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Data on socio-demographic variations in Australian dietary patterns are scarce, particularly in regional and rural Australia. For this study, a systematic sample (n = 1088, response rate 82%) of people aged 20 to 70 years on electoral rolls for the north and north-west regions of Tasmania completed written questionnaires, indicating, among other things, which of 52 specific foods (covering all major food groups) had been consumed the previous day. Individual-based socio-demographic characteristics were associated significantly (P < 0.01, after adjustment for potentially confounding variables) with consumption of many of these foods: gender (11 foods), age (ten foods) and educational attainment (nine foods). Generally, healthier food choices were found among respondents who were female, older and more educated. Geographically-based socio-demographic characteristics, however, were rarely significantly associated with consumption of specific foods: there were no significant associations with region or the socioeconomic status of the postcode area, and only one food differed in consumption between urban and rural areas. We conclude that, at least in this area, geographically-based socio-demographic characteristics are much less important predictors of dietary patterns than individual-based socio-demographic characteristics. [ABSTRACT FROM AUTHOR]

OBJECTIVES. To assess the effect of moderately decreased ambient temperature on capillary refill (CR) time in healthy children, and to measure the reliability of CR measurements between observers. DESIGN. Prospective interventional study with cross-over design. SETTING. Urban pediatric emergency department. PARTICIPANTS. 32 well-hydrated children aged 1 month to 12 years brought to the emergency department for care of minor illness or injury. INTERVENTIONS. Participants were assigned in random order to a 15-minute waiting period in each of two rooms, with and without air-conditioning (cool and warm rooms, respectively). At the end of each waiting period, fingertip CR was measured with a stopwatch, three times by each of one or more three trained observers. RESULTS. Mean CR time was 0.85 +/- 0.45 seconds in the warm room (mean ambient temperature (25.7 degrees C) vs 2.39 +/- 0.76 seconds in the cool room (mean temperature 19.4 degrees C). The mean overall difference in CR time between the two environments was 1.53 seconds (95% confidence interval [CI]: 1.31, 1.75; P < .001); the difference was significant regardless of age or sequence of exposure. 100% of patients were considered to have normal CR (less than 2 seconds) in the warm room, whereas only 31% were considered normal in the cool room. In the 16 patients with CR measured by three observers, interobserver reliability was fair, with an intraclass correlation coefficient of 0.70 (95% CI: 0.56, 0.85), and kappa of 0.54 (95% CI: 0.33, 0.73). CONCLUSIONS. Decreases in ambient temperature within a range found in typical office/emergency department settings may cause significant prolongation of CR time in children with normal circulatory status. There is marked interobserver variability in the measurement of CR even when performed by experienced observers. These findings suggest limitations to the use of CR in the assessment of ill or injured children. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the validity and reliability of various clinical findings in the diagnosis of dehydration in children. DESIGN: Prospective cohort study. SETTING: An urban pediatric hospital emergency department. PARTICIPANTS: One hundred eighty-six children ranging in age from 1 month to 5 years old with diarrhea, vomiting, or poor oral fluid intake, either admitted or followed as outpatients. Exclusion criteria included malnutrition, recent prior therapy at another facility, symptoms for longer than 5 days' duration, and hyponatremia or hypernatremia. METHODS: All children were evaluated for 10 clinical signs before treatment. The diagnostic standard for dehydration was fluid deficit as determined from serial weight gain after treatment. MAIN RESULTS: Sixty-three children (34%) had dehydration, defined as a deficit of 5% or more of body weight. At this deficit, clinical signs were already apparent (median = 5). Individual findings had generally low sensitivity and high specificity, although parent report of decreased urine output was sensitive but not specific. The presence of any three or more signs had a sensitivity of 87% and specificity of 82% for detecting a deficit of 5% or more. A subset of four factors-capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance-predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%. Interobserver reliability was good to excellent for all but one of the findings studied (quality of respirations). CONCLUSIONS: Conventionally used clinical signs of dehydration are valid and reliable; however, individual findings lack sensitivity. Diagnosis of clinically important dehydration should be based on the presence of at least three clinical findings. [ABSTRACT FROM AUTHOR]

Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking., Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations., Design, Setting, and Participants: In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks., Outcome: Consensus agenda of research priorities to identify and address health care disparities in PEC., Results: PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation., Conclusions and Relevance: These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Objectives: Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID., Patients and Methods: Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process., Results: MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID., Conclusions: Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID., (Copyright © 2023 by the American Academy of Pediatrics.)

