Publications by authors named "Mark Nimmer"

25 Publications

  • Page 1 of 1

Assessing improvements in emergency department referrals to a hospital-based violence intervention program.

Inj Epidemiol 2021 Sep 13;8(Suppl 1):44. Epub 2021 Sep 13.

Pediatrics, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.

Background: Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018-2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7-18 years who present to our Level 1 emergency department/trauma center with a violent injury.

Methods: For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts.

Results: The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase.

Conclusion(s): We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40621-021-00333-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436440PMC
September 2021

Utilization of heat-mapping tools to match a resident staffing template to emergency department arrival patterns.

AEM Educ Train 2021 Jul 1;5(3):e10633. Epub 2021 Jul 1.

Medical College of Wisconsin Milwaukee Wisconsin USA.

Objectives: Academic emergency departments (ED) rely on a steady flow of patients to provide residents with good clinical training. Understanding institutional volume patterns allows training directors to create a schedule that maximizes learning opportunities while also adequately staffing the ED. Our primary objective of this study was to utilize heat-mapping software to optimize resident staffing in an academic ED.

Methods: Heat-mapping tools within Microsoft Excel were utilized to overlay ED patient arrival patterns on top of the potential patients per hour based on published productivity data for trainees and historical averages for advanced practice providers at our institution. Time frames for under- and overstaffing were identified and color-coded. This analysis informed a revised schedule template and the same heat-mapping process was used to determine the appropriateness of the revised staffing template.

Results: The heat map for the original schedule template revealed understaffing in the morning and overstaffing the rest of the day. Informed by these findings, schedule adjustments were made. There was no net increase in the number of resident or advanced practice provider coverage hours. Prior to implementation, the ED was understaffed by 5% or more during 18.4% of operating hours. Following changes to the staffing template, only 5.9% of operating hours were understaffed (p < 0.001). Furthermore, significant understaffing (20% or more) decreased from 16.6% to 3.1% (p < 0.001).

Conclusions: Novel use of heat-mapping software has the potential to successfully match ED patient arrival patterns to an optimal resident staffing template. Future directions include incorporation of variable resident productivity to account for fatigue as the shift progresses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/aet2.10633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325434PMC
July 2021

Vaccinating in the Emergency Department, a Model to Overcome Influenza Vaccine Hesitancy.

Pediatr Qual Saf 2021 Mar-Apr;6(2):e430. Epub 2021 Apr 5.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.

Introduction: Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018-2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019-2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients.

Methods: Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months-18 years old, emergency severity index score 2-5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure.

Results: We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2.

Conclusions: This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/pq9.0000000000000430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032353PMC
April 2021

Leveraging the Electronic Medical Record to Increase Distribution of Low Literacy Asthma Education in the Emergency Department.

Acad Pediatr 2021 07 20;21(5):868-876. Epub 2020 Nov 20.

Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin.

Objective: Though low literacy asthma education is effective at reducing emergency department (ED) use, few interventions are administered in the ED. The aim was to increase the number of parents of children with asthma receiving education in the ED to 50% receiving written and 30% receiving video education over 12 months.

Methods: Using quality improvement methods, the team planned interventions including improvement of nursing workflow and availability of written and video education. Nurse champions performed peer-to-peer education regarding educational materials and health literacy-focused communication. An asthma education order opening the nursing flowsheet, which linked to written and video materials and documentation was created. The order was placed in highly used ED asthma order sets. The percent of parents receiving written or video education was followed on statistical process control charts. Balancing measures included: ED length of stay, discharge length, 30 day ED return visits, and 365 day return visits with hospitalization.

Results: The mean number of parents receiving written education at baseline was 28% and improved to 52%. Special cause variation was noted after order roll-out. Video education increased from a baseline of 0% of parents receiving to 32% with special cause variation after order roll-out. No special cause was noted in balancing measures. Revisits with hospitalization within 365 days showed a decreasing trend after order roll-out.

