An Ambulatory Antimicrobial Stewardship Initiative to Improve Diagnosis and Treatment of Urinary Tract Infections in Children.

Background: Antibiotic stewardship efforts should standardize treatment of common infections when possible. Urinary tract infections (UTIs) are common in children and require appropriate diagnostic methods and treatment. A pediatric emergency department (ED) identified an opportunity to improve care by standardizing uncomplicated UTI diagnostic testing and treatment according to local bacterial resistance patterns from January 2017 to December 2018.

Designing and implementing an outpatient management pathway for patients with newly diagnosed insulin-dependent diabetes mellitus.

Objective: Recently, our team transitioned to an outpatient diabetes education model for patients with newly diagnosed insulin-dependent diabetes mellitus (IDDM) after concerns arose regarding inconsistent education provided in the hospital, as well as additional emotional stress attributed to hospitalization. To optimize this model, an improvement initiative was implemented to redesign the outpatient care processes, refine patient education content and identify ideal educational strategies. Specific aims were to (a) achieve family self-management, (b) reduce stress and (c) ensure family and provider satisfaction with the outpatient pathway.

Improving Timeliness of β-Agonist and Corticosteroid Administration in Patients With Acute Wheezing.

Objective: Timely delivery of β-agonists and steroids to patients with acute recurrent wheezing is a key component of the National Heart, Lung, and Blood Institute recommended emergency department (ED) asthma care. We conducted an ED improvement initiative to standardize asthma care and improve time to treatments.

Methods: Our multidisciplinary team identified key contributing factors to timeliness, developed key driver diagrams, implemented and refined a management pathway, designed and executed rapid cycle improvements, and implemented interventions.

Decreasing time to antibiotics in febrile patients with central lines in the emergency department.

Background And Objective: Rapid antibiotic administration is essential for the successful management of patients who have central lines and present with fever. We conducted an emergency department (ED) improvement initiative to deliver antibiotics to 90% of patients within 60 minutes and to minimize process variation.

Methods: Our setting was an academic ED.

Improving inpatient cystic fibrosis pulmonary exacerbation care: two success stories.

Background: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are a frequent cause of hospitalisations and lead to long-term decline in pulmonary function. Successful CF inpatient care requires the coordination of multiple providers and complex therapies. Children's Hospital of Wisconsin (CHW) and Children's Healthcare of Atlanta (CHoA) independently identified PEx inpatient care for focused improvements, with emphasis on improving care coordination and patient outcomes.

A randomized trial of enema versus polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency department.

Objective: This study aimed to compare efficacy of enema versus polyethylene glycol (PEG) 3350 for pediatric fecal impaction treatment.

Methods: We conducted a prospective, randomized comparison of treatments of fecal impaction in children in a pediatric emergency department (ED). Treatment arms were a single milk and molasses enema in the ED or PEG 3350 for 3 days outpatient.

The role of exhaled nitric oxide in evaluation of acute asthma in a pediatric emergency department.

Objectives: Fractional excretion of nitric oxide (FE(NO)) has been used as a noninvasive marker to assess and manage chronic asthma in adults and children. The aim of this study was to determine the feasibility of obtaining FE(NO) concentrations in children treated in the emergency department (ED) for acute asthma exacerbation and to examine the association between FE(NO) concentrations and other measures of acute asthma severity.

Methods: This was a cross-sectional study of a convenience sample of children 2-18 years old who were seen in an urban ED for acute asthma exacerbation.

Emergency department revisits for pediatric acute asthma exacerbations: association of factors identified in an emergency department asthma tracking system.

Objective: To identify clinical variables associated with a greater likelihood of emergency department (ED) revisit for acute asthma within 7 days after an initial ED visit for acute asthma exacerbation.

Methods: Cross-sectional study of subjects from a prospectively enrolled cohort of children aged 0 to 18 years with physician-diagnosed asthma in the ED Allies Tracking System. Demographics and data on quality of life, health care utilization, environmental factors, chronic asthma severity, and ED management were collected.

Childhood asthma in the emergency department: trends, challenges, and opportunities.

Acute exacerbations of childhood asthma are frequently managed in the emergency department (ED). ED-based surveillance and intervention projects highlight the limitations and challenges of acute and chronic childhood asthma management. Because a significant number of asthmatic children currently receive and will likely continue to seek acute asthma care in the ED, provision of asthma education and initiation of controller medication therapy during the ED visit, although controversial, may contribute to improving asthma outcomes and eventually to reducing the burden of asthma on our overcrowded EDs.

National Asthma Education and Prevention Program severity classification as a measure of disease burden in children with acute asthma.

Objective: To examine the association between the National Asthma Education and Prevention Program (NAEPP) severity classification and other measures of burden of disease in children with acute asthma.

Methods: We performed a cross-sectional study of 750 children <18 years of age with a physician diagnosis of asthma and treated in an emergency department (ED) for acute asthma exacerbation. Subjects were assigned to 1 of 4 levels of severity (mild intermittent, mild persistent, moderate persistent, or severe persistent).

Emergency Department Allies: a Web-based multihospital pediatric asthma tracking system.