Objectives: Patients and families preferring languages other than English (LOE) often experience inequitable communication with their health care providers, including the underutilization of professional interpretation. This study had 2 aims: to characterize resident-perceived communication with families preferring LOE and to evaluate the impact of language preference on frequency of resident interactions with hospitalized patients and families., Methods: This was a cross-sectional study at a quaternary care children's hospital. We developed a questionnaire for residents regarding their interactions with patients preferring LOE. We concurrently developed a communication tracking tool to measure the frequency of resident communication events with hospitalized patients. Data were analyzed with logistic and Poisson regression models., Results: Questionnaire results demonstrated a high level of resident comfort with interpretation, though more than 30% of residents reported "sometimes" or "usually" communicating with families preferring LOE without appropriate interpretation (response rate, 47%). The communication tracking tool was completed by 36 unique residents regarding 151 patients, with a 95% completion rate. Results demonstrated that patients and families preferring LOE were less likely to be present on rounds compared with their counterparts preferring English (adjusted odds ratio, 0.17; 95% confidence interval [CI], 0.07-0.39). Similarly, patients and families preferring LOE were less likely to receive a resident update after rounds (adjusted odds ratio, 0.29; 95% CI, 0.13-0.62) and received fewer resident updates overall (incidence rate ratio, 0.45; 95% CI, 0.30-0.69)., Conclusions: Hospitalized patients and families preferring LOE experience significant communication-related inequities. Ongoing efforts are needed to promote equitable communication with this population and should consider the unique role of residents., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Diagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs., Methods: We developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague's patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event., Results: Of 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent-provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID., Conclusions: An international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent-provider interaction factors such as suboptimal history and physical examination. Physicians' personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clinical pathways are evidence-based guidelines adapted to local settings. They have been shown to improve patient outcomes and reduce resource utilization. However, it is unknown how physicians integrate clinical pathways into their clinical reasoning., Methods: We conducted a single-center qualitative study involving one-on-one semi-structured interviews of pediatric residents and pediatric hospitalist attendings between August 2021 and March 2022. Interviews were audio-recorded and professionally transcribed. We utilized a qualitative descriptive framework to code data and identify themes., Results: We interviewed 15 pediatric residents and 12 pediatric hospitalists. Thematic analysis of interview transcripts revealed four themes related to physician utilization of and experience with clinical pathways: (1) utility as a tool, (2) means of standardizing care, (3) reflection of institutional culture, and (4) element of the dynamic relationship with the clinician diagnostic process. These themes were generally common to both residents and attending physicians; however, some differences existed and are noted when they occurred., Conclusions: Clinical pathways are part of many clinicians' diagnostic processes. Pathways can standardize care, influence the diagnostic process, and express local institutional culture. Further research is required to ascertain the optimal clinical pathway design to augment and not inhibit the clinician's diagnostic process., (© 2022 Society of Hospital Medicine.)

