A framework for quality control in quantitative proteomics.

A thorough evaluation of the quality, reproducibility, and variability of bottom-up proteomics data is necessary at every stage of a workflow from planning to analysis. We share real-world case studies applying adaptable quality control (QC) measures to assess sample preparation, system function, and quantitative analysis. System suitability samples are repeatedly measured longitudinally with targeted methods, and we share examples where they are used on three instrument platforms to identify severe system failures and track function over months to years. Internal QCs incorporated at protein and peptide-level allow our team to assess sample preparation issues and to differentiate system failures from sample-specific issues. External QC samples prepared alongside our experimental samples are used to verify the consistency and quantitative potential of our results during batch correction and normalization before assessing biological phenotypes. We combine these controls with rapid analysis using Skyline, longitudinal QC metrics using AutoQC, and server-based data deposition using PanoramaWeb. We propose that this integrated approach to QC be used as a starting point for groups to facilitate rapid quality control assessment to ensure that valuable instrument time is used to collect the best quality data possible.

Dependence of human cell survival and proliferation on the CASP3 prodomain.

Mechanisms that regulate cell survival and proliferation are important for both the development and homeostasis of normal tissue, and as well as for the emergence and expansion of malignant cell populations. Caspase-3 (CASP3) has long been recognized for its proteolytic role in orchestrating cell death-initiated pathways and related processes; however, whether CASP3 has other functions in mammalian cells that do not depend on its known catalytic activity have remained unknown. To investigate this possibility, we examined the biological and molecular consequences of reducing CASP3 levels in normal and transformed human cells using lentiviral-mediated short hairpin-based knockdown experiments in combination with approaches designed to test the potential rescue capability of different components of the CASP3 protein. The results showed that a ≥50% reduction in CASP3 levels rapidly and consistently arrested cell cycle progression and survival in all cell types tested. Mass spectrometry-based proteomic analyses and more specific flow cytometric measurements strongly implicated CASP3 as playing an essential role in regulating intracellular protein aggregate clearance. Intriguingly, the rescue experiments utilizing different forms of the CASP3 protein showed its prosurvival function and effective removal of protein aggregates did not require its well-known catalytic capability, and pinpointed the N-terminal prodomain of CASP3 as the exclusive component needed in a diversity of human cell types. These findings identify a new mechanism that regulates human cell survival and proliferation and thus expands the complexity of how these processes can be controlled. The graphical abstract illustrates the critical role of CASP3 for sustained proliferation and survival of human cells through the clearance of protein aggregates.

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol.

INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

Impact of Respiratory Bacterial Codetection on Outcomes in Ventilated Infants With Bronchiolitis.

BACKGROUND: Viral bronchiolitis is a common cause of acute respiratory failure requiring intubation for infants. Bacterial respiratory tract infections can occur with bronchiolitis, although their prevalence and impact on outcomes are unclear, especially with increased use of noninvasive respiratory support. METHODS: This was a single-center retrospective cohort study of children <2 years old requiring intubation in the emergency department for bronchiolitis from 2012 to 2017 who had viral testing plus a lower respiratory culture obtained. We evaluated the impact of bacterial codetection (positive respiratory culture plus moderate or many polymorphonuclear neutrophils on Gram stain) on mechanical ventilation (MV) duration and intensive care unit length of stay using multivariable gamma regression. RESULTS: Of 149 patients enrolled, 52% had bacterial codetection. In adjusted analysis, patients with codetection had shorter MV duration [adjusted relative risk (aRR) 0.819, 95% confidence interval (CI): 0.69-0.98; marginal mean duration of 5.31 days (4.71-5.99) compared to 6.48 days (5.72-7.35) without codetection]. Patients with codetection had a shorter intensive care unit stay [aRR 0.806 (0.69-0.94); marginal mean length of stay 6.9 days (6.21-7.68) vs. 8.57 days (7.68-9.56) without codetection]. The association between codetection and duration of ventilation appears confined to those receiving earlier antibiotics (less than the median time) rather than later antibiotics [aRR 0.738 (0.56-0.95) for earlier vs. aRR 0.92 (0.70-1.18) for later]. CONCLUSIONS: Respiratory bacterial codetection is common and associated with shorter MV duration in infants requiring early intubation for bronchiolitis. Early antibiotics may contribute to these outcomes, but further multicenter studies are needed to understand the role of codetection and antibiotics on bronchiolitis outcomes.