Conclusions: Implementation of workflow improvement, education, and the addition of a functional education order in an existing order set led to a meaningful improvement in distribution of a low literacy asthma education intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2020.11.011DOI Listing
July 2021

Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress.

Prehosp Emerg Care 2021 Sep-Oct;25(5):664-674. Epub 2020 Oct 7.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB).

Background: The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown.

Objective: We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one's own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire.

Methods: This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to <1 and ≥1 case per shift and having children was dichotomized to either having children or not having children.

Results: Of 514 paramedics, 420 (82%) completed the questionnaire. Overall, paramedics correctly assessed the severity of respiratory distress 92% of the time. However, they only ascribed the correct diagnosis 50% and selected the correct intervention(s) 38% of the time. Increasing age, years of experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.

Conclusion: Paramedics accurately assessed severity of distress in multimedia cases of asthma/bronchospasm, bronchiolitis and croup in children, but showed significant room for improvement in correctly identifying the diagnosis and in selecting appropriate intervention(s). Age, years of EMS experience, higher volume of clinical pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/10903127.2020.1817211DOI Listing
October 2020

Vaccinating in the Emergency Department, a Novel Approach to Improve Influenza Vaccination Rates via a Quality Improvement Initiative.

Pediatr Qual Saf 2020 Jul-Aug;5(4):e322. Epub 2020 Jul 8.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.

Introduction: Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017-2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s.

Methods: Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution.

Results: We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital.

Conclusions: We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/pq9.0000000000000322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351463PMC
July 2020

Vaccinating in the Emergency Department, a Novel Approach to Improve Influenza Vaccination Rates via a Quality Improvement Initiative.

Pediatr Qual Saf 2020 Jul-Aug;5(4):e322. Epub 2020 Jul 8.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.

Introduction: Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017-2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s.

Methods: Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution.

Results: We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital.

Conclusions: We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/pq9.0000000000000322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351463PMC
July 2020

The association between timely opioid administration and hospitalization in children with sickle cell disease presenting to the emergency department in acute pain.

Pediatr Blood Cancer 2020 09 2;67(9):e28268. Epub 2020 Jul 2.

Medical College of Wisconsin, Milwaukee, Wisconsin.

Introduction: The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) pain crisis management recommend opioids within 60 minutes of emergency department (ED) registration and every 30 minutes thereafter until acute pain is managed. These guidelines are based on expert opinion without published, supporting data.

Objective: To evaluate the association between timely ED opioid administration and hospitalization rates in children with SCD.

Methods: Retrospective cohort of children presenting to a children's hospital ED with SCD pain between January 1, 2014, and April 30, 2018. Visits were extracted using ICD codes, chief complaints, and receipt of at least one opioid, and then reviewed to confirm the visit was an uncomplicated pain crisis. The primary outcome was hospitalization, yes or no. Generalized estimating equations were used to determine adjusted odds of hospitalization for the timely administration of initial and second doses of opioids.

Results: Of the 902 eligible visits, 368 (40.8%) resulted in hospitalization. The mean (SD) age was 11.9 (± 5.2) years. The first opioid was administered within 60 minutes of arrival in 601 (66.6%) visits. The second opioid was administered within 30 minutes of the first in 84 (12.3%) visits. Receipt of the first opioid within 60 minutes of arrival was not associated with decreased hospitalization (1.30 [0.96-1.76]). However, receipt of the second dose within 30 minutes of the first was associated with decreased hospitalization (0.56 [0.33-0.94]).

Conclusion: This study suggests an association between children with SCD receiving a second dose within 30 minutes of the first opioid dose and decreased hospitalizations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.28268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674235PMC
September 2020

Impact of Medical Scribes on Provider Efficiency in the Pediatric Emergency Department.

Acad Emerg Med 2019 02 23;26(2):174-182. Epub 2018 Oct 23.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

Objectives: Today's emergency department (ED) providers spend a significant amount of time on medical record documentation, decreasing clinical productivity. One proposed solution is to utilize medical scribes who assist with documentation. We hypothesized that scribes would increase provider productivity and increase provider satisfaction without affecting patient experience or nursing satisfaction.

