OBJECTIVE:Compared with first-generation antihistamines (FGAs), second-generation antihistamines (SGAs) are equally effective, longer acting, and better tolerated. We aimed to reduce the proportion of patients receiving FGAs among all receiving antihistamines from baselines of 74% in the pediatric emergency department (PED) and 54% in inpatient units by 50% within 6 months and sustain this change for 6 months. METHODS:This multidisciplinary quality improvement initiative was conducted between 2022-2024. Implemented interventions were clinician education, flyers, ensuring cetirizine availability, and clinical pathways updates. The outcome measures were the proportion of patients receiving FGAs (diphenhydramine or hydroxyzine) or SGAs (cetirizine) among all receiving antihistamines. The process measures were educational sessions, knowledge assessments, and clinical pathways usage. The balancing measures were emergency department revisit within 48 hours, median inpatient length of stay, and antihistamine cost. We assessed improvement using statistical process control charts. RESULTS:The proportion of patients receiving FGAs decreased from 74% to 28% in the PED and from 54% to 36% in inpatient units. Reductions were sustained for 8.5 and 9 months, respectively. Cetirizine use increased from 31% to 75% in the PED and from 54% to 74% in inpatient units. Knowledge scores doubled posteducation. Clinical pathways usage increased from 36 to 44 clinicians monthly. Emergency department revisits and length of stay remained stable. Monthly median antihistamine costs increased in the PED from $53 to $177 and inpatient from $57 to $104. CONCLUSIONS:Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.

BACKGROUND AND OBJECTIVES:Restraints are used in emergency departments to treat acute agitation and prevent harm but can cause injury. Local data demonstrated racial and ethnic disparities in restraint use. Of non-Hispanic Black and Hispanic patients, 2.7% were physically restrained, compared with 1.1% of non-Hispanic White patients. Intramuscular chemical restraint rates were highest among non-Hispanic Black patients at 6.0%, compared with 3.7% in Hispanic patients and 2.6% in non-Hispanic White patients. We sought to reduce these differences to less than 1% within 12 months. METHODS:We identified drivers to managing agitation, including improved staffing, standardized care protocols, enhanced deescalation training, and early assessment. A multidisciplinary team implemented interventions through Plan-Do-Study-Act cycles, including a standardized pathway, 24/7 access to behavioral health counselors, care plans, deescalation training, and education on racial disparities. Statistical process control charts were used to track restraint use. Process measures included staff knowledge of racial disparities in restraint use. The balancing measure included the frequency of staff injuries. RESULTS:Physical restraint rates remained unchanged for non-Hispanic Black and non-Hispanic white but decreased to 1.3% for Hispanic patients. We observed reductions in intramuscular restraint disparities: rates decreased to 1.4% for non-Hispanic Black and 1.2% for Hispanic patients, with 8 consecutive points below the centerline, whereas rates for non-Hispanic white patients remained at 2.6%. Staff injuries did not increase. CONCLUSION:Targeted quality improvement interventions led to reduction in disparities in restraint use. Ongoing work includes simulation-based training and addressing structural drivers.

BACKGROUND:After Hurricane Helene made landfall in September 2024, the U.S. faced a nationwide intravenous (IV) fluid shortage due to damage at a key manufacturing facility. To prioritize supplies for the most critical patients, Yale - New Haven Health System (YNHHS) introduced an interruptive pop-up within electronic health workflows, reminding clinicians of the IV fluid shortage and to consider oral hydration. OBJECTIVE:To evaluate the effectiveness of interruptive pop-up alerts during an acute medication shortage. METHODS:YNHHS deployed the pop-up across nine Emergency Departments, prompting clinicians to consider oral hydration when attempting to order IV fluids. We evaluated clinician responses to the decision support alert from inception on October 8, 2024, to January 16, 2025. RESULTS:A total of 5500 patients received IV fluids during the 15-week study period, of which 5410 (98.4%) were visits that had the pop-up. In week one, 74.7% of clinicians canceled their IV fluid orders after encountering the pop-up. However, effectiveness of the alert declined rapidly. By week 6, only 18.4% of orders were canceled, and week 15, 8.3%. The percent of visits where patients received IV fluids decreased from a baseline of 20.9% to a nadir of 3.4% during the acute phase of the crisis, but had increased to 10.1% by week 15. CONCLUSION:Interruptive alerts can be effective for immediate behavior change during acute crises. However, the effect of interruptive alerts diminishes over time due to clinician adaptation. For sustained practice change, pop-ups can be integrated into a broader strategy that includes education, workflow redesign, clinician team engagement, and timely pop-up deactivation.

