Objective Poor adherence to 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 Prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations. A multidisciplinary team designed a one-page clinical pathway based on NIH guidelines. Nurses, respiratory therapists, and physicians attended educational sessions prior to pathway implementation. 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 2006–2011. Subsequent hospital admission rates were also compared. Results 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 minutes faster (RR 0.74; 95%CI 0.67–0.81) and more patients received corticosteroids within 1 hour of arrival (45% vs 18%, OR 3.5; 95%CI 2.50–4.90). More patients received >1 bronchodilator dose within 1 hour (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.

Na-K-ATPase is associated with a variety of membrane populations in lacrimal acinar cells. Acinus-like structures formed by rabbit acinar cells in primary culture were incubated with horseradish peroxidase (HRP) to label basolateral and endosomal membranes and then analyzed by electron microscopy cytochemistry with the 3-3'-diaminobenzidine reaction or by fractionation and measurement of marker catalytic activities or immunoreactivities. HRP adsorbed to basolateral membranes at 4 degrees C. Fractionation showed it associated with low-density membranes enriched in acid phosphatase and TGN38 but containing only minor amounts of Na-K-ATPase. Cells internalized HRP to cytoplasmic vesicles, Golgi structures, and lysosomes at 37 degrees C. The major endosomal compartment revealed by fractionation coincided with major peaks of Na-K-ATPase and Rab6 and secondary peaks of galactosyltransferase and gamma-adaptin. Carbachol (10 microM) increased lysosomal and Golgi labeling. Thus most of the Na-K-ATPase is located in the basolateral membrane-oriented endosomal system, concentrated in a compartment possibly related to the trans-Golgi network. Constitutive and stimulation-accelerated traffic to and from this compartment may serve several exocrine cell functions.

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Systemic corticosteroids are under-prescribed for children who present to EDs with acute asthma exacerbations. Pediatric EDs are more likely than general EDs to treat asthma exacerbations with systemic corticosteroids. Differences in the process of care in pediatric ED settings (compared to general EDs) may increase the likelihood of adherence to NIH treatment guidelines.

Objective: To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. Methods: Data were from the 2001Y2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time 98 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. Results: Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity

Compared with the subspecialist faculty/housestaff system, the staff-only pediatric hospitalist system was associated with a marked reduction in cost and length of stay for patients with medically complex subspecialty diseases. In this era of resident duty-hour restrictions and medical complexity of conditions in inpatients, staff-only hospitalist programs may have a vital role in pediatric teaching hospitals.

Pediatric hospitalists want to conduct research to improve the quality of inpatient care but face significant obstacles including lack of dedicated time for research and mentorship. Coordinated efforts to improve access to academic resources are important for career development and academic growth of the field. National organizations and hospital programs interested in improving the quality of care for hospitalized children can provide support to meet the field's professional needs for research.

Objective To identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-severe asthma exacerbation. Methods This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED January 2006-September 2011 with a primary diagnosis of asthma (ICD-9 code 493.xx) and moderate-severe exacerbations. A moderate-severe exacerbation was defined as requiring ≥2 (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (> 1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. Results Of 1,333 pediatric asthma ED visits, 817 were for moderate-severe exacerbation; 645 (79%) received steroids. Patients <6 years (odds ratio 2.25 [95% confidence interval 1.19–4.24]), requiring more bronchodilators (2.82 [2.10–3.79]), initially hypoxic (2.78 [1.33–5.83]), or tachypneic (1.52 [1.05–2.20]) were more likely to receive steroids. Median time to steroid administration was 108 minutes (IQR: 65–164). Steroid administration was delayed in 502 (78%) visits. Patients with hypoxia (1.91 [1.11–3.27]) or tachypnea (1.82 [1.17–2.84]) were more likely to receive steroids ≤1 hour of arrival whereas children <2 years (0.16 [0.07–0.35]) and those arriving during periods of higher ED volume (0.79 [0.67–0.94]) were less likely to receive timely steroids. Conclusion In this ED, steroids were under-prescribed and frequently delayed for pediatric ED patients with moderate-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to NIH asthma guidelines.