A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.
Introduction: Febrile neutropenia is a potentially life-threatening complication of chemotherapy in pediatric oncology patients. Prompt initiation of antibiotic therapy may minimize morbidity and mortality associated with this condition, and time to antibiotic (TTA) administration <60 minutes is used as a quality benchmark by many institutions. We implemented a quality improvement initiative to achieve TTA < 60 minutes in >80% of eligible patients in the pediatric emergency department. Methods: After collecting baseline data, we employed consecutive PDSA cycles to (i) reduce time to antibiotic order after patient arrival; (ii) expedite the preparation of antibiotic by pharmacy; and (iii) enable antibiotic ordering before patient arrival. Statistical process control methodologies were used for key outcome measures to compare pre-intervention, post-intervention, and maintenance periods. Results: Comparing pre-intervention and post-intervention years, mean TTA decreased from 64 to 53 minutes and the percentage of patients receiving antibiotics in <60 minutes increased from 59% to 84%. Improvements were sustained in the maintenance period of the project, with mean TTA administration of 44 minutes and 85% of patients receiving antibiotics within our stated goal. Conclusion: Through a series of PDSA cycles, we decreased TTA and increased the percentage of febrile neutropenia patients receiving antibiotics in <60 minutes.
Significant delays occur in providing adequate pain relief for patients who present to the emergency department (ED) with extremity fractures. The median time to pain medication administration for patients presenting to our ED with extremity fractures was 72.5 minutes. We used a multidisciplinary approach to implement three improvement cycles with the goal of reducing the median time to pain medication by 15% over an eight month time period. First, we redesigned nursing triage and treatment processes. Second, we improved nursing documentation standardization to ensure accurate tracking of patients who declined pain medication. Third, through consensus building within our physician group, we implemented a department-wide standard of care to provide early pain relief for extremity fractures. Median time to pain medication for patients with an extremity fracture reduced significantly between the pre-and post-intervention periods (p=0.009). The average monthly median time to medication was 72.5 minutes (95% CI: 57.1 to 88.0) before the intervention (Jan 2013-Oct 2014) and 49.8 minutes (95% CI: 42.7 to 56.9) after the intervention (November 2014 to June 2016). In other words, monthly median time was 31% faster (22.7 minute difference) in the post intervention period. Implementing three key interventions reduced the time to pain medication for patients with extremity injuries. Since June 2016 the reductions in median time to medication have continued to improve.
Introduction Approximately 25.5 million pediatric patients are treated in Emergency Departments around the United States annually. Roughly 7% of these patients are transported by ambulance; of these, about 7% arrive in ambulances running red lights and sirens (RLS). Compared to those transporting without RLS, emergency vehicles employing RLS are involved in more accidents and are associated with more fatalities. Objective To characterize the use of RLS in pediatric transports and identify factors associated with unnecessary use of RLS. Methods As part of the Children’s Safety Initiative (CSI-EMS), a large, multi-phased National Institutes of Health-funded study, we conducted a medical record review of all pediatric RLS transports in an urban EMS system over a 4-year period (2008–2011). A standardized chart abstraction tool was adapted for the out-of-hospital setting and pilot tested. Charts were independently reviewed by physicians and paramedics, with disagreements arbitrated by a pediatric emergency physician. Reviewers were asked to judge whether RLS transport was necessary and to provide comments justifying their position. Descriptive statistics were used to measure the frequency of unnecessary transports and logistic regression analysis was employed to identify factors associated with unnecessary use of RLS. Results Of 490 RLS transports, experts identified 96 (19.6%) as unnecessary use of RLS. Necessary and unnecessary RLS transports had similar patient sex and duration of transport, though unnecessary use of RLS tended to increase with patient age. The call reasons that represented the largest proportion of unnecessary RLS transports were trauma (49.0%), respiratory distress (16.7%), and seizure/altered mental status (11.5%). Compared with necessary RLS transports, unnecessary RLS transports were less likely to require resuscitation, airway management, or medication administration. Univariate analysis revealed that patient vital signs within normal limits were associated with increased risk of unnecessary RLS transport, with the most pronounced effect seen in the normal GCS score group (odds ratio 7.74, p-value 0.001). Conclusions This analysis identified patient and transport characteristics associated with unnecessary use of RLS. Our results could help serve as the basis for designing and prospectively evaluating protocols for use of RLS, potentially mitigating the risk associated with transport in pediatric patients.
Implementing a telephone follow-up system after a patient's emergency department (ED) visit is challenging, but it may improve patient safety and care. This study's objective was to describe the development and implementation of a comprehensive ED telephone follow-up system over a 9-year period. Discharged patients who received a follow-up telephone call within 48 hours of their ED visit included all pediatric patients, those who left without being seen by a provider, and any adult patient with a "high-risk chief complaint," which was defined as a headache, visual problem, chest pain, dyspnea, abdominal pain, syncope, trauma, and neurological-related problems. There were 127 524 cases that met criteria to receive a follow-up call, with 138 331 attempted calls being made and 46 114 (36.2%) cases successfully followed up. Forty-two percent of pediatric cases and 16% of patients who left without being seen were successfully contacted with a follow-up call; 1.6% of cases were referred to the CQI Committee. In the 9 years prior and after implementation of this follow-up system, there were 3.5 (95% confidence interval [CI] = 2.1-5.9) and 2.5 (95% CI = 1.3-4.5) medical malpractice lawsuits per 100 000 ED patient visits, respectively; this represented a 28.6% reduction. A comprehensive telephone follow-up program can be developed and implemented utilizing available resources.
Funding informationLogistic support, including travel, lodging, and related expenses, was provided by Bangkok-Dusit Medical Services (BDMS). BB, JB, MH, and DS received salary support from BDMS.
Background: Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children.Methods: The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers. Results: 1018 educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent. Conclusions: Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.
Background Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children. Methods The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers. Results One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent. Conclusions Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.
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