This stepwise approach with pre-arrival planning using the Chronic Care Model, followed by standardisation of processes, created a sustainable improvement of timely antibiotic delivery in F&I patients.

Background Shiga toxin–producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. Methods We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. Results Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69–.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42–4.54]), higher hematocrit (1.83 [1.21–2.77] per 5% increase) and serum creatinine (10.82 [1.49–78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02–3.60]), lower serum sodium (1.12 [1.02–1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14–5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54–.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14–4.50]), younger age (0.83 [.74–.92] per year), lower serum sodium (1.15 [1.04–1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17–4.72]) and creatinine (7.75 [1.20–50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18–6.21]). Conclusions The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

OBJECTIVES: Bone marrow transplant (BMT) patients or patients receiving chemotherapy for oncologic diagnoses are at risk for sepsis. The association of time to antibiotics (TTA) with outcomes when adjusting for severity of illness has not been evaluated in the pediatric febrile immunocompromised (FI) population. We evaluated the association of TTA with adverse events in a cohort of FI patients presenting to our pediatric emergency department. METHODS: We performed a retrospective review of consecutive FI patients presenting over a 6.5-year period. Adverse events were defined as intensive care admission within 72 hours of emergency department arrival, laboratory signs of acute kidney injury, inotropic support subsequent to antibiotics, and all-cause mortality within 30 days. Vital signs and interventions were used to define severity of illness. Adjusting for severity of illness at presentation, age, and timing of an institutional intervention designed to reduce TTA in FI patients, we analyzed the association of TTA with individual adverse events as well as with adverse events in aggregate. RESULTS: We analyzed 1489 patient encounters. In oncology patients, TTA was not associated with the aggregate measure of whether any adverse event subsequently occurred nor with other individual adverse events. For the BMT subpopulation, TTA >60 minutes did show increased odds of intensive care admission within 72 hours as well as for aggregate adverse events. CONCLUSIONS: Although TTA >60 minutes did show increased odds of aggregate adverse events in the small subgroup of BMT patients, overall TTA was not associated with adverse events in oncology patients as a whole.

Study objective: The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. Methods: We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5 C (101.3 F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. Results: A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both). Conclusion: Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.