“Sick or not sick?” A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Laura B. O’Neill ◽  
Priti Bhansali ◽  
James E. Bost ◽  
James M. Chamberlain ◽  
Mary C. Ottolini
Keyword(s):  
Emergency Department ◽  
Mixed Methods ◽  
Clinical Reasoning ◽  
Pediatric Patients ◽  
Rapid Determination ◽  
Area Under The Curve ◽  
Pediatric Emergency ◽  
Illness Severity ◽  
Respiratory Support ◽  
Think Aloud

Abstract Objectives Experienced physicians must rapidly identify ill pediatric patients. We evaluated the ability of an illness rating score (IRS) to predict admission to a pediatric hospital and explored the underlying clinical reasoning of the gestalt assessment of illness. Methods We used mixed-methods to study pediatric emergency medicine physicians at an academic children’s hospital emergency department (ED). Physicians rated patients’ illness severity with the IRS, anchored by 0 (totally well) and 10 (critically ill), and shared their rationale with concurrent think-aloud responses. The association between IRS and need for hospitalization, respiratory support, parenteral antibiotics, and resuscitative intravenous (IV) fluids were analyzed with mixed effects linear regression. Area under the curve (AUC) receiver operator characteristic (ROC) curve and test characteristics at different cut-points were calculated for IRS as a predictor of admission. Think-aloud responses were qualitatively analyzed via inductive process. Results A total of 141 IRS were analyzed (mean 3.56, SD 2.30, range 0–9). Mean IRS were significantly higher for patients requiring admission (4.32 vs. 3.13, p<0.001), respiratory support (6.15 vs. 3.98, p = 0.033), IV fluids (4.53 vs. 3.14, p < 0.001), and parenteral antibiotics (4.68 vs. 3.32, p = 0.009). AUC for IRS as a predictor of admission was 0.635 (95% CI: 0.534–0.737). Analysis of 95 think-aloud responses yielded eight categories that describe the underlying clinical reasoning. Conclusions Rapid assessments as captured by the IRS differentiated pediatric patients who required admission and medical interventions. Think-aloud responses for the rationale for rapid assessments may form the basis for teaching the skill of identifying ill pediatric patients.

scholarly journals Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department

2020 ◽  
Author(s):  
Sarah D Fouquet ◽  
Laura Fitzmaurice ◽  
Y Raymond Chan ◽  
Evan M Palmer
Keyword(s):  
Emergency Department ◽  
Mixed Methods ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Pediatric Emergency ◽  
Second Phase ◽  
Pediatric Emergency Department ◽  
Mixed Methods Approach ◽  
Time And Motion ◽  
Attending Physician

Abstract Objective The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. Materials and Methods In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. Results Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. Discussion Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. Conclusion Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

scholarly journals Evaluation of the Efficacy of a Onetime Injectable Dexamethasone Administered Orally in the Pediatric Emergency Department for Asthma Exacerbation

2017 ◽  
Vol 22 (5) ◽  
pp. 326-331
Author(s):  
Ashley McCallister ◽  
Tsz-Yin So ◽  
Josh Stewart
Keyword(s):  
Emergency Department ◽  
Asthma Exacerbation ◽  
Pediatric Patients ◽  
Pediatric Emergency ◽  
Average Weight ◽  
Pediatric Emergency Department ◽  
Routes Of Administration ◽  
Efficacious Treatment ◽  
Randomized Control ◽  
To Receive

OBJECTIVE This study assessed the efficacy of injectable dexamethasone administered orally in pediatric patients who presented to the emergency department with asthma exacerbation. METHODS This was a retrospective study of patients 0 to 18 years of age who presented to and who were directly discharged from the emergency department at Moses H. Cone Memorial Hospital between September 1, 2012, and September 30, 2015, for the diagnosis of asthma or asthma exacerbation. Patients had to receive a onetime dose of injectable dexamethasone orally prior to discharge. Patients were followed for a 30-day period to identify the number of asthma relapses. RESULTS Ninety-nine patients were included in this study. The average weight-based dose ± SD of dexamethasone was 0.35 ± 0.18 mg/kg (range, 0.08–0.62 mg/kg) and the actual dose ± SD was 10.58 ± 1.92 mg (range, 5–16 mg). Over a 30-day period, 6 patients (6%) had one repeated emergency department visit, 6 patients (6%) were admitted to the hospital, and 3 patients (3%) presented to an outpatient clinic for asthma-related symptoms. CONCLUSIONS Injectable dexamethasone administered orally may be an efficacious treatment for asthma exacerbation in pediatric patients. A randomized control trial comparing injectable dexamethasone administered orally to other dexamethasone formulations/routes of administration should be performed to adequately assess the bioequivalence and effectiveness of the former formulation.

