Pediatric Urgent Care Research Articles

Urgent Care: A Valuable New Setting for Training Physician Assistant Students.

The purpose of this study was to assess physician assistant (PA) students' perceptions of using a pediatric urgent care clinic for their pediatric acute care experience. PA students were surveyed on completion of their pediatric urgent care rotations (June 2017 to March 2020). Positive perception was ≥4 on a 5-point scale or ≥80% on agreement for dichotomous variables. Qualitative question responses were open coded for positive themes and opportunities for improvement. Of the 32 students, 29 (90.6%) completed evaluations. Students reported an overall positive perception: patient care, 4.66 (standard deviation [SD] 0.61); system-based practice, 4.76 (SD 0.44); professionalism, 4.90 (SD 0.31); medical knowledge, 4.90 (SD 0.31); and practice-based learning and improvement, 4.66 (SD 0.61). However, interpersonal and communication skills were rated positively on only 65.5% of the evaluations. An academic pediatric urgent care clinic was regarded positively by PA students as a novel setting to complete a pediatric acute care rotation, but students required more opportunities to work collaboratively.

Practice Patterns and Perceptions of Influenza Testing Amongst Pediatric Urgent Care Providers

Practice Patterns and Perceptions of Influenza Testing Amongst Pediatric Urgent Care Providers

1137. Effect of an Antibiotic Stewardship Program on Antibiotic Choice, Dosing, and Duration in Pediatric Urgent Care

BackgroundMany studies have focused on decreasing inappropriate antibiotic prescriptions. In August 2018, our institution implemented an outpatient antibiotic stewardship program (ASP). We describe the impact of an outpatient ASP on the antibiotic choice, dose, and duration for common pediatric infections in a pediatric urgent care (PUC) setting.MethodsWe reviewed all encounters at 4 freestanding PUC centers within our organization of patients >60 days and < 18 years with a discharge diagnosis of acute otitis media (AOM), group A streptococcal (GAS) pharyngitis, community acquired pneumonia (CAP), urinary tract infection (UTI), cellulitis, abscess, and animal bite who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis that required systemic antibiotics. We used established national guidelines to determine appropriateness of antibiotic choice, dose, and duration for each diagnosis (Table 1). Our outpatient ASP efforts included the development of an antibiotic handbook, data sharing, education, quality improvement projects, and commitment letters. Pearson’s chi-square test was used to compare appropriate prescribing (choice, dose, and duration) between pre-implementation (July 2017 – July 2018) and post-implementation (August 2018 -forward). Monthly run charts evaluated improvement over time. ResultsWe included 35,915 encounters. Appropriate antibiotic agent improved in AOM (75.8% to 77.2%; p=0.03), UTI (74.9% to 89.5%; p< 0.001), cellulitis (70.5% to 75.1%; p=0.02) and abscess (53.6% to 67.7%; p< 0.001) following implementation of our ASP (Figure 1). Excluding GAS pharyngitis, all diagnoses had improvement in appropriate duration (p< 0.001) (Figure 2). Appropriate dosing improved for AOM (75.7% to 81.6%; p< 0.001), UTI (34.9% to 42.9%; p=0.01) animal bites (37.1% to 45.6%; p=0.048), and cellulitis (28.0% to 42.3%; p< 0.001) (Figure 3).Figure 1. Appropriate Agent Run chart of percentage of encounters with antibiotic choice consistent with national guideline recommendations by discharge diagnosis. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018.Figure 2. Appropriate Duration Run chart of percentage of encounters with antibiotic duration consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018.Figure 3. Appropriate Dose Run chart of percentage of encounters with antibiotic dose consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018.ConclusionOur outpatient ASP improved prescribing patterns for agent, duration, and dose for many common pediatric infections in the PUC setting. Future work will focus on identifying opportunities to improve prescribing practices when antibiotics are indicated.Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

139. Improving Skin and Soft Tissue Infection Antibiotic Duration Concordance with National Guidelines in Pediatric Urgent Care Clinics

Abstract Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive &amp;gt; 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart. Results After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers. Run Chart Conclusion Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Increasing Adherence to Acute Otitis Media Treatment Duration Guidelines using a Quality Improvement Approach.