Barriers and Facilitators to Pediatric Resident Education in the Emergency Department: A Qualitative Study.

Objective Local resident evaluations of the pediatric emergency department (ED) declined over the last five years. Sparse literature exists on resident perspectives of educational experiences. This study explored the barriers and facilitators to resident education in the Pediatric ED. Methods This qualitative study utilized focus groups at a large pediatric training hospital. Trained facilitators performed semi-structured interviews prompting discussion of resident experiences in the pediatric ED. One pilot and six focus groups (38 pediatric residents) achieved data saturation. Sessions were audio recorded, de-identified and transcribed by a professional service. Three authors (CJ, JM, SS) analyzed the transcripts independently using line-by-line coding. Following code agreement, authors identified central themes drawing on grounded theory. Results Six categories emerged: (1) ED environment, (2) consistent goals, expectations, and resources, (3) ED workflow, (4) preceptor accessibility, (5) resident growth and development, (6) ED preconceived notions. Residents value a respectful work environment despite the chaotic nature of the ED. They need clear goals and expectations with a strong orientation. Autonomy, open communication and shared decision-making allow residents to feel like team members. Residents gravitate toward welcoming, available preceptors that enthusiastically teach. More ED environment exposure increases comfort and efficiency and helps develop medical decision-making skills. Residents admit ED preconceptions and personality traits affect performance. Conclusion Residents self-identified barriers and facilitators to ED education. Educators must provide a safe and open learning environment, clear rotation expectations and goals, consistent positivity supporting shared decision making, and allow residents autonomy to build their practice styles.

Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections.

INTRODUCTION: Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs). METHODS: Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations. RESULTS: The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging. CONCLUSION: Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.

Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative.

Abusive injuries can go unrecognized or improperly managed by medical providers. This study sought to standardize the nonaccidental trauma (NAT) workup and improve NAT evaluation completion for children <7 months with concerning injuries in the pediatric emergency department (PED) and inpatient settings at an urban, tertiary care children's hospital. Methods: The quality improvement (QI) team created hospital guidelines for suspected NAT, including age-based recommendations (care bundle). The team embedded an order for NAT evaluation into the electronic health record (EHR). The QI team provided education on child abuse identification and evaluation across the hospital. Hospital providers received written guides focused on enhancing communication with families. Outcome measures included monthly NAT bundle use and cases between incomplete bundles in children with suspicious injuries. Chart review of incomplete bundles helped accurately identify patients who needed NAT bundles and improved accurate NAT bundle completion for appropriate patients. Results: Appropriate NAT bundle completion increased from 31% during the baseline period in January 2019 to 100% in April 2020 and remained at 100% for the remainder of the study period, ending June 2021. The number of patients between missed bundles was 11 from August 2019 until March 2020, when it increased to 583. There were no missed bundles from March 2020 through June 2021. Conclusions: Standardizing NAT evaluation and creating a NAT care bundle to facilitate the appropriate evaluation preceded an increase in appropriate bundle completion in patients <7 months old with possible NAT in the PED and inpatient units.

Timely Recognition of Abusive Injuries (TRAIN): Results from a Statewide Quality Improvement Collaborative.

