Quality of care for common pediatric respiratory illnesses in United States emergency departments: analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

Effectiveness of early diagnosis of cerebral palsy guideline implementation: a systematic review

INTRODUCTION

Tailored implementation interventions are required to overcome the diagnostic research-practice gap for cerebral palsy (CP). Evaluating the impact of interventions on patient outcomes is a priority. This review aimed to summarize the established evidence for the effectiveness of guideline implementations in lowering the age of CP diagnosis.

EVIDENCE ACQUISITION

A systematic review was conducted according to PRISMA. CINAHL, Embase, PubMed and MEDLINE were searched (2017-October 2022). Inclusion criteria were studies that evaluated effect of CP guideline interventions on health professional behaviour or patient outcomes. GRADE was used to determine quality. Studies were coded for use of theory (Theory Coding Scheme). Meta-analysis was performed and a standardized metric used to summarize statistics of intervention effect estimates.

EVIDENCE SYNTHESIS

Of (N.=249) records screened, (N.=7) studies met inclusion, comprising interventions following infants less than 2 years of age with CP risk factors (N.=6280). Guideline feasibility in clinical practice was established through health professional adherence and patient satisfaction. Efficacy of patient outcome of CP diagnosis by 12 months of age was established in all studies. Weighted averages were: (1) high-risk of CP (N.=2) 4.2 months and (2) CP diagnosis (N.=5) at 11.6 months. Meta-analysis of (N.=2) studies found a large, pooled effect size Z = 3.00 (P=0.003) favoring implementation interventions lowering age of diagnosis by 7.50 months, however study heterogeneity was high. A paucity of theoretical frameworks were identified in this review.

CONCLUSIONS

Multifaceted interventions to implement the early diagnosis of CP guideline are effective in improving patient outcomes by lowering the age of CP diagnosis in high-risk infant follow-up clinics. Further targeted health professional interventions including low-risk infant populations are warranted.

National survey conducted among Italian pediatricians examining the therapeutic management of croup

OBJECTIVES

Practice-to-recommendations gaps exist in croup management and have not been critically investigated. This study examined the therapeutic management of croup among a national sample of Italian pediatric providers.

METHODS

A survey was administered online to a sample of primary care and hospital-based pediatricians. Demographic data, perception regarding disease severity, treatment and knowledge of croup, choices of croup treatment medications, and knowledge of and adherence to treatment recommendations were compared between hospital and primary care pediatricians. Oral corticosteroids alone, oral corticosteroids with or without nebulized epinephrine and nebulized epinephrine plus oral or inhaled corticosteroids were considered the correct management in mild, moderate and severe croup, respectively. The determinants for correct management were examined using multivariate logistic regression analysis.

RESULTS

Six hundred forty-nine pediatricians answered at least 50% of the survey questions and were included in the analysis. Providers reported extensive use of inhaled corticosteroids for mild and moderate croup. Recommended treatment for mild, moderate and severe croup was administered in 46/647 (7.1%), 181/645 (28.0%) and 263/643 (40.9%) participants, respectively. Provider's age and knowledge of Westley Croup Score were significant predictors for correct management of mild croup. Being a hospital pediatrician and perception of croup as a clinically relevant condition were significant for moderate croup.

CONCLUSIONS

Significant differences exist between recommended guidelines and clinical practice in croup management. This study suggests wide variability in both the treatment of croup and clinical decision making strategies among hospital and primary care pediatricians. Addressing this issue could lead to noteworthy clinical and economic benefits.

Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care

BACKGROUND AND OBJECTIVES

Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC).

METHODS

A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports.

RESULTS

The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs.

CONCLUSIONS

The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.

Quality improvement for paediatric asthma care in acute settings

PURPOSE OF REVIEW

This is a summative review of recent trends and novel programming integrated into various clinical settings (i.e. emergency departments, urgent care centres and paediatric clinics) to enhance the quality of care received by paediatric asthma patients Asthma is the most common chronic disease in paediatric patients and despite recognized national management guidelines, implementation and aftercare, especially in the emergency room, remain challenging.

RECENT FINDINGS

Outcome-based systematic quality improvement initiatives are described as well as evidence-based recommendations to enhance the education of providers, patients and caregivers.

SUMMARY

Many of the care initiatives described in the literature have been integrated into the emergency room. The authors feel some of these process improvements, such as pathway-based care, reducing time to delivery of medications, and personalized asthma education, may also be applicable and add value to clinical practice in additional community-based acute care settings such as urgent care centers and paediatric clinics.

The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children

Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. ⁶⁵ Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. ⁶⁶ The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. ⁶⁷ In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

Acute bronchiolitis in Switzerland - Current management and comparison over the last two decades

BACKGROUND

Although international guidelines and Cochrane reviews emphasize that therapies do not alter the natural course of acute viral bronchiolitis (AVB), they are still prescribed frequently. This survey evaluated self-reported management of AVB by Swiss pediatricians in 2019 and compared it with previous surveys.

METHODS

We performed a cross-sectional online survey of all board-certified pediatricians in Switzerland in November 2019 and compared the reported use of therapies with that reported in the 2001 and 2006 surveys. We used multivariable ordered logistic regression to assess factors associated with reported prescription of bronchodilators, corticosteroids, antibiotics, and physiotherapy.

