Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation.

OBJECTIVE: To determine the effects of pediatric asthma pathway implementation in a diverse, national sample of emergency departments (EDs). STUDY DESIGN: In this quality improvement study, a national sample of EDs were provided pathways to tailor to local needs. Implementation strategies included local champions, external facilitators/mentors, educational seminars, and audit and feedback. Outcomes included systemic corticosteroid administration within 60 minutes (primary), assessment of severity at ED triage, chest radiograph use, hospital admission or transfer for higher level of care, and ED length of stay (balancing). Each month, EDs reviewed all charts (to a maximum of 20) of children ages 2-17 years with a primary diagnosis of asthma. Analyses were done using multilevel regression models with an interrupted time-series approach, adjusting for patient characteristics. RESULTS: We enrolled 83 EDs (37 in children's hospitals, 46 in community hospitals) and 61 (73%) completed the study (n = 22 963 visits). Pathway implementation was associated with significantly increased odds of systemic corticosteroid administration within 60 minutes of arrival (aOR, 1.26; 95% CI, 1.02-1.55), increased odds of severity assessment at triage (aOR, 1.88; 95% CI, 1.22-2.90), and decreased rate of change in odds of hospital admission/transfer (aOR, 0.97; 95% CI, 0.95-0.99). Pathway implementation was not associated with chest radiograph use or ED length of stay. CONCLUSIONS: Pathway implementation was associated with improved quality of care for children with asthma in a diverse, national group of EDs.

Impact of an Offline Pain Management Protocol on Prehospital Provider Self-Efficacy: A Randomized Trial.

BACKGROUND: Pain in children is inadequately treated in the prehospital setting despite the reported recognition by prehospital providers (PHPs) of pain treatment as an important part of patient care. The impact of pediatric pain management protocol (PPP) implementation on PHP self-efficacy (SE), a measure congruent with performance, is unknown. OBJECTIVE: The aim of this study was to evaluate the impact of PPP implementation and pain management education on PHP SE. METHODS: This was a prospective study evaluating the change in PHP SE after a PPP was implemented. Prehospital providers were randomized to 3 groups: protocol introduction alone, protocol introduction with education, and protocol introduction with education and a 3-month interim review. Prehospital provider SE was assessed for pain management given 3 age-based scenarios. Self-efficacy was measured with a tool that uses a ranked ordinal scale ranging from "certain I cannot do it" (0) to "completely certain I can do it" (100) for 10 pain management actions: pain assessment (3), medication administration (4), dosing (1), and reassessment (2). An averaged composite score (0-100) was calculated for each of the 3 age groups (adult, child, toddler). Paired-sample t tests compared post-PPP and 13-month scores to pre-PPP scores. RESULTS: Of 264 PHPs who completed initial surveys, 142 PHPs completed 13-month surveys. Ninety-three (65%) received education with protocol review, and 49 (35%) had protocol review only. Self-efficacy scores increased over the study period, most notably for pain assessment. This increase persisted at 13 months for child (6.6 [95% confidence interval {CI}, 1.4-11.8]) and toddler pain assessment (22.3 [95% CI, 16.4-28.3]). Composite SE scores increased immediately for all age groups (adult, 3.1 [95% CI, 1.3-4.9]; child, 6.1 [95% CI, 3.8-8.5]; toddler, 12.0 [95% CI, 9.5-14.5]) and persisted at 13 months for the toddler group alone (7.0 [95% CI, 4.3-9.7]). There was no difference between groups who received protocol review alone compared with those with education or education plus a 3-month interim review. CONCLUSIONS: After a pain management protocol was introduced, SE scores among PHPs increased immediately and remained elevated for some individual actions involved in pain management, most notably pain assessment. Prehospital provider pain assessment SE scores declined 13 months after protocol introduction for adults, but remained elevated compared with baseline for the pediatric age groups.

Variation in Computed Tomography Use for Evaluation of Head Injury in a Pediatric Emergency Department.

