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Schoppel K, Keilman A, Fayyaz J, Padlipsky P, Diaz MCG, Wing R, Hughes M, Franco M, Swinger N, Whitfill T, Walsh B. Comparing Leadership Skills of Senior Emergency Medicine Residents in 3-Year Versus 4-Year Programs During Simulated Pediatric Resuscitation: A Pilot Study. Pediatr Emerg Care 2024; 40:591-597. [PMID: 38809592 DOI: 10.1097/pec.0000000000003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
OBJECTIVES The majority of pediatric patients in the United States (US) are evaluated and treated at general emergency departments. It is possible that discrepancies in length of emergency medicine (EM) residency training may allow for variable exposure to pediatric patients, critical resuscitations, and didactic events. The goal of this pilot study was to compare leadership skills of graduating EM residents from 3- to 4-year programs during simulated pediatric resuscitations using a previously validated leadership assessment tool, the Concise Assessment of Leader Management (CALM). METHODS This was a prospective, multicenter, simulation-based cohort pilot study that included graduating 3 rd - and 4 th -year EM resident physicians from 6 EM residency programs. We measured leadership performance across 3 simulated pediatric resuscitations (sepsis, seizure, cardiac arrest) using the CALM tool and compared leadership scores between the 3 rd - and 4 th -year resident cohorts. We also correlated leadership to self-efficacy scores. RESULTS Data was analyzed for 47 participating residents (24 3 rd -year residents and 23 4 th -year residents). Out of a total possible CALM score of 66, residents from 3-year programs scored 45.2 [SD ± 5.2], 46.8 [SD ± 5.0], and 46.6 [SD ± 4.7], whereas residents from 4-year programs scored 45.5 [SD ± 5.2], 46.4 [SD ± 5.0], and 48.2 [SD ± 4.3] during the sepsis, seizure, and cardiac arrest cases, respectively. The mean leadership score across all 3 cases for the 3-year cohort was 46.2 [SD ± 4.8] versus 46.7 [SD ± 4.5] ( P = 0.715) for the 4-year cohort. CONCLUSIONS These data show feasibility for a larger cohort project and, while not statistically significant, suggest no difference in leadership skills between 3 rd - and 4 th -year EM residents in our study cohort. This pilot study provides the basis of future work that will assess a larger multicenter cohort with the hope to obtain a more generalizable dataset.
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Affiliation(s)
- Kyle Schoppel
- From the Indiana University School of Medicine/Riley Hospital for Children
| | | | - Jabeen Fayyaz
- The Hospital for Sick Children/University of Toronto
| | | | | | | | | | | | - Nathan Swinger
- From the Indiana University School of Medicine/Riley Hospital for Children
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Newgard CD, Rakshe S, Salvi A, Lin A, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Burd RS, Malveau S, Jenkins PC, Stephens CQ, Glass NE, Hewes H, Mann NC, Ames SG, Fallat M, Jensen AR, Ford RL, Child A, Carr B, Lang K, Buchwalder K, Remick KE. Changes in Emergency Department Pediatric Readiness and Mortality. JAMA Netw Open 2024; 7:e2422107. [PMID: 39037816 PMCID: PMC11265139 DOI: 10.1001/jamanetworkopen.2024.22107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/14/2024] [Indexed: 07/24/2024] Open
Abstract
Importance High emergency department (ED) pediatric readiness is associated with improved survival, but the impact of changes to ED readiness is unknown. Objective To evaluate the association of changes in ED pediatric readiness at US trauma centers between 2013 and 2021 with pediatric mortality. Design, Setting, and Participants This retrospective cohort study was performed from January 1, 2012, through December 31, 2021, at EDs of trauma centers in 48 states and the District of Columbia. Participants included injured children younger than 18 years with admission or injury-related death at a participating trauma center, including transfers to other trauma centers. Data analysis was performed from May 2023 to January 2024. Exposure Change in ED pediatric readiness, measured using the weighted Pediatric Readiness Score (wPRS, range 0-100, with higher scores denoting greater readiness) from national assessments in 2013 and 2021. Change groups included high-high (wPRS ≥93 on both assessments), low-high (wPRS <93 in 2013 and wPRS ≥93 in 2021), high-low (wPRS ≥93 in 2013 and wPRS <93 in 2021), and low-low (wPRS <93 on both assessments). Main Outcomes and Measures The primary outcome was lives saved vs lost, according to ED and in-hospital mortality. The risk-adjusted association between changes in ED readiness and mortality was evaluated using a hierarchical, mixed-effects logistic regression model based on a standardized risk-adjustment model for trauma, with a random slope-random intercept to account for clustering by the initial ED. Results The primary sample included 467 932 children (300 024 boys [64.1%]; median [IQR] age, 10 [4 to 15] years; median [IQR] Injury Severity Score, 4 [4 to 15]) at 417 trauma centers. Observed mortality by ED readiness change group was 3838 deaths of 144 136 children (2.7%) in the low-low ED group, 1804 deaths of 103 767 children (1.7%) in the high-low ED group, 1288 deaths of 64 544 children (2.0%) in the low-high ED group, and 2614 deaths of 155 485 children (1.7%) in the high-high ED group. After risk adjustment, high-readiness EDs (persistent or change to) had 643 additional lives saved (95% CI, -328 to 1599 additional lives saved). Low-readiness EDs (persistent or change to) had 729 additional preventable deaths (95% CI, -373 to 1831 preventable deaths). Secondary analysis suggested that a threshold of wPRS 90 or higher may optimize the number of lives saved. Among 716 trauma centers that took both assessments, the median (IQR) wPRS decreased from 81 (63 to 94) in 2013 to 77 (64 to 93) in 2021 because of reductions in care coordination and quality improvement. Conclusions and Relevance Although the findings of this study of injured children in US trauma centers were not statistically significant, they suggest that trauma centers should increase their level of ED pediatric readiness to reduce mortality and increase the number of pediatric lives saved after injury.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Shauna Rakshe
- Knight Cancer Institute Biostatistics Shared Resource, Oregon Health & Science University, Portland
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgery Care, Children’s National Hospital, Washington, DC
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | | | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Hilary Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Mary Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - Aaron R. Jensen
- Department of Surgery, University of California, San Francisco, Benioff Children’s Hospital, San Francisco
| | - Rachel L. Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland
| | - Angela Child
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Brendan Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kendrick Lang
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Kyle Buchwalder
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Katherine E. Remick
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
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3
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Remick KE, Gausche-Hill M, Lin A, Goldhaber-Fiebert JD, Lang B, Foster A, Burns B, Jenkins PC, Hewes HA, Kuppermann N, McConnell KJ, Marin J, Weyant C, Ford R, Babcock SR, Newgard CD. The hospital costs of high emergency department pediatric readiness. J Am Coll Emerg Physicians Open 2024; 5:e13179. [PMID: 38835787 PMCID: PMC11147684 DOI: 10.1002/emp2.13179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/12/2024] [Accepted: 04/03/2024] [Indexed: 06/06/2024] Open
Abstract
Objective We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS) ≥ 88 (0-100 scale) across EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness. Methods We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day-to-day ED operations (ie, direct clinical care and routine ED supplies). Results The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719-100,694) for low volume EDs to $279,134 (95% CI 196,487-362,179) for very high volume EDs; equipment costs accounted for 0.9-5.0% of expenses. The total annual cost-per-patient ranged from $3/child (95% CI 2-4/child) to $222/child (95% CI 156-288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child. Conclusions Annual hospital costs for HPR are modest, particularly when considered per child.
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Affiliation(s)
- Katherine E Remick
- Departments of Pediatrics and Surgery Dell Medical School University of Texas at Austin Austin Texas USA
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics David Geffen School of Medicine Harbor-UCLA Medical Center Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center Torrance California USA
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
| | - Jeremy D Goldhaber-Fiebert
- Department of Health Policy and Center for Health Policy Stanford Medical School and Freeman Spogli Institute Stanford University Stanford California USA
| | - Benjamin Lang
- Departments of Pediatrics and Surgery Dell Medical School University of Texas at Austin Austin Texas USA
| | - Ashley Foster
- Department of Emergency Medicine University of California San Francisco San Francisco California USA
| | - Beech Burns
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
- Center for Health Systems Effectiveness Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
| | - Peter C Jenkins
- Department of Surgery Indiana University Indianapolis Indiana USA
| | - Hilary A Hewes
- Department of Pediatrics University of Utah School of Medicine Salt Lake City Utah USA
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics University of California, Davis School of Medicine Sacramento California USA
| | - K John McConnell
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
- Center for Health Systems Effectiveness Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
| | - Jennifer Marin
- Department of Pediatrics Emergency Medicine, & Radiology University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Christopher Weyant
- Department of Health Policy and Center for Health Policy Stanford Medical School and Freeman Spogli Institute Stanford University Stanford California USA
| | - Rachel Ford
- Emergency Medical Services and Trauma Systems Program Oregon Health Authority Portland Oregon USA
| | - Sean R Babcock
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
| | - Craig D Newgard
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA
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4
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Schoppel K, Spector J, Okafor I, Church R, Deblois K, Della‐Giustina D, Kellogg A, MacVane C, Pirotte M, Snow D, Hays G, Mariorenzi A, Connelly H, Sheng A. Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates. AEM EDUCATION AND TRAINING 2023; 7:e10918. [PMID: 38037628 PMCID: PMC10685395 DOI: 10.1002/aet2.10918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 12/02/2023]
Abstract
Background More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency. Methods This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email. Results A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001). Conclusions/discussion This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.
