Introduction Newly arrived immigrants to the USA who have time-sensitive medical or mental health needs face a fragmented and often insufficient system of support. This qualitative study explored the perspectives of individuals and organisations who support immigrants across their immigration journey and sought ideas to better identify and connect people in need with care.Methods From June to August 2024, semistructured consultative sessions were conducted with individuals working with recently arrived immigrant families across both sides of the US Southern border, as they transition to and arrive at their US destination. Reflexive thematic analysis was used by researchers with relevant lived experience to interpret the data and develop the analytic themes.Results A total of 58 individuals representing 35 organisations from 14 US states and Mexico participated in the study. Participants came from a wide range of sectors including academic institutions, border respite centres, community-based organisations on both sides of the US-Mexico border, local government and Customs and Border Protection officials, health navigators, nurse midwives and physicians. Qualitative analysis of interviews revealed key themes including gaps in identification and access to care for medically at-risk immigrants at the border and throughout the USA, extensive violence and trauma that many experience and subsequent need for acute and long-term mental health support, unique social, linguistic and structural barriers faced by this population and finally the need for innovative solutions and health-centric policies to address these complex issues.Conclusions Although the immigration landscape is constantly changing, certain fundamental medical and health-related social needs remain constant. Innovative solutions are required to improve the health and well-being of immigrants. This can only be achieved by elevating the expertise of the people and organisations who engage directly with immigrants on their journey.

Objectives The aim of the study is to characterize the lactation goals and practice of pediatric emergency medicine (PEM) fellows and to identify areas of improvement related to 1) policy awareness, 2) departmental culture and accommodations, and 3) lactation space and time. Methods This study is a national, cross-sectional survey study of PEM fellows and program directors (PDs). Two surveys were developed via iterative review and distributed by the PEM-PD Survey Committee. Responses were collected anonymously via the Qualtrics survey platform. Data were summarized using descriptive statistics. Results Survey responses from 60 PEM PDs (71%, 60/84) estimated that 67% (310/461) of their fellows had the ability to lactate. One hundred fifteen study-eligible fellows (37%) completed the survey. Most fellows (57%, 66/115) reported having lactated or expected to lactate during fellowship. Fellows reported an ideal lactation time of 11.5 months. Sixty-two percent (8/13) met their lactation goal and 42% (22/66) did not or did not know if they would meet their goal. Forty-three percent (50/115) of fellows and 57% (34/60) of PDs were aware of workplace lactation policies. Sixty-one percent (38/62) of fellows discussed a lactation plan with their PDs and 18% (7/39) reported their rotations upon returning to work were scheduled with lactation needs in mind. A dedicated lactation space was available to 67% (43/64) of fellows but used by 29% (11/28). Fellows lactated on average twice during an 8-hour shift, spending 7 minutes walking to and from their chosen lactation space and 21-minute pumping per session. Conclusions PEM fellows are likely to have lactation needs during fellowship but receive inconsistent support from their programs. Based on our findings, we advocate for the creation of more visible and PEM-specific workplace lactation policies, planning with PDs pre-return to work, and improved availability and usability of designated lactation spaces. Further optimization may help support PEM fellows' personal, clinical, and academic productivity.

OBJECTIVE:Human trafficking is a public health issue affecting young people across the United States, and trafficked young people frequently present to emergency departments (EDs). The identification of trafficked young people by pediatric EDs during the COVID-19 pandemic is not well understood. We examined trends in the identification of young people with current or lifetime experiences of trafficking in US pediatric EDs before and during the COVID-19 pandemic. METHODS:We performed an interrupted time-series analysis using the Pediatric Health Information System database, which includes data from 49 US children's hospitals, to determine differences in rates of trafficked young people identified in pediatric EDs before and during the COVID-19 pandemic. RESULTS:We included 910 patients; 255 prepandemic (October 1, 2018, through February 29, 2020) and 655 during the COVID-19 pandemic (March 1, 2020, through February 28, 2023). We found a 1.92-fold increase in the incidence rate of identified trafficked young people at the start of the COVID-19 pandemic in March 2020 (incidence rate ratio = 1.92; 95% CI, 1.47-2.51; P < .001), followed by a decrease over time. CONCLUSIONS:The observed increase in identified trafficked young people during the onset of the COVID-19 pandemic should alert pediatric ED providers to the opportunity to identify and provide services for trafficked young people as an important part of improving preparedness for future disease outbreaks. Our observed identification trends do not represent the true incidence of trafficked young people presenting to pediatric EDs during the COVID-19 pandemic. Future work should seek to better understand the true occurrence and the health and service needs of trafficked young people during emergencies.