OBJECTIVES: Recent research has shown significant variation in rates of computed tomography (CT) use among pediatric hospital emergency departments (ED) for evaluation of head injured children. We examined the rates of CT use by individual ED attending physicians for evaluation of head injured children in a pediatric hospital ED. METHODS: We used an administrative database to identify children younger than 18 years evaluated for head injury from January 2011 through March 2013 at our children's hospital ED, staffed by pediatric emergency medicine (PEM) fellowship trained physicians and pediatricians. We excluded encounters with trauma team activation or previous head CT performed elsewhere. We excluded physicians whose patient volume was less than 1 standard deviation below the group mean. RESULTS: After exclusions, we evaluated 5340 encounters for head injury by 27 ED attending physicians. For individual physicians, CT rates ranged from 12.4% to 37.3%, with a mean group rate of 28.4%. Individual PEM physician CT rates ranged from 18.9% to 37.3%, versus 12.4% to 31.8% for pediatricians. Of the 1518 encounters in which CT was done, 128 (8.4%) had a traumatic brain injury on CT, and 125 (8.2%) had a simple skull fracture without traumatic brain injury on CT. Patient factors associated with CT use included age younger than 2 years, higher triage acuity, arrival time of 10:00 PM to 6:00 AM, hospital admission, and evaluation by a PEM physician. CONCLUSIONS: Physicians at our pediatric hospital ED varied in the use of CT for the evaluation of head-injured children.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children.

OBJECTIVE: To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. STUDY DESIGN: We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. RESULTS: Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). CONCLUSION: Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Reduced Computed Tomography for Appendicitis in Children after Implementation of Next-day Surgery Clinic Follow-up.

The use of computed tomography (CT) in the emergency department (ED) evaluation of pediatric patients for suspected appendicitis can be safely reduced. However, published examples of reduced CT use also report increased MRI utilization, ED length of stay, hospitalization rates, and in-ED surgical consultation. In addition, previous studies recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons. Therefore, we implemented a diagnostic algorithm that includes an option for next-day surgery clinic follow-up in cases where uncertainty remains after appendix ultrasound (US) to reduce CT utilization without increasing hospital-based resources. Methods: We implemented a diagnostic algorithm in January 2014. We retrospectively identified 4,577 patients who underwent an evaluation for suspected appendicitis from January 2012 to September 2015. CT utilization was compared before and after implementation using Statistical Process Control. In addition, we evaluated secondary outcomes, including US utilization, hospital admission, surgery clinic follow-up, ED surgery consultation, ED return visits within 7 days, and ED length of stay. Results: Following the implementation of the algorithm, CT utilization decreased significantly from 13.8% to 6%. Forty-eight patients were evaluated the next day in the optional pediatric surgery clinic for 21 months after implementation. There was no significant change in US utilization, hospital admission, ED surgery consultation, ED return visits within 7 days, or ED length of stay. Conclusion: We achieved decreased CT utilization without an increase in the utilization of other hospital-based resources after implementing a pediatric appendicitis evaluation algorithm that includes the option for next-day pediatric surgery clinic follow-up.

The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.

STUDY OBJECTIVE: Advanced imaging with computed tomography (CT) or ultrasonography is frequently used to evaluate for appendicitis. The duration of the abdominal pain may be related to the stage of disease and therefore the interpretability of radiologic studies. Here, we investigate the influence of the duration of pain on the diagnostic accuracy of advanced imaging in children being evaluated for acute appendicitis. METHODS: A secondary analysis of a prospective multicenter observational cohort of children aged 3 to 18 years with suspected appendicitis who underwent CT or ultrasonography was studied. Outcome was based on histopathology or telephone follow-up. Treating physicians recorded the duration of pain. Imaging was coded as positive, negative, or equivocal according to an attending radiologist's interpretation. RESULTS: A total of 1,810 children were analyzed (49% boys, mean age 10.9 years [SD 3.8 years]); 1,216 (68%) were assessed by CT and 832 (46%) by ultrasonography (238 [13%] had both). The sensitivity of ultrasonography increased linearly with increasing pain duration (test for trend: odds ratio=1.39; 95% confidence interval 1.14 to 1.71). There was no association between the sensitivity of CT or specificity of either modality with pain duration. The proportion of equivocal CT readings significantly decreased with increasing pain duration (test for trend: odds ratio=0.76; 95% confidence interval 0.65 to 0.90). CONCLUSION: The sensitivity of ultrasonography for appendicitis improves with a longer duration of abdominal pain, whereas CT demonstrated high sensitivity regardless of pain duration. Additionally, CT results (but not ultrasonographic results) were less likely to be equivocal with longer duration of abdominal pain.

