BACKGROUND:Intravenous (IV) fluids are commonly used in emergency departments (ED), but their supply can be vulnerable to national shortages. In September 2024, Tropical Storm Helene disrupted production at a major manufacturing facility, triggering a nationwide IV fluid shortage. In response, our ED implemented a multiphase intervention aimed at reducing non-essential fluid utilization. We aimed to reduce total IV fluid use in the ED by at least 25% through a staged, systems-based conservation strategy. METHODS:We conducted a single-center, retrospective, pre-post quality improvement initiative in a tertiary academic ED with approximately 57,000 annual visits. Interventions were deployed across three Plan-Do-Study-Act cycles: 1) clinician education on fluid stewardship (7 days); 2) protocol modifications to reduce routine IV placement (11 days); and 3) electronic health record (EHR) clinical decision support tools, including an interruptive alert and oral hydration order set (32 days). We analyzed daily fluid administration volumes, and ED census data from September 2024 (pre-intervention) and November 2024 (post-intervention). The primary outcome was total IV fluid usage per day; a secondary outcome was IV fluid volume per patient encounter. We compared mean daily utilization between periods using two-sample t-tests. RESULTS:Average daily IV fluid use declined from 56.3 to 24.8 liters, a 56.0% relative reduction (P < .001), while ED volume remained stable (155.4 vs 153.1 encounters/day pre- vs post-intervention). Normalized per-encounter IV fluid administration decreased from 0.36 to 0.16 liters per visit (P < .001), representing a 56% relative reduction. Assuming a pharmacy acquisition cost of approximately $2 per liter of crystalloid, the intervention was associated with an estimated reduction of $63 in IV fluid expenditures per day (31.5 liters), or $1,890 over the 30-day post-intervention period. CONCLUSION:A structured intervention combining education, protocol changes, and EHR decision support significantly reduced IV fluid use in the ED without disrupting operations. This approach may serve as a scalable model for resource stewardship during future supply chain crises. The most substantial reductions occurred during the final intervention phase involving EHR-based decision support.

Emergency departments (EDs) across the United States are facing unprecedented patient volumes and overcrowding, amplifying the need to optimize throughput and operational efficiency. Computed tomography (CT) turnaround time (TAT) is the interval from imaging order to interpretation, and this represents a key determinant of ED flow. At our academic medical center, overnight CT TATs exceeded national benchmarks, largely due to delays between radiology resident preliminary reads and initiation of third-party attending-level teleradiology interpretations. Our objective was to reduce the interval between preliminary resident interpretation and teleradiology service request by 25

Autism spectrum disorder (ASD) affects 1 in 36 children, with many presenting to emergency departments (EDs) for behavioral health concerns. This study examined age-specific restraint patterns in pediatric ED patients with ASD compared to patients without ASD. This retrospective cohort study included 3,469 patients aged 5–17.9 years requiring psychiatric consultation or behavioral hold at a tertiary pediatric ED (2013–2025). Physical and pharmacologic restraint use were analyzed using multivariable logistic regression with age-stratified analysis across developmentally-based categories: 5–8 years, 9–12 years, and > 12 years. Physical restraint occurred in 14.1

Our Emergency Department (ED), like many others in the US, experiences chronic congestion, slow flow, and long wait times – all of which have notably worsened in recent years. For many of our patients, computed tomography (CT) turnaround time is a key determinant of ED flow, yet strategies to reduce preacquisition delays remain under-described. Our objective was to reduce CT order-to-exam start time by 25