OBJECTIVES:The aim of the study is to characterize the lactation goals and practice of pediatric emergency medicine (PEM) fellows and to identify areas of improvement related to 1) policy awareness, 2) departmental culture and accommodations, and 3) lactation space and time. METHODS:This study is a national, cross-sectional survey study of PEM fellows and program directors (PDs). Two surveys were developed via iterative review and distributed by the PEM-PD Survey Committee. Responses were collected anonymously via the Qualtrics survey platform. Data were summarized using descriptive statistics. RESULTS:Survey responses from 60 PEM PDs (71%, 60/84) estimated that 67% (310/461) of their fellows had the ability to lactate. One hundred fifteen study-eligible fellows (37%) completed the survey. Most fellows (57%, 66/115) reported having lactated or expected to lactate during fellowship. Fellows reported an ideal lactation time of 11.5 months. Sixty-two percent (8/13) met their lactation goal and 42% (22/66) did not or did not know if they would meet their goal. Forty-three percent (50/115) of fellows and 57% (34/60) of PDs were aware of workplace lactation policies. Sixty-one percent (38/62) of fellows discussed a lactation plan with their PDs and 18% (7/39) reported their rotations upon returning to work were scheduled with lactation needs in mind. A dedicated lactation space was available to 67% (43/64) of fellows but used by 29% (11/28). Fellows lactated on average twice during an 8-hour shift, spending 7 minutes walking to and from their chosen lactation space and 21-minute pumping per session. CONCLUSIONS:PEM fellows are likely to have lactation needs during fellowship but receive inconsistent support from their programs. Based on our findings, we advocate for the creation of more visible and PEM-specific workplace lactation policies, planning with PDs pre-return to work, and improved availability and usability of designated lactation spaces. Further optimization may help support PEM fellows' personal, clinical, and academic productivity.

Introduction California State Bill 1152 (SB1152) mandated all non-state-operated hospitals meet specific criteria when discharging patients identified as experiencing homelessness. Little is known about SB1152’s effect on hospitals or compliance statewide. We studied the implementation of SB1152 in our emergency department (ED). Methods We analyzed our suburban academic ED’s institutional electronic medical record for one year before (July 1, 2018-June 20, 2019) and one year after (July 1, 2019-June 30, 2020) implementation of SB1152. We identified individuals by lack of address during registration, International Classification of Diseases, Tenth Revision (ICD-10) code of homelessness, and/or the presence of an SB1152 discharge checklist. Demographics, clinical information, and repeat visit data were collected. Results ED volumes were constant during the pre- and post-SB1152 periods (approximately 75,000 annually); however, ED visits by people experiencing homelessness more than doubled (630 (0.8%) to 1530 (2.1%) in the pre- and post-implementation periods. Age and sex distributions were similar with approximately 80% of patients aged 31-65 years and less than 1% under 18. Visits by females comprised less than 30% of the population. Visits by people of the White race decreased from 50% to 40% pre- and post-SB1152. Visits by people of the Black, Asian, and Hispanic races experiencing homelessness increased by 18% to 25%, 1% to 4%, and 19% to 21%, respectively. Acuity was unchanged with 50% of visits classified as “urgent.” Discharges increased from 73% to 81% and admissions halved from 18% to 9%. Visits by patients with only one ED visit decreased (28% to 22%); those with four or more visits increased (46% to 56%). The most common primary diagnoses pre- and post-SB1162 were alcohol use (6.8% and 9.3%, respectively), chest pain (3.3% and 4.5%, respectively), convulsions (3.0%, and 2.46%, respectively), and limb pain (2.3% and 2.3%, respectively). The primary diagnosis of suicidal ideation doubled from the pre- to post-implementation periods (1.3% to 2.2%, respectively). Checklists were completed for 92% of identified patients discharged from the ED. Conclusion Implementation of SB1152 in our ED resulted in identifying an increased number of persons experiencing homelessness. We identified opportunities for further improvement since pediatric patients were missed. Further analysis is warranted, especially with the coronavirus disease 2019 (COVID-19) pandemic, which has significantly affected healthcare-seeking behavior in EDs.

