Utilization of heat-mapping tools to match a resident staffing template to emergency department arrival patterns

OBJECTIVES

Academic emergency departments (ED) rely on a steady flow of patients to provide residents with good clinical training. Understanding institutional volume patterns allows training directors to create a schedule that maximizes learning opportunities while also adequately staffing the ED. Our primary objective of this study was to utilize heat-mapping software to optimize resident staffing in an academic ED.

METHODS

Heat-mapping tools within Microsoft Excel were utilized to overlay ED patient arrival patterns on top of the potential patients per hour based on published productivity data for trainees and historical averages for advanced practice providers at our institution. Time frames for under- and overstaffing were identified and color-coded. This analysis informed a revised schedule template and the same heat-mapping process was used to determine the appropriateness of the revised staffing template.

RESULTS

The heat map for the original schedule template revealed understaffing in the morning and overstaffing the rest of the day. Informed by these findings, schedule adjustments were made. There was no net increase in the number of resident or advanced practice provider coverage hours. Prior to implementation, the ED was understaffed by 5% or more during 18.4% of operating hours. Following changes to the staffing template, only 5.9% of operating hours were understaffed (p < 0.001). Furthermore, significant understaffing (20% or more) decreased from 16.6% to 3.1% (p < 0.001).

CONCLUSIONS

Novel use of heat-mapping software has the potential to successfully match ED patient arrival patterns to an optimal resident staffing template. Future directions include incorporation of variable resident productivity to account for fatigue as the shift progresses.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media

OBJECTIVES

To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).

METHODS

We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.

RESULTS

Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.

CONCLUSION

Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem

BACKGROUND

Pediatric adnexal torsion is rare, can be challenging to recognize, and may result in ovarian loss.

OBJECTIVE

We sought to identify and compare the defining characteristics of adnexal torsion in premenarchal and postmenarchal girls.

METHODS

A retrospective cohort study was performed at a tertiary care children's hospital, including patients diagnosed postnatally with adnexal (ovarian or tubal) torsion between 1997 and 2013. Proportions were compared using relative risk regression.

RESULTS

Adnexal torsion was found in 59 premenarchal and 43 postmenarchal girls. Abdominal pain was the most common chief complaint (54%). History included reports of pain (96%), vomiting (67%), and fever (19%). Excluding 12 patients with isolated tubal torsion and 19 with a teratoma, there were no statistically significant differences in ovarian loss in premenarchal vs. postmenarchal girls (47% and 25% respectively; relative risk [RR] = 1.8 [95% confidence interval {CI} 0.9-3.8]), left- vs. right-sided torsion (47% and 32%; RR = 1.5 [95% CI 0.8-2.7]), pain duration ≤ 2 days vs. > 2 days (31% and 41%; RR = 0.8 [95% CI 0.4-1.5]; n = 64) and severe pain vs. mild to moderate (38% and 33%; RR = 1.1 [95% CI 0.7-1.5]; n = 56).

CONCLUSIONS

The diagnosis of pediatric adnexal torsion is difficult and often delayed. Pain and tenderness may not be isolated to a unilateral lower quadrant. Although traditionally considered a postmenarchal problem, in a pediatric academic emergency department adnexal torsion occurred with similar frequency in premenarchal and postmenarchal girls. The potential for organ salvage means that adnexal torsion should be considered in all females presenting with acute abdominal pain regardless of age or menstrual history.