Objectives To examine how structural factors, such as child protective services (CPS) involvement, prehospital interactions with police or emergency medical services (EMS), and clinical factors, such as autism diagnosis, contribute to physical restraint use among pediatric patients presenting to the emergency department (ED) for behavioral health concerns. Methods In this retrospective cohort study, we reviewed pediatric ED encounters from January 1, 2021, to October 31, 2023, at a tertiary care children’s hospital. Multivariable logistic regression was used to assess associations among autism diagnosis, CPS involvement, and arrival mode (police/EMS) and physical restraint use, adjusted for demographic variables. Results Among 6288 behavioral health encounters, physical restraints were used in 124 (1.97%; 95% CI, 1.69, 2.58) encounters. Children arriving by police or EMS were 3 times more likely to be restrained than those arriving by car or walk-in (adjusted odds ratio, aOR = 3.07, 95% CI, 2.01-4.69). Children with CPS involvement were almost twice as likely to be restrained (aOR = 1.91; 95% CI, 1.26-2.88). Children diagnosed with autism were 7 times more likely to be restrained (aOR = 7.25, 95% CI, 3.61-14.55). Black children were more likely to be restrained than White children (aOR = 1.78, 95% CI, 1.12-2.84). Conclusion CPS involvement, transport by police or EMS, autism diagnosis, and Black race were independently associated with increased physical restraint use in pediatric ED patients. These findings emphasize the role of both structural and child-level factors in contributing to physical restraint in emergency behavioral health care, highlighting the need for a multifactorial approach to reduce restraint use.

BACKGROUND:Documentation is essential to patient care, research, and financial sustainability. In our pediatric emergency department (PED), existing documentation practices contributed to financial deficits and decreased workplace satisfaction. OBJECTIVE:To increase the monthly average relative value unit (RVU) per encounter by 10% over 2 years. Phase 1 aimed to reduce level of service (LOS) 99282 billing by 20%. Phase 2 targeted a 20% increase in LOS 99285 billing and aimed for 90% of admitted patients to be billed at LOS 99285. METHODS:Using the Model for Improvement and iterative Plan-Do-Study-Act (PDSA) cycles, our team implemented interventions including a billing dot phrase, revised note templates, billing reference sheets, and an LOS calculator. Outcomes were tracked using statistical process control charts. Balancing measures included coding concordance (chart audit, run charts) and provider impact (pre/post-surveys, run charts for note length, and documentation time). RESULTS:The average RVU per encounter increased by 11%. LOS 99282 billing decreased by 25%, whereas LOS 99285 billing increased from 9% to 13%, and from 50% to 70% among admitted patients. Billing discordance remained at 28%. Provider satisfaction improved: perceived ease of documentation rose from 46% to 69%, and overall satisfaction from 6% to 49%. Documentation time remained stable (6.6 min), and note length decreased. CONCLUSIONS:Targeted documentation interventions improved both RVU generation and provider satisfaction. Future work will focus on optimizing critical care documentation and enhancing collaboration with professional billers to reduce coding discordance.

Importance:Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective:To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants:This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures:Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures:The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results:Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance:Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Antihistamines (AH) are a cornerstone of treatment of acute allergic reactions in the pediatric emergency department (ED). Despite the abundant evidence demonstrating the inferiority of first-generation AH over second- and third-generation AH, first-generation AH remain inappropriately overutilized. We hypothesized that simple interventions targeting provider education could lead to a decrease in utilization rates of first-generation AH, with an associated rise in second/third-generation use.