Methods: We conducted an observational pre-post study comparing ED prescribe and postscribe clinical productivity metrics for 18 pediatric emergency medicine physicians, two general pediatricians, and two nurse practitioners working in the 12-bed nonurgent area of the pediatric ED. Productivity metrics included patients per hour (pts/hr), work relative value units per hour (wRVUs/hr), and visit duration measured for 1 year pre- and postscribe implementation. Cross-sectional satisfaction surveys were administered to patient families, providers, and nurses during the initial scribe rollout.

Results: Overall, 24,518 prescribe and 27,062 postscribe visits were analyzed. Following scribe implementation, overall provider efficiency increased by 0.24 pts/hr (11.98%, p < 0.001) and 0.72 wRVUs/hr (20.14%, p < 0.001). The largest efficiency increase (0.36 pts/hr, 0.96 wRVUs/hr) occurred in January-March, when ED census peaked. Patient visit duration was 53 minutes in both the prescribe and the postscribe periods. During initial scribe implementation, 80% of parents of patients without a scribe rated the visit as very good/great compared to 84% with a scribe (p = 0.218). Of the 34 providers surveyed, 88% preferred working with a scribe. A majority of providers (82%) felt that their skills were used more effectively when working with a scribe, decreasing their likelihood of experiencing burnout. Of the 43 nurses surveyed, 51% preferred scribes and 47% were indifferent.

Conclusions: Medical scribes increased ED efficiency without decreasing patient satisfaction. Providers strongly favored the use of scribes, while nurses were indifferent. The next steps include a cost analysis of the scribe program.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.13544DOI Listing
February 2019

Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever.

Pediatr Emerg Care 2018 Aug;34(8):574-577

Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University, Baltimore, MD.

Objectives: Urgent medical evaluation is recommended for patients with sickle cell disease (SCD) and fever. Clear recommendations exist regarding certain aspects of treatment, but other areas lack evidence. We determined practice variation for children with SCD presenting with fever to the emergency department (ED).

Methods: Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED with fever greater than or equal to 38.5°C in the ED or preceding 24 hours. Visits from 3 sickle cell centers were included. Outcomes included blood culture, complete blood count, antibiotic treatment, chest x-ray, urinalysis, electrolytes, and hospital disposition. Differences greater than 10% were considered clinically meaningful.

Results: The population included 14,454 visits, of which 4143 (29%) were febrile and met all inclusion criteria. A complete blood count and blood culture were obtained at 94% of visits, and antibiotics were given at 91%, with no differences among sites. Meaningful differences existed for disposition, with 52%, 43%, and 99% of patients admitted to the inpatient units at hospitals A, B, and C, respectively. Differences were seen in obtaining a urinalysis (33%, 17%, and 21%), electrolytes (2%, 50%, and 12%), and chest x-rays for patients 2 years and older (78%, 77%, 64%) for hospitals A, B, and C, respectively.

Conclusions: Significant variation exists in the proportion of children who receive a urinalysis, electrolytes, chest x-ray, and, most importantly, admission to the hospital. These examples of practice variation represent potential opportunities to define best care practices for children with SCD presenting to the ED for fever.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PEC.0000000000001569DOI Listing
August 2018

Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms.

Pediatrics 2017 Aug 3;140(2). Epub 2017 Jul 3.

Pediatric Emergency Medicine.

Background: Penicillin allergy is commonly reported in the pediatric emergency department (ED). True penicillin allergy is rare, yet the diagnosis results from the denial of first-line antibiotics. We hypothesize that all children presenting to the pediatric ED with symptoms deemed to be low-risk for immunoglobulin E-mediated hypersensitivity will return negative results for true penicillin allergy.

Methods: Parents of children aged 4 to 18 years old presenting to the pediatric ED with a history of parent-reported penicillin allergy completed an allergy questionnaire. A prespecified 100 children categorized as low-risk on the basis of reported symptoms completed penicillin allergy testing by using a standard 3-tier testing process. The percent of children with negative allergy testing results was calculated with a 95% confidence interval.

