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Article ; Online: Children's surgery verification and value-based care in pediatric surgery.

Mackow, Anne K / Macias, Charles G / Rangel, Shawn J / Fallat, Mary E

2023 Volume 32, Issue 2, Page(s) 151277

Abstract: With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have ... ...

Abstract	With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.
MeSH term(s)	Adult ; Humans ; Child ; United States ; Specialties, Surgical ; Surgeons ; Quality Improvement
Language	English
Publishing date	2023-04-20
Publishing country	United States
Document type	Journal Article
ZDB-ID	1133381-9
ISSN	1532-9453 ; 1055-8586
ISSN (online)	1532-9453
ISSN	1055-8586
DOI	10.1016/j.sempedsurg.2023.151277
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Article ; Online: Utilizing big data from electronic health records in pediatric clinical care.

Macias, Charles G / Remy, Kenneth E / Barda, Amie J

Pediatric research

2022 Volume 93, Issue 2, Page(s) 382–389

Abstract: Big data has the capacity to transform both pediatric healthcare delivery and research, but its potential has yet to be fully realized. Curation of large multi-institutional datasets of high-quality data has allowed for significant advances in the ... ...

Abstract	Big data has the capacity to transform both pediatric healthcare delivery and research, but its potential has yet to be fully realized. Curation of large multi-institutional datasets of high-quality data has allowed for significant advances in the timeliness of quality improvement efforts. Improved access to large datasets and computational power have also paved the way for the development of high-performing, data-driven decision support tools and precision medicine approaches. However, implementation of these approaches and tools into pediatric practice has been hindered by challenges in our ability to adequately capture the heterogeneity of the pediatric population as well as the nuanced complexities of pediatric diseases such as sepsis. Moreover, there are large gaps in knowledge and definitive evidence demonstrating the utility, usability, and effectiveness of these types of tools in pediatric practice, which presents significant challenges to provider willingness to leverage these solutions. The next wave of transformation for pediatric healthcare delivery and research through big data and sophisticated analytics will require focusing efforts on strategies to overcome cultural barriers to adoption and acceptance. IMPACT: Big data from EHRs can be used to drive improvement in pediatric clinical care. Clinical decision support, artificial intelligence, machine learning, and precision medicine can transform pediatric care using big data from the EHR. This article provides a review of barriers and enablers for the effective use of data analytics in pediatric clinical care using pediatric sepsis as a use case. The impact of this review is that it will inform influencers of pediatric care about the importance of current trends in data analytics and its use in improving outcomes of care through EHR-based strategies.
MeSH term(s)	Humans ; Child ; Big Data ; Electronic Health Records ; Artificial Intelligence ; Machine Learning ; Sepsis
Language	English
Publishing date	2022-11-24
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	4411-8
ISSN	1530-0447 ; 0031-3998
ISSN (online)	1530-0447
ISSN	0031-3998
DOI	10.1038/s41390-022-02343-x
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Zs.A 564: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (1.OG) ab Jg. 2022: Lesesaal (EG)
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Article ; Online: Quality improvement in pediatric emergency medicine.

Macias, Charles G

Academic pediatrics

2013 Volume 13, Issue 6 Suppl, Page(s) S61–8

Abstract: Pediatric patients, who accounted for 17.4% of US emergency department (ED) visits in 2010, present unique challenges that can impede an ED's ability to provide optimal care. To meet the growing demand for comprehensive, high-quality care, health care ... ...

Abstract	Pediatric patients, who accounted for 17.4% of US emergency department (ED) visits in 2010, present unique challenges that can impede an ED's ability to provide optimal care. To meet the growing demand for comprehensive, high-quality care, health care systems are incorporating quality improvement (QI) methods to reduce costs and variations in care and to improve access, safety, and ultimately the outcomes of medical care. This overview of QI initiatives within the field of pediatric emergency medicine explores how proven QI strategies are being integrated into efforts that target the care of children within the broader emergency care community. These initiatives are categorized within the domains of education, infrastructures supporting QI efforts, research, and community/government collaborations. Professional societies supporting education, such as the American Academy of Pediatrics, have made several strides to cultivate new health leaders that will use QI methodology to improve outcomes in pediatric emergency care. In addition to educational pursuits, professional societies and QI organizations (eg, Children's Hospital Association) offer stable infrastructures from which QI initiatives, either disease specific or broadly targeted, can be implemented as large-scale QI initiatives (eg, quality collaboratives). This overview also provides examples of how QI methodology has been integrated into research strategies and describes how the pediatric emergency medicine community can spread innovation and best practices into the larger emergency care community.
MeSH term(s)	Adolescent ; Child ; Child, Preschool ; Delivery of Health Care/organization & administration ; Emergency Medicine/organization & administration ; Emergency Service, Hospital/utilization ; Female ; Health Services Needs and Demand ; Humans ; Infant ; Interdisciplinary Communication ; Male ; Patient Care Team/organization & administration ; Pediatrics/organization & administration ; Quality Assurance, Health Care ; Quality Improvement ; United States
Language	English
Publishing date	2013-11
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, P.H.S. ; Review
ZDB-ID	2483385-X
ISSN	1876-2867 ; 1876-2859
ISSN (online)	1876-2867
ISSN	1876-2859
DOI	10.1016/j.acap.2013.06.007
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Article ; Online: The evolving value of older biomarkers in the clinical diagnosis of pediatric sepsis.

Lim, Peter Paul C / Bondarev, Dayle J / Edwards, Amy M / Hoyