Improving inpatient cystic fibrosis pulmonary exacerbation care: two success stories.

BACKGROUND: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are a frequent cause of hospitalisations and lead to long-term decline in pulmonary function. Successful CF inpatient care requires the coordination of multiple providers and complex therapies. Children's Hospital of Wisconsin (CHW) and Children's Healthcare of Atlanta (CHoA) independently identified PEx inpatient care for focused improvements, with emphasis on improving care coordination and patient outcomes. METHODS: Both centres began by forming multidisciplinary workgroups, including patient and family representatives. CHW's specific aim was to eliminate delays in the time to initial intravenous antibiotics. A written handoff tool was developed to allow more efficient ordering. Efforts at CHoA focused on coordination and consistent care delivery. A written schedule and patient incentive programme were devised to ensure proper administration of treatments and promote patient adherence. RESULTS: At CHW, interventions decreased the mean antibiotic order time by 59% with resultant decrease in administration time by 25%. At CHoA, improvements led to a 42% decrease in the proportion of hospitalisations unsuccessful in returning lung function back to within 90% of baseline. CONCLUSIONS: Inpatient CF PEx care is complex and requires multiple competing activities and treatments. Consistent and timely delivery of these treatments is challenging. Our improvements used the skills and insights of providers and patients to improve, standardise and synchronise care, and to develop tools to coordinate hand offs. With these improvements, applicable to hospital treatment of many other conditions, both centres were successfully able to deliver treatments in a more consistent and timely manner with improved outcomes.

A randomized trial of enema versus polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency department.

OBJECTIVE: This study aimed to compare efficacy of enema versus polyethylene glycol (PEG) 3350 for pediatric fecal impaction treatment. METHODS: We conducted a prospective, randomized comparison of treatments of fecal impaction in children in a pediatric emergency department (ED). Treatment arms were a single milk and molasses enema in the ED or PEG 3350 for 3 days outpatient. Telephone follow-up was done on days 1, 3, and 5. The primary outcome was main symptom improvement. Additional outcomes were stool frequency, consistency, and ease of stool passage. Treatment failures (home enema, ED return, or hospital admission) were tracked. RESULTS: Seventy-nine subjects participated (39 PEG; 40 enema). At day 1, PEG subjects were less likely to have improved main symptom (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.8) but no difference in other outcomes. Half (54%) in enema arm were reported as upset by ED therapy, whereas no children in PEG arm were upset (P < 0.05). At day 3, more patients in enema arm reported ideal stool consistency (74% vs 38%; P < 0.05). At day 5, no difference between groups was noted. Most treatment failures were in PEG arm (83%; P = 0.08). CONCLUSIONS: This pilot study suggests that disimpaction by enema may be superior to PEG for immediate relief of symptoms. Larger trials are needed to assess any advantage.

The role of exhaled nitric oxide in evaluation of acute asthma in a pediatric emergency department.

OBJECTIVES: Fractional excretion of nitric oxide (FE(NO)) has been used as a noninvasive marker to assess and manage chronic asthma in adults and children. The aim of this study was to determine the feasibility of obtaining FE(NO) concentrations in children treated in the emergency department (ED) for acute asthma exacerbation and to examine the association between FE(NO) concentrations and other measures of acute asthma severity. METHODS: This was a cross-sectional study of a convenience sample of children 2-18 years old who were seen in an urban ED for acute asthma exacerbation. Using a tidal breathing method with real-time display, the authors measured FE(NO) concentrations before and 1 hour after the administration of corticosteroids and at discharge from the ED. Outcome measures included pulmonary index score (PIS), hospital admission, and short-term outcomes (e.g., missed days of school). RESULTS: A total of 133 subjects were enrolled. Sixty-eight percent (95% confidence interval [CI] = 60% to 76%) of the subjects provided adequate breaths for FE(NO) measurement. There was no difference in the median initial FE(NO) concentration among subjects, regardless of the severity of their acute asthma. Most subjects showed no change in their FE(NO) concentrations from the start to the end of treatment. FE(NO) concentrations were not significantly associated with other short-term outcomes. CONCLUSIONS: Measurement of FE(NO) is difficult for a large proportion of children with acute asthma exacerbation. FE(NO) concentration during an asthma exacerbation does not correlate with other measures of acute severity and has limited utility in the ED management of acute asthma in children.

Emergency department revisits for pediatric acute asthma exacerbations: association of factors identified in an emergency department asthma tracking system.