Early recognition of physical abuse is critical as children often experience recurrent abuse if their environment remains unchanged. The Timely Recognition of Abusive Injuries (TRAIN) Collaborative was a quality improvement network of 6 Ohio children's hospitals created in 2015 to improve the management of injuries concerning for abuse in infants. TRAIN's first phase sought to reduce recurrent abuse by recognizing and responding to injured infants. This study aimed to reduce reinjury rate among infants ≤6 months by 10% at 1 year and 50% by 2 years and sustain improvement for 1 year as reflected in 3- and 12-month reinjury rates. Methods: The TRAIN Collaborative adopted the Institute for Healthcare Improvement's Breakthrough Series Collaborative Model, where partnerships between organizations facilitate learning from each other and experts. Collaborative members identified opportunities to improve injury recognition, implemented changes, responded to data, and reconvened to share successes and obstacles. As a result, institutions implemented different interventions, including education for clinical staff, increased social work involvement, and scripting for providers. Results: Data collected over 3 years were compared to a 12-month baseline. The number of injuries increased from 51 children with concerning injuries identified monthly to 76 children sustained throughout the collaborative. However, within 2 years, the 3- and 12-month reinjury rates ultimately significantly decreased from 5.7% to 2.1% and 6.5% to 3.7%, respectively. Conclusion: Our data suggest the Institute for Healthcare Improvement's Breakthrough Series model can be applied across large populations to improve secondary injury prevention in infants.

Characterizing the secretome of EGFR mutant lung adenocarcinoma.

Background: Lung cancer is the leading cause of cancer related death worldwide, mainly due to the late stage of disease at the time of diagnosis. Non-invasive biomarkers are needed to supplement existing screening methods to enable earlier detection and increased patient survival. This is critical to EGFR-driven lung adenocarcinoma as it commonly occurs in individuals who have never smoked and do not qualify for current screening protocols. Methods: In this study, we performed mass spectrometry analysis of the secretome of cultured lung cells representing different stages of mutant EGFR driven transformation, from normal to fully malignant. Identified secreted proteins specific to the malignant state were validated using orthogonal methods and their clinical activity assessed in lung adenocarcinoma patient cohorts. Results: We quantified 1020 secreted proteins, which were compared for differential expression between stages of transformation. We validated differentially expressed proteins at the transcriptional level in clinical tumor specimens, association with patient survival, and absolute concentration to yield three biomarker candidates: MDK, GDF15, and SPINT2. These candidates were validated using ELISA and increased levels were associated with poor patient survival specifically in EGFR mutant lung adenocarcinoma patients. Conclusions: Our study provides insight into changes in secreted proteins during EGFR driven lung adenocarcinoma transformation that may play a role in the processes that promote tumor progression. The specific candidates identified can harnessed for biomarker use to identify high risk individuals for early detection screening programs and disease management for this molecular subgroup of lung adenocarcinoma patients.

Identification of Initial and Subsequent Injury in Young Infants: Opportunities for Quality Improvement in the Evaluation of Child Abuse.

METHODS: Six children's hospitals identified infants with an initial injury and recurrent injury over a 1-year period using 2 methods: (1) diagnostic code method - infants 6 months or younger presenting with at least 1 diagnostic code for injury were tracked for 12 months to determine the frequency of recurrent injury, and (2) consult method - all available medical records of children 18 months or younger seen for an inpatient consultation for suspected child abuse were reviewed to identify history of a first injury at 6 months or younger. RESULTS: Using the diagnostic code method, 682 unique infants were identified with initial injuries, most commonly fractures (37.0%), bruising/ecchymosis (35.9%), and superficial injuries (28.3%). Forty-two infants (6.2%) returned with a second injury, and no demographic factors were significantly associated with the likelihood of a second injury. Using the consult method, 37 of 342 consults (10.8%) were identified as having a history of at least 1 initial injury. Of the initial injuries identified, the most common was bruising/ecchymosis (64.9%). The number of injuries identified with either method varied significantly across hospitals, as did completion of skeletal surveys for infants with bruising (range, 4.5%-71.1%; P < 0.001) and any injury (range, 4.4%-62.7%; P < 0.001). CONCLUSIONS: Our study demonstrates that young infants who experience 1 injury often experience a second injury. There exists significant variability in the identification of injury and the completion of skeletal surveys across a network of 6 children's hospitals. A standardized quality improvement approach may improve identification of injury and reduce the variability in practice observed.

Meeting the challenge of teaching bioethics: a successful residency curricula utilizing Team-Based Learning.

