Optimizing Interdisciplinary Care of Pediatric Sexual Assault and Abuse in the Emergency Department: A Quality Improvement Approach

The Ann & Robert H. Lurie Children's Hospital of Chicago identified issues with team communication, consistency of services provided, and continuity of care within the sexual abuse and assault program in the emergency department (ED) which necessitated improvement efforts. The aim of this project was to engage an interdisciplinary team to define and delineate roles and streamline clinical workflows from ED presentation to nonacute follow-up. An interdisciplinary team was convened and utilized quality improvement methodology to complete a current state analysis, develop a future state design, and prioritize interventions for improvement. The project team focused on four interventions: (1) establish a team approach with delineated roles and responsibilities; (2) develop and implement consistent workflows to reduce unwarranted variation in care; (3) expand education on the sexual assault nurse examiner (SANE) program more broadly to the care teams in the ED; and (4) implement clinical decision support (CDS) tools to streamline the continuum of sexual assault services provided. Three of the interventions (all but education) were carried out as a comprehensive care guideline for patients presenting to the ED for evaluation. The ED implemented this care guideline in August 2019. The utilization of quality improvement methodology was effective in ensuring an organized, interdisciplinary team response for the evaluation of pediatric and adolescent sexual abuse and assault in the ED. It enabled strong buy-in from team members and ownership of the process with anticipated improvements in patient care and experiences.     

Pediatric Asthma in the Community Emergency Department: Room for Improvement and Aligned Incentives

Asthma is a common reason for emergency department (ED) visits in children. Over 80% of children who visit an ED go to a general, not a pediatric-specific, ED. The treatment children with asthma receive in general EDs is not as compliant with national guidelines as is treatment in pediatric-specific centers. Several studies document improvements in pediatric asthma care through quality improvement initiatives, but few address the emergency care of pediatric asthma in the community setting. National programs such as Pathways for Improving Pediatric Asthma and Translating Emergency Knowledge for Kids provide resources to community EDs for improving pediatric asthma care. More research is needed to determine if programs such as these, as well as partnerships at the local level, can have a positive impact on the emergency care of pediatric asthma. It is essential that we bridge the gaps in care between community and pediatric-specific EDs to improve the quality of emergency care for the over 7 million children in the US with asthma.     

Increasing Metered Dose Inhaler Use for Acute Asthma Exacerbations in the Pediatric Emergency Department: A Quality Improvement Challenge

Pediatric asthma is the most common chronic condition in children and results in significant disease burden and healthcare costs. The mainstay of asthma treatment is inhaled albuterol, and different modalities of albuterol delivery have been shown to affect healthcare quality measures. Albuterol delivered via metered-dose inhaler with a valved holding chamber (MDI/VHC) has been shown to be at least as effective as nebulized albuterol while also reducing medication side effects, admission rates, length of stay in the emergency department (ED) and overall costs. However, a culture of nebulized albuterol still predominates in the ED. Quality Improvement methodology is well suited to address this healthcare quality problem. The goal of this article is to utilize The Model for Improvement framework to provide a review and a critique of the literature regarding the transition to MDI/VHCs from nebulizers in the acute care of children with asthma exacerbations.     

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators

ObjectiveAcute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care.MethodsWe conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California.ResultsPECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%).ConclusionsED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.     

Pulmonary Embolism in the Pediatric Emergency Department

Pulmonary embolism and deep venous thrombosis, although rare in children, are still present in clinically significant numbers. The clinician must always be on guard for the possibility of these disease entities, especially in the face of a compelling history and/or physical exam findings. Laboratory and diagnostic imaging studies have variable sensitivities and specificities, so the results must be interpreted in light of the clinical context. Although adolescents are the most likely to experience spontaneous VTE, children with CVLs and hospitalized children with underlying medical conditions are at greatest risk of VTE and PE.     

Status Epilepticus in the Pediatric Emergency Department

Status epilepticus is a common childhood condition accounting for a significant number of visits to the emergency department. The time threshold for consideration as SE has decreased over the past decades and is still not universally agreed upon. The treatment of SE is also not standardized across institutions and likely varies by clinician; however, in general, treatment should use appropriate doses of anticonvulsants in rapid sequence. The goal for AED administration in SE should be to give benzodiazepines followed by fosphenytoin (if required) within 20 minutes, after which the patient is considered to have refractory SE. A high index of suspicion should be maintained for continued subclinical or nonconvulsive seizures after initial SE treatment.     

Pediatric Emergency Medicine Quality of Care: Strategies for Continued Improvement

Pediatric emergency care is conducted primarily outside of academic medical centers. This care is variable among and between pediatric based providers and general emergency medicine physicians. As studies have noted these variations, there has been focus on ways to broadly improve this care and decrease variation in the non-academic community hospital setting. Initial successes have been realized in pediatric emergency preparedness, learning collaboratives and telemedicine. Although these initiatives show promise in building improvements of care for the community pediatric population, the focus towards maintaining and increasing quality in this population requires additional attention. We review current successes and offer perspective for possible future directions.     

Injury Prevention Opportunities in the Pediatric Emergency Department

Injury is the leading cause of death in children over 1 year of age, causes considerable morbidity, and is a significant source of health care cost. Injury prevention methodology has helped to decrease pediatric injuries over the last several decades; however, significant room for improvement remains. Emergency medicine providers have the expertise and opportunity to participate in injury prevention. Injury risk identification and injury prevention interventions in the emergency department have been increasingly explored over the last decade. This review discusses promising emergency department–based approaches such as safety behavior screening; screening for suicide risk, violence risk, and exposure to firearms; education and interventions; and advocacy opportunities.