Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process.

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Impact of a Bronchiolitis Clinical Pathway on Management Decisions by Preferred Language.

Background: Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care. Methods: We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition. Results: There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022). Conclusions: A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity.

Improving Discharge Safety in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement. METHODS: At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates. RESULTS: Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates. CONCLUSIONS: The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

Effect of a Multispecialty Faculty Handoff Initiative on Safety Culture and Handoff Quality.

Structured handoffs at transitions of care are vital components of patient safety. A safety culture survey showed that "handoffs and transitions" were among the lowest scoring dimensions at our hospital. We sought to improve physician handoffs and safety culture scores by implementing standardized handoff communication across multiple divisions of an academic pediatric department. Methods: We used a modified learning collaborative model to implement an I-PASS program, including training, standardized verbal handoff processes, observation and feedback, and sustainment. The setting was the Department of Pediatrics (DoP) within a tertiary academic children's hospital encompassing 13 clinical divisions. The primary outcome was a change in the DoP staff physician "handoffs and transitions" score on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture. Process measures included handoff duration and proportion of handoffs using the complete I-PASS mnemonic. Results: Five hundred sixty-seven physicians from clinical divisions participated over 14 months. One hundred percent of eligible physicians completed an introductory online I-PASS training module. The "handoffs and transitions" score improved from 46% to 54% from 2018 to 2020. From May 2019 to February 2020, the proportion of observed handoffs with all five elements of the I-PASS mnemonic improved from 62% to 100%, and the duration of handoffs per patient did not change. Conclusions: We successfully implemented an I-PASS program across an academic department of pediatrics. The departmental staff physician safety culture "handoff and transitions" score improved. The adherence to the I-PASS mnemonic improved. The duration of handoffs did not change over the study period.

Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline.

BACKGROUND: Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019. METHODS: A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System. RESULTS: Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time. CONCLUSIONS: We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.

Association of limited English proficiency and increased pediatric emergency department revisits.

OBJECTIVE: Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits. METHODS: This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted. RESULTS: There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results. CONCLUSIONS: These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Does Timing Matter?: Timing and Outcomes Among Early Unplanned PICU Transfers.

BACKGROUND: Many institutions track early ICU transfers (transfer from an inpatient floor to an ICU within 24 hours of admission) as a marker of quality of emergency department (ED) care. There are limited data evaluating whether patient characteristics or clinical outcomes differ on the basis of timing of ICU transfer within this 24-hour window. METHODS: We conducted a retrospective cohort study examining all patients ≤21 years old admitted to an inpatient pediatric floor from the ED and subsequently transferred to an ICU within 24 hours of hospitalization. Patient characteristics and clinical outcomes were compared on the basis of timing (0-6 hours, 6-12 hours, 12-24 hours) of ICU transfer. Outcomes assessed included receipt of critical intervention, timing of intervention with respect to transfer, type of intervention received, hospital and ICU length of stay, and mortality at 72 hours and during hospitalization. RESULTS: A total of 841 patients were transferred to an ICU within 24 hours from admission to a pediatric ward from the ED; 266 patients (32%) transferred within 6 hours of admission, 269 patients (32%) transferred between 6 and 12 hours, and 306 patients (36%) transferred between 12 and 24 hours. Patient characteristics did not materially differ on the basis of timing of ICU transfer, nor did clinical outcomes. CONCLUSIONS: Among children transferred to an ICU within 24 hours of hospitalization, patient characteristics and clinical outcomes did not materially differ based on the timing of transfer relative to admission from the ED.

Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine.

Gender inequity is pervasive in medicine, including emergency medicine (EM), and is well documented in workforce representation, leadership, financial compensation, and resource allocation. The reasons for gender inequities in medicine, including academic EM, are multifactorial and include disadvantageous institutional parental, family, and promotion policies; workplace environment and culture; implicit biases; and a paucity of women physician leader role models, mentors, and sponsors. To address some of the challenges of gender inequities and career advancement for women in academic EM, we established an innovative, peer-driven, multi-institutional consortium of women EM faculty employed at four distinct hospitals affiliated with one medical school. The consortium combined financial and faculty resources to execute gender-specific programs not feasible at an individual institution due to limited funding and faculty availability. The programs included leadership skill-building and negotiation seminars for consortium members. The consortium created a collaborative community designed specifically to enrich career development for women in academic EM, with a formal organizational structure to connect faculty from four hospitals under one academic institution. The objective of this report is to describe the creation of this cross-institutional consortium focused on career development, academic productivity, and networking and sharing best practices for work-life integration for academic EM women faculty. This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges.

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication.