BACKGROUND:In quaternary academic centers with sustained high demand, level-loading strategies that transfer selected emergency department (ED) admissions to community affiliates can preserve capacity and reduce boarding. In one such system in Portland, Oregon, a mature ED-to-affiliate transfer infrastructure existed; however, consent rates remained low when discussions were largely mediated by ED physicians, limiting transfer execution reliability. OBJECTIVES:To evaluate whether a team-based Transfer Consent Partner model could achieve a consent-to-transfer success rate of at least 75% for ED-to-affiliate hospital transfers. STUDY DESIGN:Single-center quality improvement initiative. METHODS:A Transfer Consent Partner was implemented during a learning launch (November 2025-January 2026) in a quaternary academic ED. The Transfer Consent Partner delivered standardized, emotionally informed consent discussions, addressed patient and family questions, prepared documentation, engaged social work for barriers, and coordinated transfer logistics. The primary outcome was the proportion of Transfer Consent Partner-involved encounters resulting in consent to transfer, with a prespecified target of at least 75%. A secondary analysis compared Transfer Consent Partner-involved encounters with non-Transfer Consent Partner encounters during the concurrent learning-launch period and calculated the absolute difference and its 95% confidence interval. Secondary outcomes included operational demand, temporal distribution, and clinician and patient experience. RESULTS:Over a 12-month evaluation period (February 2025-January 2026), 1909 eligible encounters occurred (overall consent to transfer 40.2%). During the learning launch, 27 of 35 Transfer Consent Partner-involved encounters resulted in consent to transfer (77.1%), meeting the prespecified target. Consent-to-transfer success was 48.3% among concurrent non-Transfer Consent Partner encounters, corresponding to an absolute difference of 28.8 percentage points (95% CI, 12.2 to 40.4). The Transfer Consent Partner supported 1-6 conversations per shift (median 3), lasting 5-40 min (median 10). Physician survey respondents (n = 8) rated teamwork very or extremely strong in 80% of responses. CONCLUSION:In this early learning launch involving 35 Transfer Consent Partner-supported encounters, consent-to-transfer success was higher than among concurrent encounters without Transfer Consent Partner involvement. Broader implementation and evaluation are needed to determine whether these preliminary findings are reproducible and sustainable.

BACKGROUND:Emergency department (ED) crowding and inpatient boarding delay care and increase the risk of patients leaving without being seen (LWBS). We implemented a combined physician waterfall schedule (PWS) and modified physician-in-triage (PIT) model to expand front-end capacity, accelerate early physician assessment, and reduce LWBS. METHODS:We conducted a single-center, retrospective pre-post study of adult ED encounters (≥20 years) over consecutive 12-month pre- and post-intervention periods (January 3, 2023-December 31, 2024). The intervention paired a staggered PWS (increasing attending coverage from 54 to 62 h/day) with a modified PIT model requiring full initial evaluation and clinical ownership through disposition. We used statistical process control (P-chart) to assess monthly LWBS trends and logistic regression with inverse probability of treatment weighting (IPTW) plus covariate adjustment to compare the primary outcome between periods; univariable tests were used for secondary outcomes (throughput, ED returns, and patient experience) and balancing measures (left-before-treatment-complete, ED return within 72-h resulting in hospital admission). RESULTS:Among 79,898 adult encounters, LWBS decreased from 6.5% to 4.7%. IPTW analysis showed lower odds of LWBS (OR 0.71; 95% CI 0.66-0.76), corresponding to a 28.1% relative reduction and exceeding the 25% target. ED return within 72 h decreased (5.5% to 5.1%, p = 0.004), as did returns with admission (0.8% to 0.7%, p = 0.027). Other secondary outcomes were largely unchanged. Improvements occurred despite increased boarding. CONCLUSION:A combined PWS plus modified PIT model was associated with reduced LWBS while maintaining safety and patient experience, offering a pragmatic strategy to mitigate ED crowding.

