Outcomes of Children Who Present to the Emergency Department After Hematopoietic Cell Transplantation.

OBJECTIVES: Our primary objective was to describe emergency department (ED) presentation, treatment, and outcomes for children after hematopoietic cell transplantation (HCT). Our secondary objective was to identify factors associated with serious infection in this population. METHODS: This is a retrospective review of HCT patients who presented to our university children's hospital ED from January 1, 2011, to June 30, 2013. Emergency department presentation, treatment, and outcomes were described. Descriptive statistics were used to compare children with definite serious infection with those without serious infection. Multiple binary logistic regression was performed for risk factors associated with definite serious infection. RESULTS: Fifty-four HCT patients (132 encounters) presented to our ED. Most were transplanted for a malignant (46%) or metabolic (36%) diagnosis and were recipients of bone marrow (51%) or umbilical cord blood (45%). Fever was the most common complaint (25%). Emergency department laboratory (64%) or imaging (58%) studies were frequently obtained. Admission was common (n = 70/132, 53%), with 79% (n = 55) of admissions to intensive care or bone marrow transplant units. Thirty-five encounters had definite serious infection, 5 had probable serious infection, and 92 had no serious infection. Fever (P < 0.001) and high-risk white blood cell (WBC) count of less than 5 or greater than 15 k/µL (P < 0.001) were associated with definite serious infection. Fever (odds ratio = 8.84, 95% confidence interval = 2.92-26.73) and high-risk WBC (odds ratio = 6.67, 95% confidence interval = 2.24-19.89) remained significantly associated with definite serious infection in our regression model. CONCLUSIONS: Children presenting to the ED after HCT require extensive support and resources, with more than half requiring admission. Fever and high-risk WBC are associated with serious infection.

ED RAPID: A Novel Children's Hospital Direct Admission Process Utilizing the Emergency Department.

INTRODUCTION: Direct hospital admission of children without evaluation in the emergency department (ED) is common, but few guidelines exist to maximize safety by assessing patient stability. This report describes a novel approach to support patient safety. METHODS: An interdisciplinary children's hospital team developed a brief ED-based evaluation process called the ED Rapid Assessment of Patients Intended for Inpatient Disposition (ED RAPID). It entails a brief evaluation of vital signs and clinical stability by the ED attending physician and nurse. Children deemed stable are admitted to inpatient wards, whereas those requiring immediate intervention undergo full ED evaluation and disposition. We assessed outcomes for all children evaluated through this process from March 2013 through February 2015. RESULTS: During the study period, we identified 715 patients undergoing ED RAPID evaluation. Of these, we directly admitted 691 (96.4%) to the hospital ward after ED RAPID evaluation; median ED treatment time was 4.0 minutes. We transitioned 24 (3.4%) to full ED evaluation, 14 (2.0%) because a ward bed was unavailable, and 10 (1.4%) for clinical reasons identified in the evaluation. We admitted four of the 10 stopped (40% of stops, 0.6% of total) to an intensive care unit, and 6 (60% of stops, 0.8% of total) to the hospital ward after ED care. Eight children (1.1%) admitted to the hospital ward after ED RAPID evaluation required a transfer to an intensive care unit within 12 hours. CONCLUSION: The ED RAPID evaluation process for children directly admitted to the hospital was feasible and effective in this setting.

Reduction of paediatric head CT utilisation at a rural general hospital emergency department.

BACKGROUND: Blunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily exposing the child to ionizing radiation. Pediatric academic centers have shown quality improvement (QI) measures can reduce head CT rates within their emergency departments. We aimed to reduce head CT utilization at a rural community emergency department. METHODS: Children presenting with a complaint of blunt head injury and were evaluated with or without a head CT. Head CT rate was the primary outcome. We developed a series of interventions and presented these to the general emergency department over the duration of the study. The pre and intervention data was analysed with control charts. RESULTS: The preintervention and intervention groups consisted of 576 children: 237 patients with a median age of 8.0 years and 339 patients with a median age of 9.00 years (p=0.54), respectively. The preintervention HCT rate was 41.8% (95% CI 35.6% to 48.1%) and the postintervention rate was 27.7% (95% CI 23.3% to 32.7%), a decrease of 14.1% (95% CI 6.2% to 21.9%, p=0.0004). During the intervention period, there was a decrease in HCT rate of one per month (OR 0.96, 95% CI 0.92 to 1.00, p=0.07). The initial series of interventions demonstrated an incremental decrease in HCT rates corresponding with a special cause variation. CONCLUSION: The series of interventions dispersed over the intervention period was an effective methodology and successfully reduced HCT utilisation among children with blunt head injury at a rural community emergency department.