Background:Most children receive emergency care in general emergency departments (EDs). Pediatric resuscitations require specific equipment and weight-based dosing that may be less familiar to general ED healthcare professionals. In situ simulation (ISS) improves teamwork and problem solving, and it may identify latent safety threats. This innovative program brought academic faculty to participating hospitals and taught simulation principles in a small-group environment. This format removed many of the barriers to implementing simulations for general EDs and was intended to teach principles for utilizing simulation to meet unique departmental needs. Methods:Using the Consolidated Framework for Implementation Research (CFIR) framework, ED teams at eight hospitals participated in a train-the-trainer program from 2016 to 2020 intended to help them implement their own ISSs. Training covered benefits of ISS, use of simulation for identifying latent safety threats, debriefing principles, and potential safety risks of ISS. Faculty also provided on-site mentoring during the implementation phase. We identified factors and barriers that contributed to the successful adoption of an ISS program. Results:Most hospitals continued their ISS program after the study ended. Several themes emerged as pearls and pitfalls to implementing a train-the-trainer program. Successful teams had strong nursing and physician leadership participation, and team members had positive working relationships with early positive feedback which encouraged future ISS implementation. Barriers to simulation included high staff turnover of nurses and physicians as well as social distancing protocols related to infection control. Conclusions:Academic EDs can partner with general EDs to implement a train-the-trainer simulation program. We describe facilitators and barriers to implementing a train-the-trainer ISS program in general EDs to improve emergency care for high-risk, low-frequency events.

Objective Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time. Methods This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005–2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission. Results Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87–16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46–3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90–63.20), poisoning (OR, 11.78; 95% CI, 11.30–12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84–6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46–4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45–3.79) had increased odds of transfer. Conclusion Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.

Pediatric health and mental health professionals with expertise in the physical and emotional needs of immigrant children seeking humanitarian protection are trained to understand and address the sometimes deeply traumatic nature of their experience. This expertise plays an important role in collaborating with immigration attorneys to provide compassionate, trauma-informed representation that centers on children's best interests. In medicine, we say that "children are not small adults," such that meeting a child's needs requires consideration of their developmental stage and the unique impacts of child trauma exposure. This also holds true for legal professionals dedicated to protecting the rights of children in migration. This article aims to (1) review the principles of trauma-informed care in the context of child development, (2) understand the traumatic nature of the migration paradigm for children from Mexico and Central America seeking safety and protection, and (3) suggest ways that healthcare, mental health and legal professionals can inform one another's efforts to optimize the wellbeing of children and improve legal outcomes. The application of this knowledge in practice can advance legal goals, reduce risk for child re-traumatization during interviews, and reinforce child strengths while also reducing vicarious trauma and burnout for legal professionals.

Objectives Pediatric emergency department (ED) mental health visits are increasing in the United States. At the same time, child/adolescent psychiatric services are limited. This study examines the trajectory of pediatric patients presenting with mental health emergencies to better understand availability of specialty care resources in regional networks. Methods This retrospective cohort study used a California Office of Statewide Health Planning and Development linked ED and Inpatient Discharge Dataset (2005-2015) to study pediatric patients (5-17 years) who presented to an ED with a primary mental health diagnosis. Outcomes were disposition: discharge, admission, or transfer. Patients transferred were further analyzed for disposition. Regression models to identify characteristics associated with disposition were created. Results There were 384,339 pediatric patients presented for a primary mental health emergency from 2005 to 2015; 287,997 were discharged, 17,564 were admitted, and 78,725 were transferred. Among those not discharged, patients with public (odds ratio [OR], 1.28; P < 0.01) or self-pay insurance (OR, 5.64; P < 0.01), Black (OR, 2.15; P < 0.01), or Native American race (OR, 2.32; P < 0.01), and who presented to rural EDs (OR, 3.10; P < 0.01), nonteaching hospitals (OR, 3.06; P < 0.01), or hospitals in counties without dedicated child/adolescent psychiatric beds (OR, 5.59; P < 0.01) had higher odds of transfer. Among those not discharged from the second hospital, Black patients (OR, 2.47; P < 0.03) and those who were transferred to a teaching hospital (OR, 1.9; P < 0.01) had higher odds of second transfer. Conclusions Pediatric patients with mental health emergencies experience different trajectories of care. Transfer protocols and regionalized networks may help streamline services and decrease inefficiencies in care.