Characteristics of opioid prescriptions for discharged pediatric emergency department patients with acute injuries

2019 ◽  
Vol 67 (6) ◽  
pp. 1024-1027
Author(s):  
Lauren Krystine Kahl ◽  
Martha W Stevens ◽  
Andrea C Gielen ◽  
Eileen M McDonald ◽  
Leticia Ryan
Keyword(s):  
Emergency Department ◽  
Pediatric Patients ◽  
Median Number ◽  
Pediatric Emergency ◽  
Prescription Data ◽  
Prescribing Practices ◽  
Post Graduate ◽  
Frequent Use ◽  
Acute Injuries ◽  
Level Of Training

This study describes the characteristics of opioid prescriptions for pediatric patients discharged from the emergency department (ED) with acute injuries, including type, formulation, quantity dispensed, and associations with patient age group and prescriber level of training. This retrospective cohort study enrolled all acutely injured patients receiving opioid prescriptions at discharge from an urban academic pediatric ED in a 1-year period. Electronic medical records were reviewed to abstract clinical and prescription data and prescriber level of training. Descriptive statistics were used for analysis. We identified 254 patients with injuries who received opioid prescriptions at ED discharge during the study period (mean age 9.5 years, 65% male). The most common injury was fracture (71%). Oxycodone was the opioid most frequently prescribed (96.1%). Liquid formulations were prescribed in 51.6% of cases. The median number of doses prescribed per prescription was 12 (SD±9.1), with a range of 1–50. Residents wrote 72.9% of prescriptions and prescribed more doses than non-residents (15.5 vs 12.2, p=0.01). Post-graduate year 2 (PGY2) residents prescribed more doses than PGY1 or PGY3+ residents. Our data show wide variation in the number of opioid doses prescribed to acutely injured pediatric patients at ED discharge and frequent use of liquid formulation; both factors may place this population at risk for accidental ingestion. These findings also support the development of pediatric clinical guidelines to define appropriate quantities of opioids to prescribe, promote poisoning prevention strategies, and design post-graduate education for medical trainees about safe prescribing practices.

scholarly journals Comparisons of Pediatric Patients who Visited to the Pediatric Emergency Department and the General Emergency Department

2015 ◽  
Vol 2 (1) ◽  
pp. 29-34 ◽  
Author(s):  
Hyun Noh ◽  
Do Kyun Kim ◽  
Jin Hee Lee ◽  
Young Ho Kwak ◽  
Jin Hee Jung ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pediatric Patients ◽  
Pediatric Emergency ◽  
Pediatric Emergency Department

scholarly journals Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality

2020 ◽  
Vol 7 ◽  
pp. 2333794X2094792
Author(s):  
Samita Giri ◽  
Tine Halvas-Svendsen ◽  
Tormod Rogne ◽  
Sanu Krishna Shrestha ◽  
Henrik Døllner ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Care ◽  
Low Income ◽  
Disease Burden ◽  
Pediatric Patients ◽  
Pediatric Emergency ◽  
Low Income Countries ◽  
Post Discharge ◽  
Telephone Interviews ◽  
Pediatric Emergency Care

Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.

scholarly journals Acute Abdomen in Pediatric Patients Admitted to the Pediatric Emergency Department

2008 ◽  
Vol 49 (4) ◽  
pp. 126-134 ◽  
Author(s):  
Yu-Ching Tseng ◽  
Ming-Sheng Lee ◽  
Yu-Jun Chang ◽  
Han-Ping Wu
Keyword(s):  
Emergency Department ◽  
Acute Abdomen ◽  
Pediatric Patients ◽  
Pediatric Emergency ◽  
Pediatric Emergency Department

scholarly journals Characteristics and Treatment of Anaphylaxis in Children Visiting a Pediatric Emergency Department in Korea

2020 ◽  
Vol 2020 ◽  
pp. 1-7
Author(s):  
Won Seok Lee ◽  
Jaewoo An ◽  
Young-Ho Jung ◽  
Hye Mi Jee ◽  
Kyu-Young Chae ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pediatric Patients ◽  
Pediatric Emergency ◽  
Food Allergies ◽  
Study Patient ◽  
Pediatric Emergency Department ◽  
Laboratory Findings ◽  
Korean Children ◽  
Epinephrine Injection ◽  
Tryptase Level

Anaphylaxis is a serious life-threatening allergic disease in children. This study is aimed at determining the characteristics of pediatric patients who experienced anaphylaxis along with treatments administered in order to determine the usefulness of tryptase level assessment as a marker of anaphylaxis in Korean children. A total of 107 patients who were diagnosed with anaphylaxis in a single pediatric emergency center over a 3-year period were included in the study. Patient clinical characteristics, symptoms, signs, allergy history, trigger factors, treatments, and laboratory findings, including serum tryptase levels, were included in the analysis. Food allergies (39.3%) were the most commonly reported patient allergic history, and 58 patients (54.2%) were triggered by food. Among this group, nuts and milk exposure were the most common, affecting 15 patients (25.9%). History of anaphylaxis and asthma were more common in severe anaphylaxis compared to mild or moderate anaphylaxis cases. Epinephrine intramuscular injection was administrated to 76 patients (71.0%), and a self-injectable epinephrine was prescribed to 18 patients (16.8%). The median tryptase level was 4.80 ng/mL (range: 2.70–10.40) which was lower than the 11.4 ng/mL value commonly documented for standard evaluation in adults with anaphylaxis. The most common cause of pediatric anaphylaxis was food including nuts and milk. The rate of epinephrine injection was relatively high in our pediatric emergency department. The median tryptase level associated with anaphylaxis reactions in children was lower than 11.4 ng/mL. Further studies are needed to help improve diagnostic times and treatment accuracy in pediatric patients who develop anaphylaxis.

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