BACKGROUND: Despite recognition by both the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Paediatrics (ABP) of the importance of bioethics education, curricular crowding, lack of perceived significance, and insufficient administrative support remain significant barriers to trainees gaining competency in bioethics. Few bioethics curricula at the graduate medical education level are evidence-based or comprehensive. We sought to develop and assess the effectiveness of a Team Based Learning (TBL) curriculum in improving residents' bioethics knowledge and their ability to evaluate ethical dilemmas. METHODS: We integrated L. Dee Fink's curricular design principles of "Significant Learning," Jonsen et. al's "Four-Box Method" of ethical analysis, and ABP bioethics content specifications to create 10 TBL bioethics sessions. Paediatric residents at a major academic centre then completed a 3-year longitudinal, integrated TBL-based bioethics curriculum. Primary outcomes included individual and group readiness assessment tests (iRAT/gRAT), pre-work completion, and satisfaction with sessions. RESULTS: The TBL-based bioethics curriculum contains 10 adaptable modules. Paediatric residents (n = 348 total resident encounters) were highly engaged and satisfied with the curriculum. gRAT scores (mean 89%) demonstrated significant improvement compared to iRAT scores (72%) across all TBLs and all post-graduate years (p < .001). Higher gRAT scores correlated with higher level of training. Although pre-work completion was low (28%), satisfaction was high (4.42/5 on Likert scale). CONCLUSIONS: Our TBL-based bioethics curriculum was effective in improving knowledge, practical and flexible in its implementation, and well-received. We attribute its success to its grounding in ethical theory, relevance to ABP specifications, and a multi-modal, engaging format. This curriculum is easily modified to different specialties, virtual formats, or other specific institutional needs.Key messagesDespite formidable challenges to teaching bioethics in residency education, evidence-based methods such as Team-Based Learning (TBL) can be employed to increase knowledge and satisfaction.This study reports the first successful TBL bioethics curriculum, planned and executed longitudinally over 3 years, with paediatric residents at a large academic children's hospital in the US.TBL can be utilised to teach bioethics at the graduate medical education level and is adaptable to different situational factors, disciplines, and levels of clinical experience.

Quality improvement methodology can reduce hospitalisation for abscess management.

BACKGROUND: Abscesses are a common reason for ED visits. While many are drained in the ED, some require drainage in the operating room (OR). We observed that a higher percentage of patients at our institution in Columbus, Ohio, were admitted to the hospital with abscesses for incision and drainage (I&D) in the OR than other institutions, including paediatric institutions. Our aim was to decrease hospitalisations for abscess management. METHODS: A multidisciplinary team convened to decrease hospitalisation for patients with abscesses and completed multiple 'Plan-Do-Study-Act' cycles, including increasing I&Ds performed in the ED. Other interventions included implementation of a clinical pathway, training of procedure technicians (PT), updating the electronic medical record (EMR), credentialing advanced practice nurses in sedation and individual follow-up with providers for admitted patients. Data were analysed using statistical process control charts. Gross average charges were assessed. RESULTS: Admissions for I&D decreased from 26.3% to 13.7%. Abscess drainage in the ED improved from 79.3% to 96.5%. Mean length of stay decreased from 19.5 to 11.5 hours for all patients. Patients sedated increased from 3.3% to 18.2%. The number of repeat I&Ds within 30 days decreased from 4.3% to 1.7%. CONCLUSION: We decreased hospitalisations for abscess I&D by using quality improvement methodology. The most influential intervention was an initiative to increase I&Ds performed in the ED. Additional interventions included expanded training of PTs, implementation of a clinical pathway, updating the EMR, improving interdepartmental communication and increasing sedation providers.

Pediatric exploratory ingestions involving novel pill pack packaging.

Pill packs are novel packaging systems designed to contain multiple medications and increase medication access but are not child-resistant and increase the risk of pediatric ingestions. We present two pediatric ingestion cases suspected to involve pill packs. Case 1 describes a 19-month-old male presenting to the Emergency Department with altered mental status and unsteady gait after a suspected clonidine and buspirone ingestion. The patient's father reportedly received his medications in mail delivery "baggies". Case 2 involves a 21-month-old female presenting to the Emergency Department with unsteady gait. During an extensive workup we eventually found a clonazepam metabolite in her urine. A family friend supervising the patient at the time reportedly received medications through mail delivery in "plastic packs". Emergency physicians should be alert to this packaging system as these products contain multiple medications, potentially increasing injury risk and obfuscating diagnosis. Manufacturers, regulatory agencies and public health authorities should assess and reduce the dangers these products pose to children.

