OBJECTIVES:To examine (1) differences in low-value care (LVC) for common emergency conditions by race and ethnicity in US children's hospitals and (2) the association between hospital characteristics, including LVC rate, and the magnitude of within-hospital LVC differences by race and ethnicity. We hypothesized smaller LVC differences in hospitals with lower overall LVC rates. METHODS:We performed a cross-sectional study of children younger than 18 years discharged from the emergency department with asthma, bronchiolitis, headache, or minor head injury in the Pediatric Health Information System (PHIS) from January 2021 to June 2023. Exposures were patient race and ethnicity (non-Hispanic Black, "Black"; non-Hispanic white, "white"; Hispanic) and deidentified PHIS hospital. Outcomes were LVC by race and ethnicity within and across hospitals. We used multivariable logistic regression, reporting adjusted odds ratios (aORs) and 95% CI, to estimate hospital-level and condition-specific LVC differences and linear regression to examine the association between LVC differences and LVC rates. RESULTS:Among 314 138 eligible encounters, overall LVC rates were as follows: asthma 18%, bronchiolitis 32%, headache 24%, and minor head injury 26%. White compared with Black and Hispanic patients had higher odds of LVC across multiple conditions in pooled and within-hospital analyses. The largest pooled differences were for white vs Black: asthma aOR (95% CI) = 1.51 (1.18-1.95) and headache 1.57 (1.43-1.72). Hospital LVC rate was not associated with magnitude of within-hospital LVC difference for any condition. CONCLUSIONS:Lower hospital LVC rates were not associated with reduced LVC differences. Intentional focus on LVC differences is important when designing LVC reduction efforts.

OBJECTIVE:Our objectives were to assess the rates of, variation in, and factors associated with short stay admissions (SSAs) and 7-day hospital readmissions after SSAs for children with complex chronic conditions (CCCs). METHODS:Retrospective analysis of children with >1 CCC who had a ≤1-day admission from January 1, 2018 to June 30, 2025 in 47 children's hospitals in the Pediatric Health Information System. We conducted a multivariate analysis to examine risk factors for SSAs and 7-day readmissions after SSAs. Covariates included demographics, clinical factors, child opportunity index (COI), and ambulatory care sensitive conditions (ACSCs). RESULTS:Of 1,268,019 hospital admissions for children with >1 CCC, 23.3% (n = 295,264) were SSAs, and the rate of SSA varied significantly across hospitals (range: 17.1-29.9%). Higher odds of SSA were associated with high COI, having only one CCC, and admission for ACSC. The 7-day hospital readmission after SSA was 5.8%. Higher odds of readmission were associated with more than one CCC and prior ICU admission. CONCLUSIONS:SSAs accounted for nearly one-in-four admissions for children with CCCs, and 7-day readmission rates after SSAs were low. Short stay admissions may represent opportunities to prevent unnecessary hospitalizations for children with CCCs.

Introduction:Discharging patients with new nasogastric tubes (NGTs) for enteral nutrition at home is complex and requires intricate care coordination and education from a multidisciplinary team. We designed a quality improvement (QI) initiative to improve efficiency and decrease variation in care coordination for patients discharged with a new NGT. Our objective was to reduce mean modified hospital length of stay (mLOS) by 10% from baseline within 6 months and sustain improvement for 12 months. Methods:Applying the Model for Improvement, we used plan-do-study-act cycles to improve NGT discharge care coordination using a multidisciplinary team. Primary interventions rooted in Lean methodology included creating a standardized discharge algorithm, utilizing nurse practitioners as care coordination champions, routine consultation of an enteral tube service (ETS), and implementing a formula substitution guide. The primary outcome measure was mean mLOS. The process measure was the time from NGT placement to ETS consult. Balancing measures were ETS consult volume and 30-day healthcare reutilization. Statistical process control charts measured the impact of interventions. Results:Baseline mLOS decreased from 8.2 to 7.4 days with a sustained reduction in process variability over time. Time from NGT placement to ETS consult decreased from 4.1 to 3.0 days. There were no changes in 30-day healthcare reutilization or ETS consult volume over time. Conclusions:A multidisciplinary quality improvement initiative effectively improved complex NGT transitional care planning and was sustained over time.

