Improving parent-provider communication in the pediatric emergency department: results from the clear and concise communication campaign.

OBJECTIVE: We implemented and evaluated a quality improvement initiative targeting parents' communication with clinicians in a pediatric emergency department (ED). METHODS: A quality improvement initiative ("Clear and Concise Communication" or "3C") targeting parent-provider communication was implemented in an urban tertiary care pediatric ED. A 1-page form that solicited parent worries, questions, and expectations for care was developed. Parent-provider communication was measured using an 8-item subset of questions from an ongoing satisfaction survey adopted for pediatric emergency care. The primary outcome was the communication score for a given ED visit scaled from 0 to 100 and was calculated as the simple average of answers where the best possible response was given a value of 1 and all others were scored as 0. A multivariate model adjusting for time-related factors, ED volume, and system-level events was developed to examine the influence of the communication initiative. RESULTS: A total of 29,005 patients received care during implementation of 3C; a total of 100,810 patients received care during the 2-year period of interest. Data from 1233 satisfaction surveys were used to create the communication scores. Communication scores ranged from 0 to 100, with a mean of 88 and SD of 17.7. In a linear model adjusting for day, weekend, volume, system-level introduction of electronic charting for nurses, and electronic-order entry for physicians, the 3C initiative demonstrated a positive and statistically significant effect-increasing the communication score by 2.8 points/100 d (95% confidence interval, 0.1-5.5). CONCLUSIONS: The 3C initiative succeeded in improving parents' communication experience with emergency providers during the intervention period.

Reducing Antibiotic Prescription Errors in the Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Discharge prescription errors from the pediatric emergency department (ED) are common. Despite the implementation of clinical pathways for common infections recommending specific antibiotic therapy and aids built into the electronic health record, errors in antibiotic prescriptions for patients discharged home from the ED persist. METHODS: We developed and implemented ED antibiotic discharge order panels for urinary tract infection (UTI) and skin and soft tissue infections (SSTI) that modeled antibiotic therapy from our institutional clinical pathways. We aimed to reduce antibiotic prescription errors by 50% within 6 months of implementation. RESULTS: With the implementation of the ED discharge order panels, the overall error rate for prescriptions for UTI and SSTI improved from a baseline rate of 29.3% to 12.6% (P < 0.001). Individually, the baseline number of prescriptions with errors for UTI and SSTI improved from 26.1% and 32.8%, respectively, to 13.8% and 12.5% within 6 months. Sustained improvement continued for 17 months after the implementation of the order panels. CONCLUSIONS: Development and implementation of ED antibiotic discharge order panels decrease antibiotic prescription errors for UTI and SSTI by improving compliance with institutional clinical pathways. Additional order panels should be developed and implemented for other conditions to help reduce discharge prescription errors.

Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway.

BACKGROUND AND OBJECTIVES: Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI). METHODS: The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures. RESULTS: Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders. CONCLUSIONS: Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.

Bathing suit mesh entrapment: an unusual case of penile injury.

Penile injury is a rare chief complaint in the pediatric emergency department. The most common penile injuries are iatrogenic or postsurgical complications, blunt trauma, tourniquet injuries, fractures, and zipper injuries. We report a series of 3 cases of penile foreskin entrapment within the mesh lining of bathing suits as a new, recognized form of penile injury.

Dilated cardiomyopathy in a 7-year-old girl.

Pediatric patients with dilated cardiomyopathy can initially be present for medical attention with non-specific and misleading signs and symptoms. We present the case of a 7-year-old girl with vague complaints of fever, vomiting, and abdominal pain and cardiac murmur on physical exam who progressed to congestive heart failure before her dilated cardiomyopathy was diagnosed. Clinicians should maintain a high index of suspicion for dilated cardiomyopathy in any patient with cardiac murmur and systematic symptoms.