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Berkowitz D, Cohen JS, McCollum N, Rojas CR, Chamberlain JM. Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients. Am J Emerg Med 2023; 74:130-134. [PMID: 37826993 DOI: 10.1016/j.ajem.2023.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/20/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Triage, the initial assessment and sorting of patients in the Emergency Department (ED), determines priority of evaluation and treatment. Little is known about the impact of undertriage, the underestimation of disease severity at triage, on clinical care in pediatric ED patients. We evaluate the impact of undertriage on time to disposition and treatment decisions in pediatric ED patients. METHODS This was a case control study of ED visits for patients <22 years of age, with an assigned Emergency Severity Index (ESI) score of 4 or 5, and associated hospital admission, nebulized treatment, supplemental oxygen, and/or intravenous (IV) line placement, between January 1, 2018, to June 30, 2022. Controls were sampled from a pool of patient visits with an ESI score of 3, matched by intervention, disposition, and date and hour of arrival. Primary outcome measures were time to order of intervention (nebulized treatment, oxygen administration, or IV placement) and time to disposition decision. A secondary outcome measure was return visits requiring admission or emergency intervention within 14 days of the index visit. Continuous variables (time to orders) were analyzed using Wilcoxon rank sum test and dichotomous outcomes (return visits) were compared using odds ratios with 95% confidence intervals. Analysis was performed with Python v3.10. RESULTS The final analysis included 7245 undertriaged patients. Undertriaged patients had longer times to orders for nebulized treatments, (p < 0.001) IV placement, (p < 0.001) and admission (p < 0.001) when compared to controls. There were no significant differences in time to supplemental oxygen delivery and time to discharge compared to controls. Undertriaged patients were more likely to experience a return visit requiring admission or emergency intervention (OR 3.74, 95% CI 3.32,4.22). CONCLUSIONS Undertriage in the pediatric ED is associated with delays in care and disposition decisions and increases likelihood of return visits.
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Affiliation(s)
- Deena Berkowitz
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
| | - Joanna S Cohen
- Division of Pediatric Emergency Medicine, Johns Hopkins University, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nichole McCollum
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| | - Christina R Rojas
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
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Wolfgram PM, Frenkel M, Gage P, Sprague R, Servi A, Liggett J, Huitink S, Fiallo-Scharer R, Baumer-Mouradian S. Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes. Pediatr Diabetes 2022; 23:55-63. [PMID: 34708486 DOI: 10.1111/pedi.13275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/30/2021] [Accepted: 10/12/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months. RESEARCH DESIGN AND METHODS Plan-do-study-act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two-bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO3 ) <15 mEq/L. PRIMARY OUTCOME the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO3 ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts. RESULTS From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures. CONCLUSIONS Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA.
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Affiliation(s)
| | - Mogen Frenkel
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pamela Gage
- Children's Wisconsin, Milwaukee, Wisconsin, USA
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Alsaedi H, Lutfi R, Abu-Sultaneh S, Montgomery EE, Pearson KJ, Weinstein E, Whitfill T, Auerbach MA, Abulebda K. Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center. J Pediatr 2022; 240:235-240.e1. [PMID: 34481806 DOI: 10.1016/j.jpeds.2021.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. STUDY DESIGN A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18 years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected. RESULTS A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted. CONCLUSIONS Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.
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Affiliation(s)
- Hani Alsaedi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Riad Lutfi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Kellie J Pearson
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Elizabeth Weinstein
- Division of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Marc A Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
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Loh C, Weihe P, Kuplin N, Placzek K, Weihrauch-Blüher S. Diabetic ketoacidosis in pediatric patients with type 1- and type 2 diabetes during the COVID-19 pandemic. Metabolism 2021; 122:154842. [PMID: 34332999 PMCID: PMC9188025 DOI: 10.1016/j.metabol.2021.154842] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/23/2021] [Accepted: 07/06/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND COVID-19 pandemic caused families to stay home and cancel everyday activities. Hospital admissions decreased, affecting changes in diagnoses and management of chronic disease in children. AIMS We analyzed how the first lockdown influenced clinical presentation and manifestation of children with diabetes mellitus (DM) in a German University Hospital. METHODS During March 15th and October 11th 2020, data on general patient information, clinical symptoms and on lab results related to diabetic ketoacidosis (DKA) were analyzed in children (0-18 years) who presented with new onset of DM or poor metabolic control of known DM. All data including frequency and severity of DKA were compared to data from patients who presented in 2019. RESULTS Data from 125 participants with DM were evaluated (2020: n = 52; 2019: n = 73). In 2020, twelve patients (23.1%) were diagnosed with new onset DM, two of them with type2 diabetes, and 66.7% presented with DKA including both patients T2DM. In 2019, 24.5% of patients had new onset DM, and 50% of them presented with DKA. In 2020, patients with new onset DM were younger, presented with more severe symptoms of DKA and had to stay longer in hospital compared to 2019. In 2020, six children (50%) with new onset DM were <6 years, whereas in 2019 most children with new onset DM were adolescents (n = 7, 38.9%). CONCLUSION COVID-19 lockdown aggravated complications of diabetes onset and therapy management, including severity and frequency of DKA. It underlines the need of health education for early DKA diagnosis to early identify children at risk.
