Impact of Follow-up Calls From the Pediatric Emergency Department on Return Visits Within 72 Hours

Introduction: We implemented a pharmacist-led antimicrobial stewardship (AMS) service for patients discharged from the pediatric emergency department (PED). This service, supported by a collaborative practice agreement, allows pharmacists to follow up with patients and independently stop, start, or adjust antimicrobial agents based on culture results. The primary objective of our study was to evaluate the impact of this service on the rate of return visits to the PED within 96 hours. The secondary objective was to evaluate the appropriateness of the prescribed antimicrobial agent at follow up. Methods: This study was completed as a retrospective chart review 6 months pre-implementation (January 1st, 2016 to June 31st, 2016) and 6 months post-implementation (February 1st, 2017 to July 31st, 2017) of a pharmacist-led AMS service. A research assistant extracted data from electronic medical records using a standardized data collection form. All patients discharged from the PED with a suspected infection whose cultures fell within the parameters of the collaborative practice agreement were included in this study. Data were reported descriptively and compared using a two-sided chi-square test. Results: This study included 1070 patient encounters pre-implementation and 1040 patient encounters post-implementation of the AMS service. The most commonly reviewed culture was urine (38% pre-implementation and 41% post-implementation). The rate of return visits to the PED within 96 hours was 12.0% (129/1070) pre-implementation vs 10.0% (100/1049) post-implementation phase (p = 0.07). A significantly higher percentage of inappropriate antimicrobial therapy was identified at the time of follow up in the pre-implementation phase (7.0%, 68/975) compared to the post-implementation phase (5.0%, 46/952), p = 0.047. Conclusion: Although this pharmacist-led AMS service did not affect the rate of return visits within 96 hours, it may have led to more judicious use of antimicrobial agents.

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Low Rates of Follow-Up With Primary Care Providers After Pediatric Emergency Department Visits for Respiratory Tract Illnesses

Pediatric Emergency Care ◽

10.1097/pec.0b013e31826c6dde ◽

2012 ◽

Vol 28 (10) ◽

pp. 956-961 ◽

Cited By ~ 16

Author(s):

Danica B. Liberman ◽

Deborah Q. Shelef ◽

Jianping He ◽

Robert McCarter ◽

Stephen J. Teach

Keyword(s):

Primary Care ◽

Emergency Department ◽

Respiratory Tract ◽

Primary Care Providers ◽

Pediatric Emergency ◽

Emergency Department Visits ◽

Pediatric Emergency Department ◽

Care Providers ◽

Respiratory Tract Illnesses

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The Challenge of Patient Notification and the Work of Follow-Up Generated by a 2-Step Testing Protocol for Group A Streptococcal Pharyngitis in the Pediatric Emergency Department

Pediatric Emergency Care ◽

10.1097/pec.0000000000001144 ◽

2017 ◽

Vol Publish Ahead of Print ◽

Author(s):

Michael E. Russo ◽

Jennifer Kline ◽

Preeti Jaggi ◽

Amy L. Leber ◽

Daniel M. Cohen

Keyword(s):

Emergency Department ◽

Pediatric Emergency ◽

Streptococcal Pharyngitis ◽

Pediatric Emergency Department ◽

Testing Protocol ◽

Group A

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Availability of mobile phones for discharge follow-up of pediatric Emergency Department patients in western Kenya

PeerJ ◽

10.7717/peerj.790 ◽

2015 ◽

Vol 3 ◽

pp. e790 ◽

Cited By ~ 2

Author(s):

Darlene R. House ◽

Philip Cheptinga ◽

Daniel E. Rusyniak

Keyword(s):

Emergency Department ◽

Mobile Phones ◽

Pediatric Emergency ◽

Pediatric Emergency Department ◽

Western Kenya ◽

Emergency Department Patients

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Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging

Cephalalgia ◽

10.1177/0333102418781814 ◽

2018 ◽

Vol 39 (2) ◽

pp. 185-196 ◽

Cited By ~ 2

Author(s):

Daniel S Tsze ◽

Julie B Ochs ◽

Ariana E Gonzalez ◽

Peter S Dayan

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Pediatric Emergency ◽

Pediatric Emergency Department ◽

Healthy Children ◽

High Prevalence ◽

Associated Symptoms ◽

Neurological Exam ◽

Red Flag

Background Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging. Objectives We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population. Methods A prospective cohort study of otherwise healthy children 2–17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities. Results We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging. Conclusions Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.

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Process Mapping in a Pediatric Emergency Department to Minimize Missed Urinary Tract Infections

International Journal of Pediatrics ◽

10.1155/2016/2625870 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

Morgan Black ◽

Valene Singh ◽

Vladimir Belostotsky ◽

Madan Roy ◽

Deborah Yamamura ◽

...

Keyword(s):

Emergency Department ◽

Urinary Tract ◽

Chart Review ◽

Pediatric Emergency ◽

Pediatric Emergency Department ◽

Process Mapping ◽

Number Of Children ◽

Positive Urine ◽

Tract Infections

Urinary tract infections (UTIs) are common in young children and are seen in emergency departments (EDs) frequently. Left untreated, UTIs can lead to more severe conditions. Our goal was to undertake a quality improvement (QI) initiative to help minimize the number of children with missed UTIs in a newly established tertiary care pediatric emergency department (PED). A retrospective chart review was undertaken to identify missed UTIs in children < 3 years old who presented to a children’s hospital’s ED with positive urine cultures. It was found that there was no treatment or follow-up in 12% of positive urine cultures, indicating a missed or possible missed UTI in a significant number of children. Key stakeholders were then gathered and process mapping (PM) was completed, where gaps and barriers were identified and interventions were subsequently implemented. A follow-up chart review was completed to assess the impact of PM in reducing the number of missed UTIs. Following PM and its implementation within the ED, there was no treatment or follow-up in only 1% of cases. Based on our results, the number of potentially missed UTIs in the ED decreased dramatically, indicating that PM can be a successful QI tool in an acute care pediatric setting.