Survivors of intimate partner violence and their children often seek care in emergency departments (EDs) after intimate partner violence exposure.1 Abusers may interfere with health care by accessing the electronic health records of victims legally, as a proxy, guardian, or duplicitously.2 Discovery of intimate partner violence disclosure through electronic health records may subject victims to health care access restrictions and escalated violence.2

OBJECTIVES:Medically minor but clinically important findings associated with physical child abuse, such as bruises in pre-mobile infants, may be identified by frontline clinicians yet the association of these injuries with child abuse is often not recognized, potentially allowing the abuse to continue and even to escalate. An accurate natural language processing (NLP) algorithm to identify high-risk injuries in electronic health record notes could improve detection and awareness of abuse. The objectives were to: 1) develop an NLP algorithm that accurately identifies injuries in infants associated with abuse and 2) determine the accuracy of this algorithm.METHODS:An NLP algorithm was designed to identify ten specific injuries known to be associated with physical abuse in infants. Iterative cycles of review identified inaccurate triggers, and coding of the algorithm was adjusted. The optimized NLP algorithm was applied to emergency department (ED) providers' notes on 1344 consecutive sample of infants seen in 9 EDs over 3.5 months. Results were compared with review of the same notes conducted by a trained reviewer blind to the NLP results with discrepancies adjudicated by a child abuse expert.RESULTS:Among the 1344 encounters, 41 (3.1%) had one of the high-risk injuries. The NLP algorithm had a sensitivity and specificity of 92.7% (95% confidence interval [CI]: 79.0%-98.1%) and 98.1% (95% CI: 97.1%-98.7%), respectively, and positive and negative predictive values were 60.3% and 99.8%, respectively, for identifying high-risk injuries.CONCLUSIONS:An NLP algorithm to identify infants with high-risk injuries in EDs has good accuracy and may be useful to aid clinicians in the identification of infants with injuries associated with child abuse.

The Adverse Childhood Experiences (ACEs) questionnaire is a widely used screener for pediatric trauma exposure and general household dysfunction. On a population level, ACEs are cumulative risk factors for a range of mental health and physical conditions. ACEs research has been largely based on self-reported ACEs exposures and health conditions, anthropometric measures, and biomarkers. In contrast, data mined directly from the electronic health record (EHR) allows for more objective analysis and reduces potential harms and limitations of self-report.

Objective Our primary aim was to describe pediatric residents' use of a workplace procedural training cart. An exploratory aim was to examine if the cart associated with increased resident procedural experiences with real patients. Methods Guided by the procedural training construct of "Learn, See, Practice, Prove, Do, Maintain," we created a novel workplace procedural training cart with videos (learn and see) and simulation equipment (practice and prove). An electronic logbook recorded resident use data, and a brief survey solicited residents' perceptions of the cart's educational impact. We queried our electronic medical record to compare the proportion of real procedures completed by residents before and after the intervention. Results From August 1 to December 31, 2019, 24 pediatric residents (10 interns and 14 seniors) rotated in the pediatric emergency department. Twenty-one cart encounters were logged, mostly by interns (67% [14/21]). The 21 cart encounters yielded 32 learning activities (8 videos watched and 24 procedures practiced), reflecting the residents' interest in laceration repair (50% [4/8], 54% [13/24]) and lumbar puncture (38% [3/8], 33% [8/24]). All users agreed (29% [6/21]) or strongly agreed (71% [15/21]) the cart encouraged practice and improved confidence in independently performing procedures. No changes were observed in the proportion of actual procedures completed by residents. Conclusions A workplace procedural training cart was used mostly by pediatric interns. The cart cultivated residents' perceived confidence in real procedures but was not used by all residents or influenced residents' procedural behaviors in the pediatric emergency department.

BACKGROUND:Small rare earth magnets pose a known health risk to children and many cases of ingestion and aspiration with associated complications have been described. More unusual, but also seen in children, are retained foreign bodies in the oropharynx that require extraction. CASE REPORT:We present the case of a 3-year-old boy with persistent left-sided sore throat 1 h after ingestion of several 3-mm spherical rare earth magnets. No foreign bodies were visible in the oropharynx on examination; however, a chest radiograph revealed two adjacent magnets within the lower pharyngeal space, as well as four magnets linearly clumped within the small intestine. The patient was taken to the operating room, where visual inspection under general anesthesia revealed two magnets adhered to the pharyngoepiglottic folds (one on the laryngeal surface and one on the glottic surface). They were removed in full without issue, preventing aspiration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the recent increase in incidence of rare earth magnet ingestion, emergency providers ought to be aware of the risks and complications associated with magnetic foreign body ingestion in children and the workup and considerations involved in their removal. Providers should also advocate for improved safety controls of these products, which have been found to be effective in the past.