BACKGROUND: Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency. METHODS: We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process. RESULTS: Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention. CONCLUSIONS: Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED.

A Framework for Maintenance and Scaling of an Evidence-based Guideline Program.

INTRODUCTION: Use of Evidence-based Guidelines (EBGs) has been shown to improve and standardize care. After implementation and maturation of a guideline program, next steps include incorporating new evidence, sustaining adherence, minimizing measurement burden and fostering scaling of the program. We propose a framework for maintenance and dissemination of an EBG program. METHODS: Using a program of 28 EBGs developed for use in a pediatric emergency department (ED) in 2010, we developed: a framework for iterative review and revision, a strategy to measure ongoing use in practice and an approach for minimizing repeated measurement sufficient to evaluate outcomes. Also, we created a process to spread the EBG program to the hospital's Department of Pediatrics. RESULTS: The framework for maintenance and spread of a program of EBGs resulted in an annual review of individual guidelines with 14 revisions warranted by new evidence, some leading to decreased medication utilization and hospitalization rates. We demonstrated adherence to key quality measures, and decreased the number of measures from 89 to 43, retiring 46 measures with stable peformance. We spread the process for program development to the hospital pediatric department resulting in 36 new EBGs. CONCLUSIONS: We developed a framework for maintenance and scale of a program of EBGs. Our key learning points were that regular incorporation of new evidence, assessment and feedback on performance and leadership with administrative support are necessary to maintain improvement. This framework may assure sustainability and inform other guideline programs. We offer processes to promote guideline dissemination within an academic hospital.

Reducing the Cranial CT Rate for Pediatric Minor Head Trauma at Three Community Hospitals.

OBJECTIVE: Efforts to reduce the rate of computerized cranial tomography (CT) in pediatric patients with minor head trauma (MHT) have focused on academic medical centers. However, community hospitals deliver the majority of pediatric emergency care. We aimed to reduce cranial CT utilization in patients presenting with MHT at 3 community hospital emergency departments (EDs). METHODS: Multidisciplinary stakeholder teams at each site oversaw the quality improvement effort, which included education about an evidence-based guideline for MHT and individual provider feedback on CT rates. Given the variation in hospital structure, we tailored the specifics of the intervention to each site. We used statistical process control methodology to measure CT rates over time. The primary balancing measure was returned to the ED within 72 hours with clinically important traumatic brain injury. RESULTS: We included 3,215 pediatric ED visits for MHT: 1,253 in the baseline period and 1,962 in the intervention period. The CT rate dropped from 18% in the baseline period to 13% in the intervention period, a 28% relative reduction. Pediatric providers saw 72% of the intervention period encounters and drove this reduction. There was no increase in the number of children who returned to their local ED within 72 hours with clinically important traumatic brain injury. CONCLUSIONS: We safely reduced the proportion of children with MHT who received a cranial CT through a multicenter community ED quality improvement initiative. We did not see an increase in missed clinically important traumatic brain injury.

Pediatric ICU Transfers Within 24 Hours of Admission From the Emergency Department: Rate of Transfer, Outcomes, and Clinical Characteristics.

BACKGROUND: There is a paucity of data describing pediatric patients transferred to an ICU within 24 hours of hospital admission from the emergency department (ED). METHODS: We conducted a retrospective cohort study of patients ≤21 years old transferred from an inpatient floor to an ICU within 24 hours of ED disposition from 2007 to 2016 in a tertiary children's hospital. Patients transferred to an ICU after planned operative procedures were excluded. Rate of transfer, clinical course, and baseline demographic and/or clinical characteristics of these patients are described. RESULTS: The study cohort consisted of 841 children, representing 1% of 82 397 non-ICU ED admissions over the 10-year period. Median age was 5.1 years, 43% had ≥1 complex chronic condition, and 47% were hospitalized within the previous year (27% in the ICU). The majority of transfers were for respiratory conditions (65%) and cardiovascular compromise (18%). Median time from hospitalization to ICU transfer was 9.1 hours (interquartile range 5.1-14.9 hours). Thirty-eight percent of transfers received 1 or more critical interventions within 72 hours of hospitalization, most commonly positive pressure ventilation (29%) and vasoactive infusion (9%). Median time to intervention from hospitalization was 13.6 hours (interquartile range 7.5-21.6 hours), 0.8% of children died within 72 hours of hospitalization, and 2.4% died overall. CONCLUSIONS: In this single pediatric academic center, 1% of hospitalized children were transferred to an ICU within 24 hours of ED disposition. One-third of patients received a critical intervention, and 2.4% died. Although most ED dispositions are appropriate, future efforts to identify patients at the highest risk of deterioration are warranted.