Objective: To describe the development of a Web-based multihospital pediatric asthma tracking system and present results from the initial 18-month implementation of patient tracking experience.

Design: The Emergency Department (ED) Allies tracking system is a secure, password-protected data repository. Use-case methodology served as the foundation for technical development, testing, and implementation.

Emergency department allies: a controlled trial of two emergency department-based follow-up interventions to improve asthma outcomes in children.

Objective: We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation.

Methods: Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions.

Serum neuron-specific enolase as a predictor of short-term outcome in children with closed traumatic brain injury.

Background: Closed traumatic brain injury (cTBI) is a significant cause of mortality and morbidity in children. The natural course and extent of recovery from cTBI in children are poorly understood. Neuron-specific enolase (NSE), an enzyme detected in serum following structural damage of neuronal brain cells, appears to be a good marker for intracranial injury.

Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution.

Objective: To determine the baseline level of preparedness of Wisconsin primary care physician offices for pediatric emergencies and to assess the impact of mail distribution of guidelines on this level of preparedness.

Method: Preintervention surveys were mailed to all Wisconsin physicians requesting information about pediatric equipment, medications, training, and policies. Guidelines were distributed by mail to all physicians who returned completed surveys.

Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department.

Objective: To determine whether a protocol to start patient-controlled analgesia (PCA) in the emergency department (ED-PCA) would shorten the length of time between narcotic bolus doses and PCA initiation as compared with standard inpatient initiation of PCA (IP-PCA). Also, to compare patient satisfaction and inpatient length of stay for the 2 groups.

Methods: To improve care, we developed a protocol to institute ED-PCA after an initial bolus dose of narcotics.

The short-term outcome of seizure management by prehospital personnel: a comparison of two protocols.

Objective: To evaluate the impact of an emergency medical service protocol with reduced diazepam dose on the intubation rate of children with seizure activity treated by emergency medical service personnel and to evaluate the short-term outcome comparing 2 emergency medical service treatment protocols.

Methods: Retrospective review of the emergency medical service and hospital databases of children 0-18 years with seizure activity. Prior to January 1996, the county emergency medical service protocol recommended a diazepam dose of 0.

Feasibility survey for a study on selective antibiotic management of acute otitis media.

Objective: To assess the views of community physicians on management of acute otitis media (AOM) without antibiotics and their willingness to support research on this issue.

Methods: Community physicians who admit to a children's hospital were surveyed using a questionnaire containing questions on current issues in AOM management and their willingness to support research on management of AOM without antibiotics.

Results: Fifty-two percent of the surveys were returned.

Do clinical variables predict pathologic radiographs in the first episode of wheezing?

Objective: To determine if clinical variables assessed in relation to Albuterol aerosol treatments accurately identify children with pathologic radiographs during their initial episode of bronchospasm.

Methods: A prospective convenience sample of children with a first episode of wheezing. Data collected included demographics, baseline and post-treatment clinical score and physical examination, number of aerosols, requirement for supplemental oxygen, and disposition.

Utilization of the Ottawa ankle rules by nurses in a pediatric emergency department.

Objectives: To determine the ability of pediatric emergency department (ED) nurses to accurately apply the Ottawa Ankle Rules (OAR) and to evaluate whether the rate of negative ankle radiographs can be reduced by incorporating the OAR into an existing collaborative practice protocol (CPP).

Methods: The authors' ED currently uses a CPP in which patients with ankle pain, swelling, deformity, or decreased range of motion on primary nursing assessment undergo radiography prior to physician evaluation. A cross-sectional study was conducted between June and November 2000.

Accuracy of clinical variables in the identification of radiographically proven constipation in children.

Study Objective: To determine whether clinical variables accurately identify children with radiographically proven constipation.

Methods: Prospective, cross sectional case series of children 2-12 years of age with abdominal pain (AP) requiring radiographic evaluation. Constipation was defined radiographically as the presence of fecal material throughout the colon.

Serum neuron-specific enolase as a predictor of intracranial lesions in children with head trauma: a pilot study.

Objective: To determine the reliability of serum neuron-specific enolase (NSE) levels in predicting intracranial lesions (ICL) in children with blunt head trauma (HT).

Methods: A prospective pilot study was conducted of patients 0 to 18 years of age presenting to a children's hospital emergency department (ED) between December 1997 and October 1998. Children presenting within 24 hours of injury who required head computed tomography (CT) were eligible.

The need for a second dose of ceftriaxone in febrile infants age 4-8 weeks.

Objective: To determine if a second intramuscular injection of ceftriaxone was necessary in febrile infants who meet low-risk criteria for outpatient therapy.

Setting: Children's Hospital Emergency Department.

Patients: Febrile infants 4-8 weeks of age.

Advance directives in a pediatric emergency department.

Parents of children with terminal illnesses are not always present when a life-threatening event occurs. For many of these children, an advance directive specifying alternate code orders has been written by the parent or legal guardian (hereafter the use of parent is to be interpreted as parent/legal guardian) and the patient's attending physician. Implementing a pediatric advanced directive presents significant problems for emergency personnel if the parent is not present to identify the existence of the directive and interpret the contents in the context of the current medical crisis.