Prevalence of Cardiac Dysfunction in Malawian Children With Severe Febrile Illness.

OBJECTIVES: To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels. DESIGN: Prospective observational study. SETTING: Pediatric ward of a tertiary government referral hospital in Malawi. PATIENTS: Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018. INTERVENTIONS: Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes. MEASUREMENTS AND MAIN RESULTS: Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4-40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate. CONCLUSIONS: Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.

Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice.

OBJECTIVES: This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences. METHODS: We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis. RESULTS: Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale. CONCLUSIONS: A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.

Development of a motivation-based tool to facilitate individualized self-management interventions for adolescents with asthma.

OBJECTIVE: To develop a questionnaire for segmenting adolescents with asthma into archetypes based on their motivations for individualized self-management interventions. METHODS: A prospective observational study using segmentation methodology. First, adolescents created photo diaries followed by in-person semi-structured interviews to develop a pool of candidate items for identifying and describing archetypes. Second, quantitative methods were used to test the pool of items to determine which ones best identified each archetype. RESULTS: Six archetypes based on motivations were identified and described: goal oriented visionaries; mentors and helpers; influencers; discouraged adolescents; dependent adolescents; and shame avoiders. A questionnaire with 63 candidate items was administered to 201 adolescents. Confirmatory factor analysis resulted in a 17-item questionnaire that identified the archetypes. CONCLUSION: This study is the first step towards applying a segmentation methodology to facilitate the application of interventions during a clinic visit to increase adherence. It has shown that a relatively short questionnaire can be used to identify archetypes based on motivations. PRACTICE IMPLICATIONS: The 17-item questionnaire could provide a framework and direction for healthcare professionals to customize existing adherence interventions, such as motivational interviewing, to different segments of adolescents. It would be especially helpful in primary care settings where time is limited.

Using Dry-Erase Boards to Share Information in a Pediatric Emergency Department to Improve Family Experience of Care.

OBJECTIVES: To determine whether the use of dry-erase boards for communicating the plan of care of children evaluated in the pediatric emergency department (PED) improves the family experience of care. METHODS: Dry-erase boards were mounted at eye level in patient examination rooms. The study was conducted during a 4-week period during which physicians were instructed to use the boards on alternating weeks. During the 2 intervention weeks, they were instructed to write their name and plan of care in addition to their standard verbal communication. A questionnaire was administered to a convenience sample of caregivers that measured their perceptions of physician listening skills, time spent with the physician, their understanding of the care plan, their willingness to ask questions, likelihood to recommend the PED, and overall physician care. Differences between intervention and nonintervention weeks were analyzed using adjusted multivariable modeling taking into account clustered observations within physician. RESULTS: Surveys were completed by 672 caregivers. There were no significant differences in reported experience of care between the intervention and nonintervention weeks. During the intervention weeks, 59% of caregivers recalled use of the dry-erase boards, whereas 10% of caregivers recalled use during nonintervention weeks. Caregivers who recalled the use of dry-erase boards were more likely to report better physician listening skills, better understanding of the plan of care, and higher overall physician ratings. CONCLUSIONS: Recommending use of dry-erase boards in pediatric emergency department rooms did not increase overall measures of experience of care, although patients who recalled dry-erase board use did report higher performance. Further study could explore how to effectively and efficiently use these boards.

Early prediction of pediatric acute kidney injury from the emergency department: A pilot study.

BACKGROUND: Identifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children. OBJECTIVE: To derive and test performance of an "acute" RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers. METHODS: Study of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24-72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed. RESULTS: 118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86-0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69-99) and a negative predictive value of 99% (92-100) (versus sensitivity 59% (33-82) and NPV 93% (89-96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker. CONCLUSIONS: This pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.

A Pilot Study of a Measure of Parental Trust in Pediatric Emergency Department Care Teams.