This quality improvement initiative was conducted in a network of seven urgent care sites affiliated with a large academic children's hospital. The interventions focused on clinician and family education, clinical decision support, and a discharge template that defaulted to a 7-day duration of antibiotics for patients 2 years and older diagnosed with AOM. The outcome measure was the percentage of patients receiving 7 days or fewer of antibiotics. The process measure was the percentage of prescriptions originating from the new discharge template. A repeat visit for AOM within 30 days from the initial visit was the balancing measure. The percentage of patients diagnosed with AOM receiving a short antibiotic course increased from a baseline of 7% to a new centerline mean of 67%, which exceeded the goal. This project resulted in 10,138 antibiotic days being avoided. Eighty-two percent of short-course prescriptions originated from the discharge template. Repeat visits for AOM within 1 month of the initial visit did not increase. A quality improvement initiative combining education and clinical decision support improved adherence to AOM treatment duration guidelines and avoided unnecessary antibiotic exposure in a pediatric urgent care network without increasing treatment failures.

Characteristics of low-acuity paediatric emergency department consultations in two tertiary hospitals in Switzerland: a retrospective observational study

BackgroundLow-acuity paediatric emergency department (PED) visits are common in high-income countries and are an increasing burden for the healthcare system and quality of care. Little is known about low-acuity PED...

The utility of telemedicine in pediatric emergency care: a scoping review.

The utility of telemedicine in pediatric emergency care: a scoping review. Owen Robinson, Shaelynn Zouboules, Hailey Lafave, Roger Galbraith, Eddy Lang Background: Widespread public health measures to combat COVID-19 and escalated parental fear in seeking medical care have compromised access to acute healthcare, leading clinicians to search for alternative methods of delivery. Pediatric emergency departments (ED) have seen significant reductions in documented visits without evidence of a reduction in needs. In Alberta, average daily visits to pediatric emergency and urgent care departments decreased 69.6%, from 952.2 in December 2019 to 289.6 in April 2020. While pediatric emergency telemedicine (PET) programs have the potential to alleviate said gaps in care, it is critical that these technologies are evaluated to ensure patient safety and efficacy. Implementation: This study aimed to serve as an implementation framework for future PET programs. A scoping review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-ScR). The primary objective was to map the existing literature and identify research gaps pertaining to the use of telemedicine in pediatric emergency departments. Primary areas of focus included direct-to-consumer (DTC) telemedicine, rural/regional applications, general ED utility, transfer of care and specialist consultation. This presentation focused on the aspects of DTC telemedicine, and its ability to potentially alleviate the present barriers to in-person presentations to EDs for acute pediatric health concerns. Our team consisted of two University of Calgary affiliated emergency physicians, three University of Calgary medical students, Canadian Agency for Drugs and Technology in Health research consultants, and a university librarian. Evaluation Methods: The outcomes of interest that we used to evaluate the relevant literature included: prevalence of PET; current applications; patient outcomes; patient satisfaction; provider satisfaction; and feasibility, challenges and barriers to implementation. In addition, we aimed to determine the proportion of literature focusing on DTC telemedicine, as this would be the desirable telemedicine application that could be used to supplement the gap in pediatric ED visits during the pandemic and mitigate the resulting health impacts. Lastly, we aimed to characterize both successes and challenges associated with DTC telemedicine in order to provide guidance for future research and policy. Results: Searches of the electronic databases returned 1617 studies. Following the two-step screening process, 37 studies met our inclusion criteria and six focused on DTC telemedicine. Study designs were all observational with all published in 2015 or later. The number of studies reporting data on the outcomes of interest were as follows: patient satisfaction (N=0); prevalence (N=1); provider satisfaction (N=1); patient outcomes (N=2); current applications (N=6); feasibility, challenges and barriers (N=6). Respiratory presentations were the most prevalent application. Three of six studies demonstrated agreement between telemedicine and in-person providers during acute assessments, demonstrating reliability of telemedicine. Conversely, two studies conveyed antimicrobial stewardship with conflicting results. Overall, results were largely positive with important challenges identified.Advice and Lessons Learned: Based on the lessons learned from our research, we recommend the following: 1) Implentation of a DTC telemedicine program can provide timely access to care, whileminimizing the health risks associated with visting the ED during the COVID-19 pandemic. 2) Respiratory complaints were among the most common presentations and thus we recommenddeveloping diagnostic and management algorithms to standardize the virtual care provided. 3) Continue quality improvement measures upon implementing a telemedicine program throughtimely feedback regarding physicians’ experiences and challenges in order to addressconcerns early and optimize efficacy of the program.

Patient and Visit Characteristics of Families Accessing Pediatric Urgent Care Telemedicine During the COVID-19 Pandemic.

