"They're scared that somebody's gonna judge them": Female African American youth in foster care's perspectives on sexual and reproductive health communication with caregivers.

BACKGROUND: Obtaining accurate information is critical for youth's sexual and reproductive health (SRH). Youth not in foster care often learn about SRH from their biological parents. Separated from their biological parents, youth in care depend on healthcare providers and caregivers for SRH information. However, they often receive insufficient information and feel unsupported in meeting their needs for SRH information. PURPOSE: This study explored female African American adolescents in foster care's perspectives on effective SRH communication with caregivers to help them avoid sexual risks. METHODS: A qualitative study was conducted using semi-structured interviews. We used purposive sampling to recruit 16 adolescents aged 18 to 20 years old with a history of foster care placement. The transcribed interviews underwent inductive thematic analysis. The Positive Youth Development theory underpinned this research. RESULTS: Two prominent themes emerged: establishing a relationship and preferred communication approach. Youth reported that for caregivers to engage in effective SRH communication, they must first establish a relationship by being aware of the youth's childhood trauma, building trust, having patience, and being vulnerable. Youth also appreciated caregivers who ensured comfortability and were honest and straightforward. DISCUSSION: Caregivers should be trained on adverse childhood experiences, trauma-informed approaches, SRH knowledge, and communication. IMPLICATIONS TO PRACTICE: Healthcare providers should make use of the time spent with youth and discuss SRH topics during clinical encounters. This time spent with youth may be their only chance to obtain accurate SRH information. Youth's perspectives regarding communication about SRH should be implemented in future SRH communication interventions.

A pilot clinical trial of the Screening and Tool for Awareness and Relief of Trauma for survivors of gun violence.

BACKGROUND: Survivors of gun violence have significant sequelae including reinjury with a firearm and mental health disorders that often go undiagnosed and untreated. The Screening and Tool for Awareness and Relief of Trauma (START) is a targeted behavioral mental health intervention developed for patients who come from communities of color with sustained and persistent trauma. METHODS: In this pilot study, we evaluate the feasibility of completing a randomized controlled trial to test the START intervention. Using a mixed methods study design, we used both quantitative and qualitative data collection to assess the START intervention and the feasibility of completing a randomized controlled trial. The purpose of this study was to estimate important study parameters that would enable a future randomized controlled trial. RESULTS: We were able to make conclusions about several crucial domains of a behavioral intervention trial: (1) recruitment and retention-we had a high follow-up rate, but our recruitment was low (34% of eligible participants); (2) acceptability of the intervention-the addition of audiovisual resources would make the tools more accessible; (3) feasibility of the control-more appropriate for a stepped wedge cluster randomized controlled trial design; (4) intervention fidelity-there was an 81% concordance rate between the fidelity survey results and the audio recordings; (5) approximate effect size-there was a 0.4-point decrease in the PTSD Checklist-Civilian Version in the control compared with a 10.7-point decrease in the treatment group for the first month. CONCLUSION: While it was feasible to conduct a randomized controlled trial, our findings suggest that a stepped wedge cluster randomized controlled trial design may be the most successful trial design for the START intervention. In addition, the inclusion of a "credible messenger" to recruit participants into the study and the development of audiovisual resources for START would improve recruitment and effectiveness. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Implementation of an emerging hospital-based violence intervention program: a multimethod study.

Background: Individuals who experience assaultive firearm injury are at elevated risk for violent reinjury and multiple negative physical and psychological health outcomes. Hospital-based violence intervention programs (HVIPs) may improve patient outcomes through intensive, community-based case management. Methods: We conducted a multimethod evaluation of an emerging HVIP at a large trauma center using the RE-AIM framework. We assessed recruitment, violent reinjury outcomes, and service provision from 2020 to 2022. Semistructured, qualitative interviews were performed with HVIP participants and program administrators to elicit experiences with HVIP services. Directed content analysis was used to generate and organize codes from the data. We also conducted clinician surveys to assess awareness and referral patterns. Results: Of the 319 HVIP-eligible individuals who presented with non-fatal assaultive firearm injury, 39 individuals (12%) were enrolled in the HVIP. Inpatient admission was independently associated with HVIP enrollment (OR 2.6, 95% CI 1.3 to 5.2; p=0.01). Facilitators of Reach included engaging with credible messengers, personal relationships with HVIP program administrators, and encouragement from family to enroll. Fear of disclosure to police was cited as a key barrier to enrollment. For the Effectiveness domain, enrollment was not associated with reinjury (OR 0.70, 95% CI 0.16 to 3.1). Participants identified key areas of focus where needs were not met including housing and mental health. Limited awareness of HVIP services was a barrier to Adoption. Participants described strengths of Implementation, highlighting the deep relationships built between clients and administrators. For the long-term Maintenance of the program, both clinicians and HVIP clients reported that there is a need for HVIP services for individuals who experience violent injury. Conclusions: Credible messengers facilitate engagement with potential participants, whereas concerns around police involvement is an important barrier. Inpatient admission provides an opportunity to engage patients and may facilitate recruitment. HVIPs may benefit from increased program intensity. Level of evidence: IV.