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Affiliation(s)
- Kyle Schoppel
- Indiana University School of Medicine, Riley Hospital for ChildrenIndianapolisIndianaUSA
| | - Jordan Spector
- Boston University Chobanian & Avedisian School of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Ijeoma Okafor
- Boston University Chobanian & Avedisian School of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Richard Church
- University of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | | | | | | | - Casey MacVane
- Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | | | - David Snow
- Loyola University Medical CenterMaywoodIllinoisUSA
| | - Geoffrey Hays
- Indiana University School of Medicine, Riley Hospital for ChildrenIndianapolisIndianaUSA
| | - Amy Mariorenzi
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Haley Connelly
- Boston University Chobanian & Avedisian School of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Alexander Sheng
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
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5
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Glass NE, Salvi A, Wei R, Lin A, Malveau S, Cook JNB, Mann NC, Burd RS, Jenkins PC, Hansen M, Mohr NM, Stephens C, Fallat ME, Lerner EB, Carr BG, Wall SP, Newgard CD. Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers. JAMA Surg 2023; 158:1078-1087. [PMID: 37556154 PMCID: PMC10413216 DOI: 10.1001/jamasurg.2023.3344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/25/2023] [Indexed: 08/10/2023]
Abstract
Importance Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.
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Affiliation(s)
- Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Ran Wei
- School of Public Policy, University of California, Riverside
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - E. Brooke Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen P. Wall
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
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6
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Byrne JP, Crandall ML. Improving Access to High Pediatric Readiness Emergency Departments at US Trauma Centers-A Viable Systems Approach to Improve Pediatric Survival After Injury. JAMA Surg 2023; 158:1087. [PMID: 37556124 DOI: 10.1001/jamasurg.2023.3362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Affiliation(s)
- James P Byrne
- Division of Trauma and Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marie L Crandall
- Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville
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7
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Newgard CD, Babcock SR, Song X, Remick KE, Gausche-Hill M, Lin A, Malveau S, Mann NC, Nathens AB, Cook JNB, Jenkins PC, Burd RS, Hewes HA, Glass NE, Jensen AR, Fallat ME, Ames SG, Salvi A, McConnell KJ, Ford R, Auerbach M, Bailey J, Riddick TA, Xin H, Kuppermann N. Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival. Ann Surg 2023; 278:e580-e588. [PMID: 36538639 PMCID: PMC10149578 DOI: 10.1097/sla.0000000000005741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sean R. Babcock
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Xubo Song
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, District of Columbia
| | - Hilary A. Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aaron R. Jensen
- Department of Surgery, University of California, San Francisco, Benioff Children’s Hospitals, San Francisco, California
| | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - K. John McConnell
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rachel Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland, Oregon
| | - Marc Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jessica Bailey
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tyne A. Riddick
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, Oregon
| | - Haichang Xin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California
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Michelson KA, Bachur RG, Grubenhoff JA, Cruz AT, Chaudhari PP, Reeves SD, Porter JJ, Monuteaux MC, Dart AH, Finkelstein JA. OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS. J Emerg Med 2023; 65:e9-e18. [PMID: 37355425 PMCID: PMC10527892 DOI: 10.1016/j.jemermed.2023.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/15/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Missed diagnosis can predispose to worse condition-specific outcomes. OBJECTIVE To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. RESULTS We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis. CONCLUSIONS Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Andrea T Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California; Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Scott D Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan A Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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9
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Eze JN, Edelu BO, Ndu IK, Oguonu T. Paediatric emergency medicine practice in Nigeria: a narrative review. BMC Emerg Med 2023; 23:31. [PMID: 36927266 PMCID: PMC10022062 DOI: 10.1186/s12873-023-00790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/08/2023] [Indexed: 03/18/2023] Open
Abstract
The practice of paediatric emergency medicine in Nigeria is still evolving, and laden with enormous challenges which contribute to adverse outcomes of childhood illnesses in emergency settings. Deaths from childhood illnesses presenting as emergencies contribute to overall child mortality rates in Nigeria. This narrative review discusses existing structures, organization, and practice of paediatric emergency in Nigeria. It highlights some of the challenges and suggests ways of surmounting them in order to reduce deaths in the children emergency units in Nigerian hospitals. Important aspects of this review include current capacity and need for capacity development, equipment needs for emergency care, quality of service in the context of inadequate healthcare funding and the need for improvement.
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Affiliation(s)
- Joy N Eze
- Department of Pediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, 400001, Nigeria.
- University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.
| | - Benedict O Edelu
- Department of Pediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, 400001, Nigeria
- University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Ikenna K Ndu
- Department of Paediatrics, College of Medicine, Enugu State University of Science and Technology, Enugu, Nigeria
- Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria
| | - Tagbo Oguonu
- University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
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10
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Remick K, Smith M, Newgard CD, Lin A, Hewes H, Jensen AR, Glass N, Ford R, Ames S, Cook J, Malveau S, Dai M, Auerbach M, Jenkins P, Gausche-Hill M, Fallat M, Kuppermann N, Mann NC. Impact of individual components of emergency department pediatric readiness on pediatric mortality in US trauma centers. J Trauma Acute Care Surg 2023; 94:417-424. [PMID: 36045493 PMCID: PMC9974586 DOI: 10.1097/ta.0000000000003779] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injured children initially treated at trauma centers with high emergency department (ED) pediatric readiness have improved survival. Centers with limited resources may not be able to address all pediatric readiness deficiencies, and there currently is no evidence-based guidance for prioritizing different components of readiness. The objective of this study was to identify individual components of ED pediatric readiness associated with better-than-expected survival in US trauma centers to aid in the allocation of resources targeted at improving pediatric readiness. METHODS This cohort study of US trauma centers used the National Trauma Data Bank (2012-2017) matched to the 2013 National Pediatric Readiness Project assessment. Adult and pediatric centers treating at least 50 injured children (younger than 18 years) and recording at least one death during the 6-year study period were included. Using a standardized risk-adjustment model for trauma, we calculated the observed-to-expected mortality ratio for each trauma center. We used bivariate analyses and multivariable linear regression to assess for associations between individual components of ED pediatric readiness and better-than-expected survival. RESULTS Among 555 trauma centers, the observed-to-expected mortality ratios ranged from 0.07 to 4.17 (interquartile range, 0.93-1.14). Unadjusted analyses of 23 components of ED pediatric readiness showed that trauma centers with better-than-expected survival were more likely to have a validated pediatric triage tool, comprehensive quality improvement processes, a pediatric-specific disaster plan, and critical airway and resuscitation equipment (all p < 0.03). The multivariable analysis demonstrated that trauma centers with both a physician and a nurse pediatric emergency care coordinator had better-than-expected survival, but this association weakened after accounting for trauma center level. Child maltreatment policies were associated with lower-than-expected survival, particularly in Levels III to V trauma centers. CONCLUSION Specific components of ED pediatric readiness were associated with pediatric survival among US trauma centers. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Katherine Remick
- From the Department of Pediatrics (K.R.), Dell Medical School at the University of Texas at Austin, Austin, Texas; Department of Pediatrics (M.S., H.H., S.A., M.D., N.C.M.), University of Utah School of Medicine, Salt Lake City, Utah; Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine (C.D.N., A.L., J.C., S.M.), Oregon Health & Science University, Portland, Oregon; UCSF Benioff Children's Hospitals, Department of Surgery (A.R.J.), University of California San Francisco, San Francisco, California; Department of Surgery (N.G.), Rutgers New Jersey Medical School, Newark, New Jersey; Oregon EMS for Children Program (R.F.), Oregon Health Authority, Portland, Oregon; Departments of Pediatrics (M.A.) and Emergency Medicine (M.A.), Yale University School of Medicine, New Haven, Connecticut; Indiana University School of Medicine, Department of Surgery (P.J.), Indianapolis, Indiana; Departments of Emergency Medicine (M.G.-H.) and Pediatrics (M.G.-H.), David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; Department of Surgery (M.F.), University of Louisville School of Medicine, Louisville, Kentucky; and Departments of Emergency Medicine (N.K.) and Pediatrics (N.K.), University of California Davis School of Medicine, Sacramento, California
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11
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Newgard CD, Lin A, Malveau S, Cook JNB, Smith M, Kuppermann N, Remick KE, Gausche-Hill M, Goldhaber-Fiebert J, Burd RS, Hewes HA, Salvi A, Xin H, Ames SG, Jenkins PC, Marin J, Hansen M, Glass NE, Nathens AB, McConnell KJ, Dai M, Carr B, Ford R, Yanez D, Babcock SR, Lang B, Mann NC. Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care. JAMA Netw Open 2023; 6:e2250941. [PMID: 36637819 PMCID: PMC9857584 DOI: 10.1001/jamanetworkopen.2022.50941] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. OBJECTIVE To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. EXPOSURE ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. RESULTS There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. CONCLUSIONS AND RELEVANCE These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.