Ondansetron Prescription for Home Use in a Pediatric Emergency Department.

OBJECTIVES: Ondansetron has been shown to decrease admission rate and the need for intravenous fluids among pediatric emergency department (ED) patients with acute gastroenteritis, but there is limited evidence regarding its use after ED discharge. This study describes prescribing patterns for ondansetron and assesses the effects of ondansetron home prescription on rate of return. METHODS: Data were gathered from the electronic health record on 2 separate but overlapping groups of patients seen in a pediatric ED from 2012 to 2014. The Gastroenteritis Group included all patients with a discharge diagnosis of gastroenteritis by International Classification of Diseases, Ninth Revision, code. The All Ondansetron Group included any child prescribed ondansetron at discharge. Patterns of ondansetron use and 3- and 7-day ED return rate were assessed for both groups. Discharge diagnosis was evaluated for the All Ondansetron Group. RESULTS: A total of 996 patients with acute gastroenteritis were identified during the study period. Of these, 76% received ondansetron in the ED, and 71% were discharged with prescriptions for ondansetron. Seven-day ED return rates were similar between groups (6% with prescription, 5% without, P = 0.66). A total of 2287 patients received home prescriptions for ondansetron. Fifty-four percent of these patients' discharge diagnoses were classed as gastrointestinal complaints, 14% other infectious conditions, 9% respiratory, and 4% injuries. Their return rate was 6%. There was wide variation in the number of doses prescribed. CONCLUSIONS: Home-use ondansetron is widely prescribed in this urban academic pediatric ED for a variety of indications, without effect on 3- or 7-day ED return. Further prospective studies are necessary to determine the efficacy of this practice.

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients.

BACKGROUND: Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection. OBJECTIVE: Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate. METHODS: We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus. RESULTS: There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain. CONCLUSIONS: There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication.

Optimizing information sharing at transfer of care between teams is an important target for the improvement of patient safety. Traditional emergency department (ED)-to-floor handoffs do not support a shared mental model between physicians, residents, and nurses. This report describes and evaluates acceptance of a novel process for coordinating physician and nursing handoff calls for patients being admitted to an inpatient floor from a children's hospital ED. METHODS: The Admission Conference Call (ACC) is a single conference call including attendings, residents, and nurses from the ED and inpatient teams, currently used for 29.8% of admissions from one ED. Physicians and nurses were surveyed to assess perception of its effects on patient care. RESULTS: A total of 653 ACCs were conducted during 2017. The survey was completed by 43 nurses and 89 physicians. Mean Likert scale findings were in favor of the process supporting safe patient care (4.5/5; standard deviation [SD], 0.6); none said it increased risk. Ratings favored the process improving interdisciplinary alignment (4.0/5; SD, 0.8) and the benefits outweighing the inconvenience (3.9/5; SD, 0.9). Respondents were neutral on the effect of the ACC on throughput time (3.0/5; SD, 1.0). Logistical concerns were expressed; mean satisfaction was 6.8/10 (SD, 2.1). Free text comments varied widely, from pride to frustration. CONCLUSION: The Admission Conference Call is a well-accepted alternative to a traditional multiple call process. Most participants believe it supports safe patient care. Further research is necessary to confirm measurable effects on patient outcomes, but this project provides encouragement to institutions considering innovative approaches.

Positive Peer-Pressured Productivity (P-QUAD): Novel Use of Increased Transparency and a Weighted Lottery to Increase a Division's Academic Output.

OBJECTIVE: Evaluate a dual incentive model combining positive peer pressure through increased transparency of peers' academic work with a weighted lottery where entries are earned based on degree of productivity. METHODS: We developed a dual-incentive peer mentoring model, Positive Peer-Pressured Productivity (P-QUAD), for faculty in the Pediatric Hospital Medicine Division at the University of Minnesota Masonic Children's Hospital. This model provided relative value-based incentives, with points assigned to different scholarly activities (eg. 1 point for abstract submission, 2 points for poster presentation, 3 points for oral presentation, etc.). These points translated into to lottery tickets for a semi-annual drawing for monetary prizes. Productivity was compared among faculty for P-QUAD year to the preintervention year. RESULTS: Fifteen (83%) of 18 eligible faculty members participated. Overall annual productivity per faculty member as measured by total P-QUAD score increased from a median of 3 (interquartile range [IQR] 0-14) in the preintervention year to 4 (IQR 0-27) in the P-QUAD year (P = .051). Submissions and acceptances increased in all categories except posters which were unchanged. Annual abstract submissions per faculty member significantly increased from a median of 1 (IQR 0-2) to 2 (IQR 0-2; P = .047). Seventy-three percent (8 of 11) of post-survey respondents indicated that the financial incentive motivated them to submit academic work; 100% indicated that increased awareness of their peers' work was a motivator. CONCLUSIONS: The combination of increased awareness of peers' academic productivity and a weighted lottery financial incentive appears to be a useful model for stimulating academic productivity in early-career faculty.