Results: Five hundred ninety-seven parents completed the questionnaire describing their child's reported allergy symptoms. Three hundred two (51%) children had low-risk symptoms and were eligible for testing. Of those, 100 children were tested for penicillin allergy. The median (interquartile range) age at testing was 9 years (5-12). The median (interquartile range) age at allergy diagnosis was 1 year (9 months-3 years). Rash (97 [97%]) and itching (63 [63%]) were the most commonly reported allergy symptoms. Overall, 100 children (100%; 95% confidence interval 96.4%-100%) were found to have negative results for penicillin allergy and had their labeled penicillin allergy removed from their medical record.

Conclusions: All children categorized as low-risk by our penicillin allergy questionnaire were found to have negative results for true penicillin allergy. The utilization of this questionnaire in the pediatric ED may facilitate increased use of first-line penicillin antibiotics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2017-0471DOI Listing
August 2017

Parent-Reported Penicillin Allergy Symptoms in the Pediatric Emergency Department.

Acad Pediatr 2017 04 6;17(3):251-255. Epub 2017 Mar 6.

Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.

Objective: Children often present to the pediatric emergency department (ED) with a reported penicillin allergy. The true incidence of pediatric penicillin allergy is low, and patients may be inappropriately denied first-line antibiotics. We hypothesized that more than 70% of reported penicillin allergies in the pediatric ED are low risk for true allergy.

Methods: Parents of children presenting to the pediatric ED with parent-reported penicillin allergy completed an allergy questionnaire. The questionnaire included age at allergy diagnosis, symptoms of allergy, and time to allergic reaction from first dose. The allergy symptoms were dichotomized into high and low risk in consultation with a pediatric allergist before questionnaire implementation.

Results: A total of 605 parents were approached; 500 (82.6%) completed the survey. The median (interquartile range) age of the children at diagnosis was 1 year (7 months, 2 years); 75% were diagnosed before their third birthday. Overall, 380 (76%) (95% confidence interval 72.3, 79.7) children had exclusively low-risk symptoms. The most commonly reported symptoms were rash (466, 92.8%) and itching (203, 40.6%). Of the 120 children with one or more high-risk symptom, facial swelling (50, 10%) was the most common. Overall, 354 children (71%) were diagnosed after their first exposure to penicillin. Symptom onset within 24 hours of medication administration occurred in 274 children (54.8%).

Conclusions: Seventy-six percent of patients with parent-reported penicillin allergy have symptoms unlikely to be consistent with true allergy. Determination of true penicillin allergy in patients with low-risk symptoms may permit the increased use of first-line penicillin antibiotics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2016.11.004DOI Listing
April 2017

Which Febrile Children With Sickle Cell Disease Need a Chest X-Ray?

Acad Emerg Med 2016 11 1;23(11):1248-1256. Epub 2016 Nov 1.

Pediatric Emergency Medicine and the Children's Research Institute, Medical College of Wisconsin, Milwaukee, WI.

Objective: Controversy exists regarding which febrile children with sickle cell disease (SCD) should receive a chest x-ray (CXR). Our goal is to provide data informing the decision of which febrile children with SCD presenting to the emergency department (ED) require a CXR to evaluate for acute chest syndrome (ACS).

Methods: Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED at one of two academic children's hospitals with fever ≥38.5°C between January 1, 2010, and December 31, 2012. Demographic characteristics, respiratory symptoms, and laboratory results were abstracted. The primary outcome was the presence of ACS. Binary recursive partitioning was performed to determine predictive factors for a diagnosis of ACS.

Results: A total of 185 (10%) of 1,837 febrile ED visits met ACS criteria. The current National Heart, Lung, and Blood Institute (NHLBI) consensus criteria for obtaining a CXR (shortness of breath, tachypnea, cough, or rales) identified 158 (85%) of ACS cases, while avoiding 825 CXRs. Obtaining a CXR in children with NHLBI criteria or chest pain and in children without those symptoms but with a white blood cell (WBC) count ≥18.75 × 10 /L or a history of ACS identified 181 (98%), while avoiding 430 CXRs.

