First name
Joseph
Middle name
J
Last name
Zorc

Title

Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinician Identification.

Year of Publication

2017

Date Published

2017 May 27

ISSN Number

1097-6760

Abstract

STUDY OBJECTIVE: Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department (ED).

METHODS: This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.

RESULTS: There were 182,509 ED visits during the study period, with 86,037 before electronic sepsis alert implementation and 96,472 afterward, and 1,112 (1.2%) positive electronic sepsis alerts. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the electronic sepsis alert alone to detect severe sepsis were sensitivity 86.2% (95% confidence interval [CI] 82.0% to 89.5%), specificity 99.1% (95% CI 99.0% to 99.2%), positive predictive value 25.4% (95% CI 22.8% to 28.0%), and negative predictive value 100% (95% CI 99.9% to 100%). Inclusion of the clinician screen identified 43 additional electronic sepsis alert-negative children, with severe sepsis sensitivity 99.4% (95% CI 97.8% to 99.8%) and specificity 99.1% (95% CI 99.1% to 99.2%). Electronic sepsis alert implementation increased ED sepsis detection from 83% to 96%.

CONCLUSION: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert-negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

DOI

10.1016/j.annemergmed.2017.03.019

Alternate Title

Ann Emerg Med

PMID

28583403

Title

Childhood Asthma Hospital Discharge Medication Fills and Risk of Subsequent Readmission.

Year of Publication

2015

Number of Pages

1121-7

Date Published

05/2015

ISSN Number

1097-6833

Abstract

OBJECTIVE: To assess the relationship between posthospitalization prescription fills for recommended asthma discharge medication classes and subsequent hospital readmission.

STUDY DESIGN: This was a retrospective cohort analysis of Medicaid Analytic Extract files from 12 geographically diverse states from 2005-2007. We linked inpatient hospitalization, outpatient, and prescription claims records for children ages 2-18 years with an index hospitalization for asthma to identify those who filled a short-acting beta agonist, oral corticosteroid, or inhaled corticosteroid within 3 days of discharge. We used a multivariable extended Cox model to investigate the association of recommended medication fills and hospital readmission within 90 days.

RESULTS: Of 31,658 children hospitalized, 55% filled a beta agonist prescription, 57% an oral steroid, and 37% an inhaled steroid. Readmission occurred for 1.3% of patients by 14 days and 6.3% by 90 days. Adjusting for patient and billing provider factors, beta agonist (hazard ratio [HR] 0.67, 95% CI 0.51, 0.87) and inhaled steroid (HR 0.59, 95% CI 0.42, 0.85) fill were associated with a reduction in readmission at 14 days. Between 15 and 90 days, inhaled steroid fill was associated with decreased readmission (HR 0.87, 95% CI 0.77, 0.98). Patients who filled all 3 medications had the lowest readmission hazard within both intervals.

CONCLUSIONS: Filling of beta agonists and inhaled steroids was associated with diminished hazard of early readmission. For inhaled steroids, this effect persisted up to 90 days. Efforts to improve discharge care for asthma should include enhancing recommended discharge medication fill rates.

DOI

10.1016/j.jpeds.2014.12.019

Alternate Title

J. Pediatr.

PMID

25641244

Title

Improving Emergency Care for Children With Medical Complexity: Parent and Physicians' Perspectives.

Year of Publication

2021

Number of Pages

513-520

Date Published

2021 04

ISSN Number

1876-2867

Abstract

<p><strong>OBJECTIVE: </strong>Children with medical complexity (CMC) have high rates of emergency department (ED) utilization, but little evidence exists on the perceptions of parents and pediatric emergency medicine (PEM) physicians about emergency care. We sought to explore parent and PEM physicians' perspectives about 1) ED care for CMC, and 2) how emergency care can be improved.</p>

<p><strong>METHODS: </strong>We performed semistructured interviews with parents and PEM physicians at a single academic, children's hospital. English-speaking parents were selected utilizing a standard definition of CMC during an ED visit in which their child was admitted to the hospital. All PEM physicians were eligible. We developed separate interview guides utilizing open-ended questions. The trained study team developed and modified a coding tree through an iterative process, double-coded transcripts, monitored inter-rater reliability to ensure adherence, and performed thematic analysis.</p>