OBJECTIVE: To identify clinical variables associated with a greater likelihood of emergency department (ED) revisit for acute asthma within 7 days after an initial ED visit for acute asthma exacerbation. METHODS: Cross-sectional study of subjects from a prospectively enrolled cohort of children aged 0 to 18 years with physician-diagnosed asthma in the ED Allies Tracking System. Demographics and data on quality of life, health care utilization, environmental factors, chronic asthma severity, and ED management were collected. Emergency department revisits for acute asthma within 7 days of a prior visit resulting in discharge were compared with those without a revisit, using chi2 and t tests and logistic regression. RESULTS: Four thousand two hundred twenty-eight ED asthma visits were enrolled; 3276 visits resulted in discharge. Persistent asthma was identified in 66% of visits. Emergency department revisits within 7 days of a prior visit occurred following 133 (4.1%) visits. There were no significant differences in environmental factors or ED management between visits with and without an ED revisit. In univariate analysis factors associated with a greater revisit likelihood included age younger than 2 years, black race or Hispanic ethnicity, persistent asthma, public insurance, lower quality of life, and greater health care utilization in the prior 12 months. Variables independently significant (P < 0.05) in logistic regression were chronic asthma severity classified as persistent, age younger than 2 years, and lower asthma quality of life. CONCLUSIONS: Although our design precludes drawing causal inference, our results suggest that children younger than 2 years or with persistent asthma or lower asthma quality-of-life scores are at greater risk for ED revisits after acute ED asthma care.

Childhood asthma in the emergency department: trends, challenges, and opportunities.

Acute exacerbations of childhood asthma are frequently managed in the emergency department (ED). ED-based surveillance and intervention projects highlight the limitations and challenges of acute and chronic childhood asthma management. Because a significant number of asthmatic children currently receive and will likely continue to seek acute asthma care in the ED, provision of asthma education and initiation of controller medication therapy during the ED visit, although controversial, may contribute to improving asthma outcomes and eventually to reducing the burden of asthma on our overcrowded EDs.

Emergency department allies: a controlled trial of two emergency department-based follow-up interventions to improve asthma outcomes in children.

OBJECTIVE: We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation. METHODS: Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program. OUTCOMES: The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use. RESULTS: Three hundred fifty-two children were enrolled; 78% completed follow-up, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups. CONCLUSION: ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period.

Emergency Department Allies: a Web-based multihospital pediatric asthma tracking system.

OBJECTIVE: To describe the development of a Web-based multihospital pediatric asthma tracking system and present results from the initial 18-month implementation of patient tracking experience. DESIGN: The Emergency Department (ED) Allies tracking system is a secure, password-protected data repository. Use-case methodology served as the foundation for technical development, testing, and implementation. Seventy-seven data elements addressing sociodemographics, wheezing history, quality of life, triggers, and ED managment were included for each subject visit. SETTING: The ED Allies partners comprised 1 academic pediatric ED and 5 community EDs. POPULATION: Subjects with a physician diagnosis of asthma who presented to the ED for acute respiratory complaints composed the asthma group; subjects lacking a physician diagnosis of asthma but presenting with wheezing composed the wheezing group. RESULTS: The tracking-system development and implementation process included identification of data elements, system database and use case development, and delineation of screen features, system users, reporting functions, and help screens. For the asthma group, 2005 subjects with physician-diagnosed asthma were enrolled between July 15, 2002 and January 14, 2004. These subjects accounted for 2978 visits; 10.4% had > or = 3 visits. Persistent asthma was noted in 68% of the subjects. During the same time period, 1297 wheezing subjects with a total of 1628 ED visits (wheezing group) were entered into the tracking system. After enrollment, 57% of the subjects with > or = 1 subsequent ED visits received a physician diagnosis of asthma. CONCLUSIONS: Our sophisticated tracking system facilitated data collection and identified key intervention opportunities for a diverse ED wheezing population. A significant asthma burden was identified with significant rates of hospitalization, acute care visits and persistent asthma in 68% of subjects. The surveillance component provided important insights into health care issues of both asthmatic subjects and wheezing subjects, many of whom subsequently were diagnosed with asthma.

National Asthma Education and Prevention Program severity classification as a measure of disease burden in children with acute asthma.