Conclusion: Children with SCD presenting to the ED with fever and shortness of breath, tachypnea, cough, rales, or chest pain should receive a CXR due to high ACS rates. A higher WBC count or history of ACS in a child without one of those symptoms may suggest the need for a CXR. Prospective validation of these criteria is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.13048DOI Listing
November 2016

Impact of emergency department care on outcomes of acute pain events in children with sickle cell disease.

Am J Hematol 2016 12 3;91(12):1175-1180. Epub 2016 Sep 3.

Pediatric Emergency Medicine, Medical College of Wisconsin and Children's Research Institute of the Children's Hospital of Wisconsin Milwaukee, Wisconsin.

The impact of emergency department (ED) treatment on outcomes of sickle cell disease (SCD) acute pain hospitalizations is not well described. We investigated whether length of stay (LOS) and change in health-related quality of life (HRQL) are affected by initial opioid dose and time to administration. We conducted secondary analyses of data from the randomized-controlled Magnesium for children in Crisis (MAGiC) trial. The primary outcome was LOS. Secondary outcome was change in HRQL, assessed using PedsQL SCD Pain and Hurt and Pain Impact Domains measured in ED and at discharge. Independent variables were (1) time to first IV opioid, (2) total initial opioid dose (mg/kg/hr of morphine equivalents administered between ED and first study drug), and (3) Time to first oral opioid. Spearman correlations determined the associations with LOS. Using two-sample t-tests, we compared mean change in HRQL scores between IV opioid initiated within 60 and >60 min, opioid doses in the highest and lowest tertiles, and oral opioid initiated within 24 and >24 hr. Two hundred and four patients participated at 8 sites. Mean (SD) age was 13.6 (4.7) years. Earlier initiation of oral opioids was strongly correlated with shorter LOS (r = 0.61, P < 0.01). Higher initial opioid dose was weakly correlated with longer LOS (r = 0.34, P < 0.01). Higher initial opioid doses (6 vs -2.2; P = 0.01) and oral opioids initiated within 24 hr (5.7 vs -1.7, P = 0.04) were associated with larger mean change in HRQL at discharge. Prospective trials evaluating the impact of ED care on outcomes of pain hospitalizations could improve SCD pain treatment. Am. J. Hematol. 91:1175-1180, 2016. © 2016 Wiley Periodicals, Inc.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ajh.24534DOI Listing
December 2016

The Benefits and Challenges of Preconsent in a Multisite, Pediatric Sickle Cell Intervention Trial.

Pediatr Blood Cancer 2016 09 15;63(9):1649-52. Epub 2016 Apr 15.

Pediatric Emergency Medicine, Medical College of Wisconsin, and the Children's Research Institute, Milwaukee, Wisconsin.

Enrollment of patients in sickle cell intervention trials has been challenging due to difficulty in obtaining consent from a legal guardian and lack of collaboration between emergency medicine and hematology. We utilized education and preconsent in a pediatric multisite sickle cell intervention trial to overcome these challenges. Overall, 48 patients were enrolled after being preconsented. Variable Institutional Review Board policies related to preconsent validity and its allowable duration decreased the advantages of preconsent at some sites. The utility of preconsent for future intervention trials largely depends on local Institutional Review Board policies. Preeducation may also benefit the consent process, regardless of site differences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.26013DOI Listing
September 2016

A multicenter randomized controlled trial of intravenous magnesium for sickle cell pain crisis in children.

Blood 2015 Oct 31;126(14):1651-7. Epub 2015 Jul 31.

Pediatric Hematology and Oncology, Medical College of Wisconsin, and the Children's Research Institute, Milwaukee, WI.