OBJECTIVE: To modify and test an existing measure of trust validated in a primary care setting for use in a pediatric emergency department (PED). METHODS: The study population was parents/guardians who brought their child to an urban PED with a chief complaint of abdominal pain or head injury. We used a 2-phase design with modifications resulting from cognitive interviews with 15 participants followed by a field test with 150 participants. We measured usefulness by percent missing responses and ceiling effects. Cronbach's alpha and greatest lower bound measured reliability. As evidence of validity, we calculated a total trust score by summing the item scale values and correlating the score with measures of constructs shown to be positively associated with trust in other settings. We conducted a similar analysis to test a published shortened version of the same scale. RESULTS: Four items were modified prior to field testing. Ceiling effects for each item ranged from 53% to 67%. Missing data were minimal affecting only 2 items. The modified measure exhibited high reliability (Cronbach's alpha = .88, greatest lower bound = 0.93). Total trust scores ranged from 27 to 50 with mean (standard deviation) = 45.1 (4.9). The trust score exhibited a high positive correlation with communication and overall satisfaction, and moderate correlation with intent to adhere to physician recommendations. The short version of the scale performed similarly. CONCLUSIONS: This study provides evidence that the modified Wake Forest measure of trust is applicable and useful in the PED setting for this patient population.

Resident-Sensitive Quality Measures in the Pediatric Emergency Department: Exploring Relationships With Supervisor Entrustment and Patient Acuity and Complexity.

PURPOSE: This study explores the associations between resident-sensitive quality measures (RSQMs) and supervisor entrustment as well as between RSQMs and patient acuity and complexity for encounters in the pediatric emergency department (PED) in which residents are caring for patients. METHOD: Pediatric residents rotating through Cincinnati Children's Hospital Medical Center PED as well as supervising pediatric emergency medicine faculty and fellows were recruited during the 2017-2018 academic year for the purpose of collecting the following data from the residents' patient encounters for 3 illnesses (acute asthma exacerbation, bronchiolitis, and closed head injury [CHI]): supervisor entrustment decision rating, RSQMs relevant to the care provided, and supervisor patient acuity and complexity ratings. To measure the association of RSQM composite scores with the other variables of interest, mixed models were used. RESULTS: A total of 83 residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with CHI. Entrustment decision ratings were positively associated with asthma RSQM composite scores (beta coefficient = 0.03; P < .001). There was no significant association between RSQM composite scores and entrustment decision ratings for bronchiolitis or CHI. RSQM composite scores were significantly higher when acuity was also higher and significantly lower when acuity was also lower for both asthma (P < .001) and bronchiolitis (P = .01). However, RSQM composite scores were almost identical between levels of acuity for CHI (P = .94). There were no significant differences in RSQM composite scores when complexity varied. CONCLUSION: This study found limited associations between RSQM composite scores and entrustment decision ratings but offers insight into how RSQMs could be used for the purposes of resident assessment and feedback.

Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department.

OBJECTIVE: Language barriers may influence the management of pediatric emergency department (PED) patients who may not align with evidence-based guidelines from the American Academy of Pediatrics. Our objective was to determine if a family's preferred language of Spanish versus English was associated with differences in management of bronchiolitis in the PED. METHODS: We conducted a retrospective study of children ≤2 years old diagnosed with bronchiolitis in a PED over a 7-year period. Rates of PED testing, interventions, and disposition among children whose families' preferred language was Spanish were compared to children whose families' preferred language was English. Primary outcomes were frequencies of chest x-ray and bronchodilator orders. Secondary outcomes were diagnostic testing, medication orders, and disposition. Logistic regression was used to calculate adjusted odds ratios after controlling for age, emergency severity index, prior visit, and nesting within attending physicians. RESULTS: A total of 13,612 encounters were included. Spanish-speaking families were more likely to have chest x-rays (35.8% vs 26.7%, P < .0001; adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI] 1.2-1.9), complete blood counts (8.2% vs 4.9%, P < .005; aOR 1.7; 95% CI 1.2-2.5), and blood cultures ordered (8.1% vs 5.0%, P < .05; aOR 1.7; 95% CI 1.2-2.4). No other differences in bronchodilators, medication orders, or disposition were found between the 2 groups. CONCLUSIONS: Among children diagnosed with bronchiolitis, Spanish-speaking families were more likely to have chest x-rays, complete blood counts, and blood cultures ordered compared to English-speaking families. Further research on how clinical practice guidelines and equity-focused guidelines can impact disparities in diagnostic testing within the PED is warranted.

Initial Implementation of Resident-Sensitive Quality Measures in the Pediatric Emergency Department: A Wide Range of Performance.