BACKGROUND:Regulatory bodies require the use of restraints and seclusion in health care settings to be strictly monitored and carefully documented. In our emergency department (ED), an internal audit uncovered low compliance with required patient safety documentation, the so-called "face-to-face (FTF)" assessment, within 1 hour of restraint or seclusion initiation. The primary objective of this quality improvement (QI) study is to evaluate a series of interventions as a mechanism to improve FTF documentation compliance. METHODS:This project was conducted in a single-site academic ED. Patients requiring restraints and seclusion application from November 2021 to June 2024 were included. We implemented 3 plan-do-study-act (PDSA) cycles: (1) development of FTF documentation flowsheet with delayed best practice alert (BPA) trigger, (2) direct audit and clinician feedback via email, and (3) modification to immediate BPA trigger. Our primary outcome was a change in the rate of FTF documentation completion within 60 minutes of restraint or seclusion application. We used descriptive analysis to evaluate adherence rates. RESULTS:There were 856 qualifying instances during the study period. Our intervention bundle was associated with an increase in documentation adherence from a preintervention baseline of 10.96% to a final performance of 81.28%, an absolute increase of 70.32% ( P <0.001). CONCLUSIONS:Our series of interventions, including direct feedback and technical solutions, was effective in increasing clinician FTF documentation adherence. By deploying these interventions iteratively, our approach supported practice change and behavioral modification among ED clinicians, highlighting the importance of an incremental process in changing practice and culture.

OBJECTIVE:To increase the percentage of patients who undergo rapid magnetic resonance imaging (rMRI) rather than computed tomography (CT) for evaluation of mild traumatic brain injury (TBI) from 45% in 2020 to 80% by December 2021. STUDY DESIGN:This was a quality improvement initiative targeted to patients presenting to the pediatric emergency department presenting with mild TBI, with baseline data collected from January 2020 to December 2020. From January 2021 to August 2021, we implemented a series of improvement interventions and tracked the percentage of patients undergoing neuroimaging who received rMRI as their initial study. Balancing measures included proportion of all patients with mild TBI who underwent neuroimaging of any kind, proportion of patients requiring sedation, emergency department length of stay, and percentage with clinically important TBI. RESULTS:The utilization of rMRI increased from a baseline of 45% to a mean of 92% in the intervention period. Overall neuroimaging rates did not change significantly after the intervention (19.8 vs 23.2%, P = .24). There was no difference in need for anxiolysis (12 vs 7%, P = .30) though emergency department length of stay was marginally increased (1.4 vs 1.7 hours, P = < 0.01). CONCLUSION:In this quality improvement initiative, transition to rMRI as the primary imaging modality for the evaluation of minor TBI was achieved at a level 1 pediatric trauma center with no significant increase in overall use of neuroimaging.

Objective:We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS) ≥ 88 (0-100 scale) across EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness.Methods:We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day-to-day ED operations (ie, direct clinical care and routine ED supplies).Results:The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719-100,694) for low volume EDs to $279,134 (95% CI 196,487-362,179) for very high volume EDs; equipment costs accounted for 0.9-5.0% of expenses. The total annual cost-per-patient ranged from $3/child (95% CI 2-4/child) to $222/child (95% CI 156-288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child.Conclusions:Annual hospital costs for HPR are modest, particularly when considered per child.

Introduction: The COVID-19 pandemic poses challenges in maintaining global medical education partnerships, with travel restrictions and infection control concerns forcing program adaptation. The Pediatric Emergency Medicine Specialty Training and Accelerated Review (PEM-STAR) program is one such international collaboration which addresses education and training gaps in emergency care for children within Thailand. As an assessment of PEM-STAR’s ability to deliver consistent outcomes despite COVID-19 constraints, we compared program results for Cohort #1 (2018-2019, pre-pandemic) and Cohort #2 (2019-2021, spanning pandemic). Method: Oregon Health & Science University and Bangkok Dusit Medical Services implemented the PEM-STAR tandem physician-nurse curriculum in 2018. The cornerstone of the year-long course is a set of 22 PEM-specific topic modules, incorporating remote-accessible voiceover slide lectures, quizzes, and scholarly references to teach pediatric emergency medicine essentials. Content is reviewed via monthly teleconferences. Baseline and final assessments include written knowledge tests and high-fidelity simulation cases led by physician-nurse teams. Cohort #1 simulations were performed with evaluators in-situ using critical action checklists and validated teamwork assessment tools. Due to COVID-19 restrictions, Cohort #2 final assessments were hybrid; students completed Thailand-based simulations while Oregon leaders assessed and debriefed teams via videoconference. Results: Written exam scores for pre-pandemic Cohort#1 improved from 48.6% (95%CI 40.30-56.9) to 92.0% (95%CI 88.1-95.9) (p< 0.001). Cohort #2, during the pandemic, had scores improve similarly from 48.5% (95%CI 40.1-56.9) to 96.4% (95%CI 94.8-98.0) (p< 0.001). One-hundred percent of physician-nurse teams from both Cohort #1 and Cohort #2 achieved the program’s established passing score on final simulation testing: performing >85% of critical action items and scoring > 85% on the teamwork tool. Conclusion: The PEM-STAR design, with its emphasis on videoconferencing, web-based content, and asynchronous learning, required minimal modifications to maintain satisfactory knowledge and skill acquisition during the pandemic. Educational partnerships emphasizing these features have distinct sustainability advantages in times of global disorder.