RESULTS

Among 1618 contacted board-certified pediatricians, 884 returned the questionnaires (55% response rate). After exclusions were applied, 679 were included in the final analysis. Pediatricians working in primary care reported using therapeutics more frequently than those working in a hospital setting, either always or sometimes: bronchodilators 53% versus 38%, corticosteroids 37% versus 23%, and antibiotics 39% versus 22%. The opposite occurred with physiotherapy: 53% reported prescribing it in hospital and 44% in primary care. There was an overall decrease in the prescription of therapeutics and interventions for AVB from 2001 to 2019. The proportion who reported "always" prescribing corticosteroids decreased from 71% to 2% in primary care, and of those "always" prescribing bronchodilators from 55% to 1% in hospitals.

CONCLUSION

Although we observed a significant decrease since 2001, more effort is required to reduce the use of unnecessary therapies in children with AVB.

Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments

OBJECTIVES

National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs.

METHODS

Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care.

RESULTS

More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis.

CONCLUSIONS

Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.

The Practice of Obtaining a Chest Radiograph in Pediatric Patients Presenting With Their First Episode of Wheezing: A Survey of Resident Physicians

A chest radiograph (CXR) is not routinely indicated in children presenting with their first episode of wheezing; however, it continues to be overused. A survey was distributed electronically to determine what trainees are taught and their current practice of obtaining a CXR in children presenting with their first episode of wheezing and the factors that influence this practice. Of the 1513 trainees who completed surveys, 35.3% (535/1513) reported that they were taught that pediatric patients presenting with their first episode of wheezing should be evaluated with a CXR. In all, 22.01% (333/1513) indicated that they would always obtain a CXR in these patients, and 13.75% (208/1513) would always obtain a CXR under a certain age (4 weeks to 12 years, median of 2 years). Our study identifies a target audience that would benefit from education to decrease the overuse of CXRs in children.

Shortness of breath in children at the emergency department: Variability in management in Europe

OBJECTIVE

Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability.

DESIGN

The TrIAGE project, a prospective observational study based on electronic health record data.

PATIENTS AND SETTING

Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014).

MAIN OUTCOME MEASURES

We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables.

RESULTS

In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings.

CONCLUSION

European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.

Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments

OBJECTIVES

Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children < 12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12 months.

METHODS

We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan-do-study-act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children < 1 year old with high-risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS).

RESULTS

Evidence of special cause was identified beginning in June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8-month period, the CPT was consulted for a mean of 47.5% of children with high-risk injuries; this was sustained for an additional 7 months. The average percentage of infants with high-risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%.

CONCLUSION

Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high-risk injuries. Such interventions may improve recognition of physical abuse.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

BACKGROUND AND OBJECTIVES

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics.

METHODS

We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).

RESULTS

In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

CONCLUSIONS

The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Examining the clinical management of asthma exacerbations by nurse practitioners in a pediatric emergency department

BACKGROUND

Little is known about the clinical management or quality of asthma care provided by nurse practitioners (NP) in a pediatric emergency setting.

OBJECTIVE

To describe the clinical management of asthma by NPs in our institution's emergency department, and to compare the treatment strategies between NPs, pediatricians, and pediatric emergency physicians.

METHODS

We conducted a retrospective chart review at a level-one pediatric trauma center. Data were extracted from electronic medical records for all patients between 2 and 18 years of age presenting to the emergency department with an asthma exacerbation. Data were analyzed using binary logistic regression with generalized estimating equations.

RESULTS

NPs evaluated 18% of all children presenting for asthma care. When compared to pediatric emergency physicians, patients treated by NPs had approximately twice the odds of receiving a β2-agonist (OR = 2.02; 95% CI 1.02 - 3.99) or a systemic corticosteroid (OR = 2.31; 95% CI 1.35 - 3.95) within 60 minutes of clinical evaluation. Adherence rates were similar for the other asthma quality measures between these two clinician groups.

CONCLUSIONS

NPs were best able to meet time-sensitive asthma quality measures in the emergency department. The addition of NPs to emergency staffing models may improve access to timely care for children with asthma.

The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians

BACKGROUND

Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse.

OBJECTIVE

To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians.

METHODS

A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test.

RESULTS

Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001).

CONCLUSIONS

In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.

Physician Compliance With Bronchiolitis Guidelines in Pediatric Emergency Departments

An online survey was administered through the American Academy of Pediatrics (AAP) Section of Emergency Medicine Survey Listserv in Fall, 2017. Overall compliance was measured as never using chest X-rays, viral testing, bronchodilators, or systemic steroids. Practice compliance was measured as never using those modalities in a clinical vignette. Chi-square tests assessed differences in compliance between modalities. t tests assessed differences on agreement with each AAP statement. Multivariate logistic regression determined factors associated with overall compliance. Response rate was 47%. A third (35%) agreed with all 7 AAP statements. There was less compliance with ordering a bronchodilator compared with chest X-ray, viral testing, or systemic steroid. There was no association between compliance and either knowledge or agreement with the guideline. Physicians with institutional bronchiolitis guidelines were more likely to be practice compliant. Few physicians were compliant with the AAP bronchiolitis guideline, with bronchodilator misuse being most pronounced. Institutional bronchiolitis guidelines were associated with physician compliance.

Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review

Introduction

Bronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity.

Methods

A retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant.

Results

The mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96–7.75)) versus not (4.70 (4.20–5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6–2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (–0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively.