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Evaluation of Children after Caregiver Intimate Partner Violence: A Qualitative Study of Barriers, Facilitators, and Trauma- and Violence-Informed Care.

OBJECTIVE: To identify barriers and facilitators of evaluating children exposed to caregiver intimate partner violence (IPV) and develop a strategy to optimize the evaluation. STUDY DESIGN: Using the EPIS (Exploration, Preparation, Implementation, and Sustainment) framework, we conducted qualitative interviews of 49 stakeholders, including emergency department clinicians (n = 18), child abuse pediatricians (n = 15), child protective services staff (n = 12), and caregivers who experienced IPV (n = 4), and reviewed meeting minutes of a family violence community advisory board (CAB). Researchers coded and analyzed interviews and CAB minutes using the constant comparative method of grounded theory. Codes were expanded and revised until a final structure emerged. RESULTS: Four themes emerged: (1) benefits of evaluation, including the opportunity to assess children for physical abuse and to engage caregivers; (2) barriers, including limited evidence about the risk of abuse in these children, burdening a resource-limited system, and the complexity of IPV; (3) facilitators, including collaboration between medical and IPV providers; and (4) recommendations for trauma- and violence-informed care (TVIC) in which a child's evaluation is leveraged to link caregivers with an IPV advocate to address the caregiver's needs. CONCLUSIONS: Routine evaluation of IPV-exposed children may lead to the detection of physical abuse and linkage to services for the child and the caregiver. Collaboration, improved data on the risk of child physical abuse in the context of IPV and implementation of TVIC may improve outcomes for families experiencing IPV.

Trauma-informed and family-centered paediatric resuscitation: Defining domains and practices.

Aim: For paediatric patients and families, resuscitation can be an extremely stressful experience with significant medical and psychological consequences. Psychological sequelae may be reduced when healthcare teams apply patient- and family-centered care and trauma-informed care, yet there are few specific instructions for effective family-centered or trauma-informed behaviours that are observable and teachable. We aimed to develop a framework and tools to address this gap. Methods: We reviewed relevant policy statements, guidelines, and research to define core domains of family-centered and trauma-informed care, and identified observable evidence-based practices in each domain. We refined this list of practices via review of provider/team behaviours in simulated paediatric resuscitation scenarios, then developed and piloted an observational checklist. Results: Six domains were identified: (1) Sharing information with patient and family; (2) Promoting family involvement in care and decisions; (3) Addressing family needs and distress; (4) Addressing child distress; (5) Promoting effective emotional support for child; (6) Practicing developmental and cultural competence. A 71-item observational checklist assessing these domains was feasible for use during video review of paediatric resuscitation. Conclusion: This framework can guide future research and provide tools for training and implementation efforts to improve patient outcomes through patient- and family-centered and trauma-informed care.

Emergency department visits in Connecticut for survivors of sexual assault before and during the COVID-19 pandemic.

STUDY OBJECTIVE: We evaluate the impact of the COVID-19 pandemic on care for survivors of sexual assault in three urban Emergency Departments (ED) in the United States. METHODS: A retrospective chart review was conducted on patients who presented after sexual assault to three EDs during 6-month intervals before and during the COVID-19 pandemic. We excluded individuals <18 years old. We performed a structured chart review to ascertain demographics, ED treatments, and adherence to guidelines for care of sexual assault survivors. RESULTS: Of 105 patients who received care after a sexual assault, 57 presented during the COVID-19 pandemic. The majority were female, White/Caucasian, and presented within 120 h of sexual assault. There was an increase in ED presentations for sexual assault during the pandemic. While there was no difference in medical care, there were fewer sexual assault advocates called during the pandemic. In addition, there was an increase in non-White survivors in the first 3 months of the pandemic that did not remain at 6 months. CONCLUSION: The care of survivors in the ED was disrupted by the COVID-19 pandemic. While medical care remained similar, fewer calls to sexual assault advocates, a key component of ED and long-term care of survivors, demonstrate a disruption in their care.