OBJECTIVE: To examine the association between the National Asthma Education and Prevention Program (NAEPP) severity classification and other measures of burden of disease in children with acute asthma. METHODS: We performed a cross-sectional study of 750 children <18 years of age with a physician diagnosis of asthma and treated in an emergency department (ED) for acute asthma exacerbation. Subjects were assigned to 1 of 4 levels of severity (mild intermittent, mild persistent, moderate persistent, or severe persistent). Assignments followed 3 methods: the report of symptom frequency alone (standard method); symptom frequency and reported controller-medication use (modified method); or the additive modified method in which the symptom frequency and reported controller-medication use were assigned numeric values and a score was calculated. An asthma-specific quality-of-life score was calculated by using the Integrated Therapeutics Group Child Asthma Short Form (ITG-CASF). The number of ED visits and hospital admissions for asthma over the previous 12 months was collected also. Differences between severity groups were compared with analysis of variance, and the proportion of variance explained (r2) was calculated. RESULTS: Using the standard classification method, 55% of subjects had mild intermittent asthma, 21% had mild persistent asthma, 14% had moderate persistent asthma, and 10% had severe persistent asthma. Among those classified as having mild intermittent asthma by symptoms alone, 22% were reclassified as having persistent asthma when controller medications were accounted for. With all 3 scoring methods, mean ITG-CASF scores decreased significantly with each increasing level of severity. However, the magnitude of this association was modest. There was a significant but limited association between severity level and mean number of ED visits and hospitalizations. CONCLUSION: NAEPP severity classification alone provides an incomplete picture of the burden of disease in children with asthma.

Serum neuron-specific enolase as a predictor of short-term outcome in children with closed traumatic brain injury.

BACKGROUND: Closed traumatic brain injury (cTBI) is a significant cause of mortality and morbidity in children. The natural course and extent of recovery from cTBI in children are poorly understood. Neuron-specific enolase (NSE), an enzyme detected in serum following structural damage of neuronal brain cells, appears to be a good marker for intracranial injury. However, to the best of the authors' knowledge, the usefulness of NSE as a predictor of disability in children with cTBI has not been reported. OBJECTIVES: To examine the association between posttraumatic serum NSE level and short-term physical disability in children with cTBI. METHODS: This was a retrospective analysis of a prospectively enrolled cohort of children aged 0-18 years with isolated cTBI presenting to the emergency department (ED) within 24 hours of injury, and having a cranial computed tomography (CT) scan as part of the evaluation. The NSE level was obtained at the time of ED evaluation. Physical disability was measured using the Glasgow Outcome Scale (GOS). The GOS score was assigned retrospectively for enrolled patients by a single investigator blinded to NSE level. Patient outcomes were categorized as good (GOS = 5) or poor (GOS < 5). A single radiologist reviewed all cranial CT scans. RESULTS: Ninety eligible subjects with NSE levels were identified; 86 met the enrollment criteria. Seven subjects (8%) had poor outcome. There was a significant difference in NSE levels between the poor and good outcome groups, even within high-risk subgroups. The area under the curve (AUC) for NSE prediction of poor vs. good outcome was 0.83. A serum NSE level of 21.2 ng/dL was 86% sensitive and 74% specific in predicting poor outcome. CONCLUSIONS: It appears that the serum NSE level can be used as a predictor of global short-term physical disability in children following cTBI.

Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution.

OBJECTIVE: To determine the baseline level of preparedness of Wisconsin primary care physician offices for pediatric emergencies and to assess the impact of mail distribution of guidelines on this level of preparedness. METHOD: Preintervention surveys were mailed to all Wisconsin physicians requesting information about pediatric equipment, medications, training, and policies. Guidelines were distributed by mail to all physicians who returned completed surveys. An identical postintervention survey was mailed to these physicians, and an analysis of the paired surveys for each respondent was performed. RESULTS: Baseline preparedness of 1051 Wisconsin physician offices ranged from 37% with intraosseous needles to 96% with albuterol solution for inhalation. Physician certification in pediatric advanced life support was required in 26% of offices. A total of 568 paired preintervention and postintervention surveys were analyzed. Improvements were identified for the availability of equipment and medications, transport policies, and reference guides. CONCLUSIONS: Mail distribution of guidelines was minimally effective in improving the preparedness of Wisconsin offices for pediatric emergencies.

Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department.

OBJECTIVE: To determine whether a protocol to start patient-controlled analgesia (PCA) in the emergency department (ED-PCA) would shorten the length of time between narcotic bolus doses and PCA initiation as compared with standard inpatient initiation of PCA (IP-PCA). Also, to compare patient satisfaction and inpatient length of stay for the 2 groups. METHODS: To improve care, we developed a protocol to institute ED-PCA after an initial bolus dose of narcotics. This was a nonrandomized pilot study. Patient records were reviewed for location of PCA initiation, time from narcotic bolus to initiation of PCA, and length of stay. A brief patient/parent satisfaction survey was collected. RESULTS: Sixty-nine records were reviewed. Patients treated using the protocol had initiation of PCA therapy within 35 +/- 7 minutes from the last bolus narcotic dose in the emergency department versus 211 +/- 17 minutes for nonprotocol patients. Forty-eight of 50 patient surveys indicated preference for starting ED-PCA; 2 did not have a preference. No complications were identified in either group. CONCLUSIONS: A protocol to initiate PCA for sickle cell patients in a pediatric emergency department shortened the time of its initiation and was preferred by patients.

