Closer to Home: A Quality Improvement Initiative to Optimize Satellite Site Bed Capacity.

BACKGROUND: The coronavirus disease 2019 pandemic resulted in the underutilization of inpatient beds at our satellite location. A lack of clarity and standardized admission criteria for the satellite led to frequent transfers to the main campus, resulting in patients traveling larger distances to receive inpatient care. We sought to optimize inpatient resource use at the satellite campus and keep patients "closer to home" by admitting eligible patients to that inpatient unit (LA4). Our aim was to increase bed capacity use at the satellite from 45% to 70% within 10 months. Our process measure was to increase the proportion of patients needing hospitalization who presented to the satellite emergency department (ED) and were then admitted to LA4 from 76% to 85%. METHODS: A multidisciplinary team used quality improvement methods to optimize bed capacity use. Interventions included (1) the revision and dissemination of satellite admission guidelines, (2) steps to create shared understanding of appropriate satellite admissions between ED and inpatient providers, (3) directed provider feedback on preventable main campus admissions, and (4) consistent patient and family messaging about the potential for transfer. Data were collected via chart review. Annotated run charts were used to assess the impact of interventions over time. RESULTS: Average LA4 bed capacity use increased from 45% to 69%, which was sustained for 1 year. The average percentage of patients admitted from the satellite ED to LA4 increased from 76% to 84%. CONCLUSIONS: We improved bed capacity use at our satellite campus through transparent admission criteria and shared mental models of patient care needs between ED and inpatient providers.

Impact of standardization on racial and socioeconomic disparities in non-accidental trauma evaluations in infants in a pediatric emergency department.

BACKGROUND: Studies have illustrated racial and socioeconomic disparities in evaluation of non-accidental trauma (NAT). We aimed to investigate how implementation of a standardized NAT guideline in a pediatric emergency department (PED) impacted racial and socioeconomic disparities in NAT evaluation. RESULTS: 1199 patients (541 pre- and 658 post-guideline) were included for analysis. Pre-guideline, patients with governmental insurance were more likely than those with commercial insurance to have a social work (SW) consult completed (57.4% vs. 34.7%, p < 0.001) and a Child Protective Services (CPS) report filed (33.4% vs. 13.8%, p < 0.001). Post-guideline, these disparities were still present. There were no differences in race, ethnicity, insurance type, or social deprivation index (SDI) in rates of complete NAT evaluations pre- or post-guideline implementation. Overall adherence to all guideline elements increased from 19.0% before guideline implementation to 53.2% after (p < 0.001). CONCLUSION: Implementation of a standardized NAT guideline led to significant increase in complete NAT evaluations. Guideline implementation was not associated with elimination of pre-existing disparities in SW consults or CPS reporting between insurance groups.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition.

OBJECTIVES: To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS: Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS: Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS: About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

Severe Complications From Infectious Mononucleosis After Prolonged Steroid Therapy.

ABSTRACT: Infectious mononucleosis (IM) is a disease common among adolescents in the United States. Frequently, symptoms include sore throat, malaise, fevers, lymphadenopathy, and abdominal pain. Severe complications have been reported such as splenic rupture, acute upper airway obstruction, hepatitis, acute renal failure, and hematological and neurological complications. The mainstay of treatment is supportive care. Steroids are recommended for impending airway obstruction and hematological complications. However, steroids are commonly used in uncomplicated cases of IM, with insufficient evidence on the efficacy of steroids for symptom control. Furthermore, there is a lack of research on the adverse effects and long-term complications of steroid use for IM. We present a case of an adolescent boy who presented to his primary care physician with symptoms consistent with uncomplicated IM that was treated with a prolonged course of steroids. Subsequently, he developed worsening symptoms, including fevers, headache, vomiting, and left-sided facial swelling. He presented to a pediatric emergency department in decompensated septic shock as a result of polymicrobial bacteremia. During his hospital course, he developed pulmonary septic emboli, a sinus thrombus, an empyema, and orbital cellulitis complicated by Pott puffy tumor. In this case report, we summarize the current literature on steroid treatment of uncomplicated IM and highlight how our case addresses the use and possible complications of prolonged steroid use in uncomplicated IM.

Improving Emergency Department Care for Pediatric Victims of Sexual Abuse.