The effect of the COVID-19 pandemic on community violence in Connecticut.

INTRODUCTION: Natural disasters may lead to increases in community violence due to broad social disruption, economic hardship, and large-scale morbidity and mortality. The effect of the COVID-19 pandemic on community violence is unknown. METHODS: Using trauma registry data on all violence-related patient presentations in Connecticut from 2018 to 2021, we compared the pattern of violence-related trauma from pre-COVID and COVID pandemic using an interrupted time series linear regression model. RESULTS: There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period (IRR: 1.55; 95%CI: 1.34-1.80; p-value<0.001) driven largely by penetrating injuries. This increase disproportionately impacted Black/Latinx communities (IRR: 1.61; 95%CI: 1.36-1.90; p-value<0.001). CONCLUSION: Violence-related trauma increased during the COVID-19 pandemic. Increased community violence is a significant and underappreciated negative health and social consequence of the COVID-19 pandemic, and one that excessively burdens communities already at increased risk from systemic health and social inequities.

Impact of statewide safe sleep legislation on hospital practices and rates of sudden unexpected infant deaths.

BACKGROUND: Sudden Unexpected Infant Death (SUID) is the leading cause of death in the post-neonatal period in the United States. In 2015, Connecticut (CT) passed legislation to reduce the number of SUIDs from hazardous sleep environments requiring birthing hospitals/centers provide anticipatory guidance on safe sleep to newborn caregivers before discharge. The objective of our study was to understand the barriers and facilitators for compliance with the safe sleep legislation by birthing hospitals and to determine the effect of this legislation on SUIDs associated with unsafe sleep environments. METHODS: We surveyed the directors and/or educators of the 27 birthing hospitals & one birthing center in CT, about the following: 1) methods of anticipatory guidance given to parents at newborn hospital discharge; 2) knowledge about the legislation; and 3) barriers and facilitators to complying with the law. We used a voluntary online, anonymous survey. In addition, we evaluated the proportion of SUID cases presented at the CT Child Fatality Review Panel as a result of unsafe sleep environments before (2011-2015) and after implementation of the legislation (2016-2018). Chi-Square and Fisher's exact tests were used to evaluate the proportion of deaths due to Positional Asphyxia/Accident occurring before and after legislation implementation. RESULTS: All 27 birthing hospitals and the one birthing center in CT responded to the request for the method of anticipatory guidance provided to caregivers. All hospitals reported providing anticipatory guidance; the birthing center did not provide any anticipatory guidance. The materials provided by 26/27 (96%) of hospitals was consistent with the American Academy of Pediatrics (AAP) Guidelines. There was no significant change in rates of SUID in CT before (58.86/100,000) and after (55.92/100,000) the passage of the legislation (p = 0.78). However, more infants died from positional asphyxia after (20, 27.0%) than before the enactment of the law (p < 0.01). CONCLUSIONS: Despite most CT hospitals providing caregivers with anticipatory guidance on safe sleep at newborn hospital discharge, SUIDs rates associated with positional asphyxia increased in CT after the passage of the legislation. The role of legislation for reducing the number of SUIDs from hazardous sleep environments should be reconsidered.

A tabletop school bus rollover: Connecticut-wide drills to build pediatric disaster preparedness and promote a novel hospital disaster readiness checklist.