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Affiliation(s)
- Craig D. Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Katherine E. Remick
- Department of Pediatric, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Jeremy Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children’s National Hospital, Washington, DC
| | - Hilary A. Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Apoorva Salvi
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Haichang Xin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Jennifer Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew Hansen
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K. John McConnell
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Mengtao Dai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Brendan Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland
| | - Davis Yanez
- Department of Anesthesia, Yale School of Medicine, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Sean R. Babcock
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Benjamin Lang
- Department of Pediatric, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
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12
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Brumme K, Hewes HA, Richards R, Gausche‐Hill M, Remick K, Donofrio‐Odmann J. Assessing proximity effect of high‐acuity pediatric emergency departments on the pediatric readiness scores in neighboring general emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12850. [PMID: 36381478 PMCID: PMC9660843 DOI: 10.1002/emp2.12850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 10/10/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022] Open
Abstract
Study Objectives The objective of this study was to determine if there is a proximity effect of high‐acuity, pediatric‐capable emergency departments (EDs) on the weighted pediatric readiness score of neighboring general EDs and whether this effect is attributable to specific components of the National Pediatric Readiness Guidelines. Methods Pediatric readiness was assessed using the weighted pediatric readiness score of EDs based on the 2013 National Pediatric Readiness Project assessment. High‐acuity, pediatric‐capable EDs were defined as those with a separate pediatric ED and inpatient pediatric services, including the following: pediatric ICU, pediatric ward, and neonatal ICU. Neighboring general EDs are within a 30‐minute drive time of a high‐acuity, pediatric‐capable ED. Analysis was stratified by annual ED pediatric volume: low (<1800), medium (1800–4999), medium‐high (5000–9999), and high (>10,000). We analyzed components of the readiness guidelines, including quality improvement/safety initiatives, pediatric emergency care coordinators, and availability of pediatric‐specific equipment. Groups were compared using chi‐squared or Wilcoxon rank‐sum test with P values <0.05 considered significant. Results Of the 4149 surveyed hospitals, 3933 general EDs (not high‐acuity, pediatric‐capable EDs) were identified, of which 1009 were located within a 30‐minute drive to a high‐acuity, pediatric‐capable ED. Neighboring general EDs had a statistically significantly higher median weighted pediatric readiness score across pediatric volumes (weighted pediatric readiness score 76.3 vs 65.3; P < 0.001). Neighboring general EDs were more likely to have a pediatric emergency care coordinator, a notification policy for abnormal pediatric vital signs, and >90% of pediatric‐specific equipment. Conclusions We found neighboring general EDs have a higher level of pediatric readiness as measured by the median weighted pediatric readiness score. High‐acuity, pediatric‐capable EDs may influence the pediatric readiness of neighboring general Eds, but further investigation is needed to clarify target areas for outreach by state and national partners to improve overall pediatric readiness.
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Affiliation(s)
- Kristina Brumme
- Department of Pediatrics Section of Emergency Medicine Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Hilary A. Hewes
- Department of Pediatrics Division of Pediatric Emergency Medicine School of Medicine University of Utah Salt Lake City Utah USA
| | - Rachel Richards
- Department of Pediatrics School of Medicine University of Utah Salt Lake City Utah USA
| | - Marianne Gausche‐Hill
- Los Angeles County EMS Agency Los Angeles California USA
- Departments of Emergency Medicine and Pediatrics David Geffen School of Medicine at University of California Los Angeles Los Angeles California USA
- Departments of Emergency Medicine and Pediatrics Harbor‐University of California Los Angeles Medical Center Torrance California USA
| | - Katherine Remick
- National EMS for Children Innovation and Improvement Center Departments of Pediatrics and Surgery Dell Medical School University of Texas at Austin Austin Texas USA
| | - Joelle Donofrio‐Odmann
- Department of Emergency Medicine and Pediatrics Rady Children's Hospital of San Diego University of California San Diego California USA
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13
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Tsao HS, Alter R, Kane E, Gross T, Browne LR, Auerbach M, Leonard JC, Ludwig L, Adelgais KM. Pediatric Emergency Care Coordination in EMS Agencies: Findings of a Multistate Learning Collaborative. PREHOSP EMERG CARE 2022; 27:1004-1015. [PMID: 36125189 DOI: 10.1080/10903127.2022.2126040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND In 2017, the Health Resources and Services Administration's Maternal Child and Health Bureau's Emergency Medical Services for Children program implemented a performance measure for State Partnership grants to increase the percentage of EMS agencies within each state that have designated individuals who coordinate pediatric emergency care, also called a pediatric emergency care coordinator (PECC). The PECC Learning Collaborative (PECCLC) was established to identify best practices to achieve this goal. This study's objective is to report on the structure and outcomes of the PECCLC conducted among nine states. METHODS This study used quantitative and qualitative methods to evaluate outcomes from the PECCLC. Participating state representatives engaged in a 6-month collaborative that included monthly learning sessions with subject matter experts and support staff and concluded with a two-day in-person meeting. Outcomes included reporting the number of PECCs recruited, identifying barriers and enablers to PECC recruitment, characterizing best practices to support PECCs, and identifying barriers and enablers to enhance and sustain the PECC role. Outcomes were captured by self-report from participating state representatives and longitudinal qualitative interviews conducted with representative PECCs at 6 and 18 months after conclusion of the PECCLC. RESULTS During the 6-month collaborative, states recruited 341 PECCs (92% of goal). Follow up at 5 months post-collaborative revealed an additional recruitment of 184 for a total of 525 PECCs (142% of the goal). Feedback from state representatives and PECCs revealed the following barriers: competition from other EMS responsibilities, budgetary constraints, lack of incentive for agencies to create the position, and lack of requirement for establishing the role. Enablers identified included having an EMS agency recognition program that includes the PECC role, train-the-trainer programs, and inclusion of the PECC role in agency licensure requirements. Longitudinal interviews with PECCs identified that the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support. CONCLUSION Over the 6-month Learning Collaborative, nine states were successful in recruiting a substantial number of PECCs. Financial and time constraints were significant barriers to statewide PECC recruitment, yet these can be potentially addressed by EMS agency recognition programs.
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Affiliation(s)
- Hoi See Tsao
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
| | - Rachael Alter
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
| | - Erica Kane
- EMS for Children, Emergency Medical Services for Children at Children's Health Alliance of Wisconsin, Milwaukee, Wisconsin
| | - Toni Gross
- Department of Emergency Medicine, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Lorin R Browne
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Marc Auerbach
- Yale University School of Medicine, New Haven, Connecticut
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine and the Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lorah Ludwig
- Emergency Medical Services for Children Program, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland
| | - Kathleen M Adelgais
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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14
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Michelson KA, Griffey RT. Why identifying adverse events in paediatric emergency care matters. BMJ Qual Saf 2022; 31:776-778. [PMID: 35863876 PMCID: PMC9859933 DOI: 10.1136/bmjqs-2022-014939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Richard T Griffey
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri, USA
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15
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Remick KE, Bartley KA, Gonzales L, MacRae KS, Edgerton EA. Consensus-driven model to establish paediatric emergency care measures for low-volume emergency departments. BMJ Open Qual 2022; 11:bmjoq-2021-001803. [PMID: 35803615 PMCID: PMC9272131 DOI: 10.1136/bmjoq-2021-001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/19/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Katherine E Remick
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Krystle A Bartley
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Louis Gonzales
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kate S MacRae
- Gonzaga University College of Arts and Sciences, Spokane, Washington, USA
| | - Elizabeth A Edgerton
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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16
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Zachrison KS, Hayden EM, Boggs KM, Boyle TP, Gao J, Samuels-Kalow ME, Marcin JP, Camargo CA. Emergency Departments' Uptake of Telehealth for Stroke Versus Pediatric Care: Observational Study. J Med Internet Res 2022; 24:e33981. [PMID: 35723927 PMCID: PMC9254043 DOI: 10.2196/33981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/25/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Telehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted. OBJECTIVE Our primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth. METHODS We used the 2016 National Emergency Department Inventory-USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both. RESULTS Of the 442 EDs surveyed, 378 (85.5%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1% (45/320) of EDs with telestroke services reported weekly use versus 2.9% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was "improving level of clinical care." Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8%) than for pediatric telehealth adoption (1/272, 0.4%; P=.003). CONCLUSIONS In 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Tehnaz P Boyle
- Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Jingya Gao
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - James P Marcin
- Department of Pediatrics, University of California Davis School of Medicine, University of California, Sacramento, CA, United States
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
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17
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Newgard CD, Lin A, Goldhaber-Fiebert JD, Marin JR, Smith M, Cook JNB, Mohr NM, Zonfrillo MR, Puapong D, Papa L, Cloutier RL, Burd RS. Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers. JAMA Surg 2022; 157:e217419. [PMID: 35107579 PMCID: PMC8811708 DOI: 10.1001/jamasurg.2021.7419] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023]
Abstract
IMPORTANCE There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown. OBJECTIVE To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021. EXPOSURES ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES Time to death within 365 days. RESULTS Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer R. Marin
- Departments of Pediatrics, Emergency Medicine, and Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - McKenna Smith
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - Mark R. Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Devin Puapong
- Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii
- Department of Surgery, University of Hawai’i John A. Burns School of Medicine, Honolulu
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Robert L. Cloutier
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children’s National Hospital, Washington, DC
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Kothari SY, Haynes SC, Sigal I, Magana JN, Ruttan T, Kuppermann N, Horeczko T, Ludwig L, Karsteadt L, Chapman W, Pinette V, Marcin JP. Resources for Improving Pediatric Readiness and Quality of Care in Rural Communities and Emergency Departments. Pediatr Emerg Care 2022; 38:e1069-e1074. [PMID: 35226633 DOI: 10.1097/pec.0000000000002658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To share the process and products of an 8-year, federally funded grant from the Health Resources and Services Administration Emergency Medical Services for Children program to increase pediatric emergency readiness and quality of care provided in rural communities located within 2 underserved local emergency medical services agencies (LEMSAs) in Northern California. METHODS In 2 multicounty LEMSAs with 24 receiving hospital emergency departments, we conducted focus groups and interviews with patients and parents, first responders, receiving hospital personnel, and other community stakeholders. From this, we (a regional, urban children's hospital) provided a variety of resources for improving the regionalization and quality of pediatric emergency care provided by prehospital providers and healthcare staff at receiving hospitals in these rural LEMSAs. RESULTS From this project, we provided resources that included regularly scheduled pediatric-specific training and education programs, pediatric-specific quality improvement initiatives, expansion of telemedicine services, and cultural competency training. We also enhanced community engagement and investment in pediatric readiness. CONCLUSIONS The resources we provided from our regional, urban children's hospital to 2 rural LEMSAs facilitated improvements in a regionalized system of care for critically ill and injured children. Our shared resources framework can be adapted by other regional children's hospitals to increase readiness and quality of pediatric emergency care in rural and underserved communities and LEMSAs.
