Terri L. Byczkowski

Predicting Postconcussion Syndrome After Mild Traumatic Brain Injury in Children and Adolescents Who Present to the Emergency Department

OBJECTIVE To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury. DESIGN Retrospective analysis of a prospective observational study. SETTING Pediatric emergency department (ED) in a childrens hospital. PARTICIPANTS Four hundred six children and adolescents aged 5 to 18 years. MAIN EXPOSURE Closed head trauma. MAIN OUTCOME MEASURES The Rivermead Post Concussion Symptoms Questionnaire administered 3 months after the injury. RESULTS Of the patients presenting to the ED with mild traumatic brain injury, 29.3% developed PCS. The most frequent PCS symptom was headache. Predictors of PCS, while controlling for other factors, were being of adolescent age, headache on presentation to the ED, and admission to the hospital. Patients who developed PCS missed a mean (SD) of 7.4 (13.9) days of school. CONCLUSIONS Adolescents who have headache on ED presentation and require hospital admission at the ED encounter are at elevated risk for PCS after mild traumatic brain injury. Interventions to identify this population and begin early treatment may improve outcomes and reduce the burden of disease.

Financial impact of failing to prevent surgical site infections.

Background Despite advances in infection-control practices, surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, and increased costs among hospitalized patients. Methods We used a matched cohort design to compare costs and length of stay for 16 pediatric patients with an SSI with those of 16 matched control patients who had a similar operative procedure during the same time period but in whom an SSI did not develop. Results On average, length of stay was increased by 10.6 days (P = .02) and costs were increased by

Impact of simulation-based extracorporeal membrane oxygenation training in the simulation laboratory and clinical environment.

27 288 (P = .01) for each patient with a potentially preventable SSI. On the day of the surgical procedure, costs between study patients and matched controls differed by only 1.4%. By day 3, however, costs were 36% higher for patients with an SSI. Conclusions While matching study patients and control patients requires significant time from financial and clinical staff, this approach and the resulting data analysis strengthened and focused our efforts to prevent future SSIs and aligned initiatives to reduce SSIs with the business case for quality.

Impact of a nurse practitioner-assisted preoperative assessment program on quality

Introduction: Extracorporeal membrane oxygenation (ECMO) is a high-risk, complex therapy. Opportunities to develop teamwork skills and expertise to mitigate risks are few. Our objective was to assess whether simulation would improve technical and nontechnical skills in dealing with ECMO circuit emergencies and allow transfer of skills from the simulated setting to clinical environment. Methods: Subjects were ECMO circuit providers who performed scenarios utilizing an infant simulator and functional ECMO circuit, followed immediately by video-assisted debriefings. Within the simulation laboratory, outcomes were timed responses, percentage of correct actions, teamwork, safety knowledge, and attitudes. Identification of latent safety threats (LSTs) was the focus of debriefings. Within the clinical setting, translation of learned skills was assessed by measuring circuit readiness and compliance with a cannulation initiation checklist. Results: Nineteen subjects performed 96 simulations during enrollment. In the laboratory, there was no improvement in timed responses or percent correct actions. Teamwork (P = 0.001), knowledge (P = 0.033), and attitudes (P = 0.001) all improved compared with baseline. Debriefing identified 99 LSTs. Clinically, 26 cannulations occurred during enrollment. Median time from blood available to circuit readiness was 17 minutes (range, 5–95), with no improvement during the study. Compliance with the initiation checklist improved compared with prestudy baseline (P < 0.0001). Conclusions: Simulation-based training is an effective method to improve safety knowledge, attitudes, and teamwork surrounding ECMO emergencies. On-going training is feasible and allows identification of LSTs. Further work is needed to assess translation of learned skills and behaviors into the clinical environment.

Variation in Use of Internet-Based Patient Portals by Parents of Children With Chronic Disease

Background : The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient‐centered care by instituting a nurse practitioner‐assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program.

The association of emergency department crowding and time to antibiotics in febrile neonates.