Conclusions

A large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.

Minding the Gap: A Qualitative Study of Provider Experience to Optimize Care for Critically Ill Children in General Emergency Departments

BACKGROUND

Pediatric emergency care provision in the United States is uneven. Institutional barriers to readiness in the general emergency department (GED) are known, but little is understood about the frontline providers. Our objective was to explore the lived experiences of emergency medicine (EM) providers caring for acutely ill children in the GED and identify opportunities to optimize their pediatric practice.

METHODS

This grounded theory study used theoretical sampling with snowball recruitment to enroll EM physicians and advanced practice providers from 25 Wisconsin GEDs. Participants completed one-on-one, semistructured interviews. Audio recordings were transcribed and coded by a multi-investigator team drawing on theory produced from comparative analysis.

RESULTS

We reached theoretical saturation with 18 participants. The data suggested that providers felt competent managing routine pediatric care, but critically ill children outstripped their resources and expertise. They recognized environmental constraints on the care they could safely provide, which were intensified by unanticipated knowledge gaps and lack of awareness regarding pediatric practice guidelines. A fragmented medical network to support their pediatric practice was identified as a challenge to their care provision at critical junctures. Due to lack of guidance and feedback, providers internalized their experience with critically ill children with uncertainty, which limited learning and practice change. They benefited from meaningful relationships with pediatricians and pediatric subspecialists, targeted education, timely consults, and looped feedback about care provided and patient outcomes.

CONCLUSIONS

General ED providers struggled with critically ill children because they could not anticipate their pediatric-specific knowledge gaps and only realized them at critical junctures. EM providers were isolated and frustrated when seeking help; without guidance and feedback they internalized their experience with uncertainty and were left underprepared for subsequent encounters. The data suggested the need for provider-focused interventions to address gaps in pediatric-specific continuing medical education, just-in-time assistance, and knowledge transfer.

Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

BACKGROUND

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments.

METHODS

We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge.

FINDINGS

Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50).

INTERPRETATION

Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis.

FUNDING

None.

Assessing the quality of health care in the management of bronchiolitis in Australian children: a population-based sample survey

Background

Bronchiolitis is the most common cause of respiratory hospitalisation in children aged <2 years. Clinical practice guidelines (CPGs) suggest only supportive management of bronchiolitis. However, the availability of CPGs do not guarantee that they are used appropriately and marked variation in the clinical management exists. We conducted an assessment of guideline adherence in the management of bronchiolitis in children at a subnationally representative level including inpatient and ambulatory services in Australia.

Methods

We searched for national and international CPGs relating to management of bronchiolitis in children and identified 16 recommendations which were formatted into 40 medical record audit indicator questions. A retrospective medical record review assessing compliance with the CPGs was conducted across three types of healthcare setting: hospital inpatient admissions, emergency department (ED) presentations and general practice (GP) consultations in three Australian states for children aged <2 years receiving care in 2012 and 2013.

Results

Purpose-trained surveyors conducted 13 979 eligible indicator assessments across 796 visits for bronchiolitis at 119 sites. Guideline adherence for management of bronchiolitis was 77.3% (95% CI 72.6 to 81.5) for children attending EDs, 81.6% (95% CI 78.0 to 84.9) for inpatients and 52.3% (95% CI 44.8 to 59.7) for children attending GP consultations. While adherence to some individual indicators was high, overall adherence to documentation of 10 indicators relating to history taking and examination was poorest and estimated at 2.7% (95% CI 1.5 to 4.4).

Conclusions

The study is the first to assess guideline-adherence in both hospital (ED and inpatient) and GP settings. Our study demonstrated that while the quality of care for bronchiolitis was generally adherent to CPG indicators, specific aspects of management were deficient, especially documentation of history taking.

Outcomes From Referrals and Unscheduled Visits From Community Emergency Departments to a Regional Pediatric Emergency Department in Canada

OBJECTIVES

Existing pediatric literature describing repeat visits to the emergency department (ED) for the same medical complaint has yet to report on patient flow patterns from general EDs (GEDs) to a pediatric ED (PED). We sought to characterize the population of patients who are treated in a GED and subsequently present to a PED for further care.

METHODS

We conducted a retrospective cohort study reviewing all pediatric visits (age < 17 y) at 5 GEDs in Vancouver. Our primary outcome measure was the proportion of visits with a subsequent visit to a PED (<7 days) during the 2012 to 2013 fiscal year. Secondary outcomes included reasons for PED consultation, the clinical services accessed, and disposition at the PED.

RESULTS

During the study period, 581 (3.3%) of the 17,824 children seen at GEDs subsequently presented to the PED within 7 days. The top 3 diagnoses among these were fracture, viral infection, and musculoskeletal complaints. Of the 581 children with a visit to the PED, 180 (31.0%) were referred to the PED for a consultation, whereas the rest were family initiated. Referred visits were more frequently associated with pediatric subspecialist consultation than family-initiated visits (45.0% vs 19.5%, P < 0.01). The referred group more frequently resulted in a surgical procedure (13.9% vs 2.5%, P < 0.01) or hospital admission (51.7% vs 8.7%, P < 0.01).

CONCLUSIONS

Knowing the proportion, management, and outcomes of children who are treated in a GED and subsequently at a PED may provide an important quality measure and opportunities to improve the management of common pediatric emergencies in the community.

