Implementation Barriers Encountered During a Universal Suicide Screening Program in Pediatric Emergency Departments.

OBJECTIVE: Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs. METHODS: Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported. RESULTS: Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening. CONCLUSIONS: Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

The Association of Pediatric Emergency Medicine Physicians' Self-Identified Skills in Suicide Risk Assessment and Management With Training in Mental Health.

OBJECTIVE: Because changes to pediatric emergency medicine (PEM) education may help address barriers to youth suicide risk screening programs, this study aimed to understand the impact of formal training in areas that likely include suicide-related practices, developmental-behavioral pediatrics (DBP) and adolescent medicine (AM), on PEM physician-perceived level of training, attitudes, and confidence assessing and managing youth suicide risk. METHODS: Twenty-seven PEM attendings and trainees completed an online survey and were divided into 2 groups: those who had completed DBP and AM rotations (DBP/AM+; n = 20) and those who had not completed either rotation (DBP/AM-; n = 7). We compared perceived level of training, attitudes, and confidence in assessing and managing suicide risk across groups. We also examined the relationship between perceived level of training and confidence. Finally, we conducted exploratory analyses to evaluate the effect of an additional formal rotation in child psychiatry. RESULTS: The DBP/AM+ and DBP/AM- groups did not differ on perceived level of training or on attitudes and confidence in suicide risk assessment or management. Perceived level of training in assessment and management predicted confidence in both assessing and managing suicide risk. Additional training in child psychiatry was not associated with increased perceived level of training or confidence. CONCLUSIONS: The DBP and AM rotations were not associated with higher perceived levels of suicide risk training or greater confidence; however, perceived level of training predicted physician confidence, suggesting continued efforts to enhance formal PEM education in mental health would be beneficial.

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department.

INTRODUCTION: Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. METHODS: After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. RESULTS: 82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. CONCLUSION: ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

Barriers to Universal Suicide Risk Screening for Youth in the Emergency Department.

OBJECTIVE: Given the increasing rates of youth suicide, it is important to understand the barriers to suicide screening in emergency departments. This review describes the current literature, identifies gaps in existing research, and suggests recommendations for future research. METHODS: A search of PubMed, MEDLINE, CINAHL, PsycInfo, and Web of Science was conducted. Data extraction included study/sample characteristics and barrier information categorized based on the Exploration, Preparation, Implementation, Sustainment model. RESULTS: All studies focused on inner context barriers of implementation and usually examined individuals' attitudes toward screening. No study looked at administrative, policy, or financing issues. CONCLUSIONS: The lack of prospective, systematic studies on barriers and the focus on individual adopter attitudes reveal a significant gap in understanding the challenges to implementation of universal youth suicide risk screening in emergency departments.

Universal Suicide Risk Screening for Youths in the Emergency Department: A Systematic Review.

OBJECTIVES: To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts. METHODS: A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included. RESULTS: All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%. CONCLUSIONS: Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

Implementation of Febrile Infant Management Guidelines Reduces Hospitalization.

The clinical management of well-appearing febrile infants 7-60 days of age remains variable due in part to multiple criteria differentiating the risk of a serious bacterial infection. The purpose of this quality improvement study was to standardize risk stratification in the emergency department and length of stay in the inpatient unit by implementing an evidence-based clinical practice guideline (CPG). METHODS: The Model for Improvement was used to implement a CPG for the management of well-appearing febrile infants, with collaboration between pediatric emergency medicine and pediatric hospital medicine physicians. Interventions included physician education, process audit/feedback, and development of an electronic orderset. We used statistical process control charts to assess the primary aims of appropriate risk stratification and length of stay. RESULTS: Over a 34-month period, 168 unique encounters (baseline n = 65, intervention n = 103) were included. There was strong adherence for appropriate risk stratification in both periods: the proportion of low-risk patients admitted inappropriately decreased from 14.8% to 10.8%. Among admitted high-risk patients, the mean length of stay decreased from 49.4 to 38.2 hours, sustained for 18 months. CONCLUSION: CPG implementation using quality improvement methodology can increase the delivery of evidence-based care for febrile infants, leading to a reduction in length of stay for high-risk infants.

Interpreters: telephonic, in-person interpretation and bilingual providers.

CONTEXT: Language barriers affect health care interactions. Large, randomized studies of the relative efficacy of interpreter modalities have not been conducted. OBJECTIVE: To compare the efficacy of telephonic and in-person medical interpretation to visits with verified bilingual physicians. METHODS: This was a prospective, randomized trial. The setting was an urban pediatric emergency department at which approximately 20% of visits are by families with limited English proficiency. The participants were families who responded affirmatively when asked at triage if they would prefer to communicate in Spanish. Randomization of each visit was to (1) remote telephonic interpretation via a double handset in the examination room, (2) an in-person emergency department-dedicated medical interpreter, or (3) a verified bilingual physician. Interviews were conducted after each visit. The primary outcome was a blinded determination of concordance between the caregivers' description of their child's diagnosis with the physician's stated discharge diagnosis. Secondary outcomes were qualitative measures of effectiveness of communication and satisfaction. Verified bilingual providers were the gold standard for noninferiority comparisons. RESULTS: A total of 1201 families were enrolled: 407 were randomly assigned to telephonic interpretation and 377 to in-person interpretation, and 417 were interviewed by a bilingual physician. Concordance between the diagnosis in the medical record and diagnosis reported by the family was not different between the 3 groups (telephonic: 95.1%; in-person: 95.5%; bilingual: 95.4%). The in-person-interpreter cohort scored the quality and satisfaction with their visit worse than both the bilingual and telephonic cohorts (P < .001). Those in the bilingual-provider cohort were less satisfied with their language service than those in the in-person and telephonic cohorts (P < .001). Using the bilingual provider as a gold standard, noninferiority was demonstrated for both interpreter modalities (telephonic and in-person) for quality and satisfaction of the visit. CONCLUSIONS: Both telephonic and in-person interpretation resulted in similar concordance in understanding of discharge diagnosis compared with bilingual providers. In general, noninferiority was also seen on qualitative measures, although there was a trend favoring telephonic over in-person interpretation.

Diagnosis and emergent management of anaphylaxis in children.

Anaphylactic and anaphylactoid reactions are serious, potentially life-threatening reactions with well-described clinical manifestations. Although the pathophysiology of these reactions varies with the offending agent and route of exposure, the treatment remains the same. Attention to airway, breathing, and circulation and the prompt administration of epinephrine remain the mainstays of therapy. Once an at-risk individual is identified, the proper instruction on the avoidance of the offending agent, the use of the EpiPen, and referral to a specialist in the treatment of allergic reactions may be instrumental in the future health and safety of that patient.