Objectives: Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis., Methods: We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process., Results: The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR)., Conclusions: Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning., (© 2022 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: To create an operational definition and framework to study diagnostic error in the emergency department setting., Methods: We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting., Results: The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis., Conclusions: The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Emergency department return visits significantly impact medical costs and patient flow. A comprehensive approach to understanding these patients is required to identify deficits in care, system level inefficiencies, and improve diagnosis specific management protocols. We aimed to identify factors needed to successfully analyze return visits to explore root causes leading to unplanned returns and inform system-level improvements., Methods: A multidisciplinary committee collaborated to develop a quality review process for return visits within 72 hours to our pediatric emergency department that were then subsequently admitted to the hospital. The committee developed methodology and a web-based tool for chart review and analysis., Results: Of 197,076 ED visits (159,164 discharged at initial visit), 5390 (3.4%) patients were discharged and represented to the ED within 72 hours and 1658 (1.0%) of those resulted in admission. Using defined criteria, approximately one third (n = 564) of revisits with admission were identified for chart review. Reason for revisit included natural progression of disease (67.6%), new condition or problem (11.2%), diagnostic error (6.9%), and scheduled or planned readmissions (3.5%). All diagnostic errors had not been previously identified by ED leadership. Of the reviewed cases, most were not preventable (84.0%); however, a number of system-level actions resulted from discussion of the potentially preventable revisits., Conclusions: Seventy-two-hour ED revisits were efficiently and systematically categorized with determination of root causes and preventability. This process resulted in shared provider-level feedback, identifying trends in revisits, and implementation of system-level actions, therefore, encouraging other institutions to adopt a similar process., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Event debriefing has established benefit, but its adoption is poorly characterized among pediatric ward providers. To improve patient safety, our hospital restructured its debriefing process for ward deterioration events culminating in ICU transfer. The aim of this study was to describe this process' implementation., Methods: In the restructured process, multidisciplinary ward providers are expected to debrief all ICU transfers. We conducted a multimethod analysis using facilitative guides completed by debriefing participants. Monthly debriefing completion served as an adoption metric., Results: Between March 2019 and February 2020, providers across 9 wards performed debriefing for 134 of 312 PICU transfers (43%). Bedside nurses participated most frequently (117 debriefings [87%]). There was no significant difference in debriefing by unit, acuity, season, or nurse staffing. Compared with units fully staffed by rotational frontline clinicians (FLCs; eg, resident physicians), units with dedicated FLCs whose responsibilities are primarily limited to that unit (eg, oncology hospitalists) completed significantly more monthly debriefings (average [SD] 57% [30%] vs 33% [28%] of PICU transfers; P = .004). FLC participation was also higher on these units (50% of debriefings [37%] vs 24% [37%]; P = .014). Through qualitative analysis, we identified distinct debriefing themes, with teaming activities such as communication cited most often., Conclusions: Implementation of a multidisciplinary debriefing process for ward deterioration events culminating in ICU transfer was associated with differential adoption across providers and FLC staffing models but not acuity or nurse staffing. Teaming activities were a debriefing priority. Future study will assess patient safety outcomes., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Sutton serves as the Chair of the National American Heart Association’s Get with the Guidelines-Resuscitation Pediatric Research Task Force and has been a main author of the Pediatric Advanced Life Support Guidelines since 2015; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm., Methods: We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED., Results: Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings., Conclusions: We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Background: Academic fellowships in quality improvement (QI) and patient safety (PS) have emerged as one strategy to fill a need for physicians who possess this expertise. The authors aimed to characterise the impact of two such programmes on the graduates and their value to the institutions in which they are housed., Methods: In 2018, a qualitative study of two US QIPS postgraduate fellowship programmes was conducted. Graduates' demographics and titles were collected from programme files,while perspectives of the graduates and their institutional mentors were collected through individual interviews and analysed using thematic analysis., Results: Twenty-eight out of 31 graduates (90%) and 16 out of 17 (94%) mentors participated in the study across both institutions. At a median of 3 years (IQR 2-4) postgraduation, QIPS fellowship programme graduates' effort distribution was: 50% clinical care (IQR 30-61.8), 48% QIPS administration (IQR 20-60), 28% QIPS research (IQR 17.5-50) and 15% education (7.1-30.4). 68% of graduates were hired in the health system where they trained. Graduates described learning the requisite hard and soft skills to succeed in QIPS roles. Mentors described the impact of the programme on patient outcomes and increasing the acceptability of the field within academic medicine culture., Conclusion: Graduates from two QIPS fellowship programmes and their mentors perceive programmatic benefits related to individual career goal attainment and institutional impact. The results and conceptual framework presented here may be useful to other academic medical centres seeking to develop fellowships for advanced physician training programmes in QIPS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In many centers, children with diabetic ketoacidosis (DKA) receive care either in an endocrinology ward or a pediatric intensive care unit (PICU). We conducted a quality improvement (QI) initiative to reduce potentially avoidable PICU admissions of children with DKA without increasing endocrinology ward-to-PICU transfers., Methods: A survey of providers demonstrated opportunities to increase awareness of institutional criteria for PICU admissions of children with DKA. We created an electronic health record (EHR) dot-phrase, prepopulated with these criteria, and placed a note in the EHR for all patients with DKA as a reference for all providers. An EHR-based data report was created to monitor the disposition of DKA patients and the use of the dot-phrase (process measure). The primary outcome measure was the potentially avoidable PICU admissions for patients with DKA. Endocrinology ward-to-PICU transfers were tracked as a balancing measure to ensure safe disposition., Results: After the implementation of the dot-phrase, use was variable, but averaged 33.4% over 1 year. The percentage of DKA admissions classified as potentially avoidable PICU stays decreased from 4.1% to 0.5%, with a concurrent decrease in the total percentage of PICU admissions for DKA from 19.1% to 8.4%. The percentage of endocrinology ward-to-PICU transfers also declined from 0.8% to 0%., Conclusions: A novel EHR-based intervention increasing awareness and documentation of established pediatric DKA management guidelines can be used to safely reduce PICU admissions for DKA without increasing the rate of endocrinology ward-to-intensive care unit transfers., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Pediatric emergency medicine quality work continues to focus on the National Academies of Sciences, Engineering, and Medicine's 6 domains of quality, with a need for specific emphasis on equity and patient centeredness. Adopting the principles of high-reliability organizations, pediatric emergency departments should become increasing transparent with benchmarking and collaboration across institutions in order to develop an infrastructure for quality and safety to improve the care of pediatric patients in the emergency department., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Full disclosure of patient safety events (PSE) is desired by patients and their families, is required by the Joint Commission and many state laws, and is vital to improving patient outcomes. A key barrier to consistent disclosure of patient safety events is a self-reported lack of proper training. Physicians must be trained to recognize when a PSE has occurred and effectively carry out disclosure, all while caring for a patient who is actively experiencing the consequences of an unintended outcome. Immersive simulation provides the opportunity to practice this complex skill. Objective To develop and evaluate a simulation-based workshop for pediatric residents on the disclosure of patient safety events. Methods A workshop in PSE disclosure was developed according to literature review, expert consultation, and feedback from hospital administration. The three-hour workshop included a simulated PSE with a subsequent standardized debriefing, interactive didactic session, and additional simulation-based hands-on practice in disclosure. Participants completed an anonymous survey at one-week and three-months post workshop, assessing workshop satisfaction, subsequent clinical experience, and perceived change to their practice. Results During the one-year study period, 27/31 (87.0%) second year residents completed the workshop. At the one-week follow-up, all study participants reported increased confidence and preparedness in their ability to lead the initial disclosure conversation. All study participants felt that the simulated scenarios were realistic and relevant to their current clinical duties and 33.3% (n=9) stated that they would like to repeat this workshop prior to completion of their training. At the three-month follow-up, 29.6% (N=8) of study participants reported involvement in the disclosure of a patient safety event since the workshop with all eight reporting feeling adequately prepared by the workshop for this experience. Study participants indicated that post training they were more likely to engage the attending physician, risk management and patient relations in the disclosure conversation (p <=0.05). The estimated cost of this simulation training for 27 residents was $6,993, not accounting for the 39 hours per clinician facilitator. Conclusions Immersive simulation is uniquely suited for teaching difficult conversation skills that are encountered during acute care, including the disclosure of patient safety events. While hands-on practice is critical, faculty and simulation resources required for continued implementation may not be sustainable long-term. Future training curricula should leverage creative and innovative adult-learning techniques to reach a wide range of members of the care team with less resource utilization., Competing Interests: The authors have declared that no competing interests exist.