Racial/Ethnic Variation in Emergency Department Care for Children With Asthma

OBJECTIVE

To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients.

METHODS

This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED.

RESULTS

The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01).

CONCLUSIONS

In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.

Burden and emergency department management of acute cough in children

AIM

In children presenting to an emergency department (ED) with an acute coughing illness, the aims of this study were to: (i) describe the frequency of doctor visits and medication use; and (ii) describe management and relate it to current evidence-based guidelines.

METHODS

This was a cross-sectional study in ED of a major teaching hospital (Royal Children's Hospital, Brisbane, Australia). Participants included 537 children (<15 years) presenting with acute (<2 weeks) cough, with a median age of 2.2 years (interquartile range 1.0-4.0); 61.5% were boys. Hospitalised children and those with asthma, pneumonia or chronic illnesses were excluded. Main outcome measures were: (i) frequency of pre-ED doctor visits and medication use; and (ii) comparison of management to current evidence-based recommendations related to four discharge diagnoses: bronchiolitis, 'wheeze/reactive airway disease (RAD)', croup and 'non-specific acute respiratory illness'.

RESULTS

A total of 300 children (55.9%) had seen a doctor prior to their ED presentation, and use of medications pre-ED was high (53.4%). While 93.4% of children with croup were treated in accordance with guidelines, concordance was lower for children with bronchiolitis or 'wheeze/RAD'. The majority of children with a discharge diagnosis of 'wheeze/RAD' (95.6%) received bronchodilators, and 72.7% also received oral corticosteroids but were not diagnosed with asthma. More than half (55.1%) of the children with non-specific acute respiratory illness received medication(s) either prior to or during their ED presentation.

CONCLUSIONS

The burden of acute cough-related illnesses in children is high, and there is a need for improved uptake of evidence-based guidelines. In addition, the large number of children diagnosed with 'wheeze/RAD' suggests asthma is likely under-diagnosed in this setting.

A Qualitative Study Examining Stakeholder Perspectives of a Local Child Abuse Program in Community Emergency Departments

OBJECTIVE

Emergency department (ED) providers may fail to recognize or report child abuse and/or neglect (CAN). To improve recognition and reporting, we designed the Community ED CAN Program, in which teams of local clinicians (nurses, physicians, physician assistants) received training in CAN and 1) disseminated evidence-based education; 2) provided consultation, case follow-up, and access to specialists; and 3) facilitated multidisciplinary case review. The aims of this study were to understand the Program's strengths andchallenges and to explore factors that influenced implementation.

METHODS

We used a qualitative research design with semistructured, one-on-one interviews to understand key stakeholders' perspectives of the Community ED CAN Program. We interviewed 27 stakeholders at 3 community hospitals and 1 academic medical center. Researchers analyzed transcribed data using constant comparative method of grounded theory and developed themes.

RESULTS

Program strengths included 1) comfort in seeking help from local champions, 2) access to CAN experts, 3) increased CAN education/awareness, and 4) improved networks and communication. Facilitators of implementation included: 1) leadership support, 2) engaged local champions and external change agents (eg, CAN experts), 3) positive attributes of the champions, and 4) implementation flexibility. Program challenges/barriers to implementation included 1) variability of institutional support for the champions and 2) variability in awareness about the program.

CONCLUSIONS

A Community ED CAN Program has the potential to improve recognition and reporting of CAN. Key steps to facilitate implementation include the identification of committed local champions, strong leadership support, connections to experts, program publicity, and support of the champions' time.

Use of a National Database to Assess Pediatric Emergency Care Across United States Emergency Departments

OBJECTIVES

Differences in emergency care for children exist between general and pediatric emergency departments (EDs). Some pediatric quality measures are available but are not routinely employed nationwide. We sought to create a short list of applied measures that would provide a starting point for EDs to measure pediatric emergency care quality and to compare care between general and pediatric EDs for these measures.

METHODS

Previously reported lists comprising 465 pediatric emergency care quality measures were reconciled. Preset criteria were used to create a diverse list of quality measures measurable using a national database. We used the National Hospital Ambulatory Medical Care Survey from 2010 to 2015 to measure performance. Measures were excluded for total observation counts under a prespecified power threshold, being unmeasurable in the data set, or for missing clear definitions. Using survey-weighted statistics, we reported summary performance (mean, proportion, or count) with 95% confidence intervals for each analyzed quality measure and compared general and pediatric ED performance.

RESULTS

Among 465 quality measures, 28 (6%) were included in the analysis, including seven condition-specific measures and 21 general measures. We analyzed a sample of 36,430 visits corresponding to 179.0 million survey-weighted ED visits, of which 150.8 million (84.3%) were in general EDs. Performance was better in pediatric EDs for three of seven condition-specific measures, including antibiotics for viral infections (-6.2%), chest X-rays for asthma (-18.7%), and topical anesthesia for wound closures (+25.7%). Performance was similar for four of seven condition-specific measures: computed tomography for head trauma, steroids for asthma, steroids for croup, and oral rehydration for dehydration. Compared with pediatric EDs, general EDs discharged and transferred higher proportions of children, had shorter lengths of stay, and sent patients home with fewer prescriptions. General EDs obtained fewer pain scores for injured children. Pediatric EDs had a lower proportion of pediatric visits in which patients left against medical advice. General and pediatric EDs had similar rates of mortality, left without being seen, incomplete vital signs, labs in nonacute patients, and similar numbers of medications given per patient.