Magnesium, a vasodilator, anti-inflammatory, and pain reliever, could alter the pathophysiology of sickle cell pain crises. We hypothesized that intravenous magnesium would shorten length of stay, decrease opioid use, and improve health-related quality of life (HRQL) for pediatric patients hospitalized with sickle cell pain crises. The Magnesium for Children in Crisis (MAGiC) study was a randomized, double-blind, placebo-controlled trial of intravenous magnesium vs normal saline placebo conducted at 8 sites within the Pediatric Emergency Care Applied Research Network (PECARN). Children 4 to 21 years old with hemoglobin SS or Sβ(0) thalassemia requiring hospitalization for pain were eligible. Children received 40 mg/kg of magnesium or placebo every 8 hours for up to 6 doses plus standard therapy. The primary outcome was length of stay in hours from the time of first study drug infusion, compared using a Van Elteren test. Secondary outcomes included opioid use and HRQL. Of 208 children enrolled, 204 received the study drug (101 magnesium, 103 placebo). Between-group demographics and prerandomization treatment were similar. The median interquartile range (IQR) length of stay was 56.0 (27.0-109.0) hours for magnesium vs 47.0 (24.0-99.0) hours for placebo (P = .24). Magnesium patients received 1.46 mg/kg morphine equivalents vs 1.28 mg/kg for placebo (P = .12). Changes in HRQL before discharge and 1 week after discharge were similar (P > .05 for all comparisons). The addition of intravenous magnesium did not shorten length of stay, reduce opioid use, or improve quality of life in children hospitalized for sickle cell pain crisis. This trial was registered at www.clinicaltrials.gov as #NCT01197417.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1182/blood-2015-05-647107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591790PMC
October 2015

The accuracy of using ICD-9-CM codes to determine genotype and fever status of patients with sickle cell disease.

Pediatr Blood Cancer 2015 May 12;62(5):924-5. Epub 2015 Feb 12.

Medical College of Wisconsin, Milwaukee, Wisconsin.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.25432DOI Listing
May 2015

The proportion of potentially preventable emergency department visits by patients with sickle cell disease.

J Pediatr Hematol Oncol 2015 Jan;37(1):48-53

Departments of *Pediatric Emergency Medicine †Quantitative Health Sciences ‡Pediatric Hematology, Medical College of Wisconsin, Milwaukee, WI.

Background: Emergency department (ED) visits by children with sickle cell disease (SCD) are often classified as urgent based on resource utilization. This classification may not accurately reflect the potentially preventable nature of SCD visits. We sought to determine the proportion of SCD crisis-related pediatric ED visits that are possibly preventable.

Procedure: We reviewed 2 years of ED visits with a diagnosis of SCD with crisis at a hospital with an established sickle cell program. Criteria for preventable visits were predefined by pediatric hematologists. Non-pain-related chief complaints requiring emergent evaluation or painful episodes preceded by 2 opioid doses were considered not preventable; others were potentially preventable.

Results: The study included 603 visits by 187 patients; 33% were potentially preventable. Overall, 29% of visits were emergent based on non-pain-related emergent complaints. Of the remaining pain-related visits, 26% were preceded by 2 or more doses of opioids at home. Visits by children with asthma were 0.58 times as likely to be preventable, due to more non-pain-related emergent chief complaints (32%) and more children (36%) taking 2 or more opioid doses.

Conclusions: Approximately two thirds of SCD crisis-related pediatric ED visits are not immediately preventable; that percentage is higher in children with asthma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPH.0000000000000124DOI Listing
January 2015

Self-Report of Child Care Directors Regarding Return-to-Care.

Pediatrics 2012 Dec 12;130(6):1046-52. Epub 2012 Nov 12.

Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA.

Background: The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors' practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines.

Methods: A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations.

Results: A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis-antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms-physician visit (45.6%), antibiotics (10%), and symptom resolution (25%).

Conclusions: Directors' self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2012-1184DOI Listing
December 2012

Perceptions about water and increased use of bottled water in minority children.

Arch Pediatr Adolesc Med 2011 Oct 6;165(10):928-32. Epub 2011 Jun 6.

MSCE, Children's Corporate Center, , Milwaukee, WI 53201-1997, USA.

Objective: To describe bottled water use and beliefs and attitudes about water among parents of children from different racial/ethnic groups.

