A quality improvement study to improve inpatient problem list use.

BACKGROUND: The problem list is a meaningful use incentivized criterion, and >80% of patients should have 1 problem entered as structured data. OBJECTIVE: The aim of the present study was to use a series of interventions to increase the use of the problem list for inpatients to >80% as measured by at least 1 hospital problem at discharge. METHODS: This study was a quasi-experimental time series quality improvement trial. The primary outcome was 80% of medical and psychiatric inpatients with a problem added to the problem list before discharge. Control charts of percentage (p charts) of medical and psychiatric patients with an inpatient problem list at discharge were constructed with three-σ control limits. Control limits were revised after evidence of improvement. The charts were annotated with interventions, including increasing awareness, focused education, and timely feedback in the form of performance graphs e-mailed to providers. RESULTS: For medical inpatients, use rose from 31% to 97% at its peak in April 2011 and continues to maintain above the goal of 80%. In psychiatry, problem list use rose from 2% initially to an average of 72% after the interventions. CONCLUSIONS: Significant gains were made with inpatient problem list usage by the medical and psychiatric teams. Our goal ascribed by meaningful use for >80% of inpatients to have a problem at discharge was met after initiation of our series of interventions.

Deficits in EMTALA Knowledge Among Pediatric Physicians.

OBJECTIVE: All US hospitals that participate in Medicare and Medicaid are regulated by the Emergency Medical Treatment and Active Labor Act (EMTALA). The law was enacted to prevent hospitals from turning away patients with emergency medical conditions. The law imposes specific obligations on hospitals and their physicians, and provides severe penalties for violations. The objective of this study was to evaluate hospital-based pediatric physicians' knowledge of these obligations and potential liabilities. METHODS: A questionnaire was submitted to the active medical staff and pediatric subspecialty residents at a tertiary care pediatric hospital. The questionnaire collected demographic information and posed 12 questions, based on well-established EMTALA principles, which addressed specific EMTALA obligations and liabilities. RESULTS: The questionnaire was returned by 123 of 332 (37%) potential participants. Twenty-four percent (n = 30) had never heard of EMTALA, 24% (n = 30) had only "heard of" the law, and 51% (n = 63) considered themselves "generally familiar" with EMTALA. No respondent correctly answered all 12 questions, and 13% (n = 16) answered all 12 questions incorrectly. The median score was 42%, with a range of 0% to 83% correct. Only 20% (n = 25) reported that they had ever received any EMTALA education. Prior EMTALA education was associated with a higher score (P = 0.001). Eighty percent (n = 98) expressed interest in attending a formal EMTALA education program. CONCLUSIONS: Physicians at this pediatric hospital were strikingly unaware of their EMTALA obligations and potential liabilities. A specific educational program regarding EMTALA should be provided to hospital-based pediatric physicians to improve compliance with the law and reduce potential liabilities.

A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis.

OBJECTIVE: Hypoxia is a common reason for hospital admission in infants and children with acute bronchiolitis. No study has evaluated discharge from the emergency department (ED) on home oxygen. This study evaluated the feasibility and safety of ED discharge on home oxygen in the treatment of acute bronchiolitis. METHODS: This was a prospective, randomized trial of infants and children with acute bronchiolitis and hypoxia (room-air saturations of < or =87%) aged 2 to 24 months presenting to an urban, academic, tertiary care children's hospital ED from December 1998 to April 2001. Subjects received inpatient admission or home oxygen after an 8-hour observation period in the ED. We measured the failure to meet discharge criteria during the observation period, return for hospital admission, and incidence of serious complications. RESULTS: Ninety-two patients were enrolled. Fifty three (58%) were randomly assigned to home and 39 (42%) to inpatient admission. There were no differences between the groups in age, initial room-air saturation, and respiratory distress severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen completed the observation period and were discharged from the hospital. The remaining 16 patients were excluded from the study (6), resolved their oxygen requirement (5), or failed to meet the discharge criteria and were admitted (5). One discharged patient (2.7%) returned to the hospital and was admitted for a cyanotic spell at home after the 24-hour follow-up appointment. The patient had an uncomplicated hospital course with a length of stay of 45 hours. The remaining 36 patients (97%) were treated successfully as outpatients with home oxygen. Satisfaction with home oxygen was high from the caregiver and the primary care provider. CONCLUSIONS: Discharge from the ED on home oxygen after a period of observation is an option for patients with acute bronchiolitis. Secondary to the low incidence of complications, the safety of this practice will require a larger study.

Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs.