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Affiliation(s)
- Charlotte Loh
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Paul Weihe
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Nicole Kuplin
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Kerstin Placzek
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Susann Weihrauch-Blüher
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany.
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Darmonkow G, Chafe R, Aslanova R, Hagerty D, Twells L, Barter OJ, Allwood Newhook LA. A Multi-Intervention Campaign Lowers Pediatric and Young Adult Diabetic Ketoacidosis Hospitalizations in a Canadian Province. Can J Diabetes 2021; 45:792-797. [PMID: 34016537 DOI: 10.1016/j.jcjd.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The Newfoundland and Labrador diabetic ketoacidosis Project (NLdkaP) is a multi-intervention, province-wide project aimed at lowering rates of diabetic ketoacidosis (DKA) within the pediatric and young adult populations. METHODS The NLdkaP interventions were first selected, developed and implemented. We then conducted a retrospective study of hospitalization data over three 2-year periods: pre-, during and post-NLdkaP. Data included demographic factors, DKA hospitalizations and length of hospital stay. RESULTS There were 412 DKA hospitalizations over the study period. Before the NLdkaP, the provincial hospitalization rate of DKA for patients <25 years of age was 55.61 per 100,000. During the NLdkaP, the rate dropped to 38.48 per 100,000 (p<0.001). After the NLdkaP, the rate rose to 54.53 per 100,000 (p<0.001). Hospitalization rates were highest for females (p<0.001) and for those in the 19- to 24-year age group (p<0.001). CONCLUSIONS The NLdkaP was associated with decreased rates of DKA hospitalizations, but the rates remained relatively stable in both the pre- and postintervention periods. Although the approach and resources developed in the NLdkaP appear effective, continuous preventive efforts are needed to sustain reductions in DKA hospitalizations.
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Affiliation(s)
- Georgia Darmonkow
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Roger Chafe
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Rana Aslanova
- Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Donna Hagerty
- Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Laurie Twells
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Ola Jill Barter
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Division of Children and Women's Health, Eastern Health, St. John's, Newfoundland and Labrador, Canada
| | - Leigh Anne Allwood Newhook
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Division of Children and Women's Health, Eastern Health, St. John's, Newfoundland and Labrador, Canada.
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Alter DN. Point-of-Care Testing for the Emergency Department Patient: Quantity and Quality of the Available Evidence. Arch Pathol Lab Med 2021; 145:308-319. [PMID: 33635952 DOI: 10.5858/arpa.2020-0495-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Point-of-care test (POCT) instruments produce lab results with rapid turnaround times. Based on that fact, emergency department (ED) POCT requests are predicated on the belief that rapid test turnaround times lead to improved care, typically a decreased ED length of stay (LOS). OBJECTIVE.— To compile the available peer-reviewed data regarding use of POCT in the ED with an emphasis on ED-LOS. DATA SOURCES.— An English-language PubMed search using the following free text terms: ("EMERGENCY" AND "POINT OF CARE") NOT ULTRASOUND as well as "RAPID INFECTIOUS DISEASE TESTING." In addition, the PubMed "similar articles" functionality was used to identify related articles that were not identified on the initial search. CONCLUSIONS.— Seventy-four references were identified that studied POCT ED use to determine if they resulted in significant changes in ED processes, especially ED-LOS. They were divided into 3 groups: viral-influenza (n = 24), viral-respiratory not otherwise specified (n = 8), and nonviral (n = 42). The nonviral group was further divided into the following groups: chemistry, cardiac, bacterial/strep, C-reactive protein, D-dimer, drugs of abuse, lactate, and pregnancy. Across all groups there was a trend toward a significantly decreased ED-LOS; however, a number of studies showed no change, and a third group was not assessed for ED-LOS. For POCT to improve ED-LOS it has to be integrated into existing ED processes such that a rapid test result will allow the patient to have a shorter LOS, whether it is to discharge or admission.
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Affiliation(s)
- David N Alter
- From the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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Boeder S, Kulasa K. Hospital care: improving outcomes in type 1 diabetes. Curr Opin Endocrinol Diabetes Obes 2021; 28:14-20. [PMID: 33315629 DOI: 10.1097/med.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Caring for patients with type 1 diabetes (T1D) in the hospital presents unique challenges. This review provides an update on significant issues relevant to the inpatient management of T1D. Topics include trends in diabetic ketoacidosis (DKA), hypoglycemia, and adapting ambulatory technologies for inpatient use. RECENT FINDINGS Rates of DKA in the United States are rising. Although socioeconomic status, health insurance coverage, and hemoglobin A1c are persistently associated with DKA in individuals with T1D, newer risk factors have also emerged. These include the off-label use of sodium-glucose cotransporter inhibitor medications, immune checkpoint inhibitor-induced diabetes, and infection with severe acute respiratory syndrome coronavirus 2. Hypoglycemia is common among hospitalized patients with T1D. Use of validated hypoglycemia risk prediction models and multidisciplinary care initiatives can reduce the risk of inpatient hypoglycemia. Finally, continuous glucose monitoring is being adapted for use in the hospital setting and has shown promise during the coronavirus disease 2019 (COVID-19) pandemic. SUMMARY Evidence-based treatment algorithms, risk prediction calculators, multidisciplinary interventions, and wearable technology hold promise for improved outcomes in hospitalized patients with T1D.
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Affiliation(s)
- Schafer Boeder
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, La Jolla, California, USA
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