<p><strong>RESULTS: </strong>Twenty interviews of parents of CMC and 16 of PEM physicians were necessary for saturation. Parents identified specific challenges related to ED care of their children involving time, information gathering, logistics/convenience, and multifaceted communication between health teams and parents. PEM physicians identified time, data accessibility and availability, and communication as inter-related challenges in caring for CMC in the ED. Suggestions reflected potential solutions to the challenges identified.</p>

<p><strong>CONCLUSIONS: </strong>Time, data, and communication challenges were the main focus for both parents and PEM physicians, and suggestions mirrored these challenges. Further research and quality improvement efforts to better characterize and mitigate the identified challenges could be of value for this vulnerable population.</p>

DOI

10.1016/j.acap.2020.09.006

Alternate Title

Acad Pediatr

PMID

32947009

Title

Human-centered development of an electronic health record-embedded, interactive information visualization in the emergency department using fast healthcare interoperability resources.

Year of Publication

2021

Date Published

2021 Mar 03

ISSN Number

1527-974X

Abstract

<p><strong>OBJECTIVE: </strong>Develop and evaluate an interactive information visualization embedded within the electronic health record (EHR) by following human-centered design (HCD) processes and leveraging modern health information exchange standards.</p>

<p><strong>MATERIALS AND METHODS: </strong>We applied an HCD process to develop a Fast Healthcare Interoperability Resources (FHIR) application that displays a patient's asthma history to clinicians in a pediatric emergency department. We performed a preimplementation comparative system evaluation to measure time on task, number of screens, information retrieval accuracy, cognitive load, user satisfaction, and perceived utility and usefulness. Application usage and system functionality were assessed using application logs and a postimplementation survey of end users.</p>

<p><strong>RESULTS: </strong>Usability testing of the Asthma Timeline Application demonstrated a statistically significant reduction in time on task (P &lt; .001), number of screens (P &lt; .001), and cognitive load (P &lt; .001) for clinicians when compared to base EHR functionality. Postimplementation evaluation demonstrated reliable functionality and high user satisfaction.</p>

<p><strong>DISCUSSION: </strong>Following HCD processes to develop an application in the context of clinical operations/quality improvement is feasible. Our work also highlights the potential benefits and challenges associated with using internationally recognized data exchange standards as currently implemented.</p>

<p><strong>CONCLUSION: </strong>Compared to standard EHR functionality, our visualization increased clinician efficiency when reviewing the charts of pediatric asthma patients. Application development efforts in an operational context should leverage existing health information exchange standards, such as FHIR, and evidence-based mixed methods approaches.</p>

DOI

10.1093/jamia/ocab016

Alternate Title

J Am Med Inform Assoc

PMID

33682004

Title

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations.

Year of Publication

2020

Date Published

2020 Oct 01

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.</p>

<p><strong>METHODS: </strong>Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.</p>

<p><strong>RESULTS: </strong>From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; = .02).</p>

<p><strong>CONCLUSIONS: </strong>A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.</p>

DOI

10.1542/peds.2019-3108

PMID

33004429

Title

Racial and Ethnic Disparities in the Delayed Diagnosis of Appendicitis Among Children.

Year of Publication

2020

Date Published

2020 Sep 29

ISSN Number

1553-2712

Abstract

<p><strong>BACKGROUND: </strong>Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of: 1) appendiceal perforation; 2) delayed diagnosis of appendicitis; 3) diagnostic imaging during prior visit(s).</p>

<p><strong>METHODS: </strong>3-year multicenter (7 EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7 days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, Other) with: 1) appendiceal perforation; 2) delayed diagnosis of appendicitis; 3) diagnostic imaging during prior visit(s).</p>

<p><strong>RESULTS: </strong>Of 7298 patients with appendicitis and documented race/ethnicity, 2567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; aOR 1.21 [95% CI 1.01, 1.45]). 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR 1.81 [1.09, 2.98]. Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR 0.41 [0.18, 0.96]), or definitive imaging (e.g. US/CT/MRI) (10.3% vs. 35.9%; aOR 0.15 [0.05, 0.50]) during prior visits.</p>