PURPOSE: A lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment. METHOD: During academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed. RESULTS: Eighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89. CONCLUSIONS: Individually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.

Diagnostic Testing and Antibiotic Use in Young Children With Community-Acquired Pneumonia in the United States, 2008-2015.

Diagnostic testing and antibiotics are not routinely recommended for young children with community-acquired pneumonia. In a national sample of >6 million outpatient 1- to 6-year-olds with community-acquired pneumonia between 2008 and 2015, a complete blood count was obtained for 8.6% (95% confidence interval [CI], 6.1%-11.1%), radiography was performed for 43% (95% CI, 36%-50%), and antibiotics were given for 73.9% (95% CI, 67.1%-80.7%). There were no changes in testing or antibiotic use over time.

A Video-Based, Case-Control Study of Factors Associated With Intraosseous Catheterization During Pediatric Resuscitation.

STUDY OBJECTIVE: Factors associated with intraosseous (IO) catheterization are not well described. Our objective is to identify factors associated with the attempt and timing of IO catheterization in a pediatric emergency department (ED) resuscitation setting. METHODS: We completed a video-based, case-control study (1:3 ratio) of children undergoing IO catheterization in the resuscitation area of a high-volume, academic, pediatric ED. We selected 8 independent factors a priori for analysis: younger than 2 years, Glasgow Coma Scale score less than 8, cardiopulmonary resuscitation (CPR), parent or caregiver presence, physician team leader with greater than 5 years of pediatric ED experience, 2 or more IO-catheterization-capable staff, ultrasonographically trained nurse vascular access team presence, and resuscitation occurring during the evening (4 pm to midnight) or overnight (midnight to 8 am) shift. We fit linear regression models to analyze for associations with IO access attempts and timing. RESULTS: One hundred fourteen patients were enrolled; 40 encounters involved IO catheterization (35.1%). Only CPR was associated with IO catheterization (odds ratio 39.0; 95% confidence interval 12.5 to 121.6). Mean time to IO attempt was shorter with CPR (3.2 versus 14.2 minutes) and longer with vascular access team presence (23.5 versus 3.4 minutes) or caregiver presence (10.5 versus 2.6 minutes). Of resuscitations that achieved peripheral intravenous access, only 1 (1.1%) did so in less than 90 seconds. CONCLUSION: CPR was the only factor associated with IO access attempts, whereas providers may have been more hesitant to attempt IO catheterization with vascular access team or caregiver presence. Future studies should include a larger, multicenter sample and use qualitative methods to explore reasons for IO catheterization hesitancy, especially in the nonarrest scenario.

Study of Delayed Antibiotic in Pediatric Febrile Immunocompromised Patients and Adverse Events.

OBJECTIVES: Bone marrow transplant (BMT) patients or patients receiving chemotherapy for oncologic diagnoses are at risk for sepsis. The association of time to antibiotics (TTA) with outcomes when adjusting for severity of illness has not been evaluated in the pediatric febrile immunocompromised (FI) population. We evaluated the association of TTA with adverse events in a cohort of FI patients presenting to our pediatric emergency department. METHODS: We performed a retrospective review of consecutive FI patients presenting over a 6.5-year period. Adverse events were defined as intensive care admission within 72 hours of emergency department arrival, laboratory signs of acute kidney injury, inotropic support subsequent to antibiotics, and all-cause mortality within 30 days. Vital signs and interventions were used to define severity of illness. Adjusting for severity of illness at presentation, age, and timing of an institutional intervention designed to reduce TTA in FI patients, we analyzed the association of TTA with individual adverse events as well as with adverse events in aggregate. RESULTS: We analyzed 1489 patient encounters. In oncology patients, TTA was not associated with the aggregate measure of whether any adverse event subsequently occurred nor with other individual adverse events. For the BMT subpopulation, TTA >60 minutes did show increased odds of intensive care admission within 72 hours as well as for aggregate adverse events. CONCLUSIONS: Although TTA >60 minutes did show increased odds of aggregate adverse events in the small subgroup of BMT patients, overall TTA was not associated with adverse events in oncology patients as a whole.

Emergency Department Management of Bronchiolitis in the United States.