Introduction: Telemedicine expansion during the coronavirus pandemic improved health care access for some. However, studies show disparate uptake among marginalized communities, where minority patients experience higher infection rates. We examined changes in pediatric telemedicine utilization as related to social determinants of health and characteristics of families accessing care. Materials and Methods: This IRB-approved study is a retrospective, cross-sectional comparison of completed visits for parent-initiated, urgent care telemedicine services received by a pediatric health care system between January to May 2019 and January to May 2020. Patient and visit characteristics were evaluated by region (Florida or Delaware Valley) and year for age, race, gender, ethnicity, zip code, language, median household income, insurance type, and patient draw. Results: Outcomes varied by region. Pediatric patient visits jumped by 172% in 2020 from the year prior. In Florida, the proportion of Hispanic patients utilizing telemedicine increased, as did patients utilizing government-supported health insurance during the pandemic (ps < 0.05). Practically meaningful, although nonsignificant increases in patient language diversity were found across years in both regions (ps > 0.05). Rural patient utilization remained low (2-5%; ps > 0.05). Discussion: Changes in telemedicine use were observed among pediatric patients in vulnerable populations during the coronavirus disease 2019 (COVID-19) pandemic. Despite increased utilization among Hispanic and low-income families, access to virtual care remains a challenge among patients residing in rural locales. Conclusion: Researchers, health care providers, and policymakers should examine the implementation of varying mitigation strategies that support equal access and use of virtual health care among an increasingly diverse, post-COVID-19 pediatric patient population.

Using an electronic discharge process to improve patient experience and timeliness in a pediatric urgent care setting

BackgroundMost patients in acute care settings are discharged home. Time waiting for discharge paperwork does not add value to patient experience. Quality discharge counseling is critical for patient experience and safety. ObjectiveTo increase online portal enrollment in order to decrease length of stay through use of an electronic discharge (e-discharge) process. Patient involvementWe used patient tracers to evaluate the perception of the UC discharge process at baseline, which helped identify barriers to signing up for the patient portal. MethodsWe performed a manual audit of patient encounters twice a month (N = 1431) to determine rate of portal enrollment, e-discharge, and LOS. We calculated summary distributions of LOS for those that received hardcopy vs. e-discharge instructions. We measured the percentage of positive scores for overall experience and quality of anticipatory guidance for all completed surveys. ResultsFor audited encounters portal enrollment increased from 22% to 37% (p < 0.001). Encounters with e-discharge instructions had a shorter median LOS compared to patient encounters that received hardcopy instructions (55.0 vs. 68.0 min; p < 0.001). There was no difference in overall rating or perceived quality of anticipatory guidance between groups. DiscussionPatients who received e-discharge instructions had significantly shorter LOS compared to those who received hardcopy instructions. The overall rating and perceived quality of anticipatory guidance were not negatively affected by e-discharge instructions. Practical valueEnrolling children into an online portal requires additional steps to ensure that only patients and their legal guardians have access to protected patient information. However, the benefits of offering the portal include shorter LOS without impacting the perceived quality of discharge counseling. FundingChildren’s Mercy supported all phases of this study.

#4: Antibiotic Durations for Skin and Soft Tissue Infections in Pediatric Urgent Care Clinics

Abstract Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on the latter. Children seen in the ambulatory setting for SSTIs often receive &amp;gt;7 days of antibiotics, although current society guidelines recommend 5–7 days for most diagnoses. Objectives To determine the baseline percentage of patients receiving antibiotic prescriptions for &amp;gt;7 days for SSTIs in urgent care clinics (UCC)s of a pediatric health system and to evaluate factors that influence providers towards longer durations. Methods We built a report that extracted patient encounters from the three UCCs based on International Classification of Diseases (ICD)-10 codes for common SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Data was pulled from June 2019 through June 2020. The report included patient age, concomitant diagnoses, antibiotics prescribed and their duration. We excluded encounters if the patient was transferred to the emergency department or admitted, the patient was younger than 3 months of age, no antibiotics were prescribed, or if there was a concurrent infectious diagnosis affecting antibiotic duration. We sent a 22-question survey to UCC providers to understand prescribing habits particularly focusing on factors prompting administration of longer antibiotic courses. Findings From June 2019-June 2020, we reviewed 2,575 encounters; we excluded 208 of those (8%). 823 (35%) of patients received &amp;gt;7 days of antibiotics for SSTIs while 1181 (50%) received 5–7 days and 35 (1%) received &amp;lt;5 days of antibiotics. 328 (14%) received topical therapy only. Most common antibiotics prescribed included cephalexin, clindamycin, and trimethoprim-sulfamethoxazole. A mild improvement in the 5–7 days duration was noted through our study period (Figure 1). The survey was sent to 50 providers with 27 responding (54% response rate). Of providers surveyed, 5 (19%), 7 (26%), and 8 (29%), expressed being uncomfortable with a 5-day treatment course for cellulitis, erysipelas, and abscesses respectively. Barriers for shorter treatment courses included concern for acute rheumatic fever development, parental pressure, fear of complications, and accustomed antibiotic duration. Conclusion A third of children with SSTIs in our UCCs receive long courses of antibiotics. A mild improvement noted in our study period may be due to existing antibiotic stewardship interventions. Specific provider concerns leading to overprescribing will be targeted by quality improvement efforts.

