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BACKGROUND: Persons of low socioeconomic status are overrepresented in the firearm injury patient population and may experience challenges in accessing complex outpatient health systems. Consequently, outpatient care for these patients is plagued by poor follow-up and increased emergency department (ED) utilization. We developed a Post Discharge Care Team (PDCT) consisting of a dedicated trauma nurse navigator and medical social worker to bridge the gap between hospital discharge and outpatient care to improve recovery. METHODS: Adult firearm injury survivors admitted to the trauma service were randomized 1:1 to receive either PDCT services or standard of care (SOC) workflows. The PDCT nurse provided education and set expectations regarding injuries, wound care, and outpatient follow-up. The PDCT social worker performed a comprehensive assessment to identify concerns including housing and financial instability, food insecurity, or transportation issues. The primary outcome was ED utilization, with secondary outcomes including readmissions and overall health care costs compared between groups. RESULTS: In the first 6 months of the study, a total of 44 patients were randomized to PDCT and 47 to SOC. There were 10 patients who visited the ED in the PDCT group compared with 16 in the SOC group ( p = 0.23) for a total of 14 and 23 ED visits, respectively. There were 14 patients in the PDCT and 11 patients in the SOC groups who were readmitted ( p = 0.31), but the PDCT group was readmitted for 27.9 fewer hospital days. After accounting for programmatic costs, the PDCT had a hospital savings of $34,542.71. CONCLUSION: A collaborative, specialized PDCT for firearm injury survivors consisting of a dedicated trauma nurse navigator and medical social worker decreased outpatient ED utilization, readmission days, and was cost effective. Trauma centers with high volumes of penetrating trauma should consider a similar model to improve outpatient care for firearm injury survivors. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

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OBJECTIVE: In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months. RESEARCH DESIGN AND METHODS: Plan-do-study-act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two-bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO3 ) <15 mEq/L. PRIMARY OUTCOME: the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO3 ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts. RESULTS: From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures. CONCLUSIONS: Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA.

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INTRODUCTION: Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018-2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019-2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients. METHODS: Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months-18 years old, emergency severity index score 2-5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure. RESULTS: We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2. CONCLUSIONS: This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

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INTRODUCTION: Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017-2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s. METHODS: Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution. RESULTS: We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital. CONCLUSIONS: We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.

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INTRODUCTION: Children increasingly are being seen in the emergency department for a concussion, or mild traumatic brain injury (mTBI). A key aim of the ED visit is to provide discharge advice that can help parents to identify an evolving neurosurgical crisis, facilitate recovery, and prevent reinjury. The present study examined parents' knowledge of symptoms and recall of discharge instructions after their adolescent's mTBI and the effect of supplementing written discharge instructions with verbal instruction and reinforcement. METHODS: We performed a nested observational study of parents/caregivers of patients who participated in a larger mTBI study. After their adolescent's mTBI, parents were given verbal and standardized written instructions. The ED discharge process was observed using a structured checklist, and parents were surveyed 3 days after discharge on knowledge and recall of discharge instructions. RESULTS: Ninety-three parents completed the postsurvey. Nearly 1 in 5 parents were confused about when to return to the emergency department after evaluation for head injury. Up to 1 in 4 parents could not recall specific discharge advice related to concussion. Parents who received verbal reinforcement of written discharge instructions were more likely to recall them. CONCLUSION: Emergency nurses and clinicians should strive to utilize both verbal and written discharge instructions with families to help increase understanding.

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