OBJECTIVE: The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines. METHODS: We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use. RESULTS: Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5-5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0-4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%; 95% CI, -39.3% to -0.03%) compared with GEDs (-12.2%; 95% CI, -22.3% to -2.1%), and PEDs showed a significant decline in corticosteroid use (-12.4%; 95% CI, -22.1% to -2.8%), whereas GEDs showed no significant decline (-4.6%; 95% CI, -13.5% to 4.3%). CONCLUSIONS: The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.

Characterizing Hospitalizations for Pediatric Concussion and Trends in Care.

BACKGROUND: Children hospitalized for concussion may be at a higher risk for persistent symptoms, but little is known about this subset of children. OBJECTIVE: Delineate a cohort of children admitted for concussion, describe care practices received, examine factors associated with prolonged length of stay (LOS) or emergency department (ED) readmission, and investigate changes in care over time. DESIGN, SETTING: Retrospective analysis of data submitted by 40 pediatric hospitals to the Pediatric Health Information System. PATIENTS: Children 0 to 17 years old admitted with a primary diagnosis of concussion from 2007 to 2014. MEASUREMENTS: Descriptive statistics characterized this cohort and care practices delivered, logistic regression identified factors associated with a LOS of =2 days and ED readmission, and trend analyses assessed changes in care over time. RESULTS: Of the 10,729 children admitted for concussion, 68.7% received intravenous pain or antiemetic medications. Female sex, adolescent age, and having government insurance were all associated (P = .02) with increased odds of LOS = 2 days and ED revisit. Proportions of children receiving intravenous ondansetron (slope = 1.56, P = .001) and ketorolac (slope = 0.61, P < .001) increased over time, and use of neuroimaging (slope = -1.75, P < .001) decreased. CONCLUSIONS: Although concussions are usually selflimited, hospitalized children often receive intravenous therapies despite an unclear benefit. Factors associated with prolonged LOS and ED revisit were similar to predictors of postconcussive syndrome. Since there has been an increased use of specific therapeutics, prospective evaluation of their relationship with concussion recovery could lay the groundwork for evidenced-based admission criteria and optimize recovery.

Describing pediatric acute kidney injury in children admitted from the emergency department.

OBJECTIVE: To define those children who develop acute kidney injury (AKI) within 48 h of admission from the emergency department (ED) and ascertain patient-related factors in the ED associated with AKI. METHODS: Retrospective, cohort study of children, birth to 19 years, admitted to a tertiary pediatric hospital from the ED between January 2010 and December 2013 who had serum creatinine (SCr) drawn as part of clinical care. AKI was defined as a 50% increase in SCr above baseline, as measured within 48 h of hospital presentation. Multivariable logistic regression was performed to determine factors associated with AKI by comparing those with and without kidney injury on hospital presentation. RESULTS: Of all ED admissions, 13,827 subjects (27%) were included; 10% developed AKI. Of kids with AKI, 75% had a measured SCr consistent with AKI while in the ED, 36% were admitted to the intensive care unit, and 2% died (all significantly more than children without AKI). Young age, history of AKI or solid organ transplant, receipt of intravenous fluids or central venous access in the ED, and admission to intensive care were factors independently associated with AKI (AUC = 0.793, 95% CI 0.78-0.81). CONCLUSIONS: One in 10 children who had SCr measured and were admitted to a tertiary pediatric hospital had AKI on or within 48 h of presentation. Inherent characteristics, identifiable in the ED, are associated with an increased risk of AKI. Future research should focus on improving AKI recognition in the ED by the development of a risk stratification tool.

A Validation Argument for a Simulation-Based Training Course Centered on Assessment, Recognition, and Early Management of Pediatric Sepsis.

