Clinician factors associated with delayed diagnosis of appendicitis.

OBJECTIVES: To evaluate the association of clinician demographics and practice patterns with delayed diagnosis of appendicitis. METHODS: We included children with appendicitis at 13 regional emergency departments (EDs). We screened patients with a previous ED visit within 7 days for delayed diagnosis by chart review. We evaluated the association of clinician characteristics using logistic regression with random intercepts for site and clinician and delay as the outcome. RESULTS: Among 7,452 children with appendicitis, 105 (1.4%) had delayed diagnosis. Clinicians in the lowest quartile of obtaining blood in their general practice were more likely to have delayed diagnosis (odds ratio 4.9 compared to highest quartile, 95% confidence interval 1.8, 13.8). Clinicians' imaging rates, specialty, sex, and experience were not associated with delayed diagnosis. CONCLUSIONS: Clinicians who used more blood tests in their general practice had a lower risk of delayed diagnosis of appendicitis, possible evidence that lower risk tolerance has benefits.

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments.

OBJECTIVE: To evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions. METHODS: This was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status. RESULTS: Among 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay. CONCLUSION: Delayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

Disparities in School Referrals for Agitation and Aggression to the Emergency Department.

OBJECTIVES: Describe the demographic and clinical characteristics of children presenting to the emergency department (ED) for agitation and aggression from school versus other sites. METHODS: We performed a retrospective cross-sectional study of children 5 to 18 years old who were evaluated in an urban tertiary care pediatric ED with a chief complaint of agitation or aggression. We examined demographics, disposition, and payments for children presenting from school versus other sites. We conducted multivariable logistic regression to identify predictors of referral site (school versus all other sites, school versus home) and discharge status (home versus higher level of psychiatric care). RESULTS: Of the 513 included children, 147 (29%) presented from school. Children were more likely to present from school versus other sites if they were Black (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.32, 3.88), Latinx (aOR 2.91, 95% CI 1.42, 5.97), or had special educational needs (aOR 2.55, 95% CI 1.64, 3.97). These associations persisted in the analysis of school versus home referrals. Children presenting from school versus all other sites were more likely to be discharged home (aOR 1.60, 95% CI 1.05, 2.44), although this difference did not persist when comparing school versus only home referral. A total of $154,269 (median $367 per encounter) was paid for school referrals to the ED. CONCLUSIONS: Children with agitation and aggression referred from school were more likely to be Black, Latinx, or have special educational needs. Future efforts should identify and address root causes of this disparity to decrease ED referrals, reduce healthcare spending, and address inequities.

Precrastination and the cognitive-load-reduction (CLEAR) hypothesis.

Precrastination is the tendency many individuals have to complete a task as soon as possible in order to get it out of the way [Rosenbaum, D. A., Gong, L., & Potts, C. A. (2014). Pre-crastination: Hastening subgoal completion at the expense of extra physical effort. Psychological Science, 25(7), 1487-1496. doi:10.1177/0956797614532657]. The current study (N = 48) examined whether precrastination is affected by a concurrent memory load as predicted by the cognitive-load-reduction (CLEAR) hypothesis. Participants completed a bucket-carrying task under different memory-load conditions. In addition, the amount of physical effort was manipulated by changing the distance people needed to walk while carrying the weighted buckets. The tendency to precrastinate by picking up a near bucket and carrying it further than necessary was affected by the memory load. People were more likely to precrastinate when doing so resulted in the more rapid renewal of cognitive resources and were less likely to precrastinate when this required that the memory load be held for a longer period of time. These data are consistent with the position that precrastination is linked with working memory resources and occurs in an attempt to clear items from a mental to-do list.

The impact of undergraduate clinical teaching models on the perceptions of work-readiness among new graduate nurses: A cross sectional study.

BACKGROUND: Clinical Placements are an essential component of bridging the gap between academic theory and nursing practice. There are multiple clinical models designed to ease the transition from student to professional, yet there has been little exploration of such models and their impact on graduates' perceptions of work-readiness. OBJECTIVES: This cross sectional study examined perceptions of work-readiness of new graduate nurses who attended one of the following clinical teaching models: the University Fellowship Program (UFP), the Traditional Multi-facility Clinical Model (TMCPM), and the Mixed Program (MP). METHODS: Three groups of first year graduate nurses (UFP, TMCPM, and MP) were compared using the Work-readiness Scale, a validated and reliable tool, which assessed nurses' perceptions of work-readiness in four domains: organizational acumen, personal work characteristics, social intelligence, and work competence. A multivariable Generalized Estimating Equations regression investigated socio-demographic and teaching-modelrelated factors associated with work-readiness. RESULTS: Of 43 nurses approached, 28 completed the survey (65% response rate) of whom 6 were UFP attendants, 8 attended the TMCPM and 14 the MP. Those who had attended the UFP scored higher than the other two in all four domains; however, the crude between-group comparisons did not yield statistically significant results. Only after accounting for age, gender, teaching setting and prior work experience, the multivariable model showed that undertaking the UFP was likely to increase perceptions of work-readiness by 1.4 points (95% CI 0.11-2.69), P=0.03). The UFP was superior to the other two placement models. CONCLUSION: The study suggests that the UFP may enhance graduate nurses' perceptions of work readiness.