Utilization of a pediatric observation unit for toxicologic ingestions.

OBJECTIVES: The objectives of this study were to evaluate the efficacy and utilization of an observation unit (OU) for admission of pediatric patients after a toxicologic ingestion; compare the characteristics and outcomes of patients admitted to the pediatric OU, inpatient (IP) service, and intensive care unit (ICU) after ingestions using retrospective chart review; and attempt to identify factors associated with unplanned IP admission after an OU admission. METHODS: This was a retrospective chart review of children seen in the emergency department (ED) after potentially toxic suspected ingestions and then admitted to the OU, IP service, or ICU from June 2003 to September 2007. RESULTS: One thousand twenty-three children were seen in the ED for ingestions: 18% were admitted to the OU, 15% to the IP service service, and 6% to the ICU. Observation unit patients had less mental status changes reported and were less frequently given medications while in the ED. Eighty-one percent of OU patients were admitted with poison center recommendation. Ninety-four percent of OU patients were discharged within 24 hours, and less than half of IP service/ICU patients were discharged that quickly. No significant associations were found between specific historical and physical examination or laboratory characteristics in the ED and the need for unplanned IP admission. CONCLUSIONS: Observation unit patients admitted after ingestions were young, typically ingested substances found in the home, and required observation according to poison center recommendations. Ninety-four percent were able to be discharged home within 24 hours even after ingesting some of the most concerning substances such as central nervous system depressants, cardiac/antihypertension medications, hypoglycemics, and opiates. All OU patients did well without any adverse events reported. Many patients requiring prolonged observation after an ingestion, and who do not require ICU care, may be appropriate for OU management. This study suggests a potential underutilization of observation units in this setting.

Variation in the self-reported use of computed tomography in clearing the cervical spine of pediatric trauma patients.

OBJECTIVE: Cervical spine injury (CSI) in children can be life-threatening or associated with lifelong disabilities. Whereas screening computed tomography (CT) of the cervical spine is used in the evaluation of adult trauma patients, it has no additional benefit in children when compared with plain film radiography of the cervical spine. Despite this, CT use in the pediatric patient is increasing. We sought to compare the self-reported utilization of screening cervical spine CT among pediatric emergency medicine (PEM) physicians and general emergency medicine (non-PEM) physicians. METHODS: Physicians completed an online survey consisting of a clinical vignette in which the respondents chose to evaluate a pediatric trauma patient for CSI using no imaging, plain films, or CT. Questions regarding the physician's attitudes, knowledge, and practice patterns for pediatric CSI were included. RESULTS: Six hundred fifty-four physicians responded to the survey: 463 (70.8%) non-PEM and 191 (29.2%) PEM physicians. Both groups ordered radiographic imaging at a similar rate, although non-PEM physicians were 4 times more likely to utilize CT than PEM practitioners. Non-PEM physicians were more likely to overestimate the frequency of pediatric CSI. Pediatric emergency medicine physicians were more likely to state that they would never use CT as the initial modality for CSI screening. CONCLUSIONS: In response to a clinical vignette, non-PEM physicians were more likely to self-report the use of screening CT in pediatric trauma patients than PEM physicians.

A case of transient neonatal diabetes mellitus.

We present a case of an 8-day-old infant boy with transient neonatal diabetes mellitus who presented to our emergency department with profound dehydration, failure to thrive, and hyperglycemia. The initial ill appearance of the patient required attention to a broad differential diagnosis including cardiac, metabolic, endocrine, and infectious processes. Transient neonatal diabetes mellitus is one of several causes of severe hyperglycemia in the neonatal period and is caused by genetic imprinting at the 6q24 region. It requires specific genetic testing for diagnosis. This case illustrates initial management of and recommended laboratory testing in neonates presenting with possible transient neonatal diabetes mellitus.

Lights, camera, action spotlight on trauma video review: an underutilized means of quality improvement and education.

