Comparative clinical practice of residents and attending physicians who care for pediatric patients in the emergency department

Bedside Clinicians' Perceptions on the Contributing Role of Diagnostic Errors in Acutely Ill Patient Presentation: A Survey of Academic and Community Practice

OBJECTIVES

This study aimed to explore clinicians' perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU).

METHODS

A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record.

RESULTS

A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002).

CONCLUSIONS

Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.

A Scoping Review of Physicians' Clinical Reasoning in Emergency Departments

STUDY OBJECTIVE

Clinical reasoning is considered a core competency of physicians. Yet there is a paucity of research on clinical reasoning specifically in emergency medicine, as highlighted in the literature.

METHODS

We conducted a scoping review to examine the state of research on clinical reasoning in this specialty. Our team, composed of content and methodological experts, identified 3,763 articles in the literature, 95 of which were included.

RESULTS

Most studies were published after 2000. Few studies focused on the cognitive processes involved in decisionmaking (ie, clinical reasoning). Of these, many confirmed findings from the general literature on clinical reasoning; specifically, the role of both intuitive and analytic processes. We categorized factors that influence decisionmaking into contextual, patient, and physician factors. Many studies focused on decisions in regard to investigations and admission. Test ordering is influenced by physicians' experience, fear of litigation, and concerns about malpractice. Fear of litigation and malpractice also increases physicians' propensity to admit patients. Context influences reasoning but findings pertaining to specific factors, such as patient flow and workload, were inconsistent.

CONCLUSION

Many studies used designs such as descriptive or correlational methods, limiting the strength of findings. Many gray areas persist, in which studies are either scarce or yield conflicting results. The findings of this scoping review should encourage us to intensify research in the field of emergency physicians' clinical reasoning, particularly on the cognitive processes at play and the factors influencing them, using appropriate theoretical frameworks and more robust methods.

Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department

BACKGROUND

Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED).

METHODS

The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians.

RESULTS

An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487-6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2-6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians.

CONCLUSION

Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation.

Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care

CONTEXT

Follow-up strategies after emergency department (ED) discharge, alias safety netting, is often based on the gut feeling of the attending physician.

OBJECTIVE

To systematically identify evaluated safety-netting strategies after ED discharge and to describe determinants of paediatric ED revisits.

DATA SOURCES

MEDLINE, Embase, CINAHL, Cochrane central, OvidSP, Web of Science, Google Scholar, PubMed.

STUDY SELECTION

Studies of any design reporting on safety netting/follow-up after ED discharge and/or determinants of ED revisits for the total paediatric population or specifically for children with fever, dyspnoea and/or gastroenteritis. Outcomes included complicated course of disease after initial ED visit (eg, revisits, hospitalisation).

DATA EXTRACTION

Two reviewers independently assessed studies for eligibility and study quality. As meta-analysis was not possible due to heterogeneity of studies, we performed a narrative synthesis of study results. A best-evidence synthesis was used to identify the level of evidence.

RESULTS

We summarised 58 studies, 36% (21/58) were assessed as having low risk of bias. Limited evidence was observed for different strategies of safety netting, with educational interventions being mostly studied. Young children, a relevant medical history, infectious/respiratory symptoms or seizures and progression/persistence of symptoms were strongly associated with ED revisits. Gender, emergency crowding, physicians' characteristics and diagnostic tests and/or therapeutic interventions at the index visit were not associated with revisits.

CONCLUSIONS

Within the heterogeneous available evidence, we identified a set of strong determinants of revisits that identify high-risk groups in need for safety netting in paediatric emergency care being related to age and clinical symptoms. Gaps remain on intervention studies concerning specific application of a uniform safety-netting strategy and its included time frame.

The effect of medical students and residents on measures of efficiency and timeliness in an academic medical center emergency department

PURPOSE

Research regarding the effect of trainees on emergency department (ED) operations has demonstrated mixed results. In this study, the authors evaluated the effect of trainees on ED length of stay (LOS), door to medical provider (DTMP) time, and door to disposition decision (DTDD) time while accounting for covariates known to influence ED efficiency and timeliness.

METHOD

The authors used retrospective cohort data for ED visits to Maine Medical Center's mixed adult and pediatric ED for the calendar years 2005 through 2009. Each visit was coded indicating the type of provider conducting the visit (student-attending, resident-attending, midlevel provider, or attending group). Ordinary least squares regression analyses were performed to examine the relationships between provider groups and ED LOS, DTMP time, and DTDD time. Hierarchical regression models were constructed to control for the confounding effects of triage acuity, time of year, laboratory testing, radiographic testing, and patient characteristics.

RESULTS

The analysis of 246,142 visits found significant intergroup differences across provider groups for each outcome (P < .001). Multiple regression modeling revealed that treatment by trainees was a significant predictor of longer LOS (medical students and residents), shorter DTMP time (residents), and longer DTDD time (medical students and residents), after controlling for covariates.

CONCLUSIONS

Laboratory and radiographic testing accounted for a much larger proportion of variation in outcomes than did trainees. The small increases in LOS and DTDD time are balanced by the decrease in DTMP time and the intangible benefits of educating trainees.

Effectiveness of a five-level Paediatric Triage System: an analysis of resource utilisation in the emergency department in Taiwan

Objectives

To examine the effectiveness of a five-level Paediatric Triage and Acuity System (Ped-TTAS) by comparing the reliability of patient prioritisation and resource utilisation with the four-level Paediatric Taiwan Triage System (Ped-TTS) among non-trauma paediatric patients in the emergency department (ED).

Methods

The study design used was a retrospective longitudinal analysis based on medical chart review and a computer database. Except for a shorter list of complaints and some abnormal vital sign criteria modifications, the structure and triage process for applying Ped-TTAS was similar to that of the Paediatric Canadian Emergency Triage and Acuity Scale. Non-trauma paediatric patients presenting to the ED were triaged by well-trained triage nurses using the four-level Ped-TTS in 2008 and five-level Ped-TTAS in 2010. Hospitalisation rates and medical resource utilisation were analysed by acuity levels between the contrasting study groups.

Results

There was a significant difference in patient prioritisation between the four-level Ped-TTS and five-level Ped-TTAS. Improved differentiation was observed with the five-level Ped-TTAS in predicting hospitalisation rates and medical costs.

Conclusions

The five-level Ped-TTAS is better able to discriminate paediatric patients by triage acuity in the ED and is also more precise in predicting resource utilisation. The introduction of a more accurate acuity and triage system for use in paediatric emergency care should provide greater patient safety and more timely utilisation of appropriate ED resources.

"Be quick": a systems response to overcrowding in the pediatric emergency department

OBJECTIVE

The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED.

METHODS

System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007).

RESULTS

The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007.

CONCLUSIONS

In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.