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P016: Low risk ankle rule, high reward-a quality improvement initiative to reduce ankle x-rays in the pediatric emergency department

CJEM ◽

10.1017/cem.2017.218 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S83 ◽

Cited By ~ 1

Author(s):

F. Al-Sani ◽

M. Ben-Yakov ◽

G. Harvey ◽

J. Gantz ◽

D. Jacobson ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Tertiary Care ◽

Pediatric Emergency ◽

Ankle Injuries ◽

Pediatric Emergency Department ◽

X Rays ◽

X Ray ◽

Return Visits ◽

Unnecessary Testing

Introduction: Our tertiary care institution embarked on the Choosing Wisely campaign to reduce unnecessary testing, and selected the reduction of ankle x-rays as part of its top five priority initiatives. The Low Risk Ankle Rule (LRAR), an evidence-based decision rule, has been derived and validated to clinically evaluate ankle injuries which do not require radiography. The LRAR, is cost-effective, has 100% sensitivity for clinically important ankle injuries and reduces ankle imaging rates by 30-60% in both academic and community setting. Our objective was to significantly reduce the proportion of ankle x-rays ordered for acute ankle injuries presenting to our pediatric Emergency Department (ED). Methods: Medical records were reviewed for all patients presenting to our tertiary care pediatric ED (ages 3- 18 years) with an isolated acute ankle injury from Jan 1, 2016-Sept 30, 2016. Children with outside imaging, an injury that occurred >72 hours prior, or those who had a repeat ED visit for same injury were excluded. Quality improvement (QI) initiatives included multidisciplinary staff education about the LRAR, posters placed within the ED highlighting the LRAR, development of a new diagnostic imaging requisition for ankle x-rays requiring use of the LRAR and collaboration with the Division of Radiology to ensure compliance with new requisition. The proportion of patients presenting to the ED with acute ankle injuries who received x-rays was measured. ED length of stay (LOS), return visits to the ED and orthopedic referrals were collected as balancing measures. Results: At baseline 88% of patients with acute ankle injuries received x-rays. Following our multiple interventions, the proportion of x-rays decreased significantly to 54%, (p<0.001). This decrease in x-ray rate was not associated with an increase in ED LOS, ED return visits or orthopedic referrals. There was an increase uptake of the dedicated x-ray requisition over time to 71%. Conclusion: This QI initiative to increase uptake of the LRAR, resulted in a significant reduction of ankle x-rays rates for children presenting with acute ankle injuries in our pediatric ED without increasing LOS, return visits or need for orthopedic referrals for missed injuries. Just as in the derivation and validation studies, the reductions have been sustained and reduced unnecessary testing and ionizing radiation.

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Characteristics of patients and families who make early return visits to the pediatric emergency department

Open Access Emergency Medicine ◽

10.2147/oaem.s43621 ◽

2013 ◽

pp. 9 ◽

Cited By ~ 1

Author(s):

Samina Ali ◽

Logue ◽

Spiers ◽

Newton ◽

Lander

Keyword(s):

Emergency Department ◽

Pediatric Emergency ◽

Pediatric Emergency Department ◽

Early Return ◽

Return Visits

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LO065: Reduced length of stay and adverse events using Bier block for forearm fracture reduction in the pediatric emergency department

CJEM ◽

10.1017/cem.2016.102 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S52-S53

Author(s):

E. Fauteux-Lamarre ◽

B. Burstein ◽

A. Cheng ◽

A. Bretholz

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Adverse Events ◽

Forearm Fracture ◽

Pediatric Emergency ◽

Fracture Reduction ◽

Pediatric Emergency Department ◽

Forearm Fractures ◽

Return Visits ◽

Bier Block

Introduction: Distal forearm fractures are one of the most common injuries presenting to the pediatric emergency department. Procedural sedation (PS) is commonly used to provide analgesia during fracture reduction, but requires a prolonged recovery period and can be associated with adverse respiratory events. Bier block (BB) regional anesthesia is a safe alternative to PS for fracture reduction analgesia. We sought to assess the impact of BB on length of stay (LOS) and adverse events following forearm fracture reduction compared to PS. Methods: We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. The primary outcome measure was emergency department LOS; secondary outcomes included reduction success rates, adverse events and unscheduled return visits. Results: Two-hundred and seventy-four patients were included for analysis; 109 treated with BB, 165 underwent PS. Overall, mean LOS was 82 min shorter for patients treated in the BB group (279 min vs. 361 min, p<0.05). Sub-analysis revealed a reduced LOS among patients treated with BB for fractures involving a single bone (286 min vs. 388 min, p<0.001) and both-bones of the forearm (259 min vs. 321 min, p<0.05). Both BB and PS resulted in comparable rates of successful reduction (98.2% vs. 97.6%, p=0.74). There were no major adverse events in either group. Patients who received BB experienced significantly fewer minor adverse events (2.7% vs. 14.5%, p<0.05). Return visit rates were similar in the BB and PS groups (17.6% vs. 17.1%, p<0.05). Conclusion: Compared to PS, forearm fracture reduction performed with BB was associated with a reduced emergency department LOS and fewer adverse events, with no difference in reduction success or return visits.

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