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Rogachev S, Hashavya S, Rekhtman D, Schiesel G, Benenson-Weinberg T, Weiser G, Gordon O, Gross I. Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever. Clin Pediatr (Phila) 2024:99228241234963. [PMID: 38415681 DOI: 10.1177/00099228241234963] [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: 02/29/2024]
Abstract
Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.
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Affiliation(s)
- Sonia Rogachev
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Saar Hashavya
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - David Rekhtman
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Gali Schiesel
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | | | - Giora Weiser
- Department of Pediatric Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Oren Gordon
- Infectious Disease Unit, Department of Pediatrics, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
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Seers T, Reynard C, Martin GP, Body R. Development and Internal Validation of a Multivariable Prediction Model to Predict Repeat Attendances in the Pediatric Emergency Department: A Retrospective Cohort Study. Pediatr Emerg Care 2024; 40:16-21. [PMID: 37195679 DOI: 10.1097/pec.0000000000002975] [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: 05/18/2023]
Abstract
OBJECTIVE Unplanned reattendances to the pediatric emergency department (PED) occur commonly in clinical practice. Multiple factors influence the decision to return to care, and understanding risk factors may allow for better design of clinical services. We developed a clinical prediction model to predict return to the PED within 72 hours from the index visit. METHODS We retrospectively reviewed all attendances to the PED of Royal Manchester Children's Hospital between 2009 and 2019. Attendances were excluded if they were admitted to hospital, aged older than 16 years or died in the PED. Variables were collected from Electronic Health Records reflecting triage codes. Data were split temporally into a training (80%) set for model development and a test (20%) set for internal validation. We developed the prediction model using LASSO penalized logistic regression. RESULTS A total of 308,573 attendances were included in the study. There were 14,276 (4.63%) returns within 72 hours of index visit. The final model had an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.63-0.65) on temporal validation. The calibration of the model was good, although with some evidence of miscalibration at the high extremes of the risk distribution. After-visit diagnoses codes reflecting a nonspecific problem ("unwell child") were more common in children who went on to reattend. CONCLUSIONS We developed and internally validated a clinical prediction model for unplanned reattendance to the PED using routinely collected clinical data, including markers of socioeconomic deprivation. This model allows for easy identification of children at the greatest risk of return to PED.
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Affiliation(s)
- Tim Seers
- From the Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Abstract
OBJECTIVES Unplanned return visits (URVs) to emergency departments (EDs) account internationally for 2.5% to 5.2% of all consultations. ED crowding is an increasing challenge, and URVs seem to contribute to this problem. This study aimed to assess factors for URVs at the ED of a tertiary children's hospital to analyze if they are jointly responsible for the steadily rising amount of treated patients. METHODS All patients with an URV to a pediatric ED in Switzerland between January and December 2013 were included in the study. Data were taken retrospectively from the electronic patient files, and different variables were defined and analyzed. RESULTS URVs occurred at an incidence of 4.6%, and mostly concerned infants and toddlers (46%). URVs were independent of weekdays and mostly occurred between 10 am and 10 pm. In 84.2% of the cases, the URVs were judged as unnecessary, and in 15.8%, a hospitalization was indicated, mainly for children with a worsening respiratory illness. CONCLUSIONS The occurrence of URVs in our ED was within the incidence reported in the literature. While URVs lead to hospitalization in some patients, the majority of URVs were unnecessary from a medical point of view. These results indicate that a correct evaluation of the child's health state by parents is often challenging and requires repeated medical attendance following a first ED visit, especially in infants with airway diseases and infections. Intensive counseling and scheduled short-term follow-up consultation at the pediatrician's office could prevent URVs to the ED.
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Implementation strategies in emergency management of children: A scoping review. PLoS One 2021; 16:e0248826. [PMID: 33761525 PMCID: PMC7990517 DOI: 10.1371/journal.pone.0248826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Implementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children. METHODS We conducted a scoping review using Arksey and O'Malley's framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies. RESULTS We included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%). CONCLUSIONS Studies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that 'dissemination' is the most common strategy used, and 'capacity building and scale-up' are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.
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Bressan S, Berlese P, Arpone M, Steiner I, Titomanlio L, Da Dalt L. Missed intracranial injuries are rare in emergency departments using the PECARN head injury decision rules. Childs Nerv Syst 2021; 37:55-62. [PMID: 32424442 DOI: 10.1007/s00381-020-04660-0] [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: 02/19/2020] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The PECARN head trauma (HT) prediction rules have been developed to guide computed tomography-related decision-making for children with minor HT (mHT). There are currently limited data on the rate of unscheduled revisits to emergency departments (EDs), and initially missed intracranial injuries, in children with mHT initially assessed using the PECARN rules. This study aimed to fill this gap in knowledge. METHODS Clinical charts of children assessed for mHT over a 5-year period at two EDs that implemented the PECARN rules in Italy and France were reviewed retrospectively. Children who returned to EDs for mHT-related, or potentially related complaints, within 1 month of initial assessment were included. RESULTS The total number of children with mHT presenting for the first time to the EDs of both sites was 11,749. Overall, 180 (1.5%) unscheduled revisits to the EDs occurred for mHT-related or potentially related complaints. Twenty-three of these 180 patients underwent neuroimaging, and seven had an intracranial injury (including one ischemic stroke). Of these, three were hospitalized and none needed neurosurgery or intensive care. CONCLUSION Unscheduled revisits for mHT in EDs using the PECARN rules were very uncommon. Initially missed intracranial injuries were rare, and none needed neurosurgery or intensive care.
