The importance of outcomes research in pediatric emergency medicine

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases

OBJECTIVES

Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease.

METHODS

We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations.

RESULTS

Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44).

CONCLUSIONS

Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

Quality indicators for the assessment and management of pain in the emergency department: a systematic review

Appropriate and timely treatment of pain are very important, particularly in the emergency department, where pain continues to be undertreated. One of the ways in which the undertreatment of pain can be mitigated is the use of defined quality benchmarks. This systematic review of the literature was performed to identify such quality indicators. The resulting 20 quality indicators may be used to improve pain assessment and management protocols in the emergency department setting.

BACKGROUND:

Evidence indicates that pain is undertreated in the emergency department (ED). The first step in improving the pain experience for ED patients is to accurately and systematically assess the actual care being provided. Identifying gaps in the assessment and treatment of pain and improving patient outcomes requires relevant, evidence-based performance measures.

OBJECTIVE:

To systematically review the literature and identify quality indicators specific to the assessment and management of pain in the ED.

METHODS:

Four major bibliographical databases were searched from January 1980 to December 2010, and relevant journals and conference proceedings were manually searched. Original research that described the development or collection of data on one or more quality indicators relevant to the assessment or management of pain in the ED was included.

RESULTS:

The search identified 18,078 citations. Twenty-three articles were included: 15 observational (cohort) studies; three before-after studies; three audits; one quality indicator development study; and one survey. Methodological quality was moderate, with weaknesses in the reporting of study design and methodology. Twenty unique indicators were identified, with the majority (16 of 20) measuring care processes. Overall, 91% (21 of 23) of the studies reported indicators for the assessment or management of presenting pain, as opposed to procedural pain. Three of the studies included children; however, none of the indicators were developed specifically for a pediatric population.

CONCLUSION:

Gaps in the existing literature include a lack of measures reflecting procedural pain, patient outcomes and the pediatric population. Future efforts should focus on developing indicators specific to these key areas.

Quality indicators for high acuity pediatric conditions

OBJECTIVE

Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen.

METHODS

A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED.

RESULTS

The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators.

CONCLUSIONS

A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.

Factors associated with prolonged stay in a pediatric emergency observation unit of an urban tertiary children's hospital in China

OBJECTIVES

This study aimed to examine the factors associated with increased length of stay (LOS > 24 hours) in the pediatric emergency observation unit (OU) of an urban tertiary children's hospital in China.

METHODS

This study was a retrospective cohort study. We retrieved and examined all the records of patients (age, 0-16 years) who were admitted to the OU (n = 10,852) during July 1, 2008, to June 30, 2009. The primary outcome was LOS and prolonged stay (LOS > 24 hours). We also performed a sensitivity analysis by using LOS of 3 days or greater and LOS of 6 days or greater as dependent variables in logistic regression and compared with LOS of greater than 24 hours regression to examine the robustness of the associations.

RESULTS

The overall mean (SD) LOS was 24.0 (24.4) hours; 31.3% had LOS of greater than 24 hours, of which the mean (SD) LOS was 50.2 (28.6) hours. The following factors were associated with LOS of greater than 24 hours: age, 28 days to 3 months (odds ratio, [OR], 1.87; 95% confidence interval, 1.36-2.59) and older than 3 months to 12 months (OR, 1.83; 95% CI, 1.35-2.50) compared with age 0 to 28 days; neurologic diseases (OR, 1.50; 95% CI, 1.31-1.72), infectious diseases (OR, 2.00; 95% CI, 1.61-2.49), and visits for non-respiratory-related signs and symptoms (OR, 2.00; 95% CI, 1.61-2.49); acuity level of emergent (OR, 1.79; 95% CI, 1.57-2.04); procedures (OR, 7.09; 95% CI, 4.16-12.10); emergency transfusions (OR, 1.33; 95% CI, 1.01-1.75); staffed by residents (OR, 1.12; 95% CI, 1.01-1.24); and patients living in low-annual gross domestic product districts (OR, 1.14; 95% CI, 1.01-1.29). Arrival at evening (OR, 0.54; 95% CI, 0.49-0.60) and overnight (OR, 0.43; 95% CI, 0.38-0.49) were less likely to have LOS of greater than 24 hours than arrival during day shifts.

CONCLUSIONS

We identified some risk factors for prolonged stay in an OU. These factors are the starting points in understanding issues related to prolonged stay and are needed to assess efficiency and quality of care in pediatric emergency department and OU. Our results have provided information basis for making improvements in the system and may be important considerations for similar institutions, which encounter similar challenges.

Health-related quality of life in pediatric minor injury: reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory in the emergency department

OBJECTIVE

To evaluate the feasibility, reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) in the first 2 weeks after pediatric emergency department care of minor injury.

DESIGN

Prospective cohort study.

SETTING

Pediatric hospital emergency department.