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Affiliation(s)
| | | | | | - Julia N Magana
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX
| | | | - Timothy Horeczko
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA
| | - Lorah Ludwig
- Emergency Medical Services for Children, Division of Child, Adolescent, and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD
| | | | | | - Vickie Pinette
- Sierra-Sacramento Valley Emergency Medical Services, Rocklin, CA
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Lieng MK, Marcin JP, Sigal IS, Haynes SC, Dayal P, Tancredi DJ, Gausche-Hill M, Mouzoon JL, Romano PS, Rosenthal JL. Association between emergency department pediatric readiness and transfer of noninjured children in small rural hospitals. J Rural Health 2022; 38:293-302. [PMID: 33734494 PMCID: PMC8489899 DOI: 10.1111/jrh.12566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Pediatric readiness scores may be a useful measure of a hospital's preparedness to care for children. However, there is limited evidence linking these scores with patient outcomes or other metrics, including the need for interfacility transfer. This study aims to determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of noninjured children (< 18 years old) presenting to emergency departments (EDs) in small rural hospitals in the state of California. METHODS Data from the National Pediatric Readiness Project assessment were linked with the California Office of Statewide Health Planning and Development's ED and inpatient databases to conduct a cross-sectional study of pediatric interfacility transfers. Hospitals were manually matched between these data sets. Logistic regression was performed with random intercepts for hospital and adjustment for patient-level confounders. FINDINGS A total of 54 hospitals and 135,388 encounters met the inclusion criteria. EDs with a high pediatric readiness score (>70) had lower adjusted odds of transfer (aOR: 0.55, 95% CI: 0.33-0.93) than EDs with a low pediatric readiness score (≤ 70). The pediatric readiness section with strongest association with transfer was the "policies, procedures, and protocols" section; EDs in the highest quartile had lower odds of transfer than EDs in the lowest quartile (aOR: 0.54, 95% CI: 0.31-0.91). CONCLUSIONS Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Additional studies are recommended to investigate other pediatric outcomes in relation to hospital ED pediatric readiness.
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Affiliation(s)
- Monica K. Lieng
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - James P. Marcin
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Ilana S. Sigal
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Sarah C. Haynes
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Parul Dayal
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Daniel J. Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Marianne Gausche-Hill
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Jamie L. Mouzoon
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Patrick S. Romano
- Department of Pediatrics, University of California Davis, Sacramento, California
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Cree RA, So M, Franks J, Richards R, Leeb R, Hashikawa A, Krug S, Ludwig L, Olson LM. Characteristics Associated With Presence of Pediatric Mental Health Care Policies in Emergency Departments. Pediatr Emerg Care 2021; 37:e1116-e1121. [PMID: 31738300 PMCID: PMC7217715 DOI: 10.1097/pec.0000000000001920] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The majority of US children do not have access to an emergency department (ED) with a pediatric mental health care policy in place. Our objective was to understand factors associated with whether US EDs have a pediatric mental health care policy. METHODS We analyzed data from the National Pediatric Readiness Project, a nationally representative cross-sectional survey of US EDs. Nurse managers reported whether their hospitals had a policy to care for children with social/mental health concerns (n = 3612). We calculated prevalence estimates, prevalence ratios (PRs), and confidence intervals (CIs) for regional and ED characteristics (eg, rurality and types of personnel) by whether EDs had a pediatric mental health care policy. RESULTS Overall, 46.2% (n = 1668/3612) of EDs had a pediatric mental health care policy. Emergency departments located in remote areas were 60% less likely to have such a policy compared with EDs in urban areas (PR, 0.4; CI, 0.3-0.5). Emergency department characteristics associated with having a pediatric mental health care policy included having a policy to transfer children with social/mental health concerns (PR, 5.4; CI, 4.7-6.2), having a policy to address maltreatment (PR, 3.4; CI, 2.6-4.4), and having nurse and physician pediatric emergency care coordinators (PR, 1.6; CI, 1.5-1.8). CONCLUSIONS Lower prevalence of pediatric mental health policies in rural EDs is concerning considering EDs are often the first point of contact for pediatric patients. This work highlights the importance of pediatric emergency care coordinators in fostering ED capacity to meet children's mental health needs.
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Affiliation(s)
- Robyn A. Cree
- Centers for Disease Control and Prevention, Division of Human Development and Disability, Atlanta, GA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA
| | - Marvin So
- Oak Ridge Institute for Science Education, Oak Ridge, TN
| | - Jessica Franks
- Oak Ridge Institute for Science Education, Oak Ridge, TN
| | - Rachel Richards
- University of Utah, Department of Pediatrics, Division of Critical Care, Salt Lake City, UT
| | - Rebecca Leeb
- Centers for Disease Control and Prevention, Division of Human Development and Disability, Atlanta, GA
| | - Andrew Hashikawa
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, MI
| | - Steven Krug
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lorah Ludwig
- Emergency Medical Services for Children, Division of Child, Adolescent, and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Lenora M. Olson
- University of Utah, Department of Pediatrics, Division of Critical Care, Salt Lake City, UT
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Shum M, Asnes AG, Leventhal JM, Gaither JR, Bechtel K, Powers E, Tiyyagura G. The impact of a child abuse guideline on differences between pediatric and community emergency departments in the evaluation of injuries. CHILD ABUSE & NEGLECT 2021; 122:105374. [PMID: 34737120 DOI: 10.1016/j.chiabu.2021.105374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Although child physical abuse is missed more frequently in community (CEDs) vs. pediatric emergency departments (PEDs), little information exists describing how evaluations of high-risk injuries differ between these settings. OBJECTIVES To determine differences in evaluations of infants for abuse between a PED and CEDs and whether a child abuse guideline reduced these differences. PARTICIPANTS AND SETTING Infants presenting to one PED (n = 162) and three CEDs (n = 159) with 3 injury categories: 1) Injuries for which the American Academy of Pediatrics recommends skeletal survey (SS) testing (infants <5-months with an oral injury or bruising, <9-months with a non-skull fracture, and < 12-months with an intracranial hemorrhage); 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries. METHODS We assessed differences in SS testing and child protective services (CPS) reporting between the PED and CEDs before and after implementation of a child abuse guideline. RESULTS The median (IQR) age was 4 months (2-7). Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01-8.10; Category 2: aOR 10.1, CI: 1.2-88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3-26.7; Category 2: aOR 12.0, CI: 1.4-103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category. CONCLUSIONS Implementation of a child abuse guideline minimized differences between a PED and CEDs in the evaluation of infants with injuries concerning for abuse.
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Affiliation(s)
- May Shum
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Andrea G Asnes
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - John M Leventhal
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Julie R Gaither
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Kirsten Bechtel
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Emily Powers
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Gunjan Tiyyagura
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
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22
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Genovese TJ, Roberts-Santana C, Wills H. Pediatric Trauma Readiness: A Trauma-Specific Assessment to Complement the National Pediatric Readiness Project. Pediatr Emerg Care 2021; 37:e1646-e1651. [PMID: 33170570 DOI: 10.1097/pec.0000000000002144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The National Pediatric Readiness Project of the Emergency Medical Services for Children surveyed emergency departments in the United States in 2013 for readiness to provide emergency care to children. However, that survey did not query for many elements considered essential to Advanced Trauma Life Support (ATLS). METHODS Our pediatric trauma center and state department of health collaborated to develop a survey reflecting ATLS principles regarding pediatric-specific trauma stabilization, clinical/administrative resources, and interfacility transfer to complement the 2017 PedsReady survey. We distributed the survey to all emergency department medical directors in our state in 2017. RESULTS Medical directors of all 11 emergency departments responded. Only 2 reported having physician or nurse pediatric trauma coordinators. Two reported comfort with all emergency procedures at all ages (eg, airway, traumatic pneumothorax treatment, etc), whereas 9 had variable thresholds of comfort by age and procedure. Reported utilization of pediatric trauma-specific protocols varied the following: hyperosmolar therapy (1), neurological assessment (3), chest injury (4), massive transfusion (1), triage (5), trauma transfer agreements (10), imaging-limitation protocols (4), internal (1) and inter-facility (4) quality assurance/quality improvement process (1), and real-time image transfer (11). CONCLUSIONS This survey identified gaps in the readiness of emergency departments to treat injured children in our state that were not detected by the 2013 PedsReady surveys. Future surveys of emergency department pediatric readiness should consider more detailed, trauma-specific readiness questions. This will allow for assignment of more accurate goals and benchmarking standards for national pediatric trauma readiness.