OBJECTIVE:Timely access to concise, accurate clinical information for children with medical complexity (CMC) may improve emergency department (ED) care. Our objective was to improve ED care of CMC via design and implementation of an electronic health record (EHR)-based Emergency Information Form (EIF). PATIENTS AND METHODS:Using the Model for Improvement, we engaged key stakeholders to develop and implement EIFs. We developed EIFs containing patient summary, prehospital triage instructions, resuscitation status, typical admission diagnoses, medical technologies, critical care needs and plans, and disposition guidelines. We implemented an EHR-based alert to the presence of an EIF. Our primary outcome was time to ED disposition decision. Secondary outcomes were accuracy of EIF and influence on expediting care, measured via clinician survey, and hospital admission rate. Process measures included number of CMC with EIFs, number of ED visits by children with EIFs, and percentage of providers accessing the EIF. RESULTS:From April 1, 2022, to May 31, 2024, we created and maintained EIFs for 311 CMC who experienced 838 ED visits. Ninety-eight percent and 86% of ED providers agreed or strongly agreed that EIFs contained accurate clinical information and that EIFs expedited care, respectively. A clinician leader-led initiative improved use of EIFs from 42% to 64% over 3 months. Although there was no association between EIFs and time to ED disposition decision, there was a modest reduction in hospitalization rates (53.4% to 50.5%). CONCLUSIONS:We demonstrate the feasibility/utilization of EIFs in the EHR that provide timely and accurate clinical information when accessed, but did not influence ED disposition efficiency.

Background:Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care.Methods:We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition.Results:There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022).Conclusions:A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity.

Background:Frontline healthcare safety leaders require expertise and confidence to manage local safety programs effectively yet are confronted with substantial challenges in identifying risk and reducing harm.Methods:We convened a multidisciplinary safety learning collaborative in a children's hospital pediatric department and used the Institute for Healthcare Improvement's Breakthrough Series model. Participants attended four virtual education sessions over 13 months (September 2020-September 2021) focused on identifying harm and using tools to improve safety. We analyzed departmental safety data monthly throughout the collaborative. The primary outcome was the development of improvement projects using direct application of the session content. The secondary outcome was participant confidence in improving safety via pre- and postsurveys.Results:Seventy clinicians and quality consultants participated. Fifteen divisional safety improvement projects were initiated. The percentage of survey respondents who reported feeling "completely confident" in their ability to improve safety increased from 26% (n = 39) to 58% (n = 26) from September 2020 to September 2021 (P = 0.01) and maintained at 65% 1 year after the end of the collaborative. We observed a decrease in the mean rate of reported inpatient preventable and possibly preventable moderate/serious/catastrophic events per 1000 bedded days from 1.10 (baseline) to 0.71 (intervention period).Conclusions:Through a collaborative effort in a virtual learning environment, we facilitated the development of fifteen safety projects, increased leaders' confidence in improving safety, and saw improved inpatient safety. This approach, which involves healthcare professionals from various disciplines, may be effectively adapted to other settings.

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

BACKGROUND AND OBJECTIVES: The complexity of pediatric patients’ outpatient medication regimens is increasing, and risk for medication errors is compounded in a busy emergency department (ED). As ED length of stay (LOS) increases, timely and accurate administration of essential outpatient medications has become increasingly challenging. Our objective was to increase the frequency of ordering of essential outpatient medications for patients with ED LOS >4 hours from 56% to 80% by June 2023. METHODS: We conducted a quality improvement (QI) initiative in a pediatric ED with ∼60 000 annual visits comprising a total of 91 000 annual medication orders. We defined essential outpatient medications as antiepileptic drugs, cardiovascular medications, and immunosuppressants. Our QI interventions included a combination of electronic health record interventions, a triage notification system to identify patients with essential outpatient medications, and widespread educational interventions including trainee orientation and individualized nursing education. The primary outcome measure was percentage of essential outpatient medications ordered among patients with an ED LOS >4 hours, with a secondary measure of outpatient medication safety events. RESULTS: Baseline monthly ordering rate of selected medications for patients with an ED LOS >4 hours was 54%, with an increase to 66% over the study period. Refining our population yielded a rate of 81%. Outpatient medication safety events remained unchanged, with an average of 952 ED encounters between events. CONCLUSIONS: A multidisciplinary QI initiative led to increased essential outpatient medication ordering for patients in a pediatric ED with no change in safety events.

