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Original Investigation | Caring for the Critically Ill Patient

Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments ONLINE FIRST

Marc Auerbach, MD, MSci1; Travis Whitfill, MPH1; Marcie Gawel, MSN1; David Kessler, MD, MSc2; Barbara Walsh, MD3; Sandeep Gangadharan, MD4; Melinda Fiedor Hamilton, MD, MSc, FAHA5; Brian Schultz, MD6; Akira Nishisaki, MD7; Khoon-Yen Tay, MD8; Megan Lavoie, MD8; Jessica Katznelson, MD9; Robert Dudas, MD9; Janette Baird, PhD10; Vinay Nadkarni, MD7; Linda Brown, MD, MSCE10
[+] Author Affiliations
1Division of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
2Department of Pediatrics, Columbia University Medical Center, New York, New York
3Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Massachusetts Medical Center, Worcester
4Division of Critical Care Medicine, Department of Pediatrics, Long Island Jewish Medical Center, New Hyde Park, New York
5Department of Critical Care Medicine and Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
6Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
7Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, The Children’s Hospital of Philadelphia, Philadelphia
8Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children’s Hospital of Philadelphia, Philadelphia
9Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
10Department of Emergency Medicine, Alpert School of Medicine at Brown University, Providence, Rhode Island
JAMA Pediatr. Published online August 29, 2016. doi:10.1001/jamapediatrics.2016.1550
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Importance  The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described.

Objective  To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures.

Design, Setting, and Participants  This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest).

Main Outcomes and Measures  A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS.

Results  Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (β = 4.28; 95% CI, −4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (β = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P < .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (ρ = 0.45; P < .001) and seizure (ρ = 0.43; P = .001), and strong for teamwork (ρ = 0.71; P < .001).

Conclusions and Relevance  This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality.

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Figure.
Composite Quality Score of Pediatric Emergency Departments to General Emergency Departments

Each axis of the radar graph represents a separate metric; clockwise from top: teamwork, sepsis adherence, cardiac arrest adherence, and seizure adherence. The darker shade represents the mean score on each metric by general emergency departments and the lighter shade represents the mean score on each metric by pediatric emergency departments.

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