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Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME, Auerbach MA, Lutfi R, Abu-Sultaneh S. Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program. Pediatr Emerg Care 2021; 37:543-549. [PMID: 30870337 DOI: 10.1097/pec.0000000000001751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. METHODS This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. RESULTS A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. CONCLUSIONS This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.
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Affiliation(s)
- Kamal Abulebda
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | | | | | - Rami A Ahmed
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Mara E Nitu
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | - Riad Lutfi
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
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Newgard CD, Lin A, Olson LM, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Malveau S, Smith M, Dai M, Nathens AB, Glass NE, Jenkins PC, McConnell KJ, Remick KE, Hewes H, Mann NC. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA Pediatr 2021; 175:947-956. [PMID: 34096991 PMCID: PMC8185631 DOI: 10.1001/jamapediatrics.2021.1319] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/25/2021] [Indexed: 01/20/2023]
Abstract
Importance The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. Objective To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. Design, Setting, and Participants A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. Exposures Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. Main Outcomes and Measures In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. Results There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. Conclusions and Relevance In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Lenora M. Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | | | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care, and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Biostatistics, The University of Utah School of Medicine, Salt Lake City
| | - Mengtao Dai
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - K. John McConnell
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, The University of Texas at Austin
| | - Hilary Hewes
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - N. Clay Mann
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
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Lieng MK, Marcin JP, Dayal P, Tancredi DJ, Swanson MB, Haynes SC, Romano PS, Sigal IS, Rosenthal JL. Emergency Department Pediatric Readiness and Potentially Avoidable Transfers. J Pediatr 2021; 236:229-237.e5. [PMID: 34000284 PMCID: PMC8830940 DOI: 10.1016/j.jpeds.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components. STUDY DESIGN This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates. RESULTS After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan. CONCLUSIONS Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.
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Affiliation(s)
- Monica K Lieng
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA.
| | - James P Marcin
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Parul Dayal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Morgan B Swanson
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Sarah C Haynes
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Patrick S Romano
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Ilana S Sigal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Jennifer L Rosenthal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
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Prehospital Disaster Triage Does Not Predict Pediatric Outcomes: Comparing the Criteria Outcomes Tool to Three Mass-Casualty Incident Triage Algorithms. Prehosp Disaster Med 2021; 36:503-510. [PMID: 34392857 DOI: 10.1017/s1049023x21000856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION It remains unclear which mass-casualty incident (MCI) triage tool best predicts outcomes for child disaster victims. STUDY OBJECTIVES The primary objective of this study was to compare triage outcomes of Simple Triage and Rapid Treatment (START), modified START, and CareFlight in pediatric patients to an outcomes-based gold standard using the Criteria Outcomes Tool (COT). The secondary outcomes were sensitivity, specificity, under-triage, over-triage, and overall accuracy at each level for each MCI triage algorithm. METHODS Singleton trauma patients under 16 years of age with complete prehospital, emergency department (ED), and in-patient data were identified in the 2007-2009 National Trauma Data Bank (NTDB). The COT outcomes and procedures were translated into ICD-9 procedure codes with added timing criteria. Gold standard triage levels were assigned using the COT based on outcomes, including mortality, injury type, admission to the hospital, and surgical procedures. Comparison triage levels were determined based on algorithmic depictions of the three MCI triage tools. RESULTS A total of 31,093 patients with complete data were identified from the NTDB. The COT was applied to these patients, and the breakdown of gold standard triage levels, based on their actual clinical outcomes, was: 17,333 (55.7%) GREEN; 11,587 (37.3%) YELLOW; 1,572 (5.1%) RED; and 601 (1.9%) BLACK. CareFlight had the best sensitivity for predicting COT outcomes for BLACK (83% [95% confidence interval, 80%-86%]) and GREEN patients (79% [95% CI, 79%-80%]) and the best specificity for RED patients (89% [95% CI, 89%-90%]). CONCLUSION Among three prehospital MCI triage tools, CareFlight had the best performance for correlating with outcomes in the COT. Overall, none of three tools had good test characteristics for predicting pediatric patient needs for surgical procedures or hospital admission.
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Availability of Pediatric Emergency Care Coordinators in United States Emergency Departments. J Pediatr 2021; 235:163-169.e1. [PMID: 33577802 DOI: 10.1016/j.jpeds.2021.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/28/2021] [Accepted: 02/05/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the availability of pediatric emergency care coordinators (PECCs) in US emergency departments (EDs) in 2015, and to determine the change in availability of PECCs in US EDs from 2015 to 2017. STUDY DESIGN As part of the National Emergency Department Inventory-USA, we administered a survey to all 5326 US EDs open in 2015; all 5431 in 2016; and all 5489 in 2017. Through these surveys, we assessed the availability of PECCs. Descriptive statistics characterized EDs with and without PECCs; multivariable logistic regressions identified characteristics independently associated with PECC availability. RESULTS Among the 4443 (83%) EDs with 2015 data, 763 (17.2%) reported the availability of at least 1 PECC. The states with the largest proportion of EDs with PECCs were Delaware (78%, 7/9 EDs) and Maryland (48%, 20/42 EDs), and no PECCs were reported in Mississippi, North Dakota, or Wyoming. Availability of a PECC was associated (P < .001) with larger annual total ED visit volume and a dedicated pediatric ED area. Compared with the 17.2% of EDs reporting a PECC in 2015, 833 (18.6%) reported 1 in 2016, and 917 (19.8%) reported 1 in 2017 (P < .001). CONCLUSIONS Availability of at least 1 PECC increased slightly (2.6%) between 2015 and 2017, but ∼80% of EDs continue without one.
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Burns R, Madhok M, Bank I, Nguyen M, Falk M, Waseem M, Auerbach M. Creation of a standardized pediatric emergency medicine simulation curriculum for emergency medicine residents. AEM EDUCATION AND TRAINING 2021; 5:e10685. [PMID: 34632245 PMCID: PMC8489268 DOI: 10.1002/aet2.10685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/15/2021] [Accepted: 08/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The majority of children seeking care in emergency departments are seen by general emergency medicine (EM) residency program graduates. Throughout training, EM residents manage fewer critically ill pediatric patients compared to adults, and the exposure to children with illness and injury requiring emergent assessment and management is often limited and sporadic across training sites. This report describes the creation of a robust set of simulation cases for EM trainees incorporating topics identified during a previous modified Delphi study to improve their pediatric acute care knowledge and skills. METHODS All 30 pediatric EM topics and 19/26 procedures previously identified as "must be taught by simulation" to EM residents were mapped to 15 simulation case topics. Twenty-seven authors from 16 institutions created cases and supporting materials. Each case was iteratively implemented during a peer review process at two to five sites with EM residents. Feedback from learners and facilitators was collected via electronic surveys and used to revise each case before the next implementation. RESULTS Thirty-five institutions participated in the peer review process. Fifty-one facilitators and 281 participants (90% EM residents) completed surveys. Most facilitators (98%) agreed or strongly agreed with the statement "This simulation case is relevant to the field of emergency medicine." A majority of facilitators and participants agreed or strongly agreed with the statements "The simulation case was realistic" (98% of facilitators, 94% of participants) and "This simulation case was effective in teaching resuscitation skills" (92% of facilitators, 98% of participants). Most participants reported confidence in knowledge and skills addressed in the learning objectives after participation. CONCLUSIONS Facilitators and EM residents found cases from a novel simulation-based curriculum covering critical pediatric EM topics relevant, realistic, and effective. This curriculum can help provide a standardized, uniform experience for EM residents who will care for critically ill pediatric patients in their communities.
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Affiliation(s)
- Rebekah Burns
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
| | - Manu Madhok
- Department of PediatricsChildren's MinnesotaMinneapolisMinnesotaUSA
| | - Ilana Bank
- Department of PediatricsMcGill UniversityMontrealQuebecCanada
| | - Michael Nguyen
- Department of MedicineMorsani College of MedicineUniversity of South FloridaTampaFloridaUSA
| | - Michael Falk
- Department of PediatricsChildren's Hospital Medical CenterWashingtonDCUSA
| | - Muhammad Waseem
- Departments of Pediatrics and Emergency MedicineLincoln Medical CenterBronxNew YorkUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale UniversityNew HavenConnecticutUSA
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Fallat ME. Fifteen years beyond Institute of Medicine and the future of emergency care in the US health system: Illusions, delusions, and situational awareness. J Trauma Acute Care Surg 2021; 91:6-13. [PMID: 34144555 DOI: 10.1097/ta.0000000000003242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mary E Fallat
- From the Division of Pediatric Surgery Hiram C. Polk, Jr., Department of Surgery, University of Louisville, Louisville, Kentucky
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Hewes HA, Genovesi AL, Codden R, Ely M, Ludwig L, Macias CG, Schmuhl P, Olson LM. Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting. PREHOSP EMERG CARE 2021; 26:503-510. [PMID: 34142919 DOI: 10.1080/10903127.2021.1942340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Treating pediatric patients often invokes discomfort and anxiety among emergency medical service (EMS) personnel. As part of the process to improve pediatric care in the prehospital system, the Health Resources and Services Administration (HRSA) Emergency Services for Children (EMSC) Program implemented two prehospital performance measures -access to a designated pediatric care coordinator (PECC) and skill evaluation using pediatric equipment-along with a multi-year plan to aid states in achieving the measures. Baseline data from a survey conducted in 2017 showed that less than 25% of EMS agencies had access to PECC and 47% performed skills evaluation using pediatric equipment at least twice a year. To evaluate change over time, the survey was again conducted in 2020, and agencies that participated in both years are compared. METHODS A web-based survey was sent to EMS agency administrators in 58 states and territories from January to March 2020. Descriptive statistics, odds ratios, and 95% confidence intervals were conducted. RESULTS The response rate was 56%. A total of 5,221 agencies participated in both survey periods representing over 250,000 providers. The percentage of agencies reporting the presence of a PECC increased from 24% to 34% (p= <0.001). However, some agencies reported that they no longer had a PECC, while others reported having a PECC for the first time. Fifty percent (50%) of agencies conduct pediatric psychomotor skills evaluation at least twice/year, a 2% increase over time (p = 0.041); however, a third (34%) evaluate skills using pediatric equipment less than once a year. The presence of a PECC continues to be the variable associated with the highest odds (AOR 2.15, 95% CI 1.91-2.43) of conducting at least semi-annual skills evaluation. CONCLUSIONS There is an increase in the presence of pediatric care coordination and the frequency of pediatric psychomotor skills evaluation among national EMS agencies over time. Continued efforts to increase and sustain PECC presence should be an ongoing focus to improve pediatric readiness in the prehospital system.