CONCLUSIONS

Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement.

Glucocorticoids for croup in children

BACKGROUND

Glucocorticoids are commonly used for croup in children. This is an update of a Cochrane Review published in 1999 and previously updated in 2004 and 2011.

OBJECTIVES

To examine the effects of glucocorticoids for the treatment of croup in children aged 0 to 18 years.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 2, 2018), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 3 April 2018), and Embase (Ovid) (1996 to 3 April 2018, week 14), and the trials registers ClinicalTrials.gov (3 April 2018) and the World Health Organization International Clinical Trials Registry Platform (ICTRP, 3 April 2018). We scanned the reference lists of relevant systematic reviews and of the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated children aged 0 to 18 years with croup and measured the effects of glucocorticoids, alone or in combination, compared to placebo or another pharmacologic treatment. The studies needed to report at least one of our primary or secondary outcomes: change in croup score; return visits, (re)admissions or both; length of stay; patient improvement; use of additional treatments; and adverse events.

DATA COLLECTION AND ANALYSIS

One author extracted data from each study and another verified the extraction. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed risk of bias for each study using the Cochrane 'Risk of bias' tool and the certainty of the body of evidence for the primary outcomes using the GRADE approach.

MAIN RESULTS

We added five new RCTs with 330 children. This review now includes 43 RCTs with a total of 4565 children. We assessed most (98%) studies as at high or unclear risk of bias. Compared to placebo, glucocorticoids improved symptoms of croup at two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs; 426 children; moderate-certainty evidence), and the effect lasted for at least 24 hours (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs; 351 children; low-certainty evidence). Compared to placebo, glucocorticoids reduced the rate of return visits or (re)admissions or both (risk ratio 0.52, 95% CI 0.36 to 0.75; 10 RCTs; 1679 children; moderate-certainty evidence). Glucocorticoid treatment reduced the length of stay in hospital by about 15 hours (mean difference -14.90, 95% CI -23.58 to -6.22; 8 RCTs; 476 children). Serious adverse events were infrequent. Publication bias was not evident. Uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children.

AUTHORS' CONCLUSIONS

Glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care. Our conclusions have changed, as the previous version of this review reported that glucocorticoids reduced symptoms of croup within six hours.

Creation of an Integrated Knowledge Translation Process to Improve Pediatric Emergency Care in Canada

TREKK (Translating Emergency Knowledge for Kids) was established to address knowledge needs to support care of children in general emergency departments. To achieve this goal, we developed an integrated knowledge translation (KT) process based on identified priorities to create the TREKK Evidence Repository, containing "knowledge pyramids" and Bottom Line Recommendations (summary documents) on the diagnosis and treatment of emergency pediatric conditions. The objective of this article is to describe our methods for developing and disseminating the TREKK Evidence Repository to improve pediatric emergency care in Canada. Our work was guided by the research question: Can an integrated KT process address an information gap in healthcare practice? We utilized a pyramid-shaped framework, built upon the "4S" hierarchy of evidence model, to provide detailed evidence appropriate to stakeholders' needs. For each priority condition (asthma, bronchiolitis, croup, etc.), clinical advisors and KT experts collaborated to create a Bottom Line Recommendation and to select guidelines, reviews, and key studies for that condition's topic area in the Evidence Repository on the TREKK website (trekk.ca). Targeted promotion, including a social media campaign, communicated the availability of new topics in the Evidence Repository and available knowledge tools. Feedback from 35 end-users on pilot versions of the Evidence Repository was positive with 91% indicating that they would use the resource in the emergency department. Using an integrated KT process, we responded to end-users' requests for varying level of information on priority pediatric conditions through the creation of knowledge tools and development of a process to identify and vet high quality evidence-based resources.

Dissemination of evidence in paediatric emergency medicine: a quantitative descriptive evaluation of a 16-week social media promotion

OBJECTIVES

TRanslating Emergency Knowledge for Kids (TREKK) and Cochrane Child Health collaborate to develop knowledge products on paediatric emergency medicine topics. Via a targeted social media promotion, we aimed to increase user interaction with the TREKK and Cochrane Child Health Twitter accounts and the uptake of TREKK Bottom Line Recommendations (BLRs) and Cochrane systematic reviews (SRs).

DESIGN

Quantitative descriptive evaluation.

SETTING

We undertook this study and collected data via the internet.

PARTICIPANTS

Our target users included online healthcare providers and health consumers.

INTERVENTION

For 16 weeks, we used Twitter accounts (@TREKKca and @Cochrane_Child) and the Cochrane Child Health blog to promote 6 TREKK BLRs and 16 related Cochrane SRs. We published 1 blog post and 98 image-based tweets per week.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was user interaction with @TREKKca and @Cochrane_Child. Secondary outcomes were visits to TREKK's website and the Cochrane Child Health blog, clicks to and views of the TREKK BLRs, and Altmetric scores and downloads of Cochrane SRs.

RESULTS

Followers to @TREKKca and @Cochrane_Child increased by 24% and 15%, respectively. Monthly users of TREKK's website increased by 29%. Clicks to the TREKK BLRs increased by 22%. The BLRs accrued 59% more views compared with the baseline period. The 16 blog posts accrued 28% more views compared with the 8 previous months when no new posts were published. The Altmetric scores for the Cochrane SRs increased by ≥10 points each. The mean number of full text downloads for the promotion period was higher for nine and lower for seven SRs compared with the 16-week average for the previous year (mean difference (SD), +4.0 (22.0%)).