Study objective There is a continued movement toward health data transparency, accelerated by the 21st Century CURES Act, which mandated the automatic and immediate release of clinical notes, often termed "open notes." Differences in utilization among different patient demographics and disproportionately affected populations within the emergency department (ED) are not yet known. Methods This was an observational study of 10 EDs and 3 urgent care centers across a single health system over a 13-week period from February 1, 2021 to May 2, 2021. Primary outcomes included the proportion of patients with patient portal access to open notes at the time of encounter, the proportion of patients with access who opened the clinical note, and time from clinical note signing to patient read. Results Among 98,725 patient visits, less than half (48.9%) had patient portal access, of which 13.7% read an open note. Access was less likely in patients who were under age 18 (odds ratio 0.10, 95% confidence interval 0.08 to 0.11), older than 65 (0.82, 0.73 to 0.93), Black non-Hispanic (0.66, 0.61 to 0.73), non-English speakers, and on public insurance. Patients were less likely to read open notes if they identified as Black non-Hispanic (0.61, 0.57 to 0.66), spoke Spanish (0.70, 0.60 to 0.81), or were on public insurance. Conclusion We identified substantial differences in digital access to clinical notes as well as patient utilization of open notes in a large, diverse sample. Health transparency initiatives must address not only technology adoption broadly but also the unique barriers faced by populations experiencing disadvantage to facilitate equitable access to and awareness about digital health tools without the unintended consequence of expanding disparities.

Background: Although child physical abuse is missed more frequently in community (CEDs) vs. pediatric emergency departments (PEDs), little information exists describing how evaluations of high-risk injuries differ between these settings. Objectives: To determine differences in evaluations of infants for abuse between a PED and CEDs and whether a child abuse guideline reduced these differences. Participants and setting: Infants presenting to one PED (n = 162) and three CEDs (n = 159) with 3 injury categories: 1) Injuries for which the American Academy of Pediatrics recommends skeletal survey (SS) testing (infants <5-months with an oral injury or bruising, <9-months with a non-skull fracture, and < 12-months with an intracranial hemorrhage); 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries. Methods: We assessed differences in SS testing and child protective services (CPS) reporting between the PED and CEDs before and after implementation of a child abuse guideline. Results: The median (IQR) age was 4 months (2-7). Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01-8.10; Category 2: aOR 10.1, CI: 1.2-88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3-26.7; Category 2: aOR 12.0, CI: 1.4-103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category. Conclusions: Implementation of a child abuse guideline minimized differences between a PED and CEDs in the evaluation of infants with injuries concerning for abuse.

OBJECTIVES: To examine differences in utilization across health care settings among children by body mass index (BMI) categories to help identify opportunities for interventions. METHODS: A retrospective study was conducted using 1 year of electronic health records following an index primary care visit for children 3 to 17 years old in 2016. Index visits occurred at >40 pediatric practices affiliated with a Northeastern health system. Using normal BMI as a reference group, we examined the extent to which children's BMI percentile categories were associated with primary care visits, emergency department (ED) visits, hospitalizations, and ED visit acuity. Age, sex, race/ethnicity, and insurance status were used as covariates. RESULTS: Of those with biologically plausible values for height and weight (n = 30,352), the prevalences of overweight, obesity, and severe obesity were 16.3%, 12.4%, and 5.7%, respectively. Children outside of the normal BMI range made more primary care visits; however, relative patterns of ED utilization were not consistent. Children with obesity versus normal BMI were less likely to have ED visits of high acuity. Risk of hospitalization was higher among children with overweight or severe obesity. CONCLUSIONS: Children's BMI categories were associated with health care utilization, specifically primary care visits, ED visits, and hospitalizations. Further investigation is needed to explore the drivers of these differences in utilization, such as the impact of stigma and perceived weight bias on care-seeking patterns, and to examine the role of settings outside of primary care in pediatric weight management.

