Lee S. Benjamin

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Pediatric patient safety in the prehospital/emergency department setting.

The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Handoffs: Transitions of care for children in the emergency department

Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient’s care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

The Think A-Head campaign: an introduction to ImageGently 2.0

A decade has passed since the inception of the Alliance for Radiation Safety in Pediatric Imaging [1]. This milestone marks a good time for a look back at what has been accomplished and what needs to be changed. Specifically, this commentary could comprise what has been achieved, what kind of impact the campaign has made on radiation safety in pediatric imaging and also, importantly, what missed opportunities or missteps have occurred that we can learn from. But the Alliance from the outset has been about moving ahead, sometimes intensely focused and sometimes with a broad visionary brush. The Alliance has focused on what is next and why this is important, and in the end, how to improve imaging care of children. The six campaigns of Image Gently illustrate this effort. These campaigns have primarily addressed modalities — computed tomography, radiography, fluoroscopy, nuclear medicine, interventional fluoroscopy, and most recently, dental imaging. The message, the messengers, and messaging [2] were the basis of these campaigns, and the campaigns have been a vehicle for education. The most recent campaign of Image Gently was rolled out Nov. 2, 2016. This campaign is the Think A-Head campaign for imaging children with minor closed head injury. What does this campaign tell us about the next 10 years of the Alliance? The answer comes from highlighting select changes, successes and challenges of the last 10 years and using these to understand the emphasis for the next 10 years, essentially Image Gently 2.0. This look back, then, will be a basis for the look ahead. A few operational and governance clarifications have occurred. The first deals with the branding of Image Gently. While the title Alliance for Radiation Safety in Pediatric Imaging was defensible as a name and made sense 10 years ago, the Alliance leadership thought it was time for a new name that reflects the evolved mission and role of the campaign. As a first formal announcement, the Alliance for Radiation Safety in Pediatric Imaging, an aptly descriptive name, is now officially the Image Gently Alliance. People recognize the phrase Image Gently and use it in conversations and other communications, so this change resonates. The new message and branding is more simple, direct, and now emblematic. The second change was made because progress thrives with innovation, effort * Donald P. Frush donald.frush@duke.edu

Death of a Child in the Emergency Department

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.

Pediatric Medication Safety in the Emergency Department

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. abstract

Should pediatric emergency physicians be decentralized in the medical community

Introduction Pediatric emergency physicians (PEPs) are well established as primary emergency department (ED) providers in dedicated pediatric centers and university settings. However, the optimum role of these subspecialists is less well defined in the community hospital environment. This study examined the impact on the ED care of children after the introduction of 10 PEPs into a simulated medical community. Methods A computer-generated community was created, containing 10 community hospitals treating 250,000 pediatric ED patients. Children requiring ED treatment received their care at the closest ED to their location. Ten PEPs were introduced into the community, and their impact on patient care was examined under 2 different models. In a restrictive model, the PEPs established 2 full-time pediatric EDs within the 2 busiest hospitals, whereas, in a distributive model, the PEPs were distributed throughout the 8 busiest hospitals. In the 8-hospital model, the PEPs provided direct patient care along with the general emergency physicians in that facility and also provided educational, administrative, and performance improvement support for the department. In the restrictive model, the PEPs impacted the care of 100% of the children presenting for treatment at their 2 practice sites. In the distributive model, impact included the direct patient care by the PEP but also included changes produced in the care provided by the general emergency physicians at the site. Three different levels of impact were considered for the presence of the PEPs: a low-impact version in which the PEPs’ presence only impacted 25% of the children at that site, a moderate-impact version in which the impact affected 50% of the children, and a high-impact version in which the impact affected 75% of the children. A secondary analysis was performed to account for the possibility of patients self-diverting from the closest ED to 1 of the pediatric EDs in the restrictive model. Results In the restrictive model, the addition of 10 PEPs to the community would impact 27% of the pediatric ED care in the community. In the 3 distributive models, the PEPs would impact 23% of pediatric care in the low-impact version, 46% of pediatric care in the moderate-impact version, and 69% of pediatric care in the high-impact version. If self-diversion were to occur in the restrictive model, then 19% of the patients would need to bypass the closest ED and travel to the pediatric ED to match the same effect on patient care produced in the moderate-impact version of the distributive model and 46% would need to divert to match the effect of the high-impact version. Conclusions The greatest impact of PEPs on an ED population of children is produced when the PEPs distribute themselves throughout a medical community rather than create individual pediatric EDs in a small number of hospitals.