Do the Guidelines Apply?-A Multisite, Combined Stakeholder Qualitative Case Study to Understand Care Decisions in Bronchiolitis.

BACKGROUND: Clinical practice guidelines for bronchiolitis recommend against tests and treatments that do not improve outcomes, yet most children admitted with bronchiolitis continue to receive them. An improved understanding of factors that influence care decisions across multiple stakeholders and diverse settings is needed to develop effective strategies to de-implement (or reduce) unnecessary testing and treatment. METHODS: We explored health care provider, care team, and parent perspectives on testing and treatment in bronchiolitis to develop a combined stakeholder account of care decisions. We conducted a qualitative case study across 2 geographically distinct university affiliated children's hospitals representing a generally low and high test/treatment utilizing hospital respectively from March 2019 to May 2020. We conducted 46 semistructured interviews and 3 focus groups with a total of 74 participants. Data were analyzed using applied thematic analysis and findings were triangulated across participant group and data collection method. RESULTS: Three themes emerged around care decisions: 1) awareness and perceptions of the guidelines or evidence; 2) perceptions of expected tests or treatments, and 3) organizational culture and existing care processes. Provider and care team participants commonly described parent expectations as drivers of utilization. Conversely, parents generally reported a lack of expectations for tests/treatments and that tests/treatments did not improve their experience of care. CONCLUSIONS: This study illuminated factors associated with the differential adoption of evidence and targets for future de-implementation strategies. Importantly, incongruent with provider and care team perceptions, parents reported that they desire an evidence-based, less-is-more approach to bronchiolitis care.

Respiratory Pathogen Detection in Pediatric Patients Intubated for Presumed Infection.

OBJECTIVES: Respiratory syncytial virus (RSV) in pediatric patients has been associated with low risk of concomitant bacterial infection. However, in children with severe disease, it occurs in 22% to 50% of patients. As viral testing becomes routine, bacterial codetections are increasingly identified in patients with non-RSV viruses. We hypothesized, among patients intubated for respiratory failure secondary to suspected infection, there are similar rates of codetection between RSV and non-RSV viral detections. METHODS: This retrospective chart review, conducted over a 5-year period, included all patients younger than 2 years who required intubation secondary to respiratory failure from an infectious etiology in a single pediatric emergency department. Patients intubated for noninfectious causes were excluded. RESULTS: We reviewed 274 patients, of which 181 had positive viral testing. Of these, 48% were RSV-positive and 52% were positive for viruses other than RSV. Codetection of bacteria was found in 76% (n = 65; 95% confidence interval [CI], 66%, 84%) of RSV-positive patients and 66% (n = 63, 95% CI: 57%, 76%) of patients positive with non-RSV viruses. Among patients with negative viral testing, 33% had bacterial growth on lower respiratory culture. Male sex was the only patient-related factor associated with increased odds of codetection (odds ratio [OR], 2.2; 95% CI, 1.08-4.38). The odds of codetection between RSV-positive patients and non-RSV viruses were not significantly different (OR, 1.3; 95% CI, 0.62-2.71). CONCLUSIONS: Bacterial codetection is common and not associated with anticipated patient-related factors or with a specific virus. These results suggest consideration of empiric antibiotics in infants with respiratory illness requiring intubation.

Providers' Ability to Identify Sentinel Injuries Concerning for Physical Abuse in Infants.