Trends in Visits and Costs for Mental Health Emergencies in a Pediatric Emergency Department, 2010-2016.

OBJECTIVE: Analyze trends in visit numbers, length of stay (LOS), and costs of pediatric mental health emergency department (ED) visits over time. METHODS: We conducted a cross-sectional, time-series analysis from 2010 to 2016 of mental health visits, identified by billing diagnosis codes, among children 5 to 18years old in a tertiary pediatric ED. We used Poisson regression to analyze trends in rates of mental health visits, patient-hours, and visits with LOS ≥ 24hours. We used time-series analysis to trend median costs per visit. RESULTS: From 2010 to 2016, there were 197,982 ED visits and 13,367 (6.7%) mental health visits. Mental health visits increased by 45% (from 1462 to 2119), compared to a 13% increase in non-mental health visits. The rate of mental health visits increased from 5.6 to 7.1 per 100 ED visits and increased 5.5% annually, compared to -0.4% annually for non-mental health visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.05-1.07). Mental health patient-hours increased 186%, compared to an 18% increase in non-mental health patient-hours. The rate of mental health visits with LOS ≥ 24hours increased from 4.3 to 18.8 per 100 mental health visits and increased 22% annually (IRR, 1.22; 95% CI, 1.19-1.26). Median costs per visit increased by $38 per quarter (95% CI, $28-$48). CONCLUSIONS: Rates of mental health visits, patient-hours, visits with LOS ≥ 24hours, and visit costs are increasing over time. Additional hospital and community resources are needed to address rising ED utilization for mental illness in children.

Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies.

OBJECTIVE: Opportunity exists to reduce unnecessary hospitalizations for children with anaphylaxis given wide variation in admission rates across U.S. emergency departments (EDs). We sought to identify children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies, as these patients may be candidates for ED discharge rather than inpatient hospitalization. METHODS: We conducted a single-center retrospective cohort study of children 1-21 years of age hospitalized with anaphylaxis from 2009 to 2016. Acute inpatient therapies included intramuscular (IM) or racemic epinephrine, bronchodilators, fluid boluses, vasopressors, non-invasive ventilation, or intubation. We derived age-specific (pre-verbal [<36 months] vs. verbal [≥ 36 months]) prediction rules using recursive partitioning to identify children at low risk of receiving acute inpatient therapies. RESULTS: During the study period 665 children were hospitalized for anaphylaxis, of whom 108 (16.2%) received acute inpatient therapies. The prediction rule for patients < 36 months (no wheezing, no cardiac involvement [hypotension or wide pulse pressure]) had a sensitivity of 90.5% (CI 69.6-98.8%) and a negative predictive value of 98.3% (CI 94.1-99.8%) for identifying children at low risk of receipt of acute inpatient therapies during hospitalization. For children ≥ 36 months, the prediction rule (no wheezing, no cardiac involvement, presence of gastrointestinal symptoms) had a sensitivity of 90.8% (CI 82.7-96.0%) and a negative predictive value of 92.4% (CI 85.6-96.7%). CONCLUSIONS: We derived age specific prediction rules for children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies. These children may be candidates for ED discharge rather than inpatient hospitalization.

Factors associated with boarding and length of stay for pediatric mental health emergency visits.

OBJECTIVE: To determine demographic and clinical risk factors associated with boarding (length of stay ≥24 h) for pediatric mental health emergency department (ED) visits. METHODS: This is a retrospective cross-sectional analysis of mental health visits identified by diagnosis codes for children 5-18 years old presenting to a tertiary pediatric ED in 2016. We performed multivariate logistic regression to identify demographic and clinical factors associated with boarding. RESULTS: There were 1746 mental health visits and 386 (22%) visits had length of stay ≥24 h. In the multivariate logistic regression model, factors associated with boarding included: private insurance (OR 1.59, 95% CI 1.15, 2.19) and having both private and public insurance (OR 1.68, 95% CI 1.16, 2.43) relative to public insurance; presentation during a school month (OR 2.17, 95% CI 1.30, 3.63); physical or chemical restraint use (OR 4.80, 95% CI 2.61, 8.84); comorbid autism or developmental delay (OR 1.82, 95% CI 1.35, 2.46); prior psychiatric hospitalization (OR 2.55, 95% CI 1.93, 3.36); and reasons for presentation of agitation, aggression, or homicidal ideation (OR 2.76, 95% CI 1.40, 5.45), depression, self-injury, or suicidal ideation (OR 2.79, 95% CI 1.45, 5.40), and bipolar, mania, or psychosis (OR 5.78, 95% CI 2.36, 14.09) relative to anxiety. CONCLUSIONS: Insurance status, presentation month, restraint use, autism or developmental delay comorbidity, prior psychiatric hospitalization, and reason for presentation are associated with pediatric mental health ED boarding. Resources should be directed to improve the mental health care system for children with identified risk factors for boarding.