BACKGROUND: Trauma video review (TVR) is an effective method of quality improvement and education. The objective of this study was to determine TVR practices in the United States and use of TVR for quality improvement and education. METHODS: Adult and pediatric trauma centers identified by the American College of Surgeons (n = 102) and the National Association of Children's Hospitals and Related Institutions (n = 24) were surveyed by telephone. Surveys included questions regarding program demographics, residency information, and past/present TVR practices. RESULTS: One hundred eight trauma centers (86%) were contacted, and 99% (107/108) completed surveys. Of the surveyed centers, 34% never used TVR; 37% previously used TVR and had discontinued at the time of the survey, with most reporting legal/privacy concerns; 20% were currently using TVR; and 9% were planning to use TVR in the future. Nineteen percent (14/73) of general trauma centers are using or planning to use TVR compared with 50% (17/34) of pediatric centers (P = 0.001). One hundred percent of current TVR programs report that TVR improves the trauma resuscitation process.Most pediatric emergency medicine (87%), emergency medicine (89%), and surgery (97%) trainees participate in trauma resuscitation at trauma centers. Fifty-two percent of centers using TVR report trainee attendance at TVR process/conference; 38% specifically use TVR for resident education. CONCLUSIONS: All current TVR programs report that it improves their trauma processes. More pediatric trauma centers report planning future TVR programs, but the implication of such plans remains unclear. Opportunities exist for expanded use of TVR for resident education.

An Administrative Data-based Surrogate Definition Identifies Children Evaluated Beyond Physical Examination for Suspected Appendicitis.

Previous studies have reported on the evaluation of patients diagnosed with appendicitis. Very little is known about all patients evaluated for suspected appendicitis. Patients evaluated beyond physical examination with laboratory and imaging testing, then found not to have appendicitis, are more difficult to identify. Data readily available in administrative databases may be used to identify these patients. METHODS: A multidisciplinary team developed a surrogate definition for evaluating suspected appendicitis in children based on available administrative data. Appendicitis was "suspected" if the patient underwent ultrasonography of the appendix or had a chief complaint of abdominal pain with both complete blood count performed and the word "appendicitis" in the ED provider note. Performance characteristics described the surrogate definition's ability to retrospectively identify patients evaluated for suspected appendicitis through comparison to a population identified via chart review. RESULTS: Compared with manual chart review of 498 patients from June 2014, the surrogate definition identified patients evaluated beyond physical examination for suspected appendicitis with a sensitivity of 79.8%, a specificity of 96.3%, a positive predictive value of 83.3%, and a negative predictive value of 95.3%. Of the 94 patients evaluated beyond physical examination for suspected appendicitis, 37 (39%) underwent appendectomy. CONCLUSIONS: Health systems can retrospectively identify children evaluated beyond physical examination for appendicitis using discrete administrative data and a word search of clinical notes. This surrogate definition for evaluation of suspected appendicitis enables research in quality improvement efforts and health care resource utilization.

Provider-Level and Hospital-Level Factors and Process Measures of Quality Care Delivered in Pediatric Emergency Departments.

OBJECTIVE: Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children's hospital EDs were associated with physician-level or hospital-level factors. METHODS: We included children (<18 years old) who presented to any of the 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2011 and December 2011. We measured quality of care from medical record reviews using a previously validated implicit review instrument with a summary score ranging from 5 to 35, and examined associations between process measures of quality and physician- and hospital-level factors using a mixed-effects linear regression model adjusted for patient case-mix, with hospital site as a random effect. RESULTS: Among the 620 ED encounters reviewed, we did not find process measures of quality to be associated with any physician-level factors such as physician sex, years since medical school graduation, or physician training. We found, however, that process measures of quality were positively associated with delivery at freestanding children's hospitals (1.96 points higher in quality compared to nonfreestanding status, 95% confidence interval: 0.49, 3.43) and negatively associated with higher annual ED patient volume (-0.03 points per thousand patients, 95% confidence interval: -0.05, -0.01). CONCLUSION: Process measures of quality of care delivered to children were higher among patients treated at freestanding children's hospitals but lower among patients treated at higher volume EDs.

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.

Altered Mental Status at High Altitude.

Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US Food and Drug Administration has approved baclofen for the treatment of spasticity of cerebral or spinal origin in adult and pediatric patients 4 years or older. Various complications of baclofen pumps are described in the literature. Immediately after surgery, problems from infection can arise and range from superficial skin infections to meningitis and bacteremia. Another early complication includes cerebrospinal fluid leak that can be observed by notable swelling beneath the lumbar incision. Additional problems that arise later are usually from the mechanics of the pump and catheter. Pump-related complications include failure, migration, and flipping. Catheter-related complications include disconnection, occlusion, fracture, or kink. Most of these complications typically lead to baclofen withdrawal, although there are a few case reports of overdose due to mechanical causes. Here we describe 2 cases of individuals experiencing complications of excessive baclofen exposure after significant changes in the atmospheric pressure due to travel involving ambient altitude change. These cases reflect the need to discuss this potential complication with families and patients with baclofen pumps before travel to high elevations.