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Affiliation(s)
- Hilary A Hewes
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, UT.,Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Andrea L Genovesi
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Rachel Codden
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Michael Ely
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Lorah Ludwig
- Emergency Medical Services for Children Program, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services
| | - Charles G Macias
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's/Case Western Reserve University, Cleveland, OH
| | - Patricia Schmuhl
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Lenora M Olson
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
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Brown KM, Ackerman AD, Ruttan TK, Snow SK. Access to Optimal Emergency Care for Children. Ann Emerg Med 2021; 77:523-531. [PMID: 33902828 DOI: 10.1016/j.annemergmed.2021.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Kathleen M Brown
- Department of Pediatrics and Emergency Medicine, The George Washington University School of Medicine, and Children's National Medical Center, Washington, District of Columbia
| | - Alice D Ackerman
- Department of Pediatrics, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Timothy K Ruttan
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine, Austin, Texas
| | - Sally K Snow
- Emergency Nurses Association, Schaumburg, Illinois
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Brown KM, Ackerman AD, Ruttan TK, Snow SK. Access to Optimal Emergency Care for Children. Pediatrics 2021; 147:peds.2021-050787. [PMID: 33883245 DOI: 10.1542/peds.2021-050787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Every year, millions of pediatric patients seek emergency care. Significant barriers limit access to optimal emergency services for large numbers of children. The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have a strong commitment to identifying these barriers, working to overcome them, and encouraging, through education and system changes, improved access to emergency care for all children.
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Affiliation(s)
- Kathleen M Brown
- Departments of Pediatrics and Emergency Medicine and Children's National Medical Center, School of Medicine of Health Sciences, George Washington University, Washington, DC;
| | - Alice D Ackerman
- Department of Pediatrics, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Timothy K Ruttan
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Department of Pediatrics, Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine, Austin, Texas; and
| | - Sally K Snow
- Emergency Nurses Association, Schaumburg, Illinois
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Yoong SYC, Ang PH, Chong SL, Ong YKG, Zakaria NDB, Lee KP, Pek JH. Common diagnoses among pediatric attendances at emergency departments. BMC Pediatr 2021; 21:172. [PMID: 33853569 PMCID: PMC8045375 DOI: 10.1186/s12887-021-02646-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 04/05/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pediatric patients present to Emergency Departments (EDs) with a variety of medical conditions. An appreciation of the common presenting conditions can aid EDs in the provision of pediatric emergency care. In this study, we established the common pediatric diagnoses seen at the general EDs, with reference to a pediatric ED. METHODS A retrospective review of medical records was performed for patients less than 16 years old at a pediatric ED and two general EDs from 1 January to 31 December 2018. Information including patient demographics, triage category, case type and diagnoses were collected. RESULTS There were 159,040 pediatric attendances, of which 3477 (2.2%) were seen at the general EDs. Non-traumatic conditions were most prevalent at both general (N = 1933, 55.6%) and pediatric (N = 128,415, 82.5%) EDs. There was a higher proportion of trauma related conditions seen at the general EDs (N = 1544, 44.4%) compared to the pediatric ED (N = 27,148, 17.5%; p < 0.01). Across all EDs, upper respiratory tract infection, unspecified musculoskeletal pain and gastroenteritis were the three most common non-trauma related diagnoses, while fracture, wound and contusion were the three most common trauma related diagnoses. There was a greater proportion of emergent (P1) cases seen at the general EDs (N = 233, 6.7%) than the pediatric ED (N = 3821, 2.5%; p < 0.01). Respiratory conditions including bronchiolitis, asthma and bronchitis were the most common emergent (P1) diagnoses. CONCLUSIONS The common diagnoses among pediatric attendances varied between pediatric and general EDs. Therefore, general EDs should focus their efforts on these common diagnoses, especially the emergent (P1) ones, so that they can enhance their preparedness and work towards providing quality pediatric emergency care.
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Affiliation(s)
- Shuen Yin Celine Yoong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Peck Har Ang
- Accident and Emergency Department, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Nur Diana Bte Zakaria
- Department of Emergency Medicine, Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, 110 Sengkang E Way, Singapore, 544886, Singapore.
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Schoppel KA, Stapleton S, Florian J, Whitfill T, Walsh BM. Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees? AEM EDUCATION AND TRAINING 2021; 5:e10509. [PMID: 33898912 PMCID: PMC8052997 DOI: 10.1002/aet2.10509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training. METHODS This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument. RESULTS A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%). CONCLUSIONS This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.
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Affiliation(s)
| | | | | | - Travis Whitfill
- Department of Pediatrics and Emergency MedicineYale UniversityNew HavenCTUSA
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Dolan P, Nozicka C, O'Brien CR. Pediatric Facility Recognition Program and the Illinois EMSC Experience. Pediatr Ann 2021; 50:e165-e171. [PMID: 34039176 DOI: 10.3928/19382359-20210323-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Emergency medical services (EMS) systems were initially developed in the United States during the late 1960s. Modeled from military experiences, EMS demonstrated that survival for prehospital patients could be improved with enhanced field triage, treatment, and transport protocols. Over the next few decades, it was identified that children and adolescents had poorer outcomes in similar acute medical situations as compared to adults. To address this, the emergency medical services for children (EMSC) program was established in 1985 as a federal initiative to ensure appropriate resources and adequately trained personnel are available to meet the emergency care needs of children who are critically ill and injured. In 1994, the Illinois EMSC program was established and a pediatric facility recognition program to improve the emergency care of pediatric patients was rolled out in 1998. This article reviews the development of EMSC facility recognition programs and discusses their unique characteristics and contributions to improved pediatric emergency care. [Pediatr Ann. 2021;50(4):e165-e171.].
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Stys D, Landry K, Mitra T, Grant V. A provincial assessment of readiness for paediatric emergencies: What are the existing resource gaps in Alberta? Paediatr Child Health 2020; 25:498-504. [PMID: 33354258 PMCID: PMC7739534 DOI: 10.1093/pch/pxz111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 07/09/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES A large proportion of all emergency visits for paediatric patients across Canada are to general emergency departments (EDs). These centres may not be adequately equipped to provide optimal care for high acuity paediatric emergencies. The objective of this study was to determine paediatric readiness for general EDs and urgent care centres (UCCs) across Alberta and provide each centre with an overall weighted Paediatric Readiness Score (WPRS). METHODS A paediatric readiness assessment consisting of 55-questions normalized on a 100-point scale was used to survey 107 general EDs, UCCs, and tertiary paediatric EDs in Alberta, Canada. It addresses six primary categories, including Coordination of Patient Care, Physician/Nurse Staffing and Training, Quality Improvement Activities, Patient Safety Initiatives, Policies and Procedures, and Equipment and Supplies. Descriptive statistics were used to present the WPRS score among different groups. Linear regression models were used to explore factors associated with the score. RESULTS The overall response rate was 59.8%. The median overall WPRS (/100) for all general EDs and UCCs was 48.4 ([interquartile range {IQR}] 17.6). Factors that were correlated with overall score included high paediatric patient volume (24.28, 95% confidence interval [CI]: 10.52 to 38.04) and involvement in a simulation education outreach program (9.38, 95% CI: 1.11 to 17.66). CONCLUSION Based on this survey, the WPRS of EDs and UCCs across Alberta suggest a need to improve readiness to respond to high acuity paediatric emergencies in these settings.