Objective Emergency departments (EDs) face increasing mental health visits on a backdrop of insufficient mental health resources. We study ED length of stay (LOS) and disposition by 1) mental health vs. medical visits; 2) psychiatric vs. substance use visits; and 3) the four regions of the United States. Methods We used weighted data from the National Hospital Ambulatory Medical Care Survey (2009-2015). Visits by patients ages 18-64 were categorized into mental health and medical groups. The mental health group was then subdivided into psychiatric, substance use, and co-occurring disorders. The LOS was compared by disposition. Mental health vs. medical LOS and disposition were examined across four regions of the US. Results An estimated 28 million mental health and 526 million medical visits were included in the study. Mental health visits had a median (interquartile range [IQR]) of 3.7 (4.7) hours while medical visits had a median (IQR) of 2.6 (2.7) hours. Mental health compared to medical visits were more likely to result in admission or transfer and to last >6 and >12 hours. Mental health visits resulting in transfer had the longest LOS with a median (IQR) of 6.23 (7.7) hours. Of mental health visit types, co-occurring disorders visits were more likely to be >6 and >12 hours regardless of disposition. Across US regions, there was significant variation in disposition patterns for mental health vs. medical visits. The odds of mental health visits lasting >6 and >12 hours were greatest in the Northeast and the least in the South with a median (IQR) of 4.6 (5.8) hours and 3.3 (4.0) hours, respectively. Conclusions Metal health compared to medical visits had longer LOS, especially when the patient had co-occurring disorders or required transfer. Regionally, there is a large variation in disposition for mental health vs. medical visits. This study makes it clear that there are no standards for managing psychiatric emergencies.

BACKGROUND:In the past decade, the U.S. immigration detention system regularly detained more than 30,000 people per day; in 2019 prior to the pandemic, the daily detention population exceeded 52,000 people. Inhumane detention conditions have been documented by internal government watchdogs, and news media and human rights groups who have observed over-crowding, poor hygiene and sanitation and poor and delayed medical care, as well as verbal, physical and sexual abuse. METHODS:This study surveyed health professionals across the United States who had provided care for immigrants who were recently released from immigration detention to assess clinician perceptions about the adverse health impact of immigration detention on migrant populations based on real-life clinical encounters. There were 150 survey responses, of which 85 clinicians observed medical conditions attributed to detention. RESULTS:These 85 clinicians reported seeing a combined estimate of 1300 patients with a medical issue related to their time in detention, including patients with delayed access to medical care or medicine in detention, patients with new or acute health conditions such as infection and injury attributed to detention, and patients with worsened chronic or special needs conditions. Clinicians also provided details regarding sentinel cases, categorized into the following themes: Pregnant women, Children, Mentally Ill, COVID-19, and Other serious health issue. CONCLUSIONS:This is the first survey, to our knowledge, of health care professionals treating individuals upon release from detention. Due to the lack of transparency by federal entities and limited access to detainees, this survey serves as a source of credible information about conditions experienced within immigration detention facilities and is a means of corroborating immigrant testimonials and media reports. These findings can help inform policy discussions regarding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.

OBJECTIVE: The COVID-19 pandemic prompted health sys-tems to rapidly adopt telehealth for clinical care. We examined the impact of demography, subspecialty characteristics, and broadband availability on the utilization of telehealth in pediat-ric populations before and after the early period of the COVID-19 pandemic. METHODS: Outpatients scheduled for subspecialty visits at sites affiliated with a single quaternary academic medical center between March-June 2019 and March-June 2020 were included. The contribution of demographic, socioeco-nomic, and broadband availability to visit completion and telehealth utilization were examined in multivariable regression analyses.RESULTS: Among visits scheduled in 2020 compared to 2019, in-person visits fell from 23,318 to 11,209, while telehealth visits increased from 150 to 7,675. Visits among established patients fell by 15% and new patients by 36% (P < .0001). Multivariable analysis revealed that completed visits were reduced for Hispanic patients and those with reduced broadband; high income, private non-HMO insurance, and those requesting an interpreter were more likely to complete visits. Those with visits scheduled in 2020, established patients, those with reduced broadband, and patients older than 1 year were more likely to complete TH appointments. Cardiology, oncology, and pulmonology patients were less likely to complete scheduled TH appointments.CONCLUSIONS: Following COVID-19 onset, outpatient pedi-atric subspecialty visits shifted rapidly to telehealth. However, the impact of this shift on social disparities in outpatient utili-zation was mixed with variation among subspecialties. A growing reliance on telehealth will necessitate insights from other healthcare settings serving populations of diverse social and character.