<p><strong>CONCLUSIONS: </strong>In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis, and thus, may contribute to higher perforation rates demonstrated among minority children.</p>

DOI

10.1111/acem.14142

Alternate Title

Acad Emerg Med

PMID

32991770

Title

Distinguishing Multisystem Inflammatory Syndrome in Children From Kawasaki Disease and Benign Inflammatory Illnesses in the SARS-CoV-2 Pandemic.

Year of Publication

2020

Date Published

2020 Sep 22

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVE: </strong>The aim of the study was to compare presenting clinical and laboratory features among children meeting the surveillance definition for multisystem inflammatory syndrome in children (MIS-C) across a range of illness severities.</p>

<p><strong>METHODS: </strong>This is a retrospective single-center study of patients younger than 21 years presenting between March 1 and May 15, 2020. Included patients met the Centers for Disease Control and Prevention criteria for MIS-C (inflammation, fever, involvement of 2 organ systems, lack of alternative diagnoses). We defined 3 subgroups by clinical outcomes: (1) critical illness requiring intensive care interventions; (2) patients meeting Kawasaki disease (KD) criteria but not requiring critical care; and (3) mild illness not meeting either criteria. A comparator cohort included patients with KD at our institution during the same time frame in 2019.</p>

<p><strong>RESULTS: </strong>Thirty-three patients were included (5, critical; 8, 2020 KD; 20, mild). The median age for the critical group was 10.9 years (2.7 for 2020 KD; 6.0 for mild, P = 0.033). The critical group had lower median absolute lymphocyte count (850 vs 3005 vs 2940/uL, P = 0.005), platelets (150 vs 361 vs 252 k/uL, P = 0.005), and sodium (129 vs 136 vs 136 mmol/L, P = 0.002), and higher creatinine (0.7 vs 0.2 vs 0.3 mg/dL, P = 0.002). In the critical group, 60% required vasoactive medications, and 40% required mechanical ventilation. Clinical and laboratories features were similar between the 2020 and 2019 KD groups.</p>

<p><strong>CONCLUSIONS: </strong>We describe 3 groups with inflammatory syndromes during the SARS-CoV-2 pandemic. The initial profile of lymphopenia, thrombocytopenia, hyponatremia, and abnormal creatinine may help distinguish critically ill MIS-C patients from classic/atypical KD or more benign acute inflammation.</p>

DOI

10.1097/PEC.0000000000002248

Alternate Title

Pediatr Emerg Care

PMID

32970023

Title

Trends in Pediatric Emergency Department Utilization after Institution of COVID-19 Mandatory Social Distancing.

Year of Publication

2020

Date Published

2020 Jul 20

ISSN Number

1097-6833

DOI

10.1016/j.jpeds.2020.07.048

Alternate Title

J. Pediatr.

PMID

32702427

Title

Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization.

Year of Publication

2020

Date Published

2020 Jun 06

ISSN Number

2213-2201

Abstract

<p>Compared with historical trends, we describe a dramatic decrease in pediatric asthma-related emergency department utilization for all levels of acuity coincident with coronavirus disease 2019&nbsp;emergence. These findings have implications for clinicians and researchers seeking to understand the drivers of asthma exacerbations.</p>

DOI

10.1016/j.jaip.2020.05.045

Alternate Title

J Allergy Clin Immunol Pract

PMID

32522565

Title

Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry.

Year of Publication

2020

Date Published

2020 Mar 05

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry.</p>

<p><strong>STUDY DESIGN: </strong>This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17&nbsp;years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72&nbsp;hours.</p>

<p><strong>RESULTS: </strong>Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154&nbsp;minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg.</p>

<p><strong>CONCLUSIONS: </strong>In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.</p>

DOI

10.1016/j.jpeds.2020.01.062

Alternate Title

J. Pediatr.

PMID

32147221

WATCH THIS PAGE

Subscription is not available for this page.