CONCLUSIONS

There was increased traffic to TREKK knowledge products and Cochrane SRs during the social media promotion. Quantitative evidence supports blogging and tweeting as dissemination strategies for evidence-based knowledge products.

Knowledge sharing between general and pediatric emergency departments: connections, barriers, and opportunities

OBJECTIVE

Translating Emergency Knowledge for Kids (TREKK) is a national network aimed at improving emergency care for children by increasing collaborations and knowledge sharing between general and pediatric emergency departments (EDs). This study aimed to determine patterns of knowledge sharing within the network and to identify connections, barriers, and opportunities to obtaining pediatric information and training.

METHODS

We conducted 22 semi-structured interviews with health care professionals working in general EDs, purposefully sampled to represent connected and disconnected sites, based on two previous internal quantitative social network analyses (SNA). Data were analyzed by two independent reviewers.

RESULTS

Participants included physicians (59%) and nurses (41%) from 18 general EDs in urban (68%) and rural/remote (32%) Canada. Health care professionals sought information both formally and informally, by using guidelines, talking to colleagues, and attending pediatric related training sessions. Network structure and processes were found to increase connections, support practice change, and promote standards of care. Participants identified personal, organizational and system level barriers to information and skill acquisition, including resources and personal costs, geography, dissemination, and time. Providing easy access to information at the point of care was promoted through enhancing content visibility and by embedding resources into local systems. There remains a need to share successful methods of local dissemination and implementation across the network, and to leverage local professional champions such as clinical nurse liaisons.

CONCLUSIONS

These findings reinforce the critical role of ongoing network evaluation to improve the design and delivery of knowledge mobilization initiatives.

Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care

BACKGROUND AND OBJECTIVES

There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment.

METHODS

Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure.

RESULTS

Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated.

CONCLUSIONS

Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.

Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study

BACKGROUND AND OBJECTIVES

Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics.

METHODS

Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support).

RESULTS

Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7).

CONCLUSIONS

More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.

A tale of two systems: practice patterns of a single group of emergency medical physicians in Taiwan and China

Background

The quality of pediatric emergency care has been a major concern in health care. Following a series of health system reforms in China, it is important to do this assessment of pediatric emergency care, and to explore potential influences of health care system. This study aimed to compare practice differences in treating children with respiratory illnesses in two emergency department (ED) settings within different health care systems: China and Taiwan.

Methods

A pooled cross-sectional hospital-based study was conducted in two tertiary teaching hospitals in Xiamen, China and Keelung, Taiwan belong to the same hospital chain group. A team of 21 pediatricians rotated between the EDs of the two hospitals from 2009 to 2012. There were 109,705 ED encounters treated by the same team of pediatricians and 6596 visits were analyzed for common respiratory illnesses. Twelve quality measures in process and outcomes of asthma, bronchiolitis and croup were reported. Descriptive statistics and multiple logistic regression models were applied to assess. In order to demonstrate the robustness of our findings, we analyzed the data using an alternative modeling technique, multilevel modeling.

Results

After adjustment, children with asthma presented to the ED in China had a significantly 76% lower likelihood to be prescribed a chest radiograph, and a 98% lower likelihood to be prescribed steroids and discharged home than those in Taiwan. Also, children with asthma presented to the ED in China had significantly 7.76 times higher risk to incur 24-72 h return visits. Furthermore, children with bronchiolitis in China (Odds ratio (OR): 0.21; 95% Confidence interval (CI): 0.17-0.28) were significantly less likely to be prescribed chest radiograph, but were significantly more likely to be prescribed antibiotics (OR: 2.19; 95% CI: 1.46-3.28).

Conclusions

This study illustrated that although high quality care depends on better assessment of physician performance, the delivery of pediatric emergency care differed significantly between these two healthcare systems after holding the care providers the same and adjusting for important patient characteristics. The findings suggest that the features of the health care system may play a significant role.

Pediatric information seeking behaviour, information needs, and information preferences of health care professionals in general emergency departments: Results from the Translating Emergency Knowledge for Kids (TREKK) Needs Assessment

Objectives

To determine national pediatric information needs, seeking behaviours, and preferences of health care professionals working in general EDs.

Methods

An electronic cross-sectional survey was conducted with health care professionals in 32 Canadian general EDs. Data were collected in the EDs using the iPad and in-person data collectors.

Results

Total of 1,471 surveys were completed (57.1% response rate). Health care professionals sought information on children’s health care by talking to colleagues (n=1,208, 82.1%), visiting specific medical/health websites (n=994, 67.7%), and professional development opportunities (n=941, 64.4%). Preferred child health resources included protocols and accepted treatments for common conditions (n=969, 68%), clinical pathways and practice guidelines (n=951, 66%), and evidence-based information on new diagnoses and treatments (n=866, 61%). Additional pediatric clinical information is needed about multisystem trauma (n=693, 49%), severe head injury (n=615, 43%), and meningitis (n=559, 39%). Health care professionals preferred to receive child health information through professional development opportunities (n=1,131, 80%) and printed summaries (n=885, 63%).