Introduction: Structured handoffs at transitions of care are vital components of patient safety. A safety culture survey showed that “handoffs and transitions” were among the lowest scoring dimensions at our hospital. We sought to improve physician handoffs and safety culture scores by implementing standardized handoff communication across multiple divisions of an academic pediatric department. Methods: We used a modified learning collaborative model to implement an I-PASS program, including training, standardized verbal handoff processes, observation and feedback, and sustainment. The setting was the Department of Pediatrics (DoP) within a tertiary academic children’s hospital encompassing 13 clinical divisions. The primary outcome was a change in the DoP staff physician “handoffs and transitions” score on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture. Process measures included handoff duration and proportion of handoffs using the complete I-PASS mnemonic. Results: Five hundred sixty-seven physicians from clinical divisions participated over 14 months. One hundred percent of eligible physicians completed an introductory online I-PASS training module. The “handoffs and transitions” score improved from 46% to 54% from 2018 to 2020. From May 2019 to February 2020, the proportion of observed handoffs with all five elements of the I-PASS mnemonic improved from 62% to 100%, and the duration of handoffs per patient did not change. Conclusions: We successfully implemented an I-PASS program across an academic department of pediatrics. The departmental staff physician safety culture “handoff and transitions” score improved. The adherence to the I-PASS mnemonic improved. The duration of handoffs did not change over the study period.

BACKGROUND AND OBJECTIVES Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement. METHODS At a tertiary children’s hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates. RESULTS Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates. CONCLUSIONS The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

BACKGROUND Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019. METHODS A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children’s teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals’ data from the Pediatric Health Information System. RESULTS Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time. CONCLUSIONS We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.

BACKGROUND Many institutions track early ICU transfers (transfer from an inpatient floor to an ICU within 24 hours of admission) as a marker of quality of emergency department (ED) care. There are limited data evaluating whether patient characteristics or clinical outcomes differ on the basis of timing of ICU transfer within this 24-hour window. METHODS We conducted a retrospective cohort study examining all patients ≤21 years old admitted to an inpatient pediatric floor from the ED and subsequently transferred to an ICU within 24 hours of hospitalization. Patient characteristics and clinical outcomes were compared on the basis of timing (0–6 hours, 6–12 hours, 12–24 hours) of ICU transfer. Outcomes assessed included receipt of critical intervention, timing of intervention with respect to transfer, type of intervention received, hospital and ICU length of stay, and mortality at 72 hours and during hospitalization. RESULTS A total of 841 patients were transferred to an ICU within 24 hours from admission to a pediatric ward from the ED; 266 patients (32%) transferred within 6 hours of admission, 269 patients (32%) transferred between 6 and 12 hours, and 306 patients (36%) transferred between 12 and 24 hours. Patient characteristics did not materially differ on the basis of timing of ICU transfer, nor did clinical outcomes. CONCLUSIONS Among children transferred to an ICU within 24 hours of hospitalization, patient characteristics and clinical outcomes did not materially differ based on the timing of transfer relative to admission from the ED.

Gender inequity is pervasive in medicine, including emergency medicine (EM), and is well documented in workforce representation, leadership, financial compensation, and resource allocation. The reasons for gender inequities in medicine, including academic EM, are multifactorial and include disadvantageous institutional parental, family, and promotion policies; workplace environment and culture; implicit biases; and a paucity of women physician leader role models, mentors, and sponsors. To address some of the challenges of gender inequities and career advancement for women in academic EM, we established an innovative, peer-driven, multi-institutional consortium of women EM faculty employed at four distinct hospitals affiliated with one medical school. The consortium combined financial and faculty resources to execute gender-specific programs not feasible at an individual institution due to limited funding and faculty availability. The programs included leadership skill-building and negotiation seminars for consortium members. The consortium created a collaborative community designed specifically to enrich career development for women in academic EM, with a formal organizational structure to connect faculty from four hospitals under one academic institution. The objective of this report is to describe the creation of this cross-institutional consortium focused on career development, academic productivity, and networking and sharing best practices for work-life integration for academic EM women faculty. This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges.

OBJECTIVE:Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits.METHODS:This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted.RESULTS:There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results.CONCLUSIONS:These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Background Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency. Methods We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process. Results Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention. Conclusions Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED.