Developing Standardized "Receiver-Driven" Handoffs Between Referring Providers and the Emergency Department: Results of a Multidisciplinary Needs Assessment.

BACKGROUND: Miscommunication during patient transfers is a leading cause of medical errors. Inpatient standardization of handoff communication has been associated with reduced medical errors, but less is known about best practices for handoffs from referring providers to the emergency department (ED). The study aims were to identify (1) stakeholder perceptions of current handoff processes and (2) key handoff elements and strategies to optimize patient care on transfer. METHODS: A mixed-methods needs assessment study was conducted at a tertiary care children's hospital with a communication center that receives verbal handoff via telephone from referring providers and provides written summary to the ED. ED, primary care providers, and communication center staff were surveyed to understand perceptions of handoff processes and ideal handoff elements. Focus groups were conducted to refine concepts. Descriptive statistics, chi-square analysis, and qualitative content analysis were used to analyze responses. RESULTS: The survey response rate was 129/152 providers (85%). Forty-two percent of respondents described the quality of the handoff process as "very good" or "excellent"; 43% reported miscommunication occurring "sometimes" or "frequently." Within the I-PASS framework-Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver-respondents identified 10 key elements to obtain through a receiver-driven process to optimize care on transfer. Free-text responses revealed a perceived need to standardize communication. CONCLUSION: A minority of providers perceived handoff quality between outpatient practices and the ED as "very good" or "excellent"; almost half perceived regular miscommunication. A receiver-driven process is a novel approach that may help ensure standardized communication of key handoff elements in this context.

A method to identify pediatric high-risk diagnoses missed in the emergency department.

BACKGROUND: Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review. METHODS: Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance. RESULTS: Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis. CONCLUSIONS: We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.

Hospital-Level Factors Associated with Pediatric Emergency Department Return Visits.

BACKGROUND: Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied. OBJECTIVE: To identify what hospital-level factors correspond with high RV and RVA rates. SETTING: Multicenter mixed-methods study of hospital characteristics associated with RV and RVA rates. DATA SOURCE: Pediatric Health Information System with survey of emergency department directors. MEASUREMENTS: Adjusted return rates were calculated with generalized linear mixed-effects models. Hospitals were categorized by adjusted RV and RVA rates for analysis. RESULTS: Twenty-four hospitals accounted for 1,456,377 patient visits with an overall adjusted RV rate of 3.7% and RVA rate of 0.7%. Hospitals with the highest RV rates served populations that were more likely to have government insurance and lower median household incomes and less likely to carry commercial insurance. Hospitals in the highest RV rate outlier group had lower pediatric emergency medicine specialist staffing, calculated as full-time equivalents per 10,000 patient visits: median (interquartile range) of 1.9 (1.5-2.1) versus 2.9 (2.2-3.6). There were no differences in hospital population characteristics or staffing by RVA groups. CONCLUSION: RV rates were associated with population social determinants of health and inversely related to staffing. Hospital-level variation may indicate population-level economic factors outside the control of the hospital and unrelated to quality of care.

Reducing Hospitalization Rates for Children With Anaphylaxis.

BACKGROUND AND OBJECTIVES: Most children with anaphylaxis in the emergency department (ED) are hospitalized. Opportunities exist to safely reduce the hospitalization rate for children with anaphylaxis by decreasing unnecessary hospitalizations. A quality improvement (QI) intervention was conducted to improve care and reduce hospitalization rates for children with anaphylaxis. METHODS: We used the Model for Improvement and began with development and implementation in 2011 of a locally developed evidence-based guideline based on national recommendations for the management of anaphylaxis. Guideline adoption and adherence were supported by interval reminders and feedback to providers. Patients from 2008 to 2014 diagnosed with anaphylaxis were identified, and statistical process control methods were used to evaluate change in hospitalization rates over time. The balancing measure was any return visit to the ED within 72 hours. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children's hospitals over the same time period were analyzed. RESULTS: Over the study period, there were 1169 visits for children with anaphylaxis, of which 731 (62%) occurred after the QI implementation. The proportion of children hospitalized decreased from 54% to 36%, with no increase in the 72-hour ED revisit rate. The hospitalization rate across 34 other US pediatric hospitals remained static at 52% over the study period. CONCLUSIONS: We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.