Implementing a Standardized Constipation-Management Pathway to Reduce Resource Utilization.

OBJECTIVE: Constipation is commonly diagnosed in our pediatric emergency department (ED). Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for the diagnosis of and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical examination, less reliance on AR, and standardized home management. METHODS: Using quality improvement (QI) methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management "gift basket" containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and length of stay, and ED admission rate for constipation. RESULTS: Within 3 months, >90% of patients discharged home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and gift basket changes, and a higher threshold for inpatient management led to significant decreases in AR rate (73.3%-24.6%, P < .001), average per-patient cost ($637.42-$538.85), length of stay (223-196 minutes, P < .001), and ED admission rate (15.3%-5.4%, P < .001), with no concerning missed diagnoses or increases in ED revisit rate. CONCLUSIONS: An ED QI project standardizing the care of pediatric constipation was implemented successfully, leading to a sustainable decrease in resource utilization. The next phase of the project will focus on collaborating with community providers to reduce ED utilization.

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis.

OBJECTIVE: The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS: This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS: Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS: Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.

Implicit Review Instrument to Evaluate Quality of Care Delivered by Physicians to Children in Emergency Departments.

OBJECTIVE: To evaluate the consistency, reliability, and validity of an implicit review instrument that measures the quality of care provided to children in the emergency department (ED). DATA SOURCES/STUDY SETTING: Medical records of randomly selected children from 12 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). STUDY DESIGN: Eight pediatric emergency medicine physicians applied the instrument to 620 medical records. DATA COLLECTION/EXTRACTION METHODS: We determined internal consistency using Cronbach's alpha and inter-rater reliability using the intraclass correlation coefficient (ICC). We evaluated the validity of the instrument by correlating scores with four condition-specific explicit review instruments. PRINCIPAL FINDINGS: Individual reviewers' Cronbach's alpha had a mean of 0.85 with a range of 0.76-0.97; overall Cronbach's alpha was 0.90. The ICC was 0.49 for the summary score with a range from 0.40 to 0.46. Correlations between the quality of care score and the four condition-specific explicit review scores ranged from 0.24 to 0.38. CONCLUSIONS: The quality of care instrument demonstrated good internal consistency, moderate inter-rater reliability, high inter-rater agreement, and evidence supporting validity. The instrument could be useful for systems' assessment and research in evaluating the care delivered to children in the ED.

Patient-level Factors and the Quality of Care Delivered in Pediatric Emergency Departments.

OBJECTIVE: Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient-level factors. METHODS: This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect. RESULTS: In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (-0.65 points in quality, 95% confidence interval [CI] = -1.24 to -0.06) and upper respiratory symptoms (-0.68 points in quality, 95% CI = -1.30 to -0.07). CONCLUSION: We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.

A Clinical Score to Predict Appendicitis in Older Male Children.

OBJECTIVE: To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis. METHODS: Patients with suspected appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8-18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with <10% missing data and kappa > 0.4 were entered into a multivariable model. Resultant ß-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios. RESULTS: The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval [CI], 20%-29%), specificity of 98% (95% CI, 96%-99%), and positive predictive value of 93% (95% CI, 86%-97%) for ruling in appendicitis. CONCLUSIONS: We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging.

Time From Emergency Department Evaluation to Operation and Appendiceal Perforation.

BACKGROUND AND OBJECTIVES: In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children. METHODS: We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain (<96 hours). Time of initial physical examination and time of operation were recorded. The presence of AP was determined using operative reports. We analyzed whether duration of time from initial ED physician evaluation to operation impacted the odds of AP using multivariable logistic regression, adjusting for traditionally suggested risk factors that increase the risk of perforation. We also modeled the odds of perforation in a subpopulation of patients without perforation on computed tomography. RESULTS: Of 955 children with appendicitis, 25.9% (n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8-8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96-1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89-1.02). CONCLUSIONS: Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.