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Affiliation(s)
- Dana Stys
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta
| | - Kerri Landry
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta
| | - Tatum Mitra
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Vincent Grant
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
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Tan JCL, Ang PH, Chong SL, Lee KP, Ong GYK, Zakaria NDB, Pek JH. Differences in Utilisation of the General and Paediatric Emergency Departments by Paediatric Patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020; 49:948-954. [PMID: 33463652 DOI: 10.47102/annals-acadmedsg.2020327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Paediatric patients presenting to the general emergency departments (EDs) differ from those presenting to paediatric EDs. General EDs vary in preparedness to manage paediatric patients, which may affect delivery of emergency care with varying clinical outcomes. We aimed to elucidate the differences in utilisation patterns of paediatric and general EDs by paediatric patients. METHODS This study was conducted in a public healthcare cluster in Singapore consisting of 4 hospitals. A retrospective review of the medical records of paediatric patients, defined as age younger than 16 years old, who attended the EDs from 1 January 2015 to 31 December 2018, was performed. Data were collected using a standardised form and analysed. RESULTS Of the 704,582 attendances, 686,546 (97.4%) were seen at the paediatric ED. General EDs saw greater number of paediatric patients in the emergent (P1) category (921 [5.1%] versus 14,829 [2.2%]; P<0.01) and those with trauma-related presentations (6,669 [37.0%] vs 108,822 [15.9%]; P<0.01). The mortality of paediatric patients was low overall but significantly higher in general EDs (39 [0.2%] vs 32 [0.005%]; P<0.01). Seizure, asthma/bronchitis/bronchiolitis, allergic reaction, cardiac arrest and burns were the top 5 diagnoses that accounted for 517 (56.1%) of all emergent (P1) cases seen at general EDs. CONCLUSION General EDs need to build their capabilities and enhance their preparedness according to the paediatric population they serve so that optimal paediatric emergency care can be delivered, especially for critically ill patients who are most in need of life-saving and timely treatment.
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Woolridge D, Homme J(J, Amato CS, Pauze D, Rose E, Valente J, Ishimine P, Friesen P, Baldwin S, Joseph M, Saidinejad M, Perina D, Goodloe JM. Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics. J Am Coll Emerg Physicians Open 2020; 1:1520-1526. [PMID: 33392559 PMCID: PMC7771807 DOI: 10.1002/emp2.12114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/09/2020] [Accepted: 05/05/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children. OBJECTIVES The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors. DISCUSSION Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care. CONCLUSION Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.
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Affiliation(s)
- Dale Woolridge
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - James (Jim) Homme
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | | | - Denis Pauze
- Department of Emergency MedicineAlbany Medical CenterAlbanyNew YorkUSA
| | - Emily Rose
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
- Department of Emergency MedicineLos Angeles County and USC Medical CenterLos AngelesCaliforniaUSA
| | - Jon Valente
- Departments of Emergency Medicine and PediatricsAlpert Medical School of Brown UniversityRhode Island Hospital and Hasbro Children's HospitalProvidenceRhode IslandUSA
| | - Paul Ishimine
- Departments of Emergency Medicine and PediatricsUniversity of CaliforniaSan Diego School of MedicineSan DiegoCaliforniaUSA
| | - Phillip Friesen
- Department of PediatricsThe University of Texas at Austin Dell Medical SchoolAustinTexasUSA
| | - Steve Baldwin
- Pediatric Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Madeline Joseph
- Pediatric Emergency MedicineDepartment of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Mohsen Saidinejad
- Pediatrics and Emergency MedicineDavid Geffen School of Medicine at UCLATorranceCaliforniaUSA
- Health Services and Outcomes ResearchThe Los Angeles Biomedical Research InstituteTorranceCaliforniaUSA
- Department of Emergency MedicineHarbor UCLA Medical CenterTorranceCaliforniaUSA
| | - Debra Perina
- Emergency MedicineUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Jeffrey M. Goodloe
- Department of Emergency MedicineUniversity of Oklahoma School of Community MedicineTulsaOklahomaUSA
- OU Schusterman CenterTulsaOklahomaUSA
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Enyuma CO, Moolla M, Motara F, Olorunfemi G, Geduld H, Laher AE. Paediatric Emergency Department preparedness in Nigeria: A prospective cross-sectional study. Afr J Emerg Med 2020; 10:152-158. [PMID: 32923327 PMCID: PMC7474227 DOI: 10.1016/j.afjem.2020.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/29/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Paediatric emergency medicine (PEM) is poorly developed in low and middle-income countries. The magnitude of challenges facing Paediatric Emergency Departments (PEDs) in Nigeria has not been well described. This study aimed to assess paediatric emergency care preparedness across PEDs in Nigeria. METHODS This was a prospective cross-sectional study that utilized a self-administered questionnaire and a check list to assess three key domains (managerial, medication and equipment) in tertiary care PED facilities that were recruited across Nigeria. Preparedness scores and other institutional attributes were compared between zones and regions. RESULTS Thirty-four tertiary-level PEDs across Nigeria were included. The mean number of patient visits over the 30-day period prior to data collection was 253.2 (±261.2). The mean (SD) managerial, medication and equipment performance scores of the included PEDs were 42.9% (±14.3%), 50.7% (±22.3%) and 43.9% (±11.8%) respectively. The mean (SD) total performance score was 46.9% (±15.3%). Only 13 PEDs had a total performance score of >50%. There was a statistically significant higher mean equipment score (p = 0.029) in the Southern region (47.6 ± 3.1) compared to the Northern region (38.9 ± 2.3) of the country. CONCLUSIONS This study reports a global but remediable deficiency in emergency care preparedness amongst PEDs in tertiary care facilities in Nigeria. This study highlights the need for training of PED managers in basic and advanced life support and for the improvement in medication and equipment procurement across Nigeria.
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Affiliation(s)
- Callistus O.A. Enyuma
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
- Department of Pediatrics, Faculty of Medicine, University of Calabar, Nigeria
| | - Muhammed Moolla
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Feroza Motara
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Gbenga Olorunfemi
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of Witwatersrand, South Africa
| | - Heike Geduld
- Division of Emergency Medicine, Stellenbosch University, South Africa
| | - Abdullah E. Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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Abstract
OBJECTIVES Pediatric patients represent a small proportion of emergency medical services (EMS) calls, challenging providers in maintaining skills in treating children. Having structural capacity to appropriately diagnose and treat pediatric patients is critical. Our study measured the availability of off-line and on-line medical direction and recommended pediatric equipment at EMS agencies. METHODS A Web-based survey was sent to EMS agencies in 2010 and 2013, and results were analyzed to determine availability of medical direction and equipment. RESULTS Approximately 5000 agencies in 32 states responded, representing over 80% response. Availability of off-line medical direction increased between years (78% in 2010 to 85% in 2013), was lower for basic life support (BLS) (63% and 72%) than advanced life support (ALS) agencies (90% and 93%), and was generally higher in urban than rural or frontier locations. On-line medical direction was consistently available (90% both years) with slight increases for BLS agencies (87% to 90%) and slightly greater availability for urban and rural compared with frontier agencies. The majority of agencies carried most recommended equipment; however, less than one third of agencies reported carrying all equipment. Agencies with off-line medical direction, on-line medical direction, and with both off-line and on-line medical direction were respectively 1.69, 1.31, and 2.21 times more likely to report carrying all recommended equipment. CONCLUSIONS Basic structural capacity exists in EMS for treating children, with improvements seen over time. However, gaps remain, particularly for BLS and nonurban agencies. Continuous attention to infrastructure is necessary, and the recent development of national performance measures should further promote quality emergency care for all children.
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Abstract
BACKGROUND Pediatric readiness among US emergency departments is not universal. Trauma hospitals adhere to standards that may support day-to-day readiness for children. METHODS In 2013 4,146 emergency departments participated in the NPRP to assess compliance with the 2009 Guidelines to Care for Children in the Emergency Department. Probabilistic linkage (90%) to the 2009 American Hospital Association survey found 1,247 self-identified trauma hospitals (levels 1, 2, 3, 4). Relationship between trauma hospital level and weighted pediatric readiness score (WPRS) on a 100-point scale was performed; significance was assessed using a Kruskal-Wallis test and pediatric readiness elements using χ. Adjusted relative risks were calculated using modified Poisson regression, controlling for pediatric volume, hospital configuration, and geography. RESULTS The overall WPRS among all trauma hospitals (1,247) was 71.8. Among those not self-identified as a children's hospital or emergency department approved for pediatrics (EDAP) (1088), Level 1 and 2 trauma hospitals had higher WPRS than level 3 and 4 trauma hospitals, 83.5 and 71.8, respectively versus 64.9 and 62.6. Yet, compared with EDAP trauma hospitals (median 90.5), level 1 general trauma hospitals were less likely to have critical pediatric-specific elements. Common gaps among general trauma hospitals included presence of interfacility transfer agreements for children, measurement of pediatric weights solely in kilograms, quality improvement processes with pediatric-specific metrics, and disaster plans that include pediatric-specific needs. CONCLUSION Self-identified trauma hospital level may not translate to pediatric readiness in emergency departments. Across all levels of general non-EDAP, nonchildren's trauma hospitals, gaps in pediatric readiness exist. Nonchildren's hospital EDs (i.e., EDAPs) can be prepared to meet the emergency needs of all children and trauma hospital designation should incorporate these core elements of pediatric readiness. LEVEL OF EVIDENCE Care management, level III.