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Affiliation(s)
- Silvia Bressan
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy.
| | - Paola Berlese
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy.,Pediatric Emergency Department, Robert Debré Hospital, Paris, France
| | - Marta Arpone
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Ivan Steiner
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Luigi Titomanlio
- Pediatric Emergency Department, Robert Debré Hospital, Paris, France
| | - Liviana Da Dalt
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
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Video discharge instructions for pediatric gastroenteritis in an emergency department: a randomized, controlled trial. Eur J Pediatr 2021; 180:569-575. [PMID: 33029683 PMCID: PMC7541201 DOI: 10.1007/s00431-020-03827-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 10/27/2022]
Abstract
The aim was to evaluate if the addition of video discharge instructions (VDIs) to usual verbal information improved the comprehension of information provided to caregivers of patients who consult for acute gastroenteritis (AGE). We conducted an open-label, parallel, randomized trial, enrolling patients who consulted for AGE at a tertiary hospital. First, caregivers answered a written test concerning AGE characteristics and management. They were randomly allocated to a control group, which received the usual verbal instructions, or to an intervention group, which additionally received VDI. After discharge, caregivers were contacted by telephone and answered the same test, satisfaction questions, and follow-up information. From September 2019 to March 2020, 139 patients were randomized, 118 completed follow-up. The mean score was 3.13 (SD 1.07) over 5 points in the initial test and 3.96 (SD 0.96) in the follow-up test. Patients in the intervention group had a greater improvement (1.17 points, SD 1.11) than those in the control group (0.47 points, SD 0.94, p < 0.001). In the follow-up test, 49.1% in the intervention group and 18.6% in the control group answered all questions correctly (p < 0.001). There were no significant differences in return visits. Caregivers gave high satisfaction scores regardless of the allocation group.Conclusion: Video instructions improve caregivers' understanding of discharge information.Trial registration: [NCT04463355, retrospectively registered July 9, 2020]. What is Known: • Poor comprehension of discharge instructions leads to incorrect treatment after discharge, increased readmissions and a reduction of caregivers' satisfaction. • Video discharge instructions are useful providing concise information independently of the patients' health literacy level or communication skills of the health care provider What is New: • The addition of video discharge instructions to verbal instructions improves caregivers' knowledge about AGE improved with respect to those who only receive verbal instructions • Video instructions do not add extra time to the emergency department visits.
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Bond C, Morgenstern J, Heitz C, Milne WK. Hot Off the Press: Video for Acute Otitis Media Discharge Instructions. Acad Emerg Med 2020; 27:775-778. [PMID: 31981274 DOI: 10.1111/acem.13923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 11/30/2022]
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Belisle S, Dobrin A, Elsie S, Ali S, Brahmbhatt S, Kumar K, Jasani H, Miller M, Ferlisi F, Poonai N. Video Discharge Instructions for Acute Otitis Media in Children: A Randomized Controlled Open-label Trial. Acad Emerg Med 2019; 26:1326-1335. [PMID: 31742809 DOI: 10.1111/acem.13839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/27/2019] [Accepted: 07/12/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Thirty percent of children with acute otitis media (AOM) experience symptoms < 7 days after initiating treatment, highlighting the importance of comprehensive discharge instructions. METHODS We randomized caregivers of children 6 months to 17 years presenting to the emergency department (ED) with AOM to discharge instructions using a video on management of pain and fever to a paper handout. The primary outcome was the AOM Severity of Symptom (AOM-SOS) score at 72 hours postdischarge. Secondary outcomes included caregiver knowledge (10-item survey), absenteeism, recidivism, and satisfaction (5-item Likert scale). RESULTS A total of 219 caregivers were randomized and 149 completed the 72-hour follow-up (72 paper and 77 video). The median (IQR) AOM-SOS score for the video was significantly lower than paper, even after adjusting for preintervention AOM-SOS score and medication at home (8 [7-11] vs. 10 [7-13], respectively; p = 0.004). There were no significant differences between video and paper in mean (±SD) knowledge score (9.2 [±1.3] vs. 8.8 [±1.8], respectively; p = 0.07), mean (±SD) number of children that returned to a health care provider (8/77 vs. 10/72, respectively; p = 0.49), mean (±SD) number of daycare/school days missed by child (1.2 [±1.5] vs. 1.1 [±2.1], respectively; p = 0.62), mean (±SD) number of workdays missed by caregiver (0.5 [±1] vs. 0.8 [±2], respectively; p = 0.05), or median (IQR) satisfaction score (5 [4-5] vs. 5 [4-5], respectively; p = 0.3). CONCLUSIONS Video discharge instructions in the ED are associated with less perceived AOM symptomatology compared to a paper handout.