BACKGROUND AND OBJECTIVE: Evidence-based medical care of sexual abuse victims who present to the pediatric emergency department (PED) is necessary to facilitate forensic evidence collection and prevent pregnancy and sexually transmitted infections. Adherence to testing and treatment guidelines remains low in PEDs, despite recommendations from the American Academy of Pediatrics and Centers for Disease Control and Prevention. We aimed to increase the proportion of patient encounters at a PED for reported sexual abuse that receive algorithm-adherent care from 57% to 90% within 12 months. METHODS: Our team of PED and child abuse pediatricians outlined our theory for improvement, and multiple plan-do-study-act cycles were conducted to test interventions that were aimed at key drivers. Interventions included the construction of a best practice algorithm derived from published guidelines, targeted clinician education, and integration of an electronic order set. Our primary outcome was the proportion of patient encounters in which care adhered to algorithm recommendations. Data were abstracted from the records of all patient encounters evaluated in the PED for reported sexual abuse. RESULTS: We analyzed 657 visits between July 2015 and January 2018. The proportion of patient encounters with algorithm-adherent care improved from 57% to 87% during the study period. This improvement has been sustained for 13 months. Failure to test for hepatitis and syphilis constituted the majority of nonadherent care. CONCLUSIONS: Using improvement methodology, we successfully increased algorithm-adherent evaluation and management of patients presenting for sexual abuse. Targeted education and an electronic order set were associated with improved adherence to a novel care algorithm.

Identification and Evaluation of Physical Abuse in Children.

Child physical abuse affects hundreds of thousands of children annually and is an important cause of morbidity and mortality in children. Pediatric health care providers play a key role in the recognition and treatment of suspected child abuse. Abusive injuries are often missed, which may lead to dire consequences for the child. Standardized screening tools and treatment guidelines can enhance early recognition of child abuse. This article reviews key findings in a medical history and physical examination that should raise suspicion for abuse. We also review the recommended evaluation that should occur when child abuse is suspected, as well as indications for reporting to child protective services. [Pediatr Ann. 2018;47(3):e97-e101.].

Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Variability exists in the evaluation of nonaccidental trauma (NAT) in the pediatric emergency department because of misconceptions and individual bias of clinicians. Further maltreatment, injury, and death can ensue if these children are not evaluated appropriately. The implementation of guidelines for NAT evaluation has been successful in decreasing differences in care as influenced by race and ethnicity of the patient and their family. Our Specific, Measurable, Achievable, Realistic, and Timely aim was to increase the percent of patients evaluated in the emergency department for NAT who receive guideline-adherent evaluation from 47% to 80% by December 31, 2016. METHODS: The team determined key drivers for the project and tested them by using multiple plan-do-study-act cycles. Interventions included construction of a best practice guideline, provider education, integration of the guideline into workflow, and order set construction to support guideline recommendations. Data were compiled from electronic medical records to identify patients <3 years of age evaluated in the pediatric emergency department for suspected NAT based on chart review. Adherence to guideline recommendations for age-specific evaluation (<6, 6-12, and >12-36 months) was tracked over time on statistical process control charts to evaluate the impact of the interventions. RESULTS: A total of 640 encounters had provider concern for NAT and were included in the analysis. Adherence to age-specific guideline recommendations improved from a baseline of 47% to 69%. CONCLUSIONS: With our improvement methodology, we successfully increased guideline-adherent evaluation for patients with provider concern for NAT. Education and electronic support at the point of care were key drivers for initial implementation.

Methicillin-resistant Staphylococcus aureus: decolonization and prevention prescribing practices for children treated with skin abscesses/boils in a pediatric emergency department.

OBJECTIVE: This study aimed to describe methicillin-resistant Staphylococcus aureus (MRSA) eradication/prevention practices of clinicians managing patients with skin and soft tissue infections (SSTIs), specifically, in those patients undergoing abscess incision and drainage (I&D) in a pediatric emergency department (ED). METHODS: A retrospective cohort study was performed for children aged 0 to 18 years old undergoing I&D of cutaneous abscess between January 1, 2011, and December 31, 2011, in the Cincinnati Children's Hospital Medical Center ED. RESULTS: Five hundred seventy-five patients underwent abscess I&D during our study period. Approximately 25% of our population had previous history of MRSA, SSTI, or boil/abscess; in addition, 26% of our population had a household family member with a previous history of MRSA, SSTI, or boil/abscess. Wound cultures were obtained in 399 (69%) of 575 of I&D abscesses, and of these, 57% of the I&D abscesses grew MRSA. Of all patients, only 3.7% (21 patients) had documentation of MRSA eradication/prevention instructions for patient/family. CONCLUSIONS: Methicillin-resistant S aureus eradication/prevention discussions are not commonly included in discharge instructions for patients undergoing abscess I&D. Given the significant proportion with previous MRSA infection, the ED may be a setting to provide instructions to patients/families with recurrent infections.

