Pediatric Sepsis in Community Emergency Care Settings: Guideline Concordance and Outcomes.

OBJECTIVES: Bundled pediatric sepsis care has been associated with improved outcomes in tertiary pediatric emergency departments. Sepsis care at nontertiary sites where most children seek emergency care is not well described. We sought to describe the rate of guideline-concordant care, and we hypothesized that guideline-concordant care in community pediatric emergency care settings would be associated with decreased hospital length of stay (LOS). METHOD: This retrospective cohort study of children with severe sepsis presenting to pediatric community emergency and urgent care sites included children 60 days to 17 years with severe sepsis. The primary predictor was concordance with the American College of Critical Care Medicine 2017 pediatric sepsis resuscitation bundle, including timely recognition, vascular access, intravenous fluids, antibiotics, vasoactive agents as needed. RESULTS: From January 1, 2015, to December 31, 2017, 90 patients with severe sepsis met inclusion criteria; 22 (24%) received guideline-concordant care. Children receiving concordant care had a median hospital LOS of 95.3 hours (50.9-163.8 hours), with nonconcordant care, LOS was 88.3 hours (57.3-193.2 hours). In adjusted analysis, guideline-concordant care was not associated with hospital LOS (incident rate ratio, 0.99 [0.64-1.52]). The elements that drove overall concordance were timely recognition, achieved in only half of cases, vascular access, and timely antibiotics. CONCLUSIONS: Emergency care for pediatric sepsis in the community settings studied was concordant with guidelines in only 24% of the cases. Future study is needed to evaluate additional drivers of outcomes and ways to improve sepsis care in community emergency care settings.

Feature head-start: Conjunction search following progressive feature disclosure.

When a colour/orientation conjunction search display is immediately preceded by a display that shows either the colour or the orientation of each upcoming search item, search is faster after colour-preview than after orientation-preview. One explanation for this feature asymmetry is that colour has priority access to attentional selection relative to features such as orientation and size. In support of this hypothesis, we show that this asymmetry persists even after colour and orientation feature search performance is equated. However, this notion was ruled out by our subsequent experiments in which the target was defined by conjunction of colour and size; colour-preview was less helpful than size-preview (even though colour-feature search was faster than size-feature search, for these feature values). A final set of experiments tested size-preview vs. orientation-preview for size/orientation conjunction search, using stimuli for which orientation-feature search was easier than size-feature search. Size-preview produced much faster search than orientation-preview, demonstrating again that ease of feature search does not predict effects of a feature-preview. Overall, size produced the most facilitation when presented as a feature-preview (for both colour/size and size/orientation conjunctions), followed by colour (for colour/orientation conjunction but not for colour/size conjunction) and then orientation (which never facilitated search). Whilst each feature-preview may potentially facilitate search, the transition from feature-preview display to search display could disrupt search processes, because of luminance and/or colour changes. We see evidence for some sort of disruption when the feature-preview slows search. An explanation of this set of results must focus on both facilitation and disruption: these effects are not mutually exclusive, and neither suffices alone, since performance after feature-preview can be significantly better or significantly worse than conjunction baseline.

Recognizing partially visible objects.

In two experiments we measured object recognition performance as a function of delay. In Experiment 1 we presented half of an image of an object, and then the other half after a variable delay. Objects were subdivided into top versus bottom halves, left versus right halves, or vertical strips. In Experiment 2 we separated the low (LSF) and high spatial frequency (HSF) components of an image, and presented one component followed by the other after a variable delay. For both experiments, performance was worse with a 105ms delay between the presentations of the object components than when the two components were presented simultaneously. These results are consistent with predictions made by models that combine information at a relatively early stage in processing. In addition, the results revealed that object recognition performance is significantly better when the LSF sub-image preceded the HSF sub-image than when the HSF sub-image preceded the LSF sub-image, consistent with previous work suggesting that LSF information is processed prior to HSF in object recognition.

Does previewing one stimulus feature help conjunction search?