OBJECTIVE: To assess emergency medical services (EMS) and hospital disaster plans and communication and promote an integrated pediatric disaster response in the state of Connecticut, using tabletop exercises to promote education, collaboration, and planning among healthcare entities. DESIGN: Using hospital-specific and national guidelines, a disaster preparedness plan consisting of pediatric guidelines and a hospital checklist was created by The Connecticut Coalition for Pediatric Disaster Preparedness. SETTING: Five school bus rollover tabletop exercises were conducted, one in each of Connecticut's five EMS regions. Action figures and playsets were used to depict patients, healthcare workers, vehicles, the school, and the hospital. PARTICIPANTS: EMS personnel, nurses, physicians and hospital administrators. INTERVENTION: Participants had a facilitated debriefing of the EMS and prehospital response to disasters, communication among prehospital organizations, public health officials, hospitals, and schools, and surge capacity, capability, and alternate care sites. A checklist was completed for each exercise and was used with the facilitated debriefing to generate an afteraction report. Additionally, each participant completed a postexercise survey. MAIN OUTCOME MEASURES: Each after-action report and postexercise survey was compared to established guidelines to address gaps in hospital specific pediatric readiness. RESULTS: Exercises occurred at five hospitals, with inpatient capacity ranging 77-1,592 beds, and between 0 and 221 pediatric beds. There were 27 participants in the tabletop exercises, and 20 complete survey responses for analysis (74 percent). After the exercises, pediatric disaster preparedness aligned with coalition guidelines. However, methods of expanding surge capacity and methods of generating surge capacity and capability varied (p < 0.031). CONCLUSION: Statewide tabletop exercises promoted coalition building and revealed gaps between actual and ideal practice. Generation of surge capacity and capability should be addressed in future disaster education.

A Qualitative Study Examining Stakeholder Perspectives of a Local Child Abuse Program in Community Emergency Departments.

OBJECTIVE: Emergency department (ED) providers may fail to recognize or report child abuse and/or neglect (CAN). To improve recognition and reporting, we designed the Community ED CAN Program, in which teams of local clinicians (nurses, physicians, physician assistants) received training in CAN and 1) disseminated evidence-based education; 2) provided consultation, case follow-up, and access to specialists; and 3) facilitated multidisciplinary case review. The aims of this study were to understand the Program's strengths andchallenges and to explore factors that influenced implementation. METHODS: We used a qualitative research design with semistructured, one-on-one interviews to understand key stakeholders' perspectives of the Community ED CAN Program. We interviewed 27 stakeholders at 3 community hospitals and 1 academic medical center. Researchers analyzed transcribed data using constant comparative method of grounded theory and developed themes. RESULTS: Program strengths included 1) comfort in seeking help from local champions, 2) access to CAN experts, 3) increased CAN education/awareness, and 4) improved networks and communication. Facilitators of implementation included: 1) leadership support, 2) engaged local champions and external change agents (eg, CAN experts), 3) positive attributes of the champions, and 4) implementation flexibility. Program challenges/barriers to implementation included 1) variability of institutional support for the champions and 2) variability in awareness about the program. CONCLUSIONS: A Community ED CAN Program has the potential to improve recognition and reporting of CAN. Key steps to facilitate implementation include the identification of committed local champions, strong leadership support, connections to experts, program publicity, and support of the champions' time.

The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study.

BACKGROUND: Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described. OBJECTIVES: To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation. METHODS: Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively. RESULTS: Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020). CONCLUSIONS: In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

Community-based in situ simulation: bringing simulation to the masses.

Simulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS.

Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study.

BACKGROUND AND OBJECTIVES: Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. METHODS: This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800-4,999; medium-high 5,000-9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. RESULTS: A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800-4,999/year), 24 medium-high (5,000-9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0-78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high-volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. CONCLUSIONS: This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high-volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.

A Qualitative Study of Multidisciplinary Providers' Experiences With the Transfer Process for Injured Children and Ideas for Improvement.

OBJECTIVE: Most injured children initially present to a community hospital, and many will require transfer to a regional pediatric trauma center. The purpose of this study was 1) to explore multidisciplinary providers' experiences with the process of transferring injured children and 2) to describe proposed ideas for process improvement. METHODS: This qualitative study involved 26 semistructured interviews. Subjects were recruited from 6 community hospital emergency departments and the trauma and transport teams of a level I pediatric trauma center in New Haven, Conn. Participants (n = 34) included interprofessional providers from sending facilities, transport teams, and receiving facilities. Using the constant comparative method, a multidisciplinary team coded transcripts and collectively refined codes to generate recurrent themes across interviews until theoretical saturation was achieved. RESULTS: Participants reported that the transfer process for injured children is complex, stressful, and necessitates collaboration. The transfer process was perceived to involve numerous interrelated components, including professions, disciplines, and institutions. The 5 themes identified as areas to improve this transfer process included 1) Creation of a unified standard operating procedure that crosses institutions/teams, 2) Enhancing 'shared sense making' of all providers, 3) Improving provider confidence, expertise, and skills in caring for pediatric trauma transfer cases, 4) Addressing organization and environmental factors that may impede/delay transfer, and 5) Fostering institutional and personal relationships. CONCLUSIONS: Efforts to improve the transfer process for injured children should be guided by the experiences of and input from multidisciplinary frontline emergency providers.