Objective: Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care., Setting/participants: We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics., Outcome Measures: The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008., Results: Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels., Conclusions: Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.

Objectives: Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits., Methods: We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI., Results: Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74., Conclusions: Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years., Methods: Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use., Results: A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use., Conclusions: One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To derive and test a predictive model for high-frequency (4 or more visits per year), low-acuity (emergency severity index 4 or 5) utilization of the pediatric emergency department., Methods: The study sample used 3 years of data (2012-2014) from a single tertiary-care children's hospital for patients <21 years of age. Utilization in 2013 defined the index visit; prior utilization was drawn from 2012; and 2014 was used for outcome measurement. Candidate predictor variables were those that would be available at the time of triage. Data were split into derivation and test sets randomly; variables with a significant univariate association in the derivation set were included for multivariable modeling. The final model from the derivation set was then tested in the validation set, with calculation of a receiver operating characteristic curve., Results: There were 90,972 visits in 2013, of which 61,430 were first (index) visits. A total of 590 (1%) had 4 or more triage level 4 or 5 visits in the following year (2014). The final model included site of primary care, age, acuity, previous utilization, race, and insurance, and had an area under the receiver operating characteristic curve of 0.84., Conclusions: Data available to the emergency department provider at the time of initial visit triage can predict utilization for low-acuity complaints in the subsequent year. Future work should focus on validation and refinement of the model in additional settings, and electronic calculation of risk status for targeted intervention to improve appropriate utilization of health care services., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network., Methods: This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based., Results: Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization., Conclusions: We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

