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1.
Hosp Pediatr ; 14(5): 319-327, 2024 May 01.
Article in English | MEDLINE | ID: mdl-38618654

ABSTRACT

OBJECTIVES: Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs. METHODS: At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital. RESULTS: We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals. CONCLUSIONS: Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.


Subject(s)
Electronic Health Records , Emergency Service, Hospital , Psychomotor Agitation , Humans , Child , Psychomotor Agitation/therapy , Emergency Service, Hospital/standards , Female , Male , Adolescent , Child, Preschool , Retrospective Studies , Hospitals, Pediatric , Quality of Health Care , Feasibility Studies , Restraint, Physical/statistics & numerical data , Quality Indicators, Health Care
2.
Pediatrics ; 153(4)2024 Apr 01.
Article in English | MEDLINE | ID: mdl-38426287

ABSTRACT

BACKGROUND AND OBJECTIVES: Approximately half of youth suicides involve firearms. The promotion of safe firearm storage in the home through lethal means counseling reduces suicide risk. We aimed to increase the documentation of firearm access and storage among children presenting to the emergency department (ED) with suicidal ideation or self-injury to 80% within 13 months. METHODS: We conducted a multidisciplinary quality improvement initiative to improve the documentation of firearm access and storage among children <18 years old seen in the ED for suicidal ideation or self-injury. The baseline period was February 2020 to September 2021, and interventions occurred through October 2022. Interventions included adding a templated phrase about firearm access to psychiatric social work consult notes and the subsequent modification of the note to include all firearm storage elements (ie, locked, unloaded, separate from ammunition). Statistical process control and run charts were generated monthly to monitor the documentation of firearm access and storage, which was measured through a review of keyword snippets extracted from note text. RESULTS: We identified 2158 ED encounters for suicidal ideation or self-injury during the baseline and intervention periods. Documentation of firearm access increased from 37.8% to 81.6%, resulting in a centerline shift. Among families who endorsed firearm access, the documentation of firearm storage practices increased from 50.0% to 78.0%, resulting in a centerline shift. CONCLUSIONS: The modification of note templates facilitated increased documentation of firearm access and storage practices for children with suicidal ideation in the ED. Future studies should assess whether improved documentation is associated with improved storage practices and reductions in firearm suicides after ED encounters.


Subject(s)
Firearms , Suicide , Adolescent , Humans , Child , Suicidal Ideation , Documentation , Emergency Service, Hospital
3.
J Pediatr ; 267: 113910, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38218368

ABSTRACT

In this multicenter, cross-sectional, secondary analysis of 4042 low-risk febrile infants, nearly 10% had a contaminated culture obtained during their evaluation (4.9% of blood cultures, 5.0% of urine cultures, and 1.8% of cerebrospinal fluid cultures). Our findings have important implications for improving sterile technique and reducing unnecessary cultures.


Subject(s)
Bacterial Infections , Infant , Humans , Cross-Sectional Studies , Retrospective Studies , Bacterial Infections/complications , Fever/complications , Urinalysis
4.
JAMA Pediatr ; 178(1): 55-64, 2024 Jan 01.
Article in English | MEDLINE | ID: mdl-37955907

ABSTRACT

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.


Subject(s)
Bacterial Infections , Ethnicity , Infant , Child , Infant, Newborn , Humans , Female , Middle Aged , Retrospective Studies , Cross-Sectional Studies , Language , Communication Barriers , Anti-Bacterial Agents/therapeutic use
5.
Pediatrics ; 152(1)2023 Jul 01.
Article in English | MEDLINE | ID: mdl-37317809

ABSTRACT

BACKGROUND AND OBJECTIVES: Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints. METHODS: A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints. RESULTS: During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71. CONCLUSIONS: Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.


Subject(s)
Droperidol , Quality Improvement , Humans , Child , United States , Droperidol/therapeutic use , Psychomotor Agitation/therapy , Emergency Service, Hospital , Restraint, Physical
6.
Int J Pediatr Otorhinolaryngol ; 164: 111410, 2023 Jan.
Article in English | MEDLINE | ID: mdl-36529040