Conclusion

By understanding health care professionals’ information seeking behaviour, information needs, and information preferences, knowledge synthesis and knowledge translation initiatives can be targeted to improve pediatric emergency care. The findings from this study will inform the following two phases of the TREKK initiative to bridge the research-practice gap in Canadian general EDs.

Improving Pediatric Asthma Outcomes in a Community Emergency Department

BACKGROUND

Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care.

METHODS

For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care.

RESULTS

In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes (P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99).

CONCLUSIONS

Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care.

Atlantoaxial Rotatory Subluxation: A Review for the Pediatric Emergency Physician

Pediatric emergency physicians must have a high clinical suspicion for atlantoaxial rotatory subluxation (AARS), particularly when a child presents with neck pain and an abnormal head posture without the ability to return to a neutral position. As shown in the neurosurgical literature, timely diagnosis and swift initiation of treatment have a greater chance of treatment success for the patient. However, timely treatment is complicated because torticollis can result from a variety of maladies, including: congenital abnormalities involving the C1-C2 joint or the surrounding supporting muscles and ligaments, central nervous system abnormalities, obstetric palsies from brachial plexus injuries, clavicle fractures, head and neck surgery, and infection. The treating pediatrician must discern the etiology of the underlying problem to determine both timing and treatment paradigms, which vary widely between these illnesses. We present a comprehensive review of AARS that is intended for pediatric emergency physicians. Management of AARS can vary widely bases on factors, such as duration of symptoms, as well as the patient's history. The goal of this review is to streamline the management paradigms and provide an inclusive review for pediatric emergency first responders.

Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings

Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice.

METHODS

A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables.

RESULTS

Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention.

CONCLUSIONS

This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.

Variability in the emergency department use of discretionary radiographs in children with common respiratory conditions: the mixed effect of access to pediatrician care

OBJECTIVES

The objective of this study was to investigate whether different staffing models are associated with variation in radiograph use for children seen for bronchiolitis, croup, and asthma and discharged home from emergency departments (EDs) in Ontario.

METHODS

We surveyed all Ontario EDs regarding physician staffing models and use of clinical protocols. We used a population-based ED database to determine radiograph rates and patient characteristics. Regression techniques that controlled for patient factors and clustering within EDs were applied.

RESULTS

From April 2004 to March 2006, 5,186, 10,408, and 35,150 children were discharged home from an ED with bronchiolitis, croup, and asthma, respectively. Radiograph rates were 42.7% for bronchiolitis, 10.1% for croup, and 25.9% for asthma. Over 50% of children were treated in EDs with nonpediatric front-line care but with consultant pediatricians available. Compared to children in these settings, those seen in EDs with front-line pediatric staff were less likely to have radiographs for all three conditions (adjusted odds ratios [ORs] 0.47 [95% CI 0.24-0.95], 0.47 [95% CI 0.27-0.82], 0.13 [95% CI 0.02-0.66] for bronchiolitis, croup, and asthma, respectively). Children in community hospitals with pediatricians were significantly more likely to have a radiograph if seen by a consultant pediatrician (OR 1.40, 95% CI 1.20-1.63 [bronchiolitis]; OR 2.76, 95% CI 2.16-3.53 [croup]; and OR 1.97, 95% CI 1.64-2.36 [asthma]). We found no association between clinical protocol use and radiograph rates.

CONCLUSIONS

High rates of discretionary radiograph use exist for common respiratory problems of children seen across ED settings. Quality improvement efforts should be focused in this area, and radiograph use in EDs staffed by front-line pediatrics-trained staff could serve as an initial benchmark target for other institutions.

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

OBJECTIVE

Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED.

METHODS

A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared.

RESULTS

A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76).

CONCLUSION

A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Does active dissemination of evidence result in faster knowledge transfer than passive diffusion?: An analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009

OBJECTIVE

This study aimed to compare knowledge transfer (KT) in the emergency department (ED) management of pediatric asthma and croup by measuring trends in corticosteroid use for both conditions in EDs.

METHODS

A retrospective, cross-sectional study of the National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 of corticosteroid use at ED visits for asthma or croup was conducted. Odds ratios (OR) were calculated using logistic regression. Trends over time were compared using an interaction term between disease and year and were adjusted for all other covariates in the model. We included children aged 2 to 18 years with asthma who received albuterol and were triaged emergent/urgent. Children aged between 3 months to 6 years with croup were included. The main outcome measure was the administration of corticosteroids in the ED or as a prescription at the ED visit.

RESULTS

The corticosteroid use in asthma visits increased from 44% to 67% and from 32% to 56% for croup. After adjusting for patient and hospital factors, this trend was significant both for asthma (OR, 1.07; 95% confidence interval [CI], 1.04-1.10) and croup (OR, 1.07; 95% CI, 1.03-1.12). There was no statistical difference between the 2 trends (P = 0.69). Hospital location in a metropolitan statistical area was associated with increased corticosteroid use in asthma (OR, 1.76; 95% CI, 1.10-2.82). Factors including sex, ethnicity, insurance, or region of the country were not significantly associated with corticosteroid use.

CONCLUSIONS

During a 15-year period, knowledge transfer by passive diffusion or active guideline dissemination resulted in similar trends of corticosteroid use for the management of pediatric asthma and croup.

Variability in inpatient management of children hospitalized with bronchiolitis

OBJECTIVE

To determine the variability between hospitals in diagnostic testing and management interventions for children with bronchiolitis admitted to inpatient wards and identify its association with patient characteristics.