OBJECTIVES: To compare the frequency and severity of adverse events associated with parenteral drugs commonly used for procedural sedation and analgesia (PSA) in a pediatric emergency department. METHODS: A database of consecutive patients receiving parenteral PSA was prospectively generated with the intent of monitoring safety in the emergency department. Data were logged onto a dedicated sedation sheet. A retrospective analysis was performed; comparisons were made based on sedation drugs used. RESULTS: A total of 2,609 patients from June 1, 1996, to September 16, 2003, received PSA by emergency physicians. Patients who received PSA nonparenterally (n = 109) were excluded. A total of 2,500 patients (2,279, intravenous; 221, intramuscular) remained for analysis. Age range was 19 days to 32 years (median, 6.7 years). A total of 1,511 (60.4%) were male. Four major drug combinations were identified: ketamine alone (n = 1,492; 59.7%), ketamine/midazolam (n = 299; 12.0%), midazolam/fentanyl (n = 336; 13.4%), and midazolam alone (n = 260; 10.4%). A total of 113 patients (4.5%) received various other combinations of drugs. A total of 458 adverse events were observed in 426 patients (17%). Respiratory adverse events occurred as follows: ketamine alone, 91 patients (6.1%); ketamine/midazolam, 30 patients (10%); midazolam/fentanyl, 65 patients (19.3%); midazolam alone, 15 patients (5.8%). Vomiting occurred as follows: ketamine alone, 151 patients (10.1%); ketamine/midazolam, 16 patients (5.4%); midazolam/fentanyl, six patients (1.8%); midazolam alone, two patients (0.8%). CONCLUSIONS: Drug types used in pediatric PSA are associated with different adverse event profiles. Patients receiving ketamine with or without midazolam experienced fewer respiratory adverse events but more vomiting than the commonly used combination of midazolam and fentanyl. Adverse events may occur in any patient receiving parenteral PSA.

Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids.

BACKGROUND: The serum electrolyte panel (SEP) is a frequently ordered laboratory test, but it has unproven usefulness in the treatment of dehydrated pediatric patients. Our study purpose was to evaluate the usefulness of routinely ordering a SEP in the treatment of dehydrated pediatric patients receiving intravenous fluids (IVFs). METHODS: Children 2 months to 9 years of age who were receiving IVFs because of dehydration were prospectively studied in a pediatric emergency department (PED). Historical data, physical examination findings, degree of dehydration, and SEP results were recorded. After patient evaluation, attending physicians documented whether they would have ordered a SEP. Outcome measurements included changes in clinical management on the basis of SEP results, as well as correlations of dispositions and unscheduled return visits (URVs) with SEP results. RESULTS: A total of 182 patients were enrolled in the study. One hundred eleven patients had mild dehydration, 55 moderate dehydration, and 16 severe dehydration. Eighty-eight patients (48%; 95% confidence interval: 41-56%) had > or =1 abnormal SEP value. Clinically relevant findings included bicarbonate levels of <16 mmol/L for 28% of patients, hypoglycemia for 9.9%, hypokalemia for 6.0%, and hypernatremia for 3.0%. The attending physicians predicted that a SEP would be clinically important for 34% of all patients. There was a 58% sensitivity in detecting which children would have clinically significant SEP results. Overall, SEP results changed clinical management in 10.4% of cases. One hundred sixty-five (91%) of the patients were discharged from the PED (including 48 who were initially observed), of whom 7 (3.8%) had URVs to the PED within 72 hours and were given additional IVFs. Seventeen patients were admitted (median: 2.6 days), 2 of whom had URVs after hospital discharge for additional IVFs. CONCLUSIONS: On the basis of initial presentation, attending physicians were poor at predicting which children would have clinically significant SEP results. Low bicarbonate values were correlated with observation unit use but not with hospitalization or URVs. The observation unit provided effective care for a subset of dehydrated patients, avoiding the need for hospitalization. Obtaining a SEP can provide useful information for the treatment of some children receiving IVFs because of dehydration.

Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?

STUDY OBJECTIVE: Fasting time before procedural sedation and analgesia in a pediatric emergency department (ED) was recently reported to have no association with the incidence of adverse events. This study further investigates preprocedural fasting and adverse events. METHODS: Data were analyzed from a prospectively generated database comprising consecutive sedation events from June 1996 to March 2003. Comparisons were made on the incidence of adverse events according to length of preprocedural fasting time. RESULTS: Two thousand four hundred ninety-seven patients received procedural sedation and analgesia. Four hundred twelve patients were excluded for receiving oral or intranasal drugs (n=95) or for receiving sedation for bronchoscopy by nonemergency physicians (n=317). A total of 2,085 patients received parenteral sedation by emergency physicians. Age range was 19 days to 32.1 years (median age 6.7 years); 59.9% were male patients. Adverse events observed included desaturations (169 [8.1%]), vomiting (156 [7.5%]), apnea (16 [0.8%]), and laryngospasm (3 [0.1%]). Fasting time was documented in 1,555 (74.6%) patients. Median fasting time before sedation was 5.1 hours (range 5 minutes to 32.5 hours). When the incidence of adverse events was compared among patients according to fasting time in hours (0 to 2, 2 to 4, 4 to 6, 6 to 8, >8, and not documented), no significant difference was found. No patients experienced clinically apparent aspiration. CONCLUSION: No association was found between preprocedural fasting and the incidence of adverse events occurring with procedural sedation and analgesia.