ABSTRACT

INTRODUCTION: Electronic medical record-based tools have been demonstrated to improve timeliness of x-ray order placement in patients presenting to the emergency department (ED) with coin-shaped foreign body ingestion. Similar efforts directed towards downstream processes are necessary to expedite diagnosis of an esophageal button battery. We predicted that improvement tools such as electronic medical record-based alerts and process standardization could be utilized to expedite x-ray completion. METHODS: Using Plan, Do, Study, Act methodology, iterative interventions were implemented. In July 2017 a previously designed best practice advisory was linked to an automated notification page to the x-ray technician. Next, a standardized process was created where patients were gowned in triage and placed in a designated space awaiting x-ray. Workflow planning began in December 2018 and was formalized in February 2019. Time from arrival to x-ray completion was tracked for patients presenting with coin-shaped foreign body ingestion. Control charts were used to determine special cause variation. RESULTS: An average of 10.1 patients (Range 4-21) presented monthly to the ED with coin-shaped foreign body ingestion. Automated pages to the x-ray technician were not associated with improved time to x-ray completion. Upon initiation of the new patient workflow, median time to x-ray completion decreased from 37.4 to 23.3 min. CONCLUSION: Time to x-ray completion in children presenting to the ED with ingestion of coin-shaped foreign bodies is not improved solely through electronic notification of the imaging technologist. Efforts to standardize processes for patient intake and placement are associated with more timely completion of imaging studies. Generalizability of findings may depend on contextual elements of individual healthcare units.


Subject(s)
Electronic Health Records , Foreign Bodies , Child , Humans , Infant , Esophagus , Radiography , Foreign Bodies/diagnostic imaging , Triage
7.
J Healthc Qual ; 44(4): 218-229, 2022.
Article in English | MEDLINE | ID: mdl-35067536

ABSTRACT

OBJECTIVE: Pediatric mental health emergency department (ED) visits that involve restraints for agitation are increasing. Quality measures are used to assess and improve healthcare quality. Our objective was to develop quality measures for pediatric ED agitation management informed by multidisciplinary perspectives. METHODS: A multidisciplinary panel developed quality measures for pediatric ED agitation management through the modified Delphi method. Panelists ranked measures in importance and feasibility on a 9-point scale during 2 survey rounds, with a teleconference discussion between surveys. Consensus was defined by >75% of panelists ranking a quality measure highly (≥7) in importance and a median feasibility score of ≥4. RESULTS: Panelists included 36 physicians, nurses, social workers, security, child life specialists, hospital data analysts, and parents. The panel reached consensus on 20 quality measures. Measures with the highest percentage of scores with importance ≥7 were related to adverse medication events, patients restrained, staff/patient injuries, reescalation plans, presence of an algorithm to standardize care, formal staff training on deescalation techniques, time to medication administration, and room safety. CONCLUSIONS: Twenty quality measures that incorporate multidisciplinary perspectives were developed for pediatric ED agitation management. Once operationalized and field tested, these measures may be used to assess and improve healthcare quality for pediatric agitation.


Subject(s)
Emergency Service, Hospital , Quality Indicators, Health Care , Child , Humans , Quality of Health Care , Surveys and Questionnaires
8.
Pediatr Qual Saf ; 6(4): e435, 2021.
Article in English | MEDLINE | ID: mdl-34235357

ABSTRACT

INTRODUCTION: Since 2015, the Ann and Robert H. Lurie Children's Hospital Emergency Department (ED) has improved the recognition and treatment of pediatric sepsis and septic shock. Despite existing clinical care guidelines, the ED had not yet achieved the Surviving Sepsis Campaign timeliness goals for fluid and antibiotic administration. METHODS: The team conducted a multidisciplinary Kaizen event to evaluate clinical workflows and identify opportunities to improve sepsis care adherence. Using rigorous quality improvement methodology, frontline providers mapped workflows to identify barriers and prioritize emerging solutions. RESULTS: Thirty-seven staff members across 17 disciplines participated. Nurses and physicians identified communication gaps at pathway initiation. Access to supplies, inadequate task delegation, and a lack of urgency for a subset of pathway patients delayed treatment. Prioritized interventions included scripted communication tools, a delineated response plan, and standardized reassessment processes. Revisions to the key driver diagram were made after the improvement event, guiding future plan-do-study-act cycles. CONCLUSIONS: Frontline provider participation in the Kaizen event uncovered barriers to care and identified the root causes of ineffective communication and system process inefficiencies. Engaging key stakeholders from multiple care areas in a candid context was a novel approach to process improvement within our department. The Kaizen methodology is fundamental to developing sustainable quality improvement practices, creating momentum for a continuous improvement culture to engrain quality improvement in practice. The success of Kaizen will shape the format of future ED improvement projects.

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