OBJECTIVES: The objectives of this study were to assess the ability of pediatric health care providers and social workers to recognize sentinel injuries in infants under 6 months of age and to determine what factors influence their decision to evaluate for physical abuse. METHODS: A statewide collaborative focused on sentinel injuries administered a survey to pediatric health care providers and social workers in the emergency department, urgent care, and primary care. The survey contained 8 case scenarios of infants under 6 months of age with an injury, and respondents were asked if they would consider the injury to be a sentinel injury requiring a physical abuse evaluation. Respondents were then presented with several factors and asked how much each influences the decision to perform a physical abuse evaluation. RESULTS: A total of 565 providers completed the survey. Providers had moderate interrater reliability on their classification of the cases as sentinel injuries or not (κ = 0.57). Nearly all respondents (97%) recognized genital bruising as a sentinel injury, whereas 77% of respondents recognized intraoral injuries. Agreement was highest among social workers (κ = 0.76) and physicians with categorical pediatrics training and pediatric emergency medicine fellowship (κ = 0.63) and lowest among nurse practitioners (κ = 0.48) and residents (κ = 0.51). Concern over missing the diagnosis of abuse had the greatest influence on the decision to perform a physical abuse evaluation. CONCLUSIONS: Sentinel injuries are not uniformly recognized as potential signs of child abuse requiring further evaluation by pediatric health care providers. Additional evidence and education are needed regarding sentinel injuries.

Optimizing Rapid Sequence Intubation for Medical and Trauma Patients in the Pediatric Emergency Department.

INTRODUCTION: Rapid sequence intubation (RSI) is a critical procedure for severely ill and injured patients presenting to the pediatric emergency department (PED). This procedure has a high risk of complications, and multiple attempts increase this risk. We aimed to increase successful intubation within two attempts, focusing on medical and trauma patients separately to identify improvement barriers for each group. METHODS: A multifaceted intervention was implemented using quality improvement methods. The analysis included adherence to the standardized process, successful intubation within two attempts, and frequency of oxygen saturations <92% during laryngoscopy. Trauma and medical patients were analyzed separately as team composition differed for each. RESULTS: This project began in February 2018, and we included 290 patients between April 2018 and December 2019. Adherence to the standardized process was sustained at 91% for medical patients and a baseline of 55% for trauma patients with a trend toward improvement. In May 2018, we observed and sustained special cause variations for medical patients' successful intubations within two attempts (77-89%). In September 2018, special cause variation was observed and sustained for the successful intubation of trauma patients within two attempts (89-96%). The frequency of oxygen saturation of <92% was 21% for medical patients; only one trauma patient experienced oxygen desaturation. CONCLUSION: Implementation of a standardized process significantly improved successful intubations within two attempts for medical and trauma patients. Trauma teams had more gradual adherence to the standardized process, which may be related to the relative infrequency of intubations and variable team composition.

Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department.

INTRODUCTION: Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. METHODS: The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. RESULTS: Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. DISCUSSION: The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.

A Quality Improvement Initiative to Increase the Number of Pediatric Resident Laceration Repairs.

BACKGROUND: Pediatric residents must demonstrate competence in several clinical procedures prior to graduation, including simple laceration repair. However, residents may lack opportunities to perform laceration repairs during training, affecting their ability and confidence to perform this procedure. OBJECTIVE: We implemented a quality improvement initiative to increase the number of laceration repairs logged by pediatric residents from a baseline mean of 6.75 per month to more than 30 repairs logged monthly. METHODS: We followed the Institute for Healthcare Improvement's Model for Improvement with rapid plan-do-study-act cycles. From July 2016 to February 2018, we increased the number of procedure shifts and added an education module on performing laceration repairs for residents in a pediatric emergency department at a large tertiary hospital. We used statistical process control charting to document improvement. Our outcome measure was the number of laceration repairs documented in resident procedure logs. We followed the percentage of lacerations repairs completed by residents as a process measure and length of stay as a balancing measure. RESULTS: Following the interventions, logged laceration repairs initially increased from 6.75 to 22.75 per month for the residency program. After the number of procedure shifts decreased, logged repairs decreased to 13.40 per month and the percentage of lacerations repaired by residents also decreased. We noted an increased length of stay for patients whose lacerations were repaired by residents. CONCLUSIONS: While our objective was not met, our quality improvement initiative resulted in more logged laceration repairs. The most effective intervention was dedicated procedure shifts.