Transfers From a Pediatric Urgent Care to an Academic Pediatric Emergency Department.

Patient transfers from outpatient urgent care centers are common occurrences in a pediatric emergency department (ED). A previous study done at our institution evaluated the clinical appropriateness of transfers from general urgent care centers into our pediatric ED, showing that a significant proportion (27%) of such transfers were discharged home with minimal ED resource utilization. This study investigated the hypothesis that transfers to a pediatric ED from a pediatric urgent care have higher rates of ED resource utilization when compared with patients transferred from general urgent care centers. A retrospective chart review was completed during an 11-month period on all patients transferred from a pediatric urgent care center to the pediatric ED. Demographic, diagnoses, reason for transfer, ED resource utilization, ED disposition, and 72-hour ED return data were collected from the electronic medical record. Each encounter was classified as acute or nonacute based on previously established resource utilization criteria. This data were then compared with findings from a prior study of transfers from all urgent care centers to our institution's pediatric ED. A total of 240 patients met the inclusion criteria. Of these, 160 (66.7%) were discharged from the ED. Twenty-six (10.8%) of the transferred patients met the nonacute transfer criteria. The odds of nonacute transfer from pediatric urgent care were 0.66 times lower than from general urgent care (odds ratio, 0.34; 95% confidence interval, 0.18-0.93). A significantly lower proportion of transfers from the pediatric urgent care center were classified as nonacute, as compared with transfers from general urgent care centers. This suggests that the pediatric urgent care model may help to reduce the number of nonacute ED visits, thus producing cost savings and better patient care.

Automated Analysis of Prescription Data to Reduce Prolonged Antibiotic Courses in the Pediatric Urgent Care Setting

Automated Analysis of Prescription Data to Reduce Prolonged Antibiotic Courses in the Pediatric Urgent Care Setting

Pediatric urgent care: A unique practice model: Perspectives of an urgent care practitioner

This introductory essay traces the history of Pediatric Urgent Care as a practice model. The essay describes the social and economic trends that led to the origin and enormous growth of this unique practice model. Scope of Practice, staffing models and standards of care are described. Professional Societies and the future prospects of this model are included.

Sepsis in the urgent care setting

Sepsis, in particular severe sepsis, is a major cause of morbidity and mortality in pediatrics. It is most likely to affect very young children and children with significant medical comorbidities. The definition of sepsis in pediatrics is currently rapidly evolving but the best treatment for children with severe sepsis remains early goal directed therapy with intravenous fluids and antibiotics. It is therefore important for any pediatric urgent care providers to be able to recognize and treat patients with severe sepsis. It is also important for pediatric urgent care providers to be aware of certain groups of patients who have an increased risk of mortality when they develop sepsis. This article summarizes the current understanding of pediatric sepsis and then focuses on the management of these patients in the pediatric urgent care setting, with special attention paid to groups at higher risks of negative outcomes.

Integrated pediatric urgent care: A perfect fit into patient-centered medical home and meeting the needs of population health and our profession

General Pediatricians have been constrained into a narrower band of primary care practice with the advent of hospitalists, advanced practice professionals and pediatric specific urgent cares. This new patient care structure will require electronic medical records and institutional systems to decrease interfaces and increase integration, thereby allowing a free flow of information that will provide more efficient and safe care. Pediatric specific urgent cares that are integrated will be able to utilize both efficient system level 1 thinking and deeper more thoughtful system level 2 thinking, which will benefit the pediatric patient by decreasing diagnostic errors. If done appropriately, everywhere a pediatric patient contacts the healthcare system, including pediatric specific urgent cares, the patient should be provided a longitudinal, seamless and specific high quality of care that fits the venue they contact.