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Remick K, Cramer A. Hear Our Voice: Every Child, Every Day; Pediatric Emergency Care Services in the United States. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
IMPORTANCE The availability of pediatric hospital care for common conditions is decreasing across the US. The consequences of this decrease on access to care for specific conditions need to be evaluated. OBJECTIVE To evaluate the degree of regionalization of pediatric seizure care in the US by characterizing the activity of hospital systems in 6 diverse states. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study used inpatient and emergency department administrative data sets from all acute care hospitals in Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York from 2014. All patients younger than 18 years who visited a hospital and had a primary diagnosis of seizures were included. Data were analyzed between January and June 2019. MAIN OUTCOMES AND MEASURES Characteristics of hospital encounters and pediatric Hospital Capability Index scores of transferring and admitting hospitals. RESULTS Among 57 930 encounters with pediatric patients with seizures (median [range] age, 4 [1-11] years; 31 968 [55.2%] boys) identified in 621 acute care hospitals, 15 467 patients (26.7%) were admitted as inpatients and 3748 patients (6.5%) were transferred between acute care hospitals. Among encounters that resulted in transfers between hospitals, seizure was the only diagnosis in 1554 patients (41.5%). A total of 42 463 encounters began as emergency department visits, of which 38 173 encounters (90.0%) resulted in routine discharge. While 536 hospitals (86.3%) transferred children with seizures, only 232 hospitals (37.4%) ever admitted them and only 63 hospitals (10.1%) ever received a pediatric seizure transfer. The median (interquartile range) pediatric Hospital Capability Index score of all hospitals was 0.10 (0.02-0.28), while that of hospitals occasionally admitting pediatric seizure patients was 0.34 (0.22-0.55). However, although most patients who were admitted had brief stays (ie, ≤2 days) and no comorbidities, three-quarters of all admissions (12 002 admissions [77.6%]) were to very highly capable centers (ie, hospitals with pediatric Hospital Capability Index scores >0.75). Across all states, the number of referral hospitals for pediatric seizures was less than the number of Dartmouth Atlas Hospital Referral Regions (47 referral hospitals vs 63 hospital referral regions). CONCLUSIONS AND RELEVANCE These findings suggest that although children with seizures are seen in almost all acute care hospital emergency departments, most hospitals transfer children who require admission. Condition-specific interhospital dependency challenges standard definitions of network adequacy and should be accounted for in emergency medical service planning, access to care policies, and health services research.
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Affiliation(s)
- Urbano L. França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael L. McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Whitfill TM, Remick KE, Olson LM, Richards R, Brown KM, Auerbach MA, Gausche-Hill M. Statewide Pediatric Facility Recognition Programs and Their Association with Pediatric Readiness in Emergency Departments in the United States. J Pediatr 2020; 218:210-216.e2. [PMID: 31757472 DOI: 10.1016/j.jpeds.2019.10.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Accepted: 10/09/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To describe the relationship between statewide pediatric facility recognition (PFR) programs and pediatric readiness in emergency departments (EDs) in the US. STUDY DESIGN Data were extracted from the 2013 National Pediatric Readiness Project assessment (4083 EDs). Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) based on a 100-point scale. Descriptive statistics were used to compare WPRS between recognized and nonrecognized EDs and between states with or without a PFR program. A linear mixed model with WPRS was used to evaluate state PFR programs on pediatric readiness. RESULTS Eight states were identified with a PFR program. EDs in states with a PFR program had a higher WPRS compared with states without a PFR program (overall a 9.1-point higher median WPRS; P < .001); EDs recognized in a PFR program had a 21.7-point higher median WPRS compared with nonrecognized EDs (P < .001); and between states with a statewide PFR program, there was high variability of participation within the states. We found state-level PFR programs predicted a higher WPRS compared with states without a PFR program (β = 5.49; 95% CI 2.76-8.23). CONCLUSIONS Statewide PFR programs are based on national guidelines and identify those EDs that adhere to a standard level of readiness for children. These statewide PFR initiatives are associated with higher pediatric readiness. As scalable strategies are needed to improve emergency care for children, our study suggests that statewide PFR programs may be one way to improve pediatric readiness and underscores the need for further implementation and evaluation.
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Affiliation(s)
- Travis M Whitfill
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Katherine E Remick
- Office of the Medical Director, Austin-Travis County EMS System, Austin, TX; Dell Medical School at the University of Texas, Austin, TX; San Marcos/Hays County EMS System, San Marcos, TX; EMS for Children Innovation and Improvement Center, Houston, TX
| | - Lenora M Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Rachel Richards
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Kathleen M Brown
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC; Children's National Medical Center, Washington, DC
| | - Marc A Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics, Harbor-UCLA Medical Center, Torrance, CA; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA; Emergency Medical Services Agency, Department of Health Services, Los Angeles County, Los Angeles, CA
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
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Marcin JP, Romano PS, Dayal P, Dharmar M, Chamberlain JM, Dudley N, Macias CG, Nigrovic LE, Powell EC, Rogers AJ, Sonnett M, Tzimenatos L, Alpern ER, Andrews-Dickert R, Borgialli DA, Sidney E, Casper TC, Kuppermann N. Provider-Level and Hospital-Level Factors and Process Measures of Quality Care Delivered in Pediatric Emergency Departments. Acad Pediatr 2020; 20:524-531. [PMID: 31760173 PMCID: PMC9701102 DOI: 10.1016/j.acap.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/13/2019] [Accepted: 11/16/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children's hospital EDs were associated with physician-level or hospital-level factors. METHODS We included children (<18 years old) who presented to any of the 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2011 and December 2011. We measured quality of care from medical record reviews using a previously validated implicit review instrument with a summary score ranging from 5 to 35, and examined associations between process measures of quality and physician- and hospital-level factors using a mixed-effects linear regression model adjusted for patient case-mix, with hospital site as a random effect. RESULTS Among the 620 ED encounters reviewed, we did not find process measures of quality to be associated with any physician-level factors such as physician sex, years since medical school graduation, or physician training. We found, however, that process measures of quality were positively associated with delivery at freestanding children's hospitals (1.96 points higher in quality compared to nonfreestanding status, 95% confidence interval: 0.49, 3.43) and negatively associated with higher annual ED patient volume (-0.03 points per thousand patients, 95% confidence interval: -0.05, -0.01). CONCLUSION Process measures of quality of care delivered to children were higher among patients treated at freestanding children's hospitals but lower among patients treated at higher volume EDs.
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Gausche-Hill M. Emergency and Definitive Care for Children in the United States: The Perfect Storm. Pediatrics 2020; 145:peds.2019-3372. [PMID: 31882441 DOI: 10.1542/peds.2019-3372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and Harbor-UCLA Medical Center, Torrance, California
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Moore B, Shah MI, Owusu-Ansah S, Gross T, Brown K, Gausche-Hill M, Remick K, Adelgais K, Lyng J, Rappaport L, Snow S, Wright-Johnson C, Leonard JC, Wright J, Adirim T, Agus MS, Callahan J, Gross T, Lane N, Lee L, Mazor S, Mahajan P, Timm N, Goodloe J, Brown K, Abell B, Alson R, Bachista K, Bowman L, Boynton H, Brown SA, Chang A, Copeland D, De Lorenzo R, Douglas D, Fowler R, Gallagher J, Gilliam S, Guyette F, Holland D, Jarvis J, Kalan C, Keeperman J, Kupas D, Lairet J, Levy M, Lyon K, Manifold C, McCabe-Kline K, Mell H, Miller B, Millin M, Rosen B, Ross J, Ryan K, Sanko S, Schlesinger S, Sheppard C, Sibold H, Smith S, Spigner M, Stracuzzi V, Tanski C, Tennyson J, White C, Wilcocks D, Yee A, Young T, Foresman-Capuzzi J, Johnson R, Martin H, Milici J, Brandt C, Nelson N, Lyng J, Watson S, Remick K, Dietrich A, Bates K, Flake F, Flores G. Pediatric Readiness in Emergency Medical Services Systems. Ann Emerg Med 2020; 75:e1-e6. [DOI: 10.1016/j.annemergmed.2019.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Indexed: 11/28/2022]
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Moore B, Shah MI, Owusu-Ansah S, Gross T, Brown K, Gausche-Hill M, Remick K, Adelgais K, Lyng J, Rappaport L, Snow S, Wright-Johnson C, Leonard JC. Pediatric Readiness in Emergency Medical Services Systems. Pediatrics 2020; 145:peds.2019-3307. [PMID: 31857380 DOI: 10.1542/peds.2019-3307] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.
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Affiliation(s)
- Brian Moore
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Manish I Shah
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Sylvia Owusu-Ansah
- Division of Emergency Medical Services, Department of Pediatrics and Emergency Department, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Toni Gross
- Department of Emergency Medicine, Children's HospitalNew Orleans and Louisiana State University Health New Orleans, New Orleans, Louisiana
| | - Kathleen Brown
- Departments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia.,Division of Emergency Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles and Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Katherine Remick
- San Marcos Hays County Emergency Medical Services, San Marcos, Texas.,Austin-Travis County Emergency Medical Services System, Austin, Texas.,Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Kathleen Adelgais
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - John Lyng
- Level I Adult Trauma Center and Level II Pediatric Trauma Center, North Memorial Health Hospital, Minneapolis, Minnesota
| | - Lara Rappaport
- Department of Pediatric Emergency Medicine and Urgent Care Center, Denver Health Medical Center, Denver, Colorado
| | - Sally Snow
- Pediatric Emergency and Trauma Nursing, Fort Worth, Texas
| | - Cynthia Wright-Johnson
- Emergency Medical Services for Children, Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland; and
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
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Moore B, Shah MI, Owusu-Ansah S, Gross T, Brown K, Gausche-Hill M, Remick K, Adelgais K, Lyng J, Rappaport L, Snow S, Wright-Johnson C, Leonard JC. Pediatric Readiness in Emergency Medical Services Systems. PREHOSP EMERG CARE 2019; 24:175-179. [DOI: 10.1080/10903127.2019.1685614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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