lacking. A laptop-based alcohol prevention program could reinforce other prevention efforts that adolescents may receive. We determined the feasibility of using an interactive laptop program with adolescent emergency department (ED) patients to prevent alcohol use and misuse. METHODS: We used the recruitment phase of a randomized controlled trial at an academic medical center and an urban teaching hospital. Patients were aged 14 to 18 years and presented within 24 hours of an acute injury. Measures included patient recruitment, mechanism of injury, injury severity score, alcohol use characteristics, and patients' opinion of the computer program. RESULTS: Of 843 eligible patients, 671 (79.6%) were enrolled and 655 (77.7%) completed the program. Parent or guardian reluctance was the most frequent reason for refusal. The participants averaged 16.0 years of age (range 14 to 18 years; SD 1.5 years), 66.9% were male, and 68.3% were white. Approximately 71% reported "ever" drinking. Recent alcohol use (past 3 months) by those "ever" drinking was as follows: 62.3% drank, 31.2% got drunk, and 37.4% binge drank. Seventy-four percent of recent drinkers reported that the program made them rethink their alcohol use. Ninety-four percent of participants liked the program. Only 5.3% required assistance with the program. CONCLUSION: Use of an interactive computer program in the ED appears feasible. Further work is being done to evaluate the effectiveness of the program in reducing alcohol-related behaviors among adolescents.