Background and Objectives: Urinary tract infection (UTI) screening in febrile young children can be painful and time consuming. We implemented a screening protocol for UTI in a high-volume pediatric emergency department (ED) to reduce urethral catheterization, limiting catheterization to children with positive screens from urine bag specimens., Methods: This quality-improvement initiative was implemented using 3 Plan-Do-Study-Act cycles, beginning with a small test of the proposed change in 1 ED area. To ensure appropriate patients received timely screening, care teams discussed patient risk factors and created patient-specific, appropriate procedures. The intervention was extended to the entire ED after providing education. Finally, visual cues were added into the electronic health record, and nursing scripts were developed to enlist family participation. A time-series design was used to study the impact of the 6-month intervention by using a p-chart to determine special cause variation. The primary outcome measure for the study was defined as the catheterization rate in febrile children ages 6 to 24 months., Results: The ED reduced catheterization rates among febrile young children from 63% to <30% over a 6-month period with sustained results. More than 350 patients were spared catheterization without prolonging ED length of stay. Additionally, there was no change in the revisit rate or missed UTIs among those followed within the hospital's network., Conclusions: A 2-step less-invasive process for screening febrile young children for UTI can be instituted in a high-volume ED without increasing length of stay or missing cases of UTI., (Copyright © 2016 by the American Academy of Pediatrics.)

Objective: Patient safety may be enhanced by using reports from front-line staff of near misses and unsafe conditions to identify latent safety events. We describe paediatric emergency department (ED) near-miss events and unsafe conditions from hospital reporting systems in a 1-year observational study from hospitals participating in the Pediatric Emergency Care Applied Research Network (PECARN)., Design: This is a secondary analysis of 1 year of incident reports (IRs) from 18 EDs in 2007-2008. Using a prior taxonomy and established method, this analysis is of all reports classified as near-miss (events not reaching the patient) or unsafe condition. Classification included type, severity, contributing factors and personnel involved. In-depth review of 20% of IRs was performed., Results: 487 reports (16.8% of eligible IRs) are included. Most common were medication-related, followed by laboratory-related, radiology-related and process-related IRs. Human factors issues were related to 87% and equipment issues to 11%. Human factor issues related to non-compliance with procedures accounted for 66.4%, including 5.95% with no or incorrect ID. Handoff issues were important in 11.5%., Conclusions: Medication and process-related issues are important causes of near miss and unsafe conditions in the network. Human factors issues were highly reported and non-compliance with established procedures was very common, and calculation issues, communications (ie, handoffs) and clinical judgment were also important. This work should enable us to help improve systems within the environment of the ED to enhance patient safety in the future., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Importance: Acute bronchiolitis is the most frequent lower respiratory tract infection in infants, yet there are no effective therapies available. Current evidence is unclear about the role of hypertonic saline (HS) for the acute treatment of bronchiolitis., Objective: To determine whether nebulized 3% HS compared with normal saline (NS) improves respiratory distress in infants with bronchiolitis not responding to standard treatments in the emergency department., Design, Setting, and Participants: A randomized clinical trial with blinding of investigators, health care providers, and parents was conducted at a single urban pediatric ED. The participants included children aged 2 to less than 24 months with their first episode of bronchiolitis and a Respiratory Distress Assessment Instrument score of 4 to 15 after nasal suctioning and a trial of nebulized albuterol., Interventions: Patients were randomized to receive either nebulized 3% HS (HS group) or NS (NS group)., Main Outcomes and Measures: The primary outcome was change in respiratory distress at 1 hour after the intervention, as measured by the Respiratory Assessment Change Score (a decrease indicates improvement). Secondary outcomes included vital signs, oxygen saturation, hospitalization, physician clinical impression, parental assessment, and adverse events., Results: The 31 patients enrolled in each treatment arm had similar baseline demographic and clinical characteristics. At 1 hour after the intervention, the HS group demonstrated significantly less improvement in the median Respiratory Assessment Change Score compared with the NS group (HS, -1 [interquartile range, -5 to 1] vs. NS, -5 [interquartile range, -6 to -2]; P = .01). There were no significant differences in heart rate, oxygen saturation, hospitalization rate, or other outcomes. There were no adverse events., Conclusions and Relevance: Infants with bronchiolitis and persistent respiratory distress after standard treatment in the emergency department had less improvement after receiving 3% HS compared with those who received NS. Based on these results and the existing evidence, administration of a single dose of 3% HS does not appear to be indicated to treat bronchiolitis in the acute care setting., Trial Registration: clinicaltrials.gov Identifier: NCT01247064.