The novel coronavirus (SARS-CoV-2) has had a profound impact on care delivery across the United States. First reported on December 31, 2019, in China as a case cluster,1 the United States now faces over 1.84 million reported coronavirus disease 2019 (COVID-19) cases.2 As we work to understand COVID-19 and how to optimize care, recent literature suggests most pediatric patients who test positive have mild symptoms.3 However, there are emerging data regarding the newly described serious Multisystem Inflammatory Syndrome in Children (MIS-C).4,5 Healthcare workers are at significant risk—both from direct infection and psychological stress.6 In Massachusetts, elevated transmission efficiency led the governor to issue a stay-at-home advisory on March 24, 2020.7 In part due to the stay-at-home advisory, our hospital’s pediatric emergency department (ED) volume dropped by >60%. Despite low volumes in an ED that usually treats 60,000 patients annually, we were faced with a new, unprecedented challenge. Before COVID-19, our hospital’s ED celebrated a robust quality improvement (QI) program with multiple ongoing efforts focused on optimizing patient care, reducing variation and resource utilization through a clinical pathways program, and enhancing safety through a frequently used safety hotline. When the local pandemic started, many active improvement efforts, such as Plan-Do-Study-Act (PDSA) cycles, were disrupted as we turned immediate attention to safely providing care for potentially COVID-19-infected patients while maintaining high care standards for all patients. Traditional care processes required immediate restructuring to mitigate the risk to patients and staff, and involved rapid, even daily changes as our understanding of the virus evolved. With the rapid and dramatic change to our ED landscape during the pandemic, we are left asking, where does pediatric ED quality improvement go from here? How do we determine how to balance existing quality work and our new challenges? With limited data or experience to guide how to maintain focus on COVID-19 while also continuing momentum on the prepandemic quality efforts, we have taken our pandemic experience as an opportunity to develop a new framework. The framework guides adapting to COVID-19 while also maintaining and even advancing important QI work. As COVID-19 impacts and science are evolving, we hypothesize 3 phases of response: acute, subacute, and chronic. We define the acute phase by new protocol development and frequent staff updates on rapidly evolving practices to optimize care during the immediate crisis. The subacute phase, where we believe we are now, is defined as less frequent changes in practice, protocols, and updates to support providers, but continued improvement-related care for all patients due to these changes. We imagine the chronic phase as a new “steady state,” our ED healthcare team adjusted to daily safe practice, allowing for familiarity around COVID-19-specific care, together with a fully reestablished QI portfolio. We believe the phases may vary in duration and intensity at each department and hospital. Our framework has allowed quality teams to strategize about pre-existing and new quality work. First, during the acute phase, quality efforts were prioritized to front line provider safety and physical layout reconfiguration to minimize infectious risks. As an example, our ED team developed an iterative COVID-19 triage process map. We also began simulation training in newly developed, safe airway management protocols. Additionally, building on prior QI efforts at team communication, we have brought back shift-based team huddles, now via video conference, to bring front line providers together and support clinicians who may be under significantly increased stress and fatigue.8 As a result, we were able to share the latest protocols reviewing protective equipment use and viral testing, and to provide a real-time opportunity for questions and concerns by all staff. We have found shift-based huddles have enhanced team bonding and connectivity. By observation, staff are noted to be intently engaged during these huddles. Furthermore, as part of the acute phase, focus on safety and high-quality care was maintained, but we briefly paused active PDSA cycles unrelated to safety or COVID-19. During the current subacute phase, we have started to gently redirect energy back to PDSA cycles in the active “Do” phases before COVID-19. We are prioritizing ongoing QI interventions rather than introducing new quality efforts unrelated to COVID-19. We are continuing to analyze (“Study”) data and provide feedback regarding success in these initiatives. As an example, we have encouraged project leaders to share little victories, such as progress toward SMART aim targets. We see positive communication as an essential step to avoid losing project momentum and empower staff to focus on interventions prioritized before the pandemic. Positive feedback can function as a morale booster to a stressed staff. Also, we are drafting future PDSA cycles to initiate once we are in the chronic phase of adjustment to COVID-19. In the chronic phase, we believe we will have reestablished and added to our robust quality portfolio as we anticipate the care models will be changed for the long term. We are in an uncertain time. As is true with all quality improvement initiatives, we are learning as we go. Right now, we have more questions than answers. What will ED pediatric QI look like in a few months? Will our acute, subacute, and chronic paradigm be effective? What health care problems have we neglected by perceived and real challenges to accessing care? Moreover, how will EDs, safety nets for children, be affected by profound economic consequences of a pandemic? We suggest quality work is now more critical than ever. We must be ready to jump in with skills to engender excitement, positive change, and hope for a new world. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

