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.

Equivocal Pediatric Appendicitis: Unenhanced MR Imaging Protocol for Nonsedated Children-A Clinical Effectiveness Study.

PURPOSE: To determine retrospectively the clinical effectiveness of an unenhanced magnetic resonance (MR) imaging protocol for evaluation of equivocal appendicitis in children. MATERIALS AND METHODS: Institutional review board approval was obtained. Pediatric patients (≤18 years old) underwent unenhanced MR imaging and contrast material-enhanced computed tomography (CT) of the appendix between December 2013 and November 2014 and December 2012 and November 2013, respectively, within 24 hours after an abdominal ultrasonographic examination with results equivocal for appendicitis. Pertinent MR imaging and CT reports were reviewed for visibility of the appendix, presence of appendicitis and appendiceal perforation, and establishment of an alternative diagnosis. Surgical reports, pathologic reports, and 30-day follow-up medical records were used as reference standards. Diagnostic performance with MR imaging and CT was calculated with 95% confidence intervals (CIs) for diagnosis of appendicitis and appendiceal perforation. The Fisher exact test was used to compare proportions; the Student t test was used to compare means. RESULTS: Diagnostic performance with MR imaging was comparable to that with CT for equivocal pediatric appendicitis. For MR imaging (n = 103), sensitivity was 94.4% (95% CI: 72.7%, 99.9%) and specificity was 100% (95% CI: 95.8%, 100%); for CT [n = 58], sensitivity was 100% (95% CI: 71.5%, 100%), specificity was 97.9% (95% CI: 88.7%, 100%). Diagnostic performance with MR imaging and CT also was comparable for detection of appendiceal perforation, with MR imaging (n = 103) sensitivity of 90.0% (95% CI: 55.5%, 99.8%) and specificity of 85.7% (95% CI: 42.1%, 99.6%) and CT (n = 58) sensitivity of 75.0% (95% CI: 19.4%, 99.4%) and specificity of 85.7% (95% CI: 42.1%, 99.6%). The proportion of examinations with identifiable alternative diagnoses was similar at MR imaging to that at CT (19 of 103 [18.4%] vs eight of 58 [13.8%], respectively; P = .52). The proportion of appendixes seen at MR imaging and at CT also was similar (77 of 103 [74.8%] vs 50 of 58 [86.2%], respectively; P = .11). CONCLUSION: Unenhanced MR imaging is sensitive and specific for the diagnosis of equivocal appendicitis in nonsedated pediatric patients.

Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children.

OBJECTIVES: We describe children's postconcussive symptoms (PCSs), neurocognitive function, and recovery during 4 to 5 weeks after mild traumatic brain injury (MTBI) and compare performance and recovery with those of injured control group participants without MTBIs. METHODS: A prospective, longitudinal, observational study was performed with a convenience sample from a tertiary care, pediatric emergency department. Participants were children 10 to 17 years of age who were treated in the emergency department and discharged. The MTBI group included patients with blunt head trauma, Glasgow Coma Scale scores of 13 to 15, loss of consciousness for < or = 30 minutes, posttraumatic amnesia of < or = 24 hours, altered mental status, or focal neurologic deficits, and no intracranial abnormalities. The control group included patients with injuries excluding the head. The Post-Concussion Symptom Questionnaire and domain-specific neurocognitive tests were completed at baseline and at 1 and 4 to 5 weeks after injury. RESULTS: Twenty-eight MTBI group participants and 45 control group participants were compared. There were no significant differences in demographic features. Control group participants reported some PCSs; however, MTBI group participants reported significantly more PCSs at all times. Among MTBI group participants, PCSs persisted for 5 weeks after injury, decreasing significantly between 1 and 4 to 5 weeks. Patterns of recovery on the Trail-Making Test Part B differed significantly between groups; performance on other neurocognitive measures did not differ. CONCLUSIONS: In children 10 to 17 years of age, self-reported PCSs were not exclusive to patients with MTBIs. However, PCSs and recovery patterns for the Trail-Making Test Part B differed significantly between the groups.