PARTICIPANTS

Children and adolescents with minor injury (n = 334).

MAIN OUTCOME MEASURES

Child- and parent-reported clinical outcomes and PedsQL scale scores.

RESULTS

The PedsQL had good to excellent internal consistency reliability (α range, 0.73-0.93). For each day that the clinical symptoms persisted, there were consistent decreases in mean health-related quality of life (HRQOL) scores (validity testing). There were significantly greater negative changes in mean HRQOL scores for fractures vs soft-tissue injuries and for lower vs upper extremity injuries. Clinical outcomes categorized as poor had large negative changes in HRQOL not seen in good outcome groups. Distribution-based indicators of change supported good responsiveness (effect sizes for the physical summary score, 0.01-2.44; group differences at follow-up exceeded estimates of the minimal importance difference).

CONCLUSIONS

The PedsQL is feasible, reliable, and demonstrates good construct and discriminant validity and responsiveness in measuring short-term outcome after minor injury care in the pediatric emergency department. Assessing short-term outcome from the patient perspective with HRQOL measures may greatly enhance our ability to evaluate the effectiveness of emergency department care.

Emergency department crowding is associated with decreased quality of care for children

OBJECTIVE

We sought to determine which of several simple indicators of emergency department crowding are most predictive of quality of care in 2 pediatric disease models: acute asthma and pain associated with long-bone fractures.

METHODS

We performed a retrospective, cross-sectional study of patients 2 to 21 years old seen for acute asthma and patients 0 to 21 years old seen for acute, isolated long-bone fractures from November 1, 2007, to October 31, 2008, at a single, academic children's hospital emergency department. The main outcome measures were quality measures based on 3 asthma care-related processes-asthma score, β-agonist, and corticosteroid-and 2 fracture-related processes-analgesic and opioid analgesic. Good quality care was defined as receipt of an indicated process within 1 hour of arrival. Poor quality care was defined as nonreceipt or delayed receipt of an indicated process. Nine crowding measures were assigned based on conditions at each patient's arrival. We calculated the adjusted risk of receiving good quality care for each quality measure at 5 percentiles of crowding for each crowding measure.

RESULTS

The asthma population included 927 patients, and the fracture population included 1229 patients. Among the 5 quality measures, we found rates of good quality care ranging from 23% to 64%. In adjusted models, we found an inverse association between crowding and quality. The 2 crowding measures with a consistently inverse association with the 5 quality measures across both populations were total patient-care hours and number arriving in prior 6 hours. Across the 10 models combining 1 of 2 key crowding variables with 1 of 5 quality measures, patients in the 2 populations were 0.40 (95% confidence interval, 0.27-0.55) to 0.78 (confidence interval, 0.71-0.85) times as likely to receive the indicated care process within 1 hour when each crowding measure was at the 75th than at the 25th percentile.

CONCLUSIONS

Two measures of ED crowding are consistently associated with lower-quality asthma- and fracture-specific care in the ED for pediatric patients.

Emergency department crowding is associated with decreased quality of care for children with acute asthma

STUDY OBJECTIVE

We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations.

METHODS

This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care-asthma score, β-agonist, and corticosteroid administration-and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models.

RESULTS

The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05).

CONCLUSION

ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.

Development of measures of the quality of emergency department care for children using a structured panel process

BACKGROUND

Performance measures are essential components of public reporting and quality improvement. To date, few such measures exist to provide a comprehensive assessment of the quality of emergency department services for children.

OBJECTIVES

Our goal was to use a systematic process to develop measures of emergency department care for children (0-19 years) that are (1) based on research evidence and expert opinion, (2) representative of a range of conditions treated in most emergency departments, (3) related to links between processes and outcomes, and (4) feasible to measure.

METHODS

We presented a panel of providers and managers data from emergency department use to identify common conditions across levels of patient acuity, which could be targets for quality improvement. We used a structured panel process informed by a literature review to (1) identify condition-specific links between processes of care and defined outcomes and (2) select indicators to assess these process-outcome links. We determined the feasibility of calculating these indicators using an administrative data set of emergency department visits for Ontario, Canada.

RESULTS

The panel identified 18 clinical conditions for indicator development and 61 condition-specific links between processes of care and outcomes. After 2 rounds of ratings, the panel defined 68 specific clinical indicators for the following conditions: adolescent mental health problems, ankle injury, asthma, bronchiolitis, croup, diabetes, fever, gastroenteritis, minor head injury, neonatal jaundice, seizures, and urinary tract infections. Visits for these conditions account for 23% of all pediatric emergency department use. Using an administrative data set, we were able to calculate 19 indicators, covering 9 conditions, representing 20% of all emergency department visits by children.

CONCLUSIONS

Using a structured panel process, data on emergency department use, and literature review, it was possible to define indicators of emergency department care for children. The feasibility of these indicators will depend on the availability of high-quality data.