OBJECTIVE: Analyze trends in visit numbers, length of stay (LOS), and costs of pediatric mental health emergency department (ED) visits over time. METHODS: We conducted a cross-sectional, time-series analysis from 2010 to 2016 of mental health visits, identified by billing diagnosis codes, among children 5 to 18 years old in a tertiary pediatric ED. We used Poisson regression to analyze trends in rates of mental health visits, patient-hours, and visits with LOS >= 24 hours. We used time-series analysis to trend median costs per visit. RESULTS: From 2010 to 2016, there were 197,982 ED visits and 13,367 (6.7%) mental health visits. Mental health visits increased by 45% (from 1462 to 2119), compared to a 13% increase in non-mental health visits. The rate of mental health visits increased from 5.6 to 7.1 per 100 ED visits and increased 5.5% annually, compared to -0.4% annually for non-mental health visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.05-1.07). Mental health patient-hours increased 186%, compared to an 18% increase in non-mental health patient-hours. The rate of mental health visits with LOS >= 24 hours increased from 4.3 to 18.8 per 100 mental health visits and increased 22% annually (IRR, 1.22; 95% CI, 1.19-1.26). Median costs per visit increased by $38 per quarter (95% CI, $28-$48). CONCLUSIONS: Rates of mental health visits, patient-hours, visits with LOS >= 24 hours, and visit costs are increasing over time. Additional hospital and community resources are needed to address rising ED utilization for mental illness in children.

BACKGROUND:There is a paucity of data describing pediatric patients transferred to an ICU within 24 hours of hospital admission from the emergency department (ED).METHODS:We conducted a retrospective cohort study of patients ≤21 years old transferred from an inpatient floor to an ICU within 24 hours of ED disposition from 2007 to 2016 in a tertiary children's hospital. Patients transferred to an ICU after planned operative procedures were excluded. Rate of transfer, clinical course, and baseline demographic and/or clinical characteristics of these patients are described.RESULTS:The study cohort consisted of 841 children, representing 1% of 82 397 non-ICU ED admissions over the 10-year period. Median age was 5.1 years, 43% had ≥1 complex chronic condition, and 47% were hospitalized within the previous year (27% in the ICU). The majority of transfers were for respiratory conditions (65%) and cardiovascular compromise (18%). Median time from hospitalization to ICU transfer was 9.1 hours (interquartile range 5.1-14.9 hours). Thirty-eight percent of transfers received 1 or more critical interventions within 72 hours of hospitalization, most commonly positive pressure ventilation (29%) and vasoactive infusion (9%). Median time to intervention from hospitalization was 13.6 hours (interquartile range 7.5-21.6 hours), 0.8% of children died within 72 hours of hospitalization, and 2.4% died overall.CONCLUSIONS:In this single pediatric academic center, 1% of hospitalized children were transferred to an ICU within 24 hours of ED disposition. One-third of patients received a critical intervention, and 2.4% died. Although most ED dispositions are appropriate, future efforts to identify patients at the highest risk of deterioration are warranted.

OBJECTIVE:Efforts to reduce the rate of computerized cranial tomography (CT) in pediatric patients with minor head trauma (MHT) have focused on academic medical centers. However, community hospitals deliver the majority of pediatric emergency care. We aimed to reduce cranial CT utilization in patients presenting with MHT at 3 community hospital emergency departments (EDs). METHODS:Multidisciplinary stakeholder teams at each site oversaw the quality improvement effort, which included education about an evidence-based guideline for MHT and individual provider feedback on CT rates. Given the variation in hospital structure, we tailored the specifics of the intervention to each site. We used statistical process control methodology to measure CT rates over time. The primary balancing measure was returned to the ED within 72 hours with clinically important traumatic brain injury. RESULTS:We included 3,215 pediatric ED visits for MHT: 1,253 in the baseline period and 1,962 in the intervention period. The CT rate dropped from 18% in the baseline period to 13% in the intervention period, a 28% relative reduction. Pediatric providers saw 72% of the intervention period encounters and drove this reduction. There was no increase in the number of children who returned to their local ED within 72 hours with clinically important traumatic brain injury. CONCLUSIONS:We safely reduced the proportion of children with MHT who received a cranial CT through a multicenter community ED quality improvement initiative. We did not see an increase in missed clinically important traumatic brain injury.