A Quality Improvement Initiative to Decrease Time to Analgesia in Patients With Sickle Cell and Vaso-Occlusive Crisis: A Population With Disparities in Treatment.

INTRODUCTION: Vaso-occlusive crises (VOCs) are the leading cause of emergency department (ED) visits and hospitalizations in patients with sickle cell disease (SCD). Timely administration of analgesia, within 60 minutes of patient registration, is the standard of care for SCD patients with VOCs. Patients with VOCs have longer times to initial analgesia compared to similar painful conditions. The primary aim of the project is to have 75% of patients with VOCs receive initial analgesia within 60 minutes of being registered, the current recommended time frame from the National Heart, Lung, and Blood Institute (NHLBI). METHODS: A multi-disciplinary team used quality improvement (QI) methodology to develop a plan involving multiple Plan-Do-Study-Act (PDSA) cycles. A rapid evaluation process was employed which included notification of a patient with a VOC being placed in a room, rapid evaluation by all team members and use of an electronic order set. RESULTS: The aim was met 72% of the time during our intervention period, compared to 17% pre-intervention. Average time to initial analgesia was decreased from 61 minutes to 42 minutes (p-value < 0.001), while time to disposition was also decreased when time goals were achieved. CONCLUSION: Using a rapid evaluation process we were able to decrease time to initial analgesia in a patient population that has previously experienced delays in care and decrease overall time to disposition.

Pediatric pain management in the emergency department.

Adequate analgesia is critical in the management of pediatric patients in the emergency department. Suboptimal treatment of pain can have deleterious effects in the short term, and it can also affect a patient's development and reaction to future painful experiences. Tools exist to quantify a patient's pain level regardless of age or developmental stage. Both pharmacologic and nonpharmacologic methods can be effective in the management of pediatric pain. Emergency clinicians must remain vigilant in the recognition, treatment, and reassessment of pediatric pain, as patients' developmental level may limit their ability to independently express their pain experience without prompting or tools. This issue reviews pain scales that are suitable for pediatric patients and discusses pediatric pain management using nonpharmacologic methods, topical, local, and regional anesthesia as well as systemic agents.

Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine.

Emergency physicians work in a fast-paced environment that is characterized by frequent interruptions and the expectation that they will perform multiple tasks efficiently and without error while maintaining oversight of the entire emergency department. However, there is a lack of definition and understanding of the behaviors that constitute effective task switching and multitasking, as well as how to improve these skills. This article reviews the literature on task switching and multitasking in a variety of disciplines-including cognitive science, human factors engineering, business, and medicine-to define and describe the successful performance of task switching and multitasking in emergency medicine. Multitasking, defined as the performance of two tasks simultaneously, is not possible except when behaviors become completely automatic; instead, physicians rapidly switch between small tasks. This task switching causes disruption in the primary task and may contribute to error. A framework is described to enhance the understanding and practice of these behaviors.

Point-of-care Ultrasound: A New Tool for the Identification of Gastric Foreign Bodies in Children?

BACKGROUND: Point-of-care ultrasound (POCUS) has been used to identify ingested gastric foreign bodies. Our aim was to describe the sonographic findings of radiopaque and radiolucent gastric foreign bodies (FBs) in children. CASE REPORT: Three children ingested different FBs. Two were confirmed with standard radiographs, one was not identified radiographically but was passed in the stool. All three objects were initially found in the stomach using POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increased training and comfort, emergency physicians may begin to use POCUS for identification and monitoring of ingested FBs in the pediatric population.

Wound management.

The care of wounds is common in pediatric practice. Most simple wounds can be handled by clinicians in the office or by trained emergency medicine clinicians. Knowledge of appropriate wound care, wound repair techniques, and judicious use of antibiotics for prophylaxis ensures the best possible long-term outcomes. The following review describes appropriate recommendations for acute and long-term wound care, management, and special circumstances common to pediatric practice.

Miscellaneous causes of pediatric chest pain.

This article describes some of the miscellaneous etiologies of pediatric chest pain that are important to recognize early and diagnose. Up to 45% of pediatric chest pain cases may elude definitive diagnosis. Serious morbidity or mortality is infrequent. Accurate diagnosis of more obscure causes may help to avoid unnecessary emergency department evaluation and cardiology referral, while also alleviating the concern and stress families and patients experience when dealing with chest pain.