Implicit Review Instrument to Evaluate Quality of Care Delivered by Physicians to Children in Emergency Departments

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144238/1/hesr12800_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144238/2/hesr12800.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144238/3/hesr12800-sup-0001-AppendixSA1.pd

Patientâ level Factors and the Quality of Care Delivered in Pediatric Emergency Departments

ObjectiveQuality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient’s race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patientâ level factors.MethodsThis was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect.ResultsIn the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (â 0.65 points in quality, 95% confidence interval [CI] = â 1.24 to â 0.06) and upper respiratory symptoms (â 0.68 points in quality, 95% CI = â 1.30 to â 0.07).ConclusionWe found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142981/1/acem13347_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142981/2/acem13347-sup-0001-DataSupplementS1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142981/3/acem13347.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142981/4/acem13347-sup-0002-DataSupplementS2.pd

Association Between the Seat Belt Sign and Intra‐abdominal Injuries in Children With Blunt Torso Trauma in Motor Vehicle Collisions

Objectives The objective was to determine the association between the abdominal seat belt sign and intra‐abdominal injuries ( IAI s) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions ( MVC s). Methods This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVC s. Patient history and physical examination findings were documented before abdominal computed tomography ( CT ) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk ( RR ) of IAI with 95% confidence intervals ( CI s) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale ( GCS ) scores of 14 or 15, was also calculated. Results A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVC s were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing ( CT , laparotomy/laparoscopy, or autopsy), IAI s were more common in patients with seat belt signs than those without (19% vs. 12%; RR  = 1.6, 95% CI  = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR  = 9.4, 95% CI  = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI  = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15. Conclusions Patients with seat belt signs after MVC s are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAI s are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary. Resumen Objetivos Determinar la asociación entre el signo del cinturón de seguridad ( SCS ) y las lesiones intra‐abdominales ( LIA ) en los niños atendidos en los servicios de urgencias por traumatismo torácico cerrado tras colisiones de vehículo de motor ( CVM ). Metodología Éste fue un análisis de subgrupo planificado de los datos prospectivos de un estudio de cohorte multicéntrico de niños con traumatismo torácico cerrado tras CVM . Se documentó la historia clínica y la exploración física del paciente antes de la tomografía computarizada ( TC ) abdominal o la laparotomía. El SCS se definió como un área continua de eritema, equimosis o abrasión a través del abdomen secundaria a la contención del cinturón de seguridad. Se calculó el riesgo relativo ( RR ) de LIA con los intervalos de confianza ( IC ) al 95% para los niños con SCS en comparación con aquéllos que no lo tenían. También se calculó el riesgo de LIA en aquellos pacientes con SCS que no tuvieron molestia o dolor abdominal con puntuaciones de 14 o 15 de la Escala de Coma de Glasgow ( ECG ). Resultados Se incluyeron 3.740 niños tras un traumatismo torácico cerrado en CVM ; 585 (16%) tuvieron SCS . Entre los 1.864 niños en los que se llevó a cabo un test diagnóstico abdominal definitivo ( TC , laparotomía/ laparoscopia, o autopsia), las LIA fueron más frecuentes en los pacientes con SCS que en aquéllos sin SCS (19% vs. 12%, RR  = 1,6; IC 95% = 1,3 a 2,1). Esta diferencia fue principalmente debida a un mayor riesgo de lesiones gastrointestinales (víscera hueca o asociadas al mesenterio) en aquéllos con SCS (11% vs. 1%, RR  = 9,4; IC 95% = 5,4 a 16,4). La LIA se diagnosticó en 11 de 194 pacientes (5,7%, IC 95% = 2,9% a 9,9%) con SCS que no tuvieron quejas iniciales de molestia o dolor abdominal y tuvieron puntuaciones de 14 o 15 en la ECG . Conclusiones Los pacientes con SCS tras una CVM tienen mayor riesgo de LIA que aquéllos sin SCS , debido fundamentalmente a lesiones gastrointestinales. Aunque las LIA son menos comunes en los pacientes con SCS que están alerta y que no tienen quejas iniciales de molestia o dolor abdominal, el riesgo de LIA es suficiente para que evaluaciones como la observación, las pruebas de laboratorio y potencialmente la TC abdominal sean generalmente necesarios.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109632/1/acem12506.pd

Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma

ObjectiveThe objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma.MethodsThis was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes.ResultsWe enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI.ConclusionsThe pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/133544/1/acem13014_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/133544/2/acem13014.pd

Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections.

ObjectiveTo determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections.Study designPlanned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants.ResultsOf the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis.ConclusionsFebrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis

Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections.

ObjectiveTo determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections.Study designPlanned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants.ResultsOf the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis.ConclusionsFebrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis

Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60&nbsp;Days of Age

BackgroundFebrile infants commonly present to emergency departments for evaluation.ObjectiveWe describe the variation in diagnostic testing and hospitalization of febrile infants ≤60&nbsp;days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network.MethodsWe enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60&nbsp;days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28&nbsp;days of age) and older (29-60&nbsp;days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age&nbsp;group using chi-square tests and by site using analysis of variance.ResultsFour thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28&nbsp;days of age. Rates of lumbar puncture and hospitalization were high (&gt;90%) among infants ≤28&nbsp;days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60&nbsp;days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%.ConclusionsThe evaluation and disposition of febrile infants ≤60&nbsp;days of age is highly variable, particularly among infants who are 29-60&nbsp;days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization

Provider-Level and Hospital-Level Factors and Process Measures of Quality Care Delivered in Pediatric Emergency Departments.

ObjectiveDifferences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children's hospital EDs were associated with physician-level or hospital-level factors.MethodsWe included children (&lt;18 years old) who presented to any of the 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2011 and December 2011. We measured quality of care from medical record reviews using a previously validated implicit review instrument with a summary score ranging from 5 to 35, and examined associations between process measures of quality and physician- and hospital-level factors using a mixed-effects linear regression model adjusted for patient case-mix, with hospital site as a random effect.ResultsAmong the 620 ED encounters reviewed, we did not find process measures of quality to be associated with any physician-level factors such as physician sex, years since medical school graduation, or physician training. We found, however, that process measures of quality were positively associated with delivery at freestanding children's hospitals (1.96 points higher in quality compared to nonfreestanding status, 95% confidence interval: 0.49, 3.43) and negatively associated with higher annual ED patient volume (-0.03 points per thousand patients, 95% confidence interval: -0.05, -0.01).ConclusionProcess measures of quality of care delivered to children were higher among patients treated at freestanding children's hospitals but lower among patients treated at higher volume EDs