OBJECTIVE:Trauma centers provide coordinated specialty care and have been demonstrated to save lives. Many states do not have a comprehensive statewide trauma system. Variable geography, resources, and population distributions present significant challenges to establishing an effective uniform system for pediatric trauma care. We aimed to identify patterns of primary (field) triage and transfer of serious pediatric trauma throughout California. We hypothesized that pediatric primary triage to trauma center care would be positively associated with younger age, increased injury severity, and local emergency medical service (EMS) regions with increased resources. We hypothesized that pediatric trauma transfer would be associated with younger age, increased injury severity, and rural regions with decreased resources. Methods: We conducted a retrospective cohort study of the California Office of Statewide Health Planning and Development emergency department and inpatient discharge data (2005-2015). All patients with serious injury, defined as Injury Severity Score (ISS) >9 were included. Demographic, injury, hospital, and regional characteristics such as distances between patient residence and destination hospitals were tabulated. Univariate and multinomial logit analyses were conducted to analyze individual, hospital, and regional characteristics associated with the outcomes of location of primary triage and transfer. Estimates were converted into predicted probabilities for ease of data interpretation. Results: Primary triage to was to either a pediatric trauma center (37.8%), adult level I/II trauma center (35.0%), adult level III/IV trauma center (1.9%), pediatric non-trauma hospital (3.4%), or an adult non-trauma hospital (21.9%).Younger age, private non-HMO insurance, motor vehicle mechanism, and rural areas were the major factors influencing primary triage to any trauma hospital. Younger age, private non-HMO insurance, higher ISS, fall mechanism, <200 bed hospital, and rural areas were the major factors influencing transfer from a non-trauma hospital to any trauma center. Conclusions: We demonstrate statewide primary triage and transfer patterns for pediatric trauma in a large and varied state. Specifically we identified previously unrecognized individual, hospital, and EMS system associations with pediatric trauma regionalization. Knowledge of these de facto trauma care access patterns has policy and process implications that could improve care for all injured children in need.

Problem Given the complex interaction among patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care. Approach Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, nonacademic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients. Outcomes Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-its ability to provide emergency care for children-was evaluated at baseline and 12 months. Next Steps The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes.

Introduction: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. Methods: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. Results: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelterin-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. Conclusion: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Interview with Dr. N. Ewen Wang on threats to the health and well-being of immigrant children. (10:43)Download Actions by the Biden administration to end harmful immigration policies are critically important. But solutions should also include creating conditions within the United States that will allow children exposed to immigration-related trauma to grow, learn, and thrive.

BackgroundMedical school admission requirements increasingly encompass competencies beyond the traditional premedical curriculum, such as service orientation and knowledge of "social determinants of health."ActivityThe Stanford Help Desk is an undergraduate service-learning program that provides didactic and experiential exposure to the social determinants of health through screening for social and legal needs of emergency department (ED) patients. We assessed student perceptions of program impact through student applications, course evaluations, and an online program survey.Results and DiscussionThis course strengthened students' understanding of their career aspirations in medicine. Students were resolved to incorporate consideration of social determinants of health in future practice.

Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

Introduction: Hospitals commonly use Press Ganey (PG) patient satisfaction surveys for benchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest, which is known as the "topbox" score. Our objective was to identify patient and physician factors associated with topbox PG scores in the emergency department (ED). Methods: We looked at PG surveys from January 2015-December 2017 at an academic, urban hospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions: "Likelihood of your recommending our ED to others"; and "Courtesy of the doctor." We analyzed topbox scores using generalized estimating equation models clustered by physician and adjusted for patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED area where patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical (urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physician factors included age, gender, race, ethnicity, and number of years at current institution. Results: We analyzed a total of 3,038 surveys. For "Likelihood of your recommending our ED to others," topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12); less likely among female compared to male patients (OR 0.81; 95% CI, 0.70-0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60-0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54-0.93) and vertical areas (OR 0.71; 95% CI 0.53-0.95) compared to fast track. For "Courtesy of the doctor," topbox scores were more likely with increasing patient age (OR 1.1; CI, 1.06-1.14); less likely among Asian (OR 0.70; 95% CI, 0.58-0.84), Black (OR 0.66; 95% CI,0.45-0.96), and Hispanic patients (OR 0.68; 95% CI,0.55-0.83) compared to White patients; and less likely in urgent area (OR 0.69; 95% CI,0.50-0.95) compared to fast track. Conclusion: Increasing patient age was associated with increased likelihood of topbox scores, while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. We encourage hospitals that use PG topbox scores as financial incentives to understand the contribution of non-service factors to these scores.