The effect of family presence on the efficiency of pediatric trauma resuscitations.

STUDY OBJECTIVE: Family presence has broad professional organizational support and is gaining acceptance. We seek to determine whether family presence prolonged pediatric trauma team resuscitations as measured by time from emergency department arrival to computed tomographic (CT) scan, and to resuscitation completion. METHODS: A prospective trial offered families of pediatric trauma patients family presence on even days and no family presence on odd days. Primary outcome measures were time from arrival to CT scan and to resuscitation completion (laboratory tests, emergency procedures, portable radiographs, and secondary survey). We evaluated the effect of family presence in an adjusted Cox proportional hazards model. Staff and family experiencing a resuscitation with family presence were asked their opinions of that experience. RESULTS: Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves. CONCLUSION: This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

Prehospital intranasal midazolam for the treatment of pediatric seizures.

BACKGROUND: The local emergency medical services (EMS) council implemented a new pediatric treatment protocol using a Mucosal Atomization Device (MAD) to deliver intranasal (IN) midazolam for seizure activity. METHODS: We sought to compare outcomes in seizing pediatric patients treated with IN midazolam using a MAD (IN-MAD midazolam) to those treated with rectal (PR) diazepam, 18 months before and after the implementation of the protocol. RESULTS: Of 857 seizure patients brought by EMS to our emergency department (ED), 124 patients (14%) had seizure activity in the presence of EMS and were eligible for inclusion in this study. Of the 124 patients eligible for this study, 67 patients (54%) received no medications in the prehospital setting, 39 patients (32%) were treated with IN-MAD midazolam, and 18 patients (15%) were treated with PR diazepam. Median seizure time noted by EMS was 19 minutes longer for PR diazepam (30 minutes) when compared with IN-MAD midazolam (11 minutes, P = 0.003). Patients treated with PR diazepam in the prehospital setting were significantly more likely to have a seizure in the ED (odds ratio [OR], 8.4; confidence interval [CI], 1.6-43.7), ED intubation (OR, 12.2; CI, 2.0-75.4), seizure medications in the ED to treat ongoing seizure activity (OR, 12.1; CI, 2.2-67.8), admission to the hospital (OR, 29.3; CI, 3.0-288.6), and admission to the pediatric intensive care unit (OR, 53.5; CI, 2.7-1046.8). CONCLUSIONS: The IN-MAD midazolam controlled seizures better than PR diazepam in the prehospital setting and resulted in fewer respiratory complications and fewer admissions.

Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service.

BACKGROUND: The occurrence of delayed diagnosis of injury (DDI) among pediatric trauma patients represents a breakdown in trauma care. Although some DDI may be unavoidable, the rate of DDI may be used as a measure of quality improvement. OBJECTIVE: We sought to investigate DDI in admitted pediatric trauma patients while a designated pediatric trauma response team was used and compare this with the prior incidence of DDI (4.3%) before initiation of the response team. METHODS: Primary Children's Medical Center (PCMC) is a regional tertiary pediatric trauma center. This analysis used the prospectively gathered PCMC Trauma Database, and included all hospitalized pediatric trauma patients from 1997 through 2000. RESULTS: A total of 3265 patients were included; no patients were excluded. A DDI occurred in 15 (0.46%; 95% CI: 0.31, 0.79) trauma patients. The DDI patients were more severely injured with significantly higher Injury Severity Scores, lower TRISS Probability of Survival values, longer hospitalizations (P < or = 0.05, Mann-Whitney U), and were more frequently admitted to the PICU (P < or = 0.05, chi2) than the non-DDI patient population. In a previous study, our incidence of missed injury was 4.3% (50/1175; 95% CI: 3.3, 5.6); with implementation of a designated trauma response team and trauma service, the incidence of DDI was reduced nearly 10-fold to 0.46% (15/3265; 95% CI: 0.31, 0.79). CONCLUSIONS: Implementation of an effective trauma team and trauma service was associated with a significant reduction in DDI.