Costs to provide a tobacco cessation intervention with parents of pediatric emergency department patients.

INTRODUCTIONPediatric emergency department (PED) visits are opportune times in which to provide smoking cessation interventions for parents who smoke. This study reports on the costs of providing parental smokers who bring their children to the emergency setting, with a screening, brief intervention, and assisted referral to treatment (SBIRT) intervention, which includes counseling about tobacco cessation and nicotine replacement therapy.METHODSCost data were collected during a randomized controlled trial with 750 parental smokers whose child was presented to a PED or pediatric Urgent Care unit with a potential tobacco smoke exposure-related illness. Interventionist training, screening, and SBIRT costs are reported from the organizational perspective (i.e. that of the providing hospital). A spreadsheet tool was created to allow for organizations to estimate their own costs based on their settings, for each aspect of the intervention.RESULTSThe mean costs per parent included interventionist training, screening and enrollment, SBIRT delivery, distribution of take-home materials and nicotine replacement therapy, booster text messages, and follow-up phone contact. The total cost per parent was approximately $97. Varying the underlying cost assumptions led to total costs ranging from $85 to $124 per treated parent.CONCLUSIONSThe emergency setting is an important locus of tobacco control that could have a large public health benefit to parents and children. The costs reported in this report and the accompanying spreadsheet tool will permit emergency settings to estimate the costs and assist with planning, staffing and resource allocation necessary to implement an SBIRT smoking cessation intervention in research-based and clinically-based cessation interventions into adult or pediatric emergency visits.

Association of Receipt of Antibiotics with Patient Satisfaction for Caregivers of Children Presenting to Urgent-Care Settings

Background: The Press Ganey (PG) Medical Practice Survey is a commonly used questionnaire for measuring patient experience in healthcare. Our objective was to evaluate the PG surveys completed by caregivers of children presenting for urgent care evaluation of acute respiratory infections (ARIs) to determine any correlation with receipt of antibiotics during their visit. Methods: We evaluated responses to the PG urgent-care surveys for encounters of children &lt;18 years presenting with ARIs (ie, sinusitis, bronchitis, pharyngitis, upper respiratory infection, acute otitis media, or serous otitis media with effusion) within 9 University of Utah urgent-care centers. Scores could range from 0 to 100. Because the distributions of scores followed right- skewed distribution with a high ceiling effect, we defined scores as dissatisfied with their care (≤25th percentile) and satisfied with their care (scores &gt;25th percentile). Univariate and multivariable generalized mixed-effects logistic regression was used to assess correlates of patient dissatisfaction. Random intercepts were included for each provider to account for correlation within the same provider. Separate models were used for each PG component score. Multivariable models adjusted for receipt of antibiotics, age, gender, race, ethnicity, and provider type. Results: Overall, 388 of 520 responses (74.6%) indicated satisfaction and 132 responses (25.4%) indicated dissatisfaction. Among patients who did not receive antibiotics, 87 of 284 responses (30.6%) indicated dissatisfaction versus 45 of 236 (19.1%) who did receive antibiotics. Among patients who were dissatisfied with their clinician, raw clinician PG scores were higher among patients who received antibiotics (mean, 64.5; standard deviation [SD], 16.9) versus those who did not receive antibiotics (mean, 54.7; SD, 24.4; P = .015) (Table 1). In a multivariable analysis, receipt of antibiotics was associated with a reduction in patient dissatisfaction overall (odds ratio, 0.55; 95% CI, 0.36–0.85). Conclusions: Overall, most responses for patients seen for ARIs in pediatric urgent care were satisfied. However, a significantly higher proportion of responses for patients who did not receive antibiotics were dissatisfied than for those patients who received antibiotics. Antibiotic stewardship strategies to communicate appropriate prescribing while preserving patient satisfaction are needed in pediatric urgent-care settings.Funding: NoneDisclosures: None

Survey of Current Institutional Practices in the Use of High-Flow Nasal Cannula for Pediatric Patients.