Background: Physical abuse is a significant cause of infant morbidity and mortality. Early detection in the emergency department (ED) is crucial. Objective: We describe the impact of a clinical pathway focused on early involvement of the child protection team (CPT) and social work (SW) team for infants presenting to a pediatric emergency department with an injury concerning for abuse. Methods: The pathway lists 10 injuries associated with abuse in infants and directs consultation of the CPTand SW. It was implemented at a single site on April 1, 2014. Seasonally matched data were collected 12 months before and after implementation on all children < 12 months of age with a qualifying injury. Demographics, CPT and SW consults, referral to Child Protective Services, diagnostic studies, and ultimate determination of abuse by the CPT were collected. Results: Implementation of the pathway was associated with an increase in consultation of the CPT from 17% to 47% (p < 0.001) and SW from 33% to 52% (p < 0.001). CPT and SW consultations were obtained more frequently for those on public compared to private insurance prior to implementation but not after (CPT: odds ratio [OR] 4.32; p = 0.046; 95% confidence interval [CI] 1.03-18.15; SW: OR 3.23, p = 0.034; 95% CI 1.09-9.74). Diagnostic testing increased in the post-pathway period. There was no difference in the detection of abusive injury or number of missed cases. Conclusions: These findings suggest that this clinical pathway was successful in increasing involvement of the CPT and SW teams and reducing socioeconomic disparity in the evaluation of infants with injuries concerning for abuse. (C) 2019 Elsevier Inc. All rights reserved.

BACKGROUND: Many internal medicine residency programs have transitioned to an X + Y clinic schedule, in which weekly continuity clinics are removed and clinic experience is instead condensed into 2-week blocks interspersed throughout the year, but few pediatric training programs have adopted this approach. We initiated X + Y scheduling in the 2015 academic year, with the hypothesis that outpatient continuity could be maintained or improved while inpatient handoffs would be reduced. We also hypothesized that learner experience with X + Y scheduling would be positive. METHODS: Continuity and handoffs were compared over a 7 -month period in 2013 to 2014 and 2015 to 2016. Outpatient continuity was calculated as the proportion of visits in which the patient was seen by the designated primary care provider (PCP). Handoffs were calculated through analysis of the online resident schedule with comparison of weekly totals for all inpatient teams. Resident perceptions were obtained in an online survey of residents who experienced both systems. RESULTS: With X + Y scheduling, overall outpatient continuity improved from 2914 of 9882 (29.5%) of visits seen by a patient's PCP to 3066 of 9769 (31.4%) (P =.004), but preventive visit continuity decreased from 2170 of 4687 (46.2%) to 2025 of 4709 (43%) (P =.001). Inpatient handoffs decreased with X + Y scheduling from 30 to 20 weekly handoffs (P <.001). In total, 85% of residents reported a positive experience with X + Y scheduling. CONCLUSIONS: An X + Y scheduling approach in pediatrics is a viable alternative to weekly clinics, resulting in improved learner experience, reductions in inpatient handoffs, and small mixed effects on outpatient continuity.

Background: Residents and fellows are required to receive data on quality metrics and benchmarks related to their patient populations. Despite near universal use of electronic health records (EHRs) and other software for monitoring trainee activities, the promise of meaningful feedback derived from these systems has yet to be fully realized. In the 2016–2017 ACGME resident surveys, only 70% of trainees reported being provided data about practice habits.

Objective Clinical decision support (CDS) hard-stop alerts-those in which the user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party-are increasingly common but can be problematic. To understand their appropriate application, we asked 3 key questions: (1) To what extent are hard-stop alerts effective in improving patient health and healthcare delivery outcomes? (2) What are the adverse events and unintended consequences of hard-stop alerts? (3) How do hard-stop alerts compare to soft-stop alerts? Methods and Materials Studies evaluating computerized hard-stop alerts in healthcare settings were identified from biomedical and computer science databases, gray literature sites, reference lists, and reviews. Articles were extracted for process outcomes, health outcomes, unintended consequences, user experience, and technical details. Results Of 32 studies, 15 evaluated health outcomes, 16 process outcomes only, 10 user experience, and 4 compared hard and soft stops. Seventy-nine percent showed improvement in health outcomes and 88% in process outcomes. Studies reporting good user experience cited heavy user involvement and iterative design. Eleven studies reported on unintended consequences including avoidance of hard-stopped workflow, increased alert frequency, and delay to care. Hard stops were superior to soft stops in 3 of 4 studies. Conclusions Hard stops can be effective and powerful tools in the CDS armamentarium, but they must be implemented judiciously with continuous user feedback informing rapid, iterative design. Investigators must report on associated health outcomes and unintended consequences when implementing IT solutions to clinical problems.