A formal emergency care system for children in the United States began in the 1980s with the establishment of specialized training programs in academic children's hospitals. The ensuing three decades have witnessed the establishment of informal regional networks for clinical care and a federally funded research consortium that allows for multisite research on evidence-based practices. However, pediatric emergency care suffers from problems common to emergency departments (EDs) in general, which include misaligned incentives for care, overcrowding, and wide variation in the quality of care. In pediatric emergency care specifically, there are problems with low-volume EDs that have neither the experience nor the equipment to treat children, poor adherence to clinical guidelines, lack of resources for mental health patients, and a lack of widely accepted performance metrics. We call for policies to address these issues, including providing after-hours care in other settings and restructuring payment and reimbursement policies to better address patients' needs.

Objective: Medication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. We describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric research network in 2007-2008., Methods: Confidential, deidentified incident reports (IRs) were collected, and MEs were independently categorised by two investigators. Discordant responses were resolved by consensus., Results: MEs (597) accounted for 19% of all IRs, with reporting rates varying 25-fold across sites. Anti-infective agents were the most commonly reported, followed by analgesics, intravenous fluids and respiratory medicines. Of the 597 MEs, 94% were medication errors and 6% adverse reactions; further analyses are reported for medication errors. Incorrect medication doses were related to incorrect weight (20%), duplicate doses (21%), and miscalculation (22%). Look-alike/sound-alike MEs were 36% of incorrect medications. Human factors contributed in 85% of reports: failure to follow established procedures (41%), calculation (13%) or judgment (12%) errors, and communication failures (20%). Outcomes were: no deaths or permanent disability, 13% patient harm, 47% reached patient (no harm), 30% near miss or unsafe conditions, and 9% unknown., Conclusions: ME reporting by the system revealed valuable data across sites on medication categories and potential human factors. Harm was infrequently reported. Our analyses identify trends and latent systems issues, suggesting areas for future interventions to reduce paediatric ED medication errors.

Background: A unit-based Patient Safety Leadership Walkrounds (PSWR) model was deployed in six medical/surgical units at The Children's Hospital of Philadelphia to identify patient safety issues in the clinical microsystem. Specific objectives of PSWR were to (1) provide a forum for frontline staff to freely report and discuss patient safety problems with unit local leaders, (2) improve teamwork and communication within and across units, and (3) develop a supportive environment in which staff and leaders brainstorm on potential solutions., Methods: Baseline data collection and discussion with leaders and staff from the pilot units were used to create a standard set of safety tools and questions. Through multiple Plan-Do-Study-Act cycles, safety tools and questions were refined, while the process of walkrounds in each of the six pilot units was customized., Results: Leaders in all six pilot units indicated that PSWR helped them to uncover previously unidentified safety concerns. Top-impact areas included nurse-medical team relationship, work-flow flaws, equipment defects, staff education, and medication safety. The project engaged 149 individuals across all disciplines, including 33 physicians, and entailed 34 PSWR in its first year. Information from these pilot units initiated safety changes that spread across multiple units, with identification of hospital-wide quality and patient safety issues., Conclusions: For participating units, the PSWR process is a situational awareness tool that helps management periodically assess new or unresolved vulnerabilities that may affect safety and care quality on the unit. Unit-based PSWR help identify safety concerns at the microsystem level while improving communication about safety events across units and to hospital leaders in the macrosystem.

Objective: Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system., Methods: A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors., Results: A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%)., Conclusions: Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.

The objectives were to evaluate clinical performance measures used for pediatric emergency medicine (PEM) physicians for reliability, correlation with one another, and relationship with clinical experience. This retrospective cohort study collected performance data for PEM physicians working at an urban children's hospital emergency department (ED) for each of 7 consecutive 6-month periods. Low correlations were seen between patients per hour or admission rate and 72-hour revisit rates. No significant association existed between level of experience and any performance measure. Physician treatment times appeared to be most reliable, and revisit rates were least reliable. Increase in number of patients seen per hour or lower admission rates in the ED are not significantly associated with an increase in revisit rates. Provider experience did not affect performance measures. Physician treatment time, patients per hour, admission rate, and charges per hour are reliable measures to assess the clinical performance of PEM physicians working at a single center.