High-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated humidified air with higher flow rates. The purpose of this survey is to look at institutional practice patterns of HFNC initiation, weaning, and disposition for pediatric patients across the United States. Survey was sent via electronic listservs to pediatric physicians in emergency medicine, hospital medicine, critical care, and urgent care. The questionnaire was divided into demographics and HFNC practices (initiation, management, and weaning). One response per institution was included in the analysis. Two hundred twenty-four responses were included in the analysis, composed of 40% pediatric emergency medicine physicians, 46% pediatric hospitalists, 13% pediatric intensive care unit (PICU) physicians, and 1% pediatric urgent care physicians. Ninety-eight percent of the participants have HFNC at their institution. Thirty-seven percent of the respondents had a formal guideline for HFNC initiation. Nearly all guideline and nonguideline institutions report HFNC use in bronchiolitis. Guideline cohort is more likely to have exclusion criteria for HFNC (42% in the guideline cohort vs 17% in the nonguideline cohort; P < 0.001) and less frequently mandates PICU admissions once on HFNC (11% in the guideline cohort vs 56% in the nonguideline cohort; P < 0.001). Forty-six percent of guideline cohort had an objective scoring system to help determine the need for HFNC, and 73% had a weaning guideline. Although there is general agreement to use HFNC in bronchiolitis, great practice variation remains in the initiation, management, and weaning of HFNC across the United States. There is also a discordance on PICU use when a patient is using HFNC.

Antibiotic Prescribing for Viral Respiratory Infections in the Pediatric Emergency Department and Urgent Care.

Viral acute respiratory tract infections (vARTI) are a frequent source of inappropriate antibiotic prescribing. We describe the prevalence of antibiotic prescribing for vARTI in the pediatric emergency department (ED) and urgent care (UC) within a health system, and identify factors associated with overall and broad-spectrum antibiotic prescribing. Retrospective chart review within a single pediatric referral health system. Visits of patients, 3 months- 17 years old, with a discharge diagnosis of a vARTI from 2010 to 2015. Data collected included specific vARTI diagnosis, site type (ED or UC), provider type [pediatric emergency medicine subspecialist or physicians, nurse practitioners, physician assistants (non-PEM)] and discharge antibiotics. Odds ratios and 95% confidence intervals (CI) were calculated where appropriate. There were 132,458 eligible visits, mean age 4.1 ± 4.3 years. Fifty-three percent were treated in an ED. Advanced practice providers, a term encompassing nurse practitioners and physician assistants, were the most common provider type (47.7%); 16.5% of patients were treated by a pediatric emergency medicine subspecialist. Antibiotics were prescribed for 3.8% (95% CI: 3.72-3.92) of children with vARTI; 25.4% (95% CI: 24.2-26.6) of these were broad-spectrum, most commonly first-generation cephalosporins (11%; 95% CI 10.2-11.9). Patients treated in an ED or by a non-PEM and those receiving chest radiograph (CXR) received antibiotics most frequently. Prescribing rates varied by specific vARTI diagnosis. Patients discharged from the pediatric ED or UC with vARTI receive inappropriate antibiotics at a lower rate than reported in other community settings; however, they frequently receive broad-spectrum agents.

Educational Benefits of Allowing Pediatrician Supervision of Emergency Medicine Residents.

According to the Accreditation Council for Graduate Medical Education emergency medicine (EM) program requirements, EM residents on EM rotations must be supervised by board-certified/board-prepared EM or pediatric EM (PEM) faculty. We sought to understand the effect of allowing EM residents to be supervised by attending pediatricians while caring for pediatric urgent care patients. The EM residents were permitted to staff pediatric urgent care patients with either an EM/PEM attending or an attending pediatrician from August 2017 to July 2018. Outcomes were assessed through resident focus groups, a mixed-methods survey of EM residents and EM/PEM/pediatrician attendings, and clinical outcomes, including length of stay, best evidence/clinical care guideline adherence, and 48-hour return visits requiring admission. Qualitative data were inductively coded using a phenomenological framework, with themes emerging from consensus discussion. Ninety percent of residents participated in 1 of 7 focus groups. Four key themes emerged from qualitative analysis of focus group transcripts: (1) pediatricians have unique skills that complement those of EM physicians; (2) EM resident education improved; (3) patients may get better care with dual staffing; and (4) other PEM department and urgent care team members may have benefited from the change. The survey response rate was 72%, and it did not uncover additional themes. Length of stay was shorter for patients supervised by attending pediatricians (114 versus 128 minutes, P < .001); there was no difference in best evidence/clinical care guideline adherence or 48-hour return visits requiring admission. Physicians' perceived education was improved by adding complementary perspectives without significant negative consequences for learners or patients.