Design: Cross-sectional survey.

Setting: Urban/suburban emergency department.

Participants: Parents of children treated between September 2009 and March 2010.

Main Outcome Measures: The respondents completed a questionnaire in English or Spanish, describing their use of bottled water and tap water for their children and rating their agreement with a series of belief statements about bottled water and tap water. Logistic regression was used to evaluate the association between bottled water use and beliefs and demographic characteristics with odds ratios (ORs).

Results: A total of 632 surveys were completed (35% white, 33% African American, and 32% Latino respondents). African American and Latino parents were more likely to give their children mostly bottled water; minority children were exclusively given bottled water 3 times more often than non-Latino white children (24% vs 8%, P < .01). In logistic regression analysis, the following factors were independently associated with mostly bottled water use: belief that bottled water is safer (OR, 2.4), cleaner (OR, 2.0), better tasting (OR, 2.8), or more convenient (OR, 1.7). After other factors were adjusted for, race/ethnicity, household income, and prior residence outside the United States were not associated with bottled water use.

Conclusions: Minority parents are more likely to exclusively give bottled water to their children. Disparities in bottled water use are driven largely by differences in beliefs and perceptions about water. Interventions to reduce bottled water use among minority families should be based on knowledge of the factors that are related to water use in these communities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archpediatrics.2011.83DOI Listing
October 2011

Outpatient follow-up and rehospitalizations for sickle cell disease patients.

Pediatr Blood Cancer 2012 Mar 14;58(3):406-9. Epub 2011 Apr 14.

Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Background: Rehospitalization rates are increasingly used as quality indicators for a variety of illnesses, including sickle cell disease. While one small, single center study suggested outpatient follow-up with a pediatric hematologist was associated with fewer rehospitalizations, no study has examined the effect of post-discharge outpatient follow-up on rehospitalization rates across ages and beyond a single site.

Procedure: This is a retrospective cohort study using Wisconsin Medicaid claims data for hospitalized children and adults with sickle cell disease from 2003 to 2007. The primary outcomes were rehospitalization at both 14 and 30 days after an index hospitalization for sickle cell pain crisis (ICD-9-CM codes 28242, 28262, 28264, 28269). Univariate survival analyses were performed based on outpatient visit, severe disease, asthma, and age. The Cox proportional hazards model was used for multivariate analyses yielding hazard ratios for the association between outpatient visits and subsequent rehospitalization rates.

Results: Of the 408 patients included, 42 (10.2%) patients were rehospitalized within 14 days and 70 (17.1%) were rehospitalized within 30 days. Multivariate analysis showed that an outpatient visit is associated with lower rates of both 30-day rehospitalization (Hazard Ratio (HR) 0.442; 95%CI: 0.330-0.593) and 14-day rehospitalization (HR 0.226; 95%CI: 0.124-0.412), with the majority of 30-day rehospitalizations occurring within 14 days.

Conclusions: For sickle cell disease, post-discharge planning should emphasize early follow-up to prevent subsequent hospitalization and improve care quality. Pediatr Blood Cancer 2012; 58: 406-409. © 2011 Wiley Periodicals, Inc.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.23140DOI Listing
March 2012

Nonurgent emergency-department care: analysis of parent and primary physician perspectives.

Pediatrics 2011 Feb 17;127(2):e375-81. Epub 2011 Jan 17.

Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.

Objective: To better understand parental decisions to seek care for their children and physician perceptions of parents' decisions to seek nonurgent emergency-department care.

Patients And Methods: In-depth interviews of 26 parents of children and 20 primary care physicians of the same children presenting for nonurgent care at a children's hospital emergency department were completed. Parent accounts of events that preceded the emergency-department visit were coded and qualitatively analyzed for themes. Physician evaluations of the accounts of events and parental decisions were ascertained through interviews with primary care physicians, who also described their practice characteristics. The parent/physician analyses allowed for an investigation of all aspects of the child's care and were designed to reveal differences between parent and physician beliefs.