Objectives: Pediatric mental health presentations continue to increase across the US. These patients often board for significant periods of time and may require more resources than other acute non-mental health patients. This has important implications for the overall function of the emergency department (ED) as well as care of all ED patients.Methods: This study evaluated a policy developed to allow for inpatient hospital admission when 30% of the ED was occupied by boarding patients at a tertiary care children's hospital.Results: We found an increase in the number of patients for whom this policy applied, and increased days/month this policy was executed over time. There was an increase in the average ED LOS and left without being seen rate during this time which we hypothesize would have been higher without this policy.Conclusions: A hospital policy allowing mental health patients to be admitted to the inpatient hospital once stabilized has the potential to improve ED flow and functionality.& COPY; 2023 Elsevier Inc. All rights reserved.

Pediatric patients with shunted hydrocephalus are frequently evaluated in the emergency department (ED) with concern for shunt failure. Because shunt failure is potentially life-threatening, accurate diagnosis is essential. However, neuroimaging imperfectly detects children in failure, with reported sensitivities of 53% to 92% for computed tomography and 51% to 59% for magnetic resonance imaging. Objectives We sought to identify clinical characteristics that would negatively predict shunt failure, thus potentially obviating the need for further diagnostic workup or extended periods of observation. We hypothesized that viral symptoms and a patient history of epilepsy or chronic headaches would be negative predictors of shunt failure. Methods Data were retrospectively collected for children 19 years or younger with a cerebrospinal fluid diverting shunt in their medical history or problem list who underwent neuroimaging during an ED visit from March 2008 to September 2016. Patients were defined as having shunt failure if they required surgical exploration for shunt revision within 7 days of the ED visit. Descriptive statistics were used for patient demographics, current symptoms, and historical features. We conducted a logistic regression analysis to determine which characteristics were associated with the odds of shunt failure and used binary recursive partitioning to determine if there were features or a combination of features that were able to accurately classify patients without shunt failure. Results There were 606 visits by 277 patients during this interval, 34% of whom were experiencing shunt failure. Variables found to be significantly predictive of shunt failure were revision within the prior 6 months, vomiting, personality changes, family opinion of shunt failure, and cranial nerve palsies. Viral symptoms and a history of epilepsy or chronic headaches were not predictive of shunt failure. Binary recursive partitioning identified family opinion and personality changes as predictive of shunt failure, with a sensitivity of 72.2% (95% confidence interval, 65.5%–78.2%) and specificity of 46.6% (95% confidence interval, 41.7%–51.7%). Conclusions Although certain clinical and historical features have modest predictive value in children with shunted hydrocephalus, these factors are insufficiently sensitive to exclude shunt failure, arguing for liberal neuroimaging and extended observation.

When a patient is admitted to the hospital from the emergency department (ED), the ED clinician passes on relevant clinical information to the admitting team to transition care, a process known as patient hand-off and commonly referred to as ‘calling report’. This information exchange between clinical teams is not only important for care continuity but also signifies a transition of care.However, there are unique challenges in this hand-off process given the unpredictability of the busy ED environment, ED boarding and discontinuity in physician, nursing and transportation workflows. These challenges create the potential for gaps in communication and can create patient safety concerns, particularly if a patient is transported to an inpatient bed before hand-off takes place.We set out to determine whether introducing a visual cue on the electronic health record (EHR) ED trackboard to communicate that report had been given would improve hand-off compliance. We sought to improve the utility of the visual cue and compliance of calling report prior to patient transport through a series of several Plan Do Study Act (PDSA) cycles.Baseline compliance using the ‘Report Called’ button prior to implementation of our visual intervention was 9.8%. With staff education alone, compliance rose to 41.3%. However, with an easily recognisable visual cue highlighted on the trackboard and an improved workflow compliance immediately rose to >97% and has been sustained for 84 months. Additionally, we have had zero reported incidents of patients being transported to a hospital bed before physician report was called since implementation.Our study demonstrates that simple visual cues and incorporation of a user-friendly process in the workflow can improve compliance with ensuring report is called prior to patient transfer from the ED. This may have a positive impact on physician communication and patient safety during the admission process.

Abstract Background Clinical evaluation alone is not effective in identifying serious bacterial infections (SBI) in neonates presenting with suspected sepsis and fever. A clinical decision making tool to aide in evaluating neonates presenting to the pediatric emergency department (PED) uses urinalysis, absolute neutrophil count (ANC), and procalcitonin (PCT) and together has high negative predictive value (NPV) for SBI. Use may decrease invasive testing, antibiotic exposure, and rates of admission. The tool was incorporated into hospital guidelines in October 2020. The purpose is to assess implementation and prediction of SBIs. Methods This is a single-center quality improvement study at an academic medical center. Neonates less than 60 days presenting with fever or suspected sepsis were included in the baseline group from October 2019- March 2020 or the post-implementation group from October 2020- March 2021. Exclusion criteria were receiving antibiotics 48 hours before PED visit, pre-existing medical conditions, indwelling devices, soft-tissue infections, and ≤ 36 weeks gestation. Implementation and guideline compliance was assessed in neonates aged 29-60 days as the primary outcome. Secondary endpoints include initiation of empiric antibiotics, rates of admission, rates of re-presentation within 30 days, and rates of lumbar punctures in all included patients. Results The baseline group had 29 patients and the post-implementation group had 35 patients who met inclusion/exclusion criteria. Baseline characteristics were similar with higher SBI rates in the post-implementation group having 8 SBIs while the baseline group had 4. There were 16 patients aged 29-60 days in the baseline (55%) and 17 in the post-implementation groups (49%). Complete labs were available for 9 patients (53%) and guideline compliance was 89%. NPV in neonates aged 0-60 days with negative urinalysis, ANC, and PCT was 100%. Rates of secondary endpoints were slightly higher in the post-implementation group along with higher rates of infections. Conclusion High NPV in this small cohort is an indication for continued use of this tool in neonates presenting to the PED with suspected sepsis or fever. Further education to increase use and expansion to all neonates should be considered based on overall NPV and previous studies. Disclosures All Authors: No reported disclosures

In Thailand, there are few pediatric emergency medicine (PEM) fellowship‐trained providers, and emergency departments (EDs) are staffed by pediatricians and emergency physicians. Our pediatric ED collaborated with Thailand's largest private hospital system to develop a training program designed to improve emergency care for children.

Background Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. Objectives To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). Methods We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. Results Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%–99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, −0.053–0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). Conclusions 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 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.

Pediatric fever is one of the most common presenting complaints to emergency departments (ED). While often due to a viral illness, in young children without a source the most common bacterial infection is pyelonephritis. For this reason, when no focal source can be identified a urinary specimen is recommended. In young children who are unable to urinate on demand, a straight catheter is required to obtain a sterile specimen. This is generally a benign procedure and is performed frequently in EDs. We report a case of a young girl who underwent straight bladder catheterization and was subsequently found to have a retained catheter that had become knotted in the bladder. This case report highlights a rare complication of this common procedure and describes the technique required to remove the catheter. An understanding of these issues may avoid the need for transfer to a pediatric facility or for subspecialty consultation.