We examined the effects of previewing one aspect of a search display, in order to determine what subset of display information is most useful as a prelude to a search task. Observers were asked to indicate the presence or absence of a known target, in a conjunction search where the target was defined by the combination of colour and orientation (a yellow horizontal line presented among yellow vertical and pink horizontal distractors). In the colour preview condition of experiment 1, observers were first shown a 1 s preview of the locations and colours of the search items before the actual search set was presented. That is, search items first appeared as yellow and pink squares for 1 s, which each then turned into yellow and pink oriented lines (in the same locations) which comprised the display to be searched. In the orientation preview condition, observers were first shown a 1 s preview of the locations and orientations of the search items before the actual search display was presented. These two conditions were compared to a control condition consisting of standard conjunction search without any preview display. There was no effect of colour preview; there was a marginal effect of orientation preview, but in the opposite direction from what was expected reaction time increased for orientation preview searches. In experiment 2 these previews were compared to two spatial cueing conditions; in this experiment the colour preview did provide a small amount of help. Finally, in experiment 3 both previews were presented in succession, and increased facilitation was found, in particular when the colour preview preceded the orientation preview. These findings are discussed in relation to the literature, in particular the Guided Search model (Wolfe et al 1989 Journal of Experimental Psychology: Human Perception and Performance 15 419-433; Wolfe 1994 Psychonomic Bulletin & Review 1 202-238).

Search of jumping items: visual marking and discrete motion.

Watson and Humphreys (1997 Psychological Review 104 90-122) showed that when searching for a target, observers can ignore a previewed set of distractors (other items), effectively decreasing the number of relevant items in a difficult search display and thus speeding performance ('visual marking'). Other researchers have more recently investigated visual marking for continuously moving items, finding that shared features, and preserved inter-item spatial relationships, are helpful. Here, we tested whether visual marking occurs for a set of initial items that moves in one discrete jump (preserving shared features and inter-item spatial relationships). Marking did not occur in these displays, and we interpret this result in the context of previous research on visual marking.

Does partial difficult search help difficult search?

Olds, Cowan, and Jolicoeur (2000a, 2000b) showed that exposure to a display that affords pop-out search a target among distractors of only one color) can assist processing of a related display that requires difficult search. They added distractors of an additional color to the initial simple display and analyzed response time distributions to show that exposure to the initial display aided subsequent search in the difficult portion (this finding was called search assistance). To test whether search assistance depends on perceptual grouping of the initial items, we presented initial items that were more difficult to group (two colors of distractors, instead of just one). The target appeared (on 50% of the trials) among distractors of two colors, and then after a delay, more distractors of those two colors were added to the display. Exposure to the initial easier portion of the display did not assist processing of the second portion of the display when the initial display contained a large number of items; we found tentative evidence for assistance with small numbers of initial items. In the Olds et al. (2000a, 2000b) studies, it was easy to group the initial distractor items, because they were all the same color. In contrast, in the present study, it was difficult to group the heterogeneous initial distractor items. Search assistance is found only when initial item grouping is relatively easy, and thus we conclude that search assistance depends on grouping.

The decay and interruption of interactions between search mechanisms.

The attentional mechanisms in the brain responsible for fast pop-out search and slower difficult search have been shown to interact. Even if pop-out search is interrupted, by the addition of extra distractors to an initially simple search display, the partial computations calculated by the mechanisms responsible for pop-out can facilitate subsequent difficult search ("search assistance"; Psychon. Bull. Rev. 7 (2000) 292; Vision Res. 40 (2000) 891). With the present experiments, we aimed to discover whether search assistance is disrupted when the display that affords pop-out search disappears before the appearance of the display that must be examined by difficult search. Search assistance was not disrupted by the insertion of a blank screen in between the first and second portions of the display (Experiment 1). Search assistance for target-present trials was not disrupted by the insertion of black disks in between the first and second portions of the display (Experiment 2), but this manipulation did disrupt search assistance for target-absent trials. Implications for the relationship between search assistance and visual marking of distractors (Psychol. Rev. 104 (1997) 90) are discussed.