Feasibility of providing child restraint devices after a motor vehicle crash in a pediatric emergency department.

OBJECTIVE: Motor vehicle crashes (MVCs) cause disproportionate childhood morbidity and mortality. Ensuring that children are placed in appropriate child restraint devices (CRDs) would significantly reduce injuries and deaths as well as medical costs. The goal of the study is to evaluate the feasibility of providing child restraint devices after an MVC in a pediatric emergency department (PED). METHODS: A guideline was developed to assess the need for CRDs for patients discharged from a PED after an MVC. Providers were educated on the use of the guideline. Caregivers were provided a brief educational intervention on legislation, proper installation, and best practices prior to distribution of a CRD. Quality assurance was conducted weekly to monitor for any missed opportunities. RESULTS: From August 31, 2015, to August 31, 2016, 291 patients <7 years were evaluated in the PED of a level 1 trauma center following an MVC. Two hundred forty-seven children were correctly identified according to the guidelines (84.9%). Of these, 187 (75.7%) were identified as not requiring a replacement seat and 60 (24.3%) required a CRD replacement based on crash mechanisms and restraint use status and received a CRD replacement. Of the remaining 44 children, 38 (86.4%) whose crash mechanisms were severe enough or who were inappropriately restrained were not provided a CRD and thus missed; 6 (13.6%) received a replacement seat even though criteria were not met. Thus, PED providers correctly identified 61.2% (60/98) of children who required CRD replacement after an MVC. CONCLUSION: Caring for children who present for evaluation after an MVC offers an opportunity for ED personnel to provide education to caregivers about the appropriate use of CRDs and state legislation. Establishing guidelines for the provision of a CRD for children who present to an ED following an MVC may help to improve the safety of children being transported in motor vehicles. Having a systematic process and adequate supply of CRDs readily available contributes to the success of children being discharged with the appropriate age- and weight-based CRD after being treated in an ED following an MVC.

A Grounded Theory Qualitative Analysis of Interprofessional Providers' Perceptions on Caring for Critically Ill Infants and Children in Pediatric and General Emergency Departments.

OBJECTIVE: The objective of this study was to explore pediatric emergency department (PED) and general emergency department (GED) providers' perceptions on caring for critically ill infants and children. METHODS: This study utilized qualitative methods to examine the perceptions of emergency department providers caring for critically ill infants and children. Teams of providers participated in 4 in situ simulation cases followed by facilitated debriefings. Debriefings were recorded and professionally transcribed. The transcripts were reviewed independently and followed by group coding discussions to identify emerging themes. Consistent with grounded theory, the team iteratively revised the debriefing script as new understanding was gained. A total of 188 simulation debriefings were recorded in 24 departments, with 15 teams participating from 8 PEDs and 32 teams from 16 GEDs. RESULTS: Twenty-four debriefings were audiotaped and professionally transcribed verbatim. Thematic saturation was achieved after 20 transcripts. In our iterative qualitative analysis of these transcripts, we observed 4 themes: (1) GED provider comfort with algorithm-based pediatric care and overall comfort with pediatric care in PED, (2) GED provider reliance on cognitive aids versus experience-based recall by PED providers, (3) GED provider discomfort with locating and determining size or dose of pediatric-specific equipment and medications, and (4) PED provider reliance on larger team size and challenges with multitasking during resuscitation. CONCLUSIONS: Our qualitative analysis produced several themes that help us to understand providers' perceptions in caring for critically ill children in GEDs and PEDs. These data could guide the development of targeted educational and improvement interventions.

A Simulation-Based Quality Improvement Initiative Improves Pediatric Readiness in Community Hospitals.