METHODS

A prospective, multicenter (16 hospitals), multiyear (2007-2010) observational study of children (age <2 years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator, systemic corticosteroid, antibiotic, IV placement) by hospital. A modified Respiratory Distress Severity Score was utilized to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate the random effects of hospital without added covariates and compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted and adjusted model was created for age ≥ 2 months.

RESULTS

Of 2207 subjects, 1715 were identified as admitted to inpatient wards. We observed wide variations in the proportion of patients who received diagnostic testing (complete blood count 21-75%, chest radiograph 36-85%) and medications/interventions (bronchodilators 19-91%, systemic corticosteroids 8-44%, antibiotics 17-43%, IV placement 38-93%). Adjusting for demographic and clinical patient characteristics did not materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment <4%).

CONCLUSIONS

Wide variations in diagnostic test utilization and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care for bronchiolitis through active quality improvement strategies.

Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines

OBJECTIVE

To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes.

STUDY DESIGN

We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission.

RESULTS

In total, 64,994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission.

CONCLUSIONS

Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.

PRAM score as predictor of pediatric asthma hospitalization

OBJECTIVES

The objective was to determine the association between asthma severity as measured by the Pediatric Respiratory Assessment Measure (PRAM) score and the likelihood of admission for pediatric patients who present to the emergency department (ED) with moderate-to-severe asthma exacerbations and who receive intensive asthma therapy.

METHODS

This was a secondary analysis of a prospective study of triage nurse-initiated steroid therapy in pediatric asthma. Children aged 2 to 17 years inclusive, presenting with moderate-to-severe acute asthma exacerbations (defined as PRAM ≥ 4), were included. To be eligible for inclusion in the study, children must have received "intensive asthma therapy," defined as nurse-initiated initial bronchodilator and oral steroid therapy at arrival to triage. PRAM scores were measured hourly as per ED protocol. The primary outcome was inpatient hospitalization; secondary outcome was ED stay greater than 8 hours. Logistic regression models were used to predict admission based on PRAM score at triage and then hourly thereafter. The area under the receiver operating characteristic curve (AUC) was calculated for each hour.

RESULTS

A total of 297 patients were included in the analysis, with an admission rate of 11.4% for patients receiving intensive therapy. The 3-hour PRAM (AUC = 0.85) significantly improved prediction of admission compared to PRAM at triage (p = 0.04).

CONCLUSIONS

The 3-hour PRAM scores best predicts the need for hospitalization. These results may be applied in clinical settings to facilitate the decision to admit or initiate more aggressive adjunctive therapy to decrease the need for hospitalization.

Assessing the impact of national guidelines on the management of children hospitalized for acute bronchiolitis

BACKGROUND

Acute bronchiolitis is a common illness accounting for $500 million annually in hospitalizations. Despite the frequency of bronchiolitis, its diagnosis and management is variable. To address this variability, the American Academy of Pediatrics (AAP) published an evidence-based practice management guideline for bronchiolitis in 2006.

OBJECTIVE

Assess for changes in physician behavior in the management of bronchiolitis before and after publication of the 2006 AAP bronchiolitis guideline.

METHODS

A retrospective chart review was performed at two academic medical centers of children <24 months of age admitted to the hospital with a primary or secondary discharge diagnosis of bronchiolitis. Pre-guideline charts were gathered from 2004 to 2005 and post-guideline charts from 2007 to 2008. Evaluation and therapeutic interventions prior to and during hospitalization were analyzed. Data were analyzed using chi-squared analysis for categorical variables, Mann-Whitney testing for continuous variables.

RESULTS

One thousand two hundred thirty-three patients met inclusion criteria. Diagnostic laboratory testing rates did not decline after guideline publication. The number of chest X-rays obtained decreased from 72.9% to 66.7% post-guidelines (P = 0.02). Fewer children received a trial of racemic epinephrine (17.8% vs. 12.2%, P = 0.006) or albuterol (81.6% vs. 72.6%, P < 0.0001) post-guidelines, and physicians more often discontinued albuterol when documented ineffective in the post-guidelines period (28.6% vs. 78.9%, P < 0.0001). Corticosteroid use in children without a history of RAD or asthma dropped post-guidelines (26.5% vs. 17.5%, P < 0.0001).

CONCLUSIONS

A modest change in physician behavior in the inpatient management of bronchiolitis was seen post-guidelines. Additional health care provider training and education is warranted to reduce unnecessary interventions and healthcare resources use.

Improving outcomes for underserved adolescents with asthma

BACKGROUND AND OBJECTIVE

Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting.

METHODS

Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections.

RESULTS

Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent's asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels.

CONCLUSIONS

Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.

Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010

BACKGROUND

To examine temporal trends in emergency departments (EDs) visits for bronchiolitis among US children between 2006 and 2010.

METHODS

Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We used International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate and ED charges.

RESULTS

Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend = 0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase;Ptrend < 0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend < 0.001). Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted odds ratio for comparison of 2010 with 2006, 0.84; 95% confidence interval: 0.76-0.93; P < 0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend < 0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend < 0.001).

CONCLUSIONS

Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.

Impact of a bronchiolitis guideline on ED resource use and cost: a segmented time-series analysis

OBJECTIVE

Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED).

METHODS

We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS).

RESULTS

There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge.

CONCLUSIONS

A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.

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.