Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation.

OBJECTIVE: Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling. DESIGN: Retrospective chart review, modified Delphi, and nominal group techniques. SETTING: Large, urban, quaternary care children's hospital in the Midwestern United States. PARTICIPANTS: Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment). MAIN OUTCOME MEASURES: Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication). RESULTS: The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS. CONCLUSIONS: Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.

Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment.

BACKGROUND AND PURPOSE: Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting. METHODS: This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change. RESULTS: Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information. CONCLUSION: This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.

Decision-making for pediatric cervical spine imaging after blunt trauma: Investigating team dynamics in the emergency department.

Objective: Cervical spine imaging decision-making for pediatric traumas is complex and multidisciplinary. Implementing a risk assessment tool has the potential to reduce variation in these decisions and unnecessary radiation exposure for pediatric patients. We sought to determine how emergency department-trauma team dynamics may affect implementation of such a tool. Methods: We interviewed (pediatric and general emergency physicians, trauma surgeons, neurosurgeons, orthopedic surgeons and ED nurses at 21 hospitals to ascertain how team dynamics affect the pediatric cervical spine imaging decision-making process. Data were coded following a framework-driven deductive coding process and thematic analysis was used. Results: Forty-eight physicians, advanced practice providers, and nurses from 21 hospitals (inclusive of three US regions, trauma levels I-III, and serving towns/cities of various population sizes) were interviewed. Overall, emergency physicians and trauma surgeons indicate being generally responsible for pediatric cervical spine imaging decisions. Conflict often occurs between these specialties due to differential weighting of concerns for missing an injury versus avoiding radiation exposure. Participants described a lack of trust and unclear roles regarding ownership for the final imaging decision. Nurses commonly described low psychological safety that prohibits them from participating in the decision-making process. Conclusions: Implementation of a standardized risk assessment tool for cervical spine trauma imaging decisions must consider perspectives of both emergency medicine and trauma. Policies to define appropriate use of standardized tools within this team environment should be developed.

The relationship between emergency medical services use and social service needs in a pediatric emergency department population.

BACKGROUND: Emergency Medical Services (EMS) use for children is correlated with areas of resource deprivation as well as child maltreatment. Households using EMS may have more social needs and be willing to accept services. OBJECTIVE: To compare social service needs and willingness to accept services in families arriving to a pediatric emergency department (ED) via EMS vs non-EMS, before and during COVID-19. PARTICIPANTS AND SETTING: Caregivers of children 0-5 years old in a quaternary pediatric ED, with a 1:1 ratio of EMS vs non-EMS arrivals. METHODS: Participants completed a survey of demographics, social service needs, and willingness to accept services, before and during COVID-19. RESULTS: Of 220 participants, 84 were enrolled before COVID-19. The EMS group reported less full-time employment (34.6% vs 51.8%, p < 0.05) and more social service needs (2.47 vs 1.76 needs, p < 0.05). Mean score for willingness to accept a service provider in the home was 3.62 for EMS and 3.19 for non-EMS (p = 0.09). Mean score for accepting a phone referral was 3.84 for EMS and 3.40 for non-EMS (p = 0.07). COVID-19 impacted needs for both groups (20.9% EMS vs 30.3% non-EMS). For all subjects presenting to the ED, COVID-19 was associated with decreased food insecurity (28.6% vs 15.4%) and children with a chronic medical condition (31.0% vs 12.5%). CONCLUSIONS: The EMS group had more social service needs. There was no difference in social services acceptance. COVID-19 affected both groups' needs. Future interventions may use EMS systems to mitigate social service needs which may be risk factors for child abuse.