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Affiliation(s)
- Sheena Belisle
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
| | - Andrei Dobrin
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
| | - Sharlene Elsie
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
| | - Samina Ali
- the Department of Pediatrics Division of Paediatric Emergency Medicine University of Alberta Edmonton Alberta
- Women and Children's Health Research Institute Edmonton Alberta
| | - Shaily Brahmbhatt
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
| | - Kriti Kumar
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
| | - Hardika Jasani
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
| | - Michael Miller
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
- the Children's Health Research Institute London Health Sciences Centre London Ontario
| | - Frank Ferlisi
- and the Department of Family Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada
| | - Naveen Poonai
- From the Department of Pediatrics Division of Paediatric Emergency Medicine Schulich School of Medicine & Dentistry, Western University London Ontario
- the Children's Health Research Institute London Health Sciences Centre London Ontario
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Doan Q, Goldman RD, Meckler GD. Management practice-related and modifiable factors associated with paediatric emergency return visits. Paediatr Child Health 2019; 24:e1-e7. [PMID: 30792602 PMCID: PMC6376311 DOI: 10.1093/pch/pxy039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED). METHODS We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors. RESULTS There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process. CONCLUSIONS Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.
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Affiliation(s)
- Quynh Doan
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia
| | - Ran D Goldman
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia
| | - Garth D Meckler
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia
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Patient understanding of discharge instructions in the emergency department: do different patients need different approaches? Int J Emerg Med 2018; 11:5. [PMID: 29423767 PMCID: PMC5805670 DOI: 10.1186/s12245-018-0164-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 01/22/2018] [Indexed: 11/26/2022] Open
Abstract
Background Previous studies have demonstrated that patients have poor understanding of the discharge instructions provided from the emergency department (ED). The aims of this study are to determine if patient factors, such as income and level of education, correlate with patient understanding of discharge instructions and to explore if different patient populations prefer different resources for receiving discharge instructions. Methods We conducted live observations of physicians providing discharge instructions in the ED to 100 patients followed by a patient survey to determine their understanding in four domains (diagnosis, treatment plan, follow-up instructions, and return to ED (RTED) instructions) and collect patient demographics. We enrolled patients over the age of 18 being discharged home. We excluded non-English- or French-speaking patients and those with significant psychiatric history or cognitive impairment. We performed a two-way ANOVA analysis of patient factors and patient understanding. Results We found that patients had poor understanding of discharge instructions, ranging from 24.0% having poor understanding of their follow-up plan to 64.0% for RTED instructions. Almost half (42%) of patients did not receive complete discharge instructions. Lower income was correlated with a significant decrease in patient understanding of discharge diagnosis (p = 0.01) and RTED instructions (p = 0.04). Patients who did not complete high school trended towards lower levels of understanding of their diagnosis and treatment plan (p = 0.06). Lower income patients had a preference for receiving a follow-up phone call by a nurse, while higher income patients preferred online resources. Conclusions Lower income patients and those who have not completed high school are at a higher risk of poor understanding discharge instructions. As new technological solutions emerge to aid patient understanding of discharge instructions, our study suggests they may not aid those who are at the highest risk of failing to understand their instructions. Electronic supplementary material The online version of this article (10.1186/s12245-018-0164-0) contains supplementary material, which is available to authorized users.
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Borland ML, Shepherd M. Quality in paediatric emergency medicine: Measurement and reporting. J Paediatr Child Health 2016; 52:131-6. [PMID: 27062615 DOI: 10.1111/jpc.13077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/12/2015] [Accepted: 07/30/2015] [Indexed: 11/29/2022]
Abstract
There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.
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Affiliation(s)
- Meredith L Borland
- Emergency Department, Princess Margaret Hospital, Perth, Western Australia, Australia.,Schools of Paediatric and Child Health, Western Australia, Australia.,Primary Aboriginal and Rural Healthcare, University of Western Australia, Perth, Western Australia, Australia
| | - Mike Shepherd
- Children's Emergency Department, Starship Children's Hospital.,Auckland District Health Board.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
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Goodacre S. Uncontrolled before-after studies: discouraged by Cochrane and theEMJ. Emerg Med J 2015; 32:507-8. [DOI: 10.1136/emermed-2015-204761] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2015] [Indexed: 11/03/2022]
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