BACKGROUND: The National Pediatric Readiness Project Pediatric Readiness Survey (PRS) measured pediatric readiness in 4149 US emergency departments (EDs) and noted an average score of 69 on a 100-point scale. This readiness score consists of 6 domains: coordination of pediatric patient care (19/100), physician/nurse staffing and training (10/100), quality improvement activities (7/100), patient safety initiatives (14/100), policies and procedures (17/100), and availability of pediatric equipment (33/100). We aimed to assess and improve pediatric emergency readiness scores across Connecticut's hospitals. OBJECTIVE: The aim of this study was to compare the National Pediatric Readiness Project readiness score before and after an in situ simulation-based assessment and quality improvement program in Connecticut hospitals. METHODS: We leveraged in situ simulations to measure the quality of resuscitative care provided by interprofessional teams to 3 simulated patients (infant septic shock, infant seizure, and child cardiac arrest) presenting to their ED resuscitation bay. Assessments of EDs were made based on a composite quality score that was measured as the sum of 4 distinct domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. After the simulation, a detailed report with scores, comparisons to other EDs, and a gap analysis were provided to sites. Based on this report, a regional children's hospital team worked collaboratively with each ED to develop action items and a timeline for improvements. The National Pediatric Readiness Project PRS scores, the primary outcome of this study, were measured before and after participation. RESULTS: Twelve community EDs in Connecticut participated in this project. The PRS scores were assessed before and after the intervention (simulation-based assessment and gap analysis/report-out). The average time between PRS assessments was 21 months. The PRS scores significantly improved 12.9% from the first assessment (mean ± SEM = 64 ± 4.4) to the second assessment (77 ± 4.0, P = 0.022). The PRS score domains also showed improvements in coordination of pediatric patient care (median improvement, 50%), quality improvement activities (median improvement, 79%), patient safety initiatives (mean improvement, 7%), policies and procedures (mean improvement, 17%), and availability of pediatric equipment (mean improvement, 7%). CONCLUSIONS: Participation in a simulation-based quality improvement collaborative was associated with improvements in pediatric readiness.

Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers.

BACKGROUND: One in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF); 23% of these patients are readmitted to the hospital within 30 days. The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers. A study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and the SNF. METHODS: Hospital (N = 25) and SNF (N = 16) providers participated in qualitative interviews assessing patient transfers and experiences with unplanned hospital readmissions. Data were analyzed by a multidisciplinary coding team using the constant comparison method. RESULTS: Four main themes emerged: increasing patient complexity, identifying an optimal care setting, rising financial pressure, and barriers to effective communication. The data highlighted hospital and SNF providers' shared concerns about patient-level risk factors and escalating costs of care. The data also identified issues that separate hospital and SNF providers, including different access to resources and information. CONCLUSION: Hospital and SNF providers are challenged to meet the needs of complex patients. They are asked to establish comprehensive care plans for patients with significant medical and psychosocial issues while navigating tense relationships between health care institutions and rising financial pressures. The concerns of both hospital and SNF providers must be considered in order to develop practices that can improve the quality, cost, and safety of care transitions.

Safety Threats During the Care of Infants with Hypoglycemic Seizures in the Emergency Department: A Multicenter, Simulation-Based Prospective Cohort Study.

BACKGROUND: Errors in the timely diagnosis and treatment of infants with hypoglycemic seizures can lead to significant patient harm. It is challenging to precisely measure medical errors that occur during high-stakes/low-frequency events. Simulation can be used to assess risk and identify errors. OBJECTIVE: We hypothesized that general emergency departments (GEDs) would have higher rates of deviations from best practices (errors) compared to pediatric emergency departments (PEDs) when managing an infant with hypoglycemic seizures. METHODS: This multicenter simulation-based prospective cohort study was conducted in GEDs and PEDs. In situ simulation was used to measure deviations from best practices during management of an infant with hypoglycemic seizures by inter-professional teams. Seven variables were measured: five nonpharmacologic (i.e., delays in airway assessment, checking dextrose, starting infusion, verbalizing disposition) and two pharmacologic (incorrect dextrose dose and incorrect dextrose concentration). The primary aim was to describe and compare the frequency and types of errors between GEDs and PEDs. RESULTS: Fifty-eight teams from 30 hospitals (22 GEDs, 8 PEDs) were enrolled. Pharmacologic errors occurred more often in GEDs compared to PEDs (p = 0.043), while nonpharmacologic errors were uncommon in both groups. Errors more frequent in GEDs related to incorrect dextrose concentration (60% vs. 88%; p = 0.025), incorrect dose (20% vs. 56%; p = 0.033), and failure to start maintenance dextrose (33% vs. 65%; p = 0.040). CONCLUSIONS: During the simulated care of an infant with hypoglycemic seizures, errors were more frequent in GEDs compared to PEDs. Decreasing annual pediatric patient volume was the best predictor of errors on regression analysis.