OBJECTIVES To assess the use of Internet-based portals among families of children with chronic diseases and to describe characteristics of portal registrants and users. DESIGN Retrospective observational study. SETTING Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio, using data from September 1, 2003, through February 29, 2008. Patients/ PARTICIPANTS Parents of children with diabetes mellitus, juvenile idiopathic arthritis, or cystic fibrosis. INTERVENTIONS Parents of children with a chronic disease were given the opportunity to access health-related information for their children via an Internet-based portal. OUTCOME MEASURES Percentage of families who obtained a portal account (registered), used the portal for the first time within 3 months and again 3 to 6 months after registration, number of times logged in, and session length. RESULTS Of 1900 families, 27.9% obtained a portal account. Of those, 47.8% used the portal within 3 months of registration and 15.9% continued to use the portal 3 to 6 months after registration. Families of African American patients and of patients insured by Medicaid were less likely to obtain a portal account. More outpatient visits and having private health insurance coverage were associated with increased portal registration and use. CONCLUSIONS Understanding the feasibility of portal use by parents is an important first step to using portals for improving self-management, patient-provider interactions, and outcomes for children with chronic diseases. Subsequent studies should address parent perceptions of the value portals add to the management of the chronic disease of their child and ways to increase that value. Barriers to using portals among racial minorities and publicly insured families should also be studied to address disparities.

A Comprehensive View of Parental Satisfaction With Pediatric Emergency Department Visits

OBJECTIVES The objective was to assess the relationship between emergency department (ED) crowding and timeliness of antibiotic administration to neonates presenting with fever in a pediatric ED. METHODS This was a retrospective cohort study of febrile neonates (aged 0-30 days) evaluated for serious bacterial infections (SBIs) in a pediatric ED from January 2006 to January 2008. General linear models were used to evaluate the association of five measures of ED crowding with timeliness of antibiotic administration, controlling for patient characteristics. A secondary analysis was conducted to determine which part of the ED visit for this population was most affected by crowding. RESULTS A total of 190 patients met inclusion criteria. Mean time to first antibiotic was 181.7 minutes (range = 18-397 minutes). At the time of case presentation, the number of patients waiting in the waiting area, total number of hours spent in the ED by current ED patients, number of ED patients awaiting admission, and hourly boarding time were all positively associated with longer times to antibiotic. The time from patient arrival to room placement exhibited the strongest association with measures of crowding. CONCLUSIONS Emergency department crowding is associated with delays in antibiotic administration to the febrile neonate despite rapid recognition of this patient population as a high-risk group. Each component of ED crowding, in terms of input, throughput, and output factors, was associated with delays. Further work is required to develop processes that foster a more rapid treatment protocol for these high-risk patients, regardless of ED crowding pressures.

Family perceptions of the usability and value of chronic disease web-based patient portals

STUDY OBJECTIVE We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data. METHODS This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview-style question. RESULTS Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview-style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their childs diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care. CONCLUSION Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.

Improving Outcomes for Underserved Adolescents With Asthma

The objective of this study was to understand perceptions of the usability and value of web-based patient portals among parents of children with a chronic condition (diabetes, juvenile idiopathic arthritis, and cystic fibrosis). The design was a cross-sectional telephone survey with semistructured interviews and was conducted at a tertiary children’s hospital. Parent ratings of their experiences with and the value of a web-based portal and reasons for not using the portal were ascertained. Most parents agreed that the portal information was accurate, timely, and useful. Confidentiality and seeing worrisome health-related information about their child was not a major concern, and parents felt that the portal helped to improve their understanding of and ability to manage their child’s condition. In conclusion, the results of this study support the notion that web-based patient portals have the potential to be a useful tool for parents of children with a chronic disease.

Ability of S100B to predict severity and cranial CT results in children with TBI

BACKGROUND AND OBJECTIVE: Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting. METHODS: Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections. RESULTS: Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent’s asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels. CONCLUSIONS: Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.