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED's outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.

Objective: To explore the effect of a non-aerobic movement based activity on cognition in people with Alzheimer's type dementia (AD)., Methods: The sample consisted of 27 patients fulfilling the AD ICD-10 diagnostic criteria. The patient sample was randomly divided into two groups: The Exercise Group received 6 weeks movement training and comprised 15 participants with a mean age of 70.5 years (SD: 8). Control Group participated in a standard care group, which served as a control intervention, and consisted of 12 patients with an average age of 75.7 years (SD: 6.90). Cognitive functions were assessed using six computerised tests from the CANTAB, pre and post training. Data were analysed using t-tests. The false discovery rate (FDR) for multiple comparisons as well as Cohen's d effect size was used to assess the significant effects., Results: Significant improvements in sustained attention, visual memory and a trend in working memory were found in the Exercise Group compared to Control Group after the 6 weeks training. In addition, after 6 weeks the Control Group deteriorated significantly in attention, while the AD patients who undertook the physical exercise showed a discrete improvement., Conclusions: The present study shows that a short course of non-aerobic movement based exercise is already effective at least in some aspects of cognitive functioning in patients with AD. Although the present study is a pilot study with small samples, nevertheless, the results are promising for the further investigation and development of non-aerobic movement programmes., (Copyright © 2010 John Wiley & Sons, Ltd.)

Objectives: The goals were (1) to describe emergency department (ED) characteristics thought to be related to patient safety within the Pediatric Emergency Care Applied Research Network, (2) to measure staff perceptions of the climate of safety in EDs, and (3) to measure associations between ED characteristics and a climate of safety., Methods: Twenty-one EDs were surveyed to assess physical structure, staffing patterns, overcrowding, medication administration, teamwork, and methods for promoting patient safety. A validated survey on the climate of safety was administered to all emergency department staff members. Safety climate scores were compared to evaluate associations with ED characteristics., Results: A total of 1747 staff members (49%) responded to the survey on the climate of safety. A minority of EDs had organized safety activities such as safety committees (48%) or walk-rounds (38%), used computerized physician order entry (38%), had ED pharmacists (19%), or had formal physician/registered nurse teams (38%). The majority (67%) treated patients in hallways. Most (67%) varied staffing on the basis of seasonal patient volume. Of the 1747 ED staff members (49%) responding to the survey, there was a wide range (28%-82%) in the proportion reporting a positive safety climate. Physicians' ratings of the climate of safety were higher than nurses' ratings, and perceptions varied according to work experience. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee., Conclusions: Large variability existed among EDs in structures and processes thought to be associated with patient safety and in staff perception of the safety climate. Several ED characteristics were associated with a positive climate of safety.

Background: The onsets of needling sensation introduced by acupuncture stimulus can vary widely from subject to subject. This should be explicitly accounted for by the model blood oxygenation-level dependent (BOLD) time course used in general linear model (GLM) analysis to obtain more consistent across-subject group results. However, in standard GLM analysis, the model BOLD time course obtained by convolving a canonical hemodynamic response function with an experimental paradigm time course is assumed identical across subjects. Although some added-on properties to the model BOLD time course, such as temporal and dispersion derivatives, may be used to account for different BOLD response onsets, they can only account for the BOLD onset deviations to the extent of less than one repetition time (TR)., Methods: In this study, we explicitly manipulated the onsets of model BOLD time course by shifting it with -2, -1, or 1 TR and used these temporally shifted BOLD model to analyze the functional magnetic resonance imaging (fMRI) data obtained from three acupuncture fMRI experiments with GLM analysis. One involved acupuncture stimulus on left ST42 acupoint and the other two on left GB40 and left BL64 acupoints., Results: The model BOLD time course with temporal shifts, in addition to temporal and dispersion derivatives, could result in better statistical power of the data analysis in terms of the average correlation coefficients between the used BOLD models and extracted BOLD responses from individual subject data and the T-values of the activation clusters in the grouped random effects., Conclusions: The GLM analysis with ordinary BOLD model failed to catch the large variability of the onsets of the BOLD responses associated with the acupuncture needling sensation. Shifts in time with more than a TR on model BOLD time course might be required to better extract the acupuncture stimulus-induced BOLD activities from individual fMRI data.