Results: Parents believed that they acted appropriately, and physicians approved of parents' decisions. Four main themes emerged: (1) immediate reassurance that their children are safe from harm is critical to parents' decisions; (2) primary care offices lack specific tests and treatments that parents and physicians believe may be necessary, regardless of whether they are actually needed; (3) discrepancies exist between physician and parent perceptions of adequate communication and access; and (4) nonurgent emergency-department visits are not perceived as a significant enough breach in continuity of care by physicians and parents to warrant any concern.

Conclusions: When individual interviews were evaluated, neither parents nor primary care physicians saw nonurgent emergency-department visits as a significant enough problem to warrant any change in physician care practices or parent care-seeking behavior.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2010-1723DOI Listing
February 2011

Unnecessary child care exclusions in a state that endorses national exclusion guidelines.

Pediatrics 2010 May 19;125(5):1003-9. Epub 2010 Apr 19.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Objective: No study has evaluated the association between state endorsement of American Academy of Pediatrics (AAP) and American Public Health Association (APHA) national guidelines and unnecessary exclusion decisions. We sought to determine the rate of unnecessary exclusion decisions by child care directors in a state that endorses AAP/APHA guidelines and to identify factors that are associated with higher unnecessary exclusion decisions.

Methods: A telephone survey was administered to directors in metropolitan Milwaukee, Wisconsin. Directors were randomly sampled from a list of 971 registered centers. Director, center, and neighborhood characteristics were obtained. Directors reported whether immediate exclusion was indicated for 5 vignettes that featured children with mild illness that do not require exclusion by AAP/APHA guidelines. Weighted data were summarized by using descriptive statistics. Regression analysis was used to identify factors that were associated with directors' exclusion decisions.

Results: A total of 305 directors completed the survey. Overall, directors would unnecessarily exclude 57% of children. More than 62% had never heard of the AAP/APHA guidelines. Regression analysis showed fewer exclusions among more experienced compared with less experienced directors, among larger centers compared with smaller centers, and among centers that were located in areas with a higher percentage of female heads of household. Centers with < or =10% children on state-assisted tuition excluded more.

Conclusions: High rates of inappropriate exclusion persist despite state endorsement of AAP/APHA guidelines. Focused initial and ongoing training of directors regarding AAP/APHA guidelines may help to reduce high rates of unnecessary exclusions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2009-2283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047469PMC
May 2010

Dissatisfaction with hospital care for children with sickle cell disease not due only to race and chronic disease.

Pediatr Blood Cancer 2009 Aug;53(2):174-8

Department of Pediatrics, Children's Research Institute, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.

Background: A previous study reported increased dissatisfaction with hospital care for children with sickle cell disease (SCD); however, its small size excluded determining whether race and chronic disease explained the difference.

Procedure: At hospital discharge, parents of children with SCD completed a survey assessing satisfaction with their child's hospital care. Results were compared to three years of satisfaction surveys for children with asthma or admitted to a general pediatrician's service collected as quality improvement for the hospital. The primary outcome was parent reported dissatisfaction with care. A chi-square was used to compare dissatisfaction between SCD and each comparison group.

Results: Parents of 639 children were included, 34 children with SCD, 124 with asthma, and 481 general pediatric patients. Parents of children with SCD were more often dissatisfied with their child's care compared to children with asthma (32.4% vs. 16.9%, P < 0.05) and general pediatric patients (32.4% vs. 14.6%, P < 0.05). Among all children, dissatisfaction was higher in families with minority children (21.1% vs. 12.6%); this difference did not exist among children with asthma. Among African-American children, a higher proportion of parents of children with SCD believed their child was treated differently because of race than children with asthma (45.5% vs. 2.8%, P < 0.01) or general pediatric patients (45.5% vs. 8.3%, P < 0.01).

Conclusion: Parents of children with SCD report increased dissatisfaction with care. While dissatisfaction was higher in minority families, the high rate of parental concern about race as a reason for families of children with SCD is not seen in African-American families of children with asthma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.22039DOI Listing
August 2009
-->