The short-term outcome of seizure management by prehospital personnel: a comparison of two protocols.

OBJECTIVE: To evaluate the impact of an emergency medical service protocol with reduced diazepam dose on the intubation rate of children with seizure activity treated by emergency medical service personnel and to evaluate the short-term outcome comparing 2 emergency medical service treatment protocols. METHODS: Retrospective review of the emergency medical service and hospital databases of children 0-18 years with seizure activity. Prior to January 1996, the county emergency medical service protocol recommended a diazepam dose of 0.2-0.5 mg/kg i.v. or pr for termination of seizure activity (group 1). As of January 1996, the diazepam dose was reduced to 0.05-0.1 mg/kg i.v. or pr (group 2). Demographics, emergency medical service and emergency department interventions, and disposition data were abstracted. RESULTS: 1516 subjects met the enrollment criteria: 1003 (66%) in group 1 and 513 (34%) in group 2. Emergency medical service administered diazepam to 288 subjects: 189 (19%) in group 1 and 99 (19%) in group 2. Twenty (7%) of all treated subjects required intubation: 19 in group 1 and 1 in group 2 (relative risk 9.7, 95% CI 1.30-72.5). Mean diazepam dose was 0.17 mg/kg in group 1 and 0.13 mg/kg in group 2 (mean difference 0.04, 95% CI 0.02-0.06). No significant difference in the requirement for repeated anticonvulsant dose, complications, or emergency department interventions was noted. However, hospital admission rate was lower in group 2 (rate difference 0.06, 95% CI 0.01-0.11). CONCLUSIONS: Our study demonstrated a reduction in intubation rate and a need for hospitalization in the reduced diazepam dose emergency medical service protocol. The reduction in the diazepam dose was effective in terminating the seizure activity and did not increase the risk of adverse events.

Do clinical variables predict pathologic radiographs in the first episode of wheezing?

OBJECTIVE: To determine if clinical variables assessed in relation to Albuterol aerosol treatments accurately identify children with pathologic radiographs during their initial episode of bronchospasm. METHODS: A prospective convenience sample of children with a first episode of wheezing. Data collected included demographics, baseline and post-treatment clinical score and physical examination, number of aerosols, requirement for supplemental oxygen, and disposition. Chest radiographs were obtained and interpreted, and patients were divided into 2 groups based on a pathologic versus nonpathologic radiograph interpretation. Chi2 testing was performed for categoric variables, and the student t test was performed for continuous variables. A discriminant analysis was used to develop a model. RESULTS: Pathologic radiographs were identified in 61 patients (9%). Between groups, a significant difference was noted for pretreatment oxygen saturation only. Clinical score, respiratory rate, and presence of rales both pretreatment and posttreatment were not significantly different between groups. The discriminant analysis correctly predicted 90% of nonpathologic radiographs but only 15% of pathologic radiographs. CONCLUSIONS: Clinical variables, either isolated or as components of a model, could not identify all children with pathologic radiographs.

Utilization of the Ottawa ankle rules by nurses in a pediatric emergency department.

OBJECTIVES: To determine the ability of pediatric emergency department (ED) nurses to accurately apply the Ottawa Ankle Rules (OAR) and to evaluate whether the rate of negative ankle radiographs can be reduced by incorporating the OAR into an existing collaborative practice protocol (CPP). METHODS: The authors' ED currently uses a CPP in which patients with ankle pain, swelling, deformity, or decreased range of motion on primary nursing assessment undergo radiography prior to physician evaluation. A cross-sectional study was conducted between June and November 2000. Patients aged 5-19 years with an ankle injury who met at least one of the CPP criteria were eligible for enrollment. The OAR were applied by the primary nurse after initial assessment. Ankle radiographs were ordered for all enrolled patients. The interobserver variability between nurses was evaluated on a random sample. RESULTS: One hundred ninety subjects were enrolled in the study. The OAR were correctly interpreted by nurses in 98.4% of subjects. Agreement on the interobserver reliability sample was 100%. Of the 185 subjects, 31 (16.8%) had positive radiographs. Positive OAR results were noted in 30 of 31 subjects with positive radiographs. The sensitivity of the OAR was 97% (95% CI = 0.82 to 0.99) with a specificity of 25% (95% CI = 0.18 to 032). Use of the OAR would have reduced the radiography rate by 21%. CONCLUSIONS: Trained nurses can accurately apply and interpret the OAR. The incorporation of the OAR into the nursing assessment of children with acute ankle injuries may reduce the number of radiographs ordered.