It Pays to be Accurate: Improving Critical Care Documentation in a Pediatric Emergency Department.

BACKGROUND: Clinician documentation is highly variable, and awareness of documentation requirements remains low despite post-training experience. At our hospital, critical care (CC) documentation was inconsistent. Our aim was to increase appropriate CC attestations from 51% to 90% for status asthmaticus, anaphylaxis, and diabetic ketoacidosis in the pediatric emergency department by December 2021. METHODS: A physician team developed a key driver diagram. Retrospective baseline data using International Classification of Diseases, Ninth and Tenth Revision codes were obtained from January 2018 to September 2020, after which data were followed prospectively in consecutive groups of 20 encounters. Statistical process control charts were used to analyze data. Nelson rules were used to detect special cause variation. Primary outcome was the inclusion of appropriate CC attestations. Interventions included education, CC attestation templates, and provider feedback. We also tracked charges for the 3 diagnoses studied. Process measures included template use. Balancing measure was refusal of payment by insurers. RESULTS: P-charts were used to analyze primary outcome and process measures. X-bar charts were used to analyze charges. Baseline data represented 706 encounters with 51% including CC documentation. Following clinician education and release of the CC template, special cause variation was detected, and centerline shifted to 88.1% (Fig 2). Average charges per encounter increased from $4527 to $5385. There was no reported refusal of payment. CONCLUSIONS: We successfully achieved improvements in CC documentation in the 3 diagnoses of interest through education and process changes in documentation, leading over $1 million in new charges over the past 15 months.

Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit.

OBJECTIVE: The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU. DATA SOURCES: We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, ß2-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines. RESULTS AND CONCLUSIONS: Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.

A 6-year-old girl with undiagnosed hemophagocytic lymphohistiocytosis and takotsubo cardiomyopathy: a case report and review of the literature.

Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder of highly stimulated immune responses to antigens that leads to life-threatening inflammation and multiple organ dysfunction. At presentation, HLH may uncommonly mimic septic shock. In this case, we present a 6-year-old girl presenting to the pediatric emergency department with a febrile illness and anemia that subsequently developed decompensated shock, initially thought to be septic. She was ultimately diagnosed with HLH. During initial HLH treatment, this patient also developed takotsubo cardiomyopathy, a unique pattern of reversible left ventricular dysfunction characterized by transient apical ballooning and hypokenesis of the left ventricle that spontaneously resolves. There are very few case reports of HLH-associated takotsubo cardiomyopathy. We believe that this is the first case of takotsubo cardiomyopathy in a child with HLH.

Massive hemoptysis in a post-Fontan procedure patient.

Aortopulmonary collateral vessels (AP collaterals) are frequently seen in patients with cyanotic heart disease. However, massive hemoptysis leading to life-threatening hemorrhage is rare. In this case, we present a 7-year-old girl who presented to the pediatric emergency department with massive hemoptysis secondary to AP collateral hemorrhage. We were able to control her hemoptysis initially through calming techniques, but the patient eventually went on to have 2 cardiac catherization procedures, during which coiling of many AP collateral vessels was performed.