Parental tobacco screening and counseling in the pediatric emergency department: practitioners' attitudes, perceived barriers, and suggestions for implementation and maintenance.

INTRODUCTION: The pediatric emergency department (PED) is a venue that underuses parental tobacco screening and brief cessation counseling. We sought to explore PED practitioners' attitudes and perceived barriers regarding the implementation and adoption of tobacco screening/cessation counseling of parental smokers in the PED setting, as well as to solicit suggestions for improving the sustainability and maintenance of such practices. METHODS: We conducted an exploratory, qualitative study of a convenience sample of PED practitioners using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Individual, focused interviews were conducted to determine factors that would maximize the implementation and maintenance of parental tobacco screening and intervention counseling as standard PED practice. RESULTS: Thirty interviews were conducted from which relevant data, patterns, and themes were identified. Reach factors included targeting parental smokers with children with respiratory diseases, having adequate training of practitioners, and providing "prearranged" counseling packages. Effectiveness factors included practitioner desire for outcome data about intervention effectiveness (eg, changes in children's secondhand smoke exposure and parental quit rates). Solutions to increase intervention adoption included quick electronic health record prompts and the provision of onsite tobacco cessation experts. Implementation suggestions emphasized the importance of financial support and the alignment of tobacco screening/counseling with strategic plans. Maintenance factors included institutional and technical support, as well as the importance of intervention "champions" in the PED. DISCUSSION: By highlighting important viewpoints of practitioners regarding tobacco screening and counseling, the findings can help guide and direct the development and evaluation of sustainable interventions to facilitate tobacco use treatment in the PED.

Posterior rib fractures in a young infant who received chiropractic care.

We report on a 21-day-old infant with healing posterior rib fractures that were noted after a chiropractic visit for colic. Chiropractors are the third largest group of health care professionals in the United States, and colic is the leading complaint for pediatric chiropractic care. Rib fractures, specifically when posterior, are traditionally considered to be secondary to nonaccidental trauma. Thorough investigation is necessary to rule out bone fragility and genetic disorders, but patient history is key when evaluating unexplained fractures.

Experience-based guidance for implementing a direct observation checklist in a pediatric emergency department setting.

BACKGROUND: The importance and benefits of direct observation in residency training have been underscored by a number of studies. Yet, implementing direct observation in an effective and sustainable way is hampered by demands on physicians' time and shrinking resources for educational innovation. OBJECTIVE: To describe the development and pilot implementation of a direct observation tool to assess the history and physical examination skills of interns in a pediatric emergency department rotation. METHODS: A task force developed specific history and physical examination checklists for a range of common conditions. For the pilot implementation, 10 pediatric emergency medicine faculty attendings conducted the initial observations of 34 interns during the course of 1 academic year. At the conclusion of the pilot, the faculty observers and interns were interviewed to assess the feasibility and benefits of the process. RESULTS: A total of 33 of the 34 interns were observed during their rotation, with 26 of the observations conducted when the faculty observer was off shift, and it took approximately 20 minutes to complete each observation. In terms of learning benefits, interns and faculty observers reported that it facilitated clear and useful feedback and revealed gaps that would not have otherwise been identified. Faculty observers also mentioned that it helped them focus their teaching effort, built empathy with learners, and gave them a way to demonstrate a true concern for their learning. CONCLUSION: Our results offer evidence for the feasibility and benefits of the direct observation checklists. The description of the implementation, challenges, and response to those challenges may help others avoid some of the common problems faced when implementing direct observation methods.

Identifying children with pneumonia in the emergency department.

Emergency physicians need to clinically differentiate children with and without radiographic evidence of pneumonia. In this prospective cohort study of 510 patients 2 to 59 months of age presenting with symptoms of lower respiratory tract infection, 100% were evaluated with chest radiography and 44 (8.6%) had pneumonia on chest radiography. With use of multivariate analysis, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) of the clinical findings significantly associated with focal infiltrates were age older than 12 months (AOR 1.4, CI 1.1-1.9), RR 50 or greater (AOR 3.5, CI 1.6-7.5), oxygen saturation 96% or less (AOR 4.6, CI 2.3-9.2), and nasal flaring (AOR 2.2 CI 1.2-4.0) in patients 12 months of age or younger. The combination of age older than 12 months, RR 50 or greater, oxygen saturation 96% or less, and in children under age 12 months, nasal flaring, can be used in determining which young children with lower respiratory tract infection symptoms have radiographic pneumonia.