INTRODUCTION: Early recognition of sepsis remains one of the greatest challenges in medicine. Novice clinicians are often responsible for the recognition of sepsis and the initiation of urgent management. The aim of this study was to create a validity argument for the use of a simulation-based training course centered on assessment, recognition, and early management of sepsis in a laboratory-based setting. METHODS: Five unique simulation scenarios were developed integrating critical sepsis cues identified through qualitative interviewing. Scenarios were piloted with groups of novice, intermediate, and expert pediatric physicians. The primary outcome was physician recognition of sepsis, measured with an adapted situation awareness global assessment tool. Secondary outcomes were physician compliance with pediatric advanced life support (PALS) guidelines and early sepsis management (ESM) recommendations, measured by two internally derived tools. Analysis compared recognition of sepsis by levels of expertise and measured association of sepsis recognition with the secondary outcomes. RESULTS: Eighteen physicians were recruited, six per study group. Each physician completed three sepsis simulations. Sepsis was recognized in 19 (35%) of 54 simulations. The odds that experts recognized sepsis was 2.6 [95% confidence interval (CI) = 0.5-13.8] times greater than novices. Adjusted for severity, for every point increase in the PALS global performance score, the odds that sepsis was recognized increased by 11.3 (95% CI = 3.1-41.4). Similarly, the odds ratio for the PALS checklist score was 1.5 (95% CI = 0.8-2.6). Adjusted for severity and level of expertise, the odds of recognizing sepsis was associated with an increase in the ESM checklist score of 1.8 (95% CI = 0.9-3.6) and an increase in ESM global performance score of 4.1 (95% CI = 1.7-10.0). CONCLUSIONS: Although incomplete, evidence from initial testing suggests that the simulations of pediatric sepsis were sufficiently valid to justify their use in training novice pediatric physicians in the assessment, recognition, and management of pediatric sepsis.

A Randomized Trial of User-Controlled Text Messaging to Improve Asthma Outcomes: A Pilot Study.

We enrolled 64 patients age 12 to 22 years with a diagnosis of poorly controlled persistent asthma in a 6-month longitudinal crossover study. During the 3 intervention months, participants created personalized text messages to be sent to their phones. Adherence was objectively monitored in 22 of the participants. The adolescent participants gave high ratings on the acceptability of the text messaging system. Asthma control improved from baseline to month 1 regardless of whether teens were in the texting or control group. While participants were in the texting group, their quality of life improved and worry about their asthma decreased. Receiving the text intervention resulted in an increase in adherence of 2.75% each month relative to no intervention, but the improvements were not sustained. There was modest improvement in asthma control and quality of life outcomes, as well as improved adherence during the texting intervention.

Long-Term Sustainability of Timely Emergency Department Analgesia for Fractures: A Time Series Study.

OBJECTIVES: To determine the long-term sustainability and unintended consequences of a quality improvement project to improve the timeliness of intravenous (IV) opioid administration to patients with long-bone extremity fractures within a dynamic pediatric emergency department. METHODS: A retrospective study of patients with long-bone extremity fractures was conducted using electronic medical record data from 2007 to 2014. The primary outcome was the percentage of patients receiving timely IV opioids. Control charts and time series models were used to determine if changes in the clinical microenvironment were associated with shifts in the outcome measure. Unintended consequences included patients receiving potentially avoidable IVs and use of the quality improvement process for patients without long-bone extremity fractures. RESULTS: Improved timeliness of IV opioids was sustained. The type of physician who staffed the process and optimization of faculty staffing hours were associated with a 9.6% decrease and 11.8% increase in timely IV opioids, respectively. Implementation of the IV opioid process was not associated with increased placement of potentially avoidable IVs. Of patients receiving the IV opioid process, 22% did not have a long-bone extremity fracture, of whom 91% were diagnosed with a different painful injury. CONCLUSION: Sustainability of IV opioid timeliness was robust, despite changes in the clinical microenvironment. Changes in physician staffing and responsibilities in a pediatric emergency department may be especially important to consider when planning future improvement initiatives. Our findings support the importance of higher reliability interventions, such as identification and utilization of existing patterns of behavior, as high yield for sustaining outcomes.

Worker, workplace, and community/environmental risk factors for workplace violence in emergency departments.

Workplace violence committed by patients and visitors has high propensity to occur against emergency department employees. This article reports the association of worker, workplace, and community/environmental factors with violence risks. A cross-sectional research design was used with 280 employees from six emergency departments in the Midwest United States. Respondents completed the Survey of Violence Experienced by Staff and a 10-item demographic questionnaire. Data were analyzed using frequencies, percentages, Chi-square tests, and adjusted relative risks with 95% confidence intervals. Over 80% of respondents experienced at least one type of workplace violence with their current employer and approximately 40% experienced all three types. Risks for workplace violence were significantly higher for registered nurses and hospital-based emergency departments. Workplace violence can impact all employees in the emergency department regardless of worker, workplace, and community/environmental factors.