Improving Quality and Efficiency in Pediatric Emergency Department Behavioral Health Care.

INTRODUCTION: Many children with behavioral health concerns increasingly utilize the emergency department for assessment and care. These visits are increasing in frequency, length, and cost, further stressing already limited resources. To improve the quality of care in this population, we developed a multidisciplinary improvement initiative to decrease the length of stay by 10% (from 5.2 hours), increase suicide screening to 90%, and improve patient and family experience by 10% (from 89.7). METHODS: We leveraged a multidisciplinary team to map care processes, standardize suicide risk screening, optimize staffing, and develop a brochure to demystify patients' and families' visits. We developed dashboards and a call-back system following discharge to understand engagement in post-acute care plans. We utilized run charts to identify signals of nonrandom variation. RESULTS: We reduced overall length of stay from 5.2 to 4 hours, improved patient experience scores from 89.7 to 93.2, and increased the suicidality screening rate from 0% to 94%. There was no change in the 72-hour return rate in this population. CONCLUSIONS: Engagement of a multidisciplinary team, with strategic implementation of improvements, measurably improved many aspects of care for pediatric patients with behavioral health crises in the emergency department setting. Recidivism, however, remains unchanged in this population and continues as a goal for future work.

Reliability of Telemedicine in the Assessment of Seriously Ill Children.

BACKGROUND AND OBJECTIVE: Data are limited that establish the clinical reliability of telemedicine in evaluating children who are seriously ill. Evaluation of a seriously ill child poses a challenge in that telemedicine is primarily visual, without the ability to perform a "hands-on" physical examination. Previous studies evaluating observation in assessing febrile children and children in respiratory distress have validated observation as both predictive and reliable in detecting underlying illness. The purpose of this study was to determine the interobserver reliability of telemedicine observations, compared with bedside observations, in assessing febrile children and children in respiratory distress. METHODS: Children 2 to 36 months old presenting with a fever were evaluated by using the Yale Observation Scale; patients aged 2 months to 18 years presenting with respiratory symptoms were evaluated by using the Respiratory Observation Checklist, a list of observational signs of respiratory distress derived from validated studies and developed specifically for the present study by the authors. Telemedicine communication used commercially available tablet devices that provided 2-way, live-streamed images with audio. RESULTS: A total of 132 febrile subjects were evaluated by using the Yale Observation Scale. Strong agreement (Pearson's correlation coefficient, 0.81) was found between bedside and telemedicine observers. A total of 145 subjects were evaluated by using the Respiratory Observation Checklist. Excellent agreement between bedside and telemedicine observers was found for the impression of respiratory distress (κ = .85) and good agreement (κ > .6) for the majority of the remaining components of the checklist. CONCLUSIONS: Telemedicine, using commercially available telecommunications equipment, is reliable in the assessment of febrile children and children with respiratory distress.

Respiratory failure caused by a suspicious white powder: a case report of intentional methadone poisoning in an infant.

Methadone exposures in children have increased as the drug has gained more prevalence in the treatment of adult narcotic dependency. Previous literature concerning pediatric methadone ingestion has focused primarily on unintentional ingestions. We describe a 2-month-old male infant presenting with respiratory failure from suspected intentional methadone administration. The infant was born to a mother with narcotic dependency and at birth was treated for neonatal abstinence syndrome. After discharge for neonatal abstinence syndrome treatment, the infant continued to be fussy and persistently irritable. We believe the infant was intentionally given methadone at home by his mother for these symptoms. It is important for pediatric providers to be vigilant of households with methadone present. Family-centered education on prevention of methadone ingestion (eg, safe storage) and anticipatory guidance on the signs, symptoms, and treatment of toxicity are key.

Assessment of pediatric residents' communication and interpersonal skills during family-centered rounds.

OBJECTIVES: Residency training programs are required to assess and document residents' competency in communication. Multisource evaluations that include direct resident observations are preferred. Previous studies have often used methods of asking faculty members to evaluate residents on behaviors they did not witness. METHODS: Twenty first year pediatric residents (interns) were evaluated preand post-FCR introduction by a faculty member, a parent, and a nurse after the encounter with the patients and their families during rounds. All participants used the CAT. Mean CAT scores and associations between the evaluator groups were determined. RESULTS: Nurses and faculty were significantly more likely to observe how interns communicated with the parents in the post-FCR period (P < .001). Pre-FCR, compared to parent scores, intern scores were significantly lower (P < .05) and the scores were not correlated (P = .84). Post-FCR, the difference in internparent scores disappeared and their scores were significantly correlated (r18 = 0.73, P < .001). Intern scores did not correlate with faculty and nurse scores. Cronbach a coefficients for the CAT ranged from 0.90 to 0.99. CONCLUSIONS: Family-centered rounds provide more opportunities for direct observation of residents' competence in accordance with Accreditation Council for Graduate Medical Education guidelines. This rounds format also encourages a climate that improves residents' ability to self-assess. Residents' communication skills can be assessed by using the Communication Assessment Tool in an efficient and timely manner, because all evaluators are present at the bedside during family-centered rounds.

Arm pain and fever as an unusual presentation of lobar pneumonia in a 3-year-old girl: case report.

Children with pneumonia presenting with extrathoracic pain, such as abdominal pain, have been previously described. In this report, we describe a 3-year-old girl with fever and right arm pain who was found to have an apical lobar pneumonia.