This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are ...heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.
Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services ...for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.
Pediatric Readiness in the Emergency Department Remick, Katherine; Gausche-Hill, Marianne; Joseph, Madeline M. ...
Annals of emergency medicine,
December 2018, 2018-12-00, 20181201, Volume:
72, Issue:
6
Journal Article
Pediatric Readiness in the Emergency Department Remick, Katherine; Gausche-Hill, Marianne; Joseph, Madeline M. ...
Journal of emergency nursing,
January 2019, 2019-Jan, 2019-01-00, 20190101, Volume:
45, Issue:
1
Journal Article
Peer reviewed
Note: This is a revision of the previous joint policy statement titled “Guidelines for Care of Children in the Emergency Department.” Children have unique physical and psychosocial needs that are ...heightened in the setting of serious or life-threatening emergencies. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of proximity. It is, therefore, imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. This policy statement outlines resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report “The Future of Emergency Care in the United States Health System.” Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meetor exceedthese recommendations to ensure high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership of EDs as they strive to improve their readiness for children of all ages.
There is an unmet need to monitor human and natural environments for substances that are intentionally or unintentionally introduced. A long-sought goal is to adapt plants to sense and respond to ...specific substances for use as environmental monitors. Computationally re-designed periplasmic binding proteins (PBPs) provide a means to design highly sensitive and specific ligand sensing capabilities in receptors. Input from these proteins can be linked to gene expression through histidine kinase (HK) mediated signaling. Components of HK signaling systems are evolutionarily conserved between bacteria and plants. We previously reported that in response to cytokinin-mediated HK activation in plants, the bacterial response regulator PhoB translocates to the nucleus and activates transcription. Also, we previously described a plant visual response system, the de-greening circuit, a threshold sensitive reporter system that produces a visual response which is remotely detectable and quantifiable.
We describe assembly and function of a complete synthetic signal transduction pathway in plants that links input from computationally re-designed PBPs to a visual response. To sense extracellular ligands, we targeted the computational re-designed PBPs to the apoplast. PBPs bind the ligand and develop affinity for the extracellular domain of a chemotactic protein, Trg. We experimentally developed Trg fusions proteins, which bind the ligand-PBP complex, and activate intracellular PhoR, the HK cognate of PhoB. We then adapted Trg-PhoR fusions for function in plants showing that in the presence of an external ligand PhoB translocates to the nucleus and activates transcription. We linked this input to the de-greening circuit creating a detector plant.
Our system is modular and PBPs can theoretically be designed to bind most small molecules. Hence our system, with improvements, may allow plants to serve as a simple and inexpensive means to monitor human surroundings for substances such as pollutants, explosives, or chemical agents.
Objective
To test the hypotheses that use of the Head CT Choice decision aid would be similarly effective in all parent/patient dyads but parents with high (vs low) numeracy experience a greater ...increase in knowledge while those with low (vs high) health literacy experience a greater increase in trust.
Methods
This was a secondary analysis of a cluster randomized trial conducted at seven sites. One hundred seventy‐two clinicians caring for 971 children at intermediate risk for clinically important traumatic brain injuries were randomized to shared decision making facilitated by the DA (n = 493) or to usual care (n = 478). We assessed for subgroup effects based on patient and parent characteristics, including socioeconomic status (health literacy, numeracy and income). We tested for interactions using regression models with indicators for arm assignment and study site.
Results
The decision aid did not increase knowledge more in parents with high numeracy (P for interaction Pint = 0.14) or physician trust more in parents with low health literacy (Pint = 0.34). The decision aid decreased decisional conflict more in non‐white parents (decisional conflict scale, −8.14, 95% CI: −12.33 to −3.95; Pint = 0.05) and increased physician trust more in socioeconomically disadvantaged parents (trust in physician scale, OR: 8.59, 95% CI: 2.35‐14.83; Pint = 0.04).
Conclusions
Use of the Head CT Choice decision aid resulted in less decisional conflict in non‐white parents and greater physician trust in socioeconomically disadvantaged parents. Decision aids may be particularly effective in potentially vulnerable parents.
Blunt head trauma is a common cause of death and disability in children worldwide. Cranial computed tomography (CT), the reference standard for the diagnosis of traumatic brain injury (TBI), exposes ...children to ionizing radiation which has been linked to the development of brain tumors, leukemia, and other cancers. We describe the methods used to develop and test the effectiveness of a decision aid to facilitate shared decision-making with parents regarding whether to obtain a head CT scan or to further observe their child at home.
This is a protocol for a multicenter clinician-level parallel randomized trial to compare an intervention group receiving a decision aid, 'Head CT Choice', to a control group receiving usual care. The trial will be conducted at five diverse emergency departments (EDs) in Minnesota and California. Clinicians will be randomized to decision aid or usual care. Parents visiting the ED with children who are less than 18-years-old, have experienced blunt head trauma within 24 hours, and have one or two risk factors for clinically-important TBI (ciTBI) from the Pediatric Emergency Care Applied Research Network head injury clinical prediction rules will be eligible for enrollment. We will measure the effect of Head CT Choice on: (1) parent knowledge regarding their child's risk of ciTBI, the available diagnostic options, and the risks of radiation exposure associated with a cranial CT scan (primary outcome); (2) parent engagement in the decision-making process; (3) the degree of conflict parents experience related to feeling uninformed; (4) patient and clinician satisfaction with the decision made; (5) the rate of ciTBI at seven days; (6) the proportion of patients in whom a cranial CT scan is obtained; and (7) seven-day healthcare utilization. To capture these outcomes, we will administer parent and clinician surveys immediately after each clinical encounter, obtain video recordings of parent-clinician discussions, administer parent healthcare utilization diaries, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up.
This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in parents of children with minor head trauma in five diverse EDs.
ClinicalTrials.gov registration number: NCT02063087. Registration date February 13, 2014.
Background
Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with ...specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children.
Objectives
The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub‐committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors.
Discussion
Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP‐certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP‐certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP‐certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care.
Conclusion
Recognition that the training of ABP‐certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.
IMPORTANCE: The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic ...brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI. OBJECTIVE: To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI. DESIGN, SETTINGS, AND PARTICIPANTS: This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents. INTERVENTIONS: Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care. MAIN OUTCOMES AND MEASURES: The primary outcome, selected by parent stakeholders, was knowledge of their child’s risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI. RESULTS: A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean SD questions correct: 6.2 2.0 vs 5.3 2.0; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean SD decisional conflict score, 14.8 15.5 vs 19.2 16.6; mean difference, −4.4; 95% CI, −7.3 to −2.4), and were more involved in CT decision-making (observing patient involvement OPTION scores: mean SD, 25.0 8.5 vs 13.3 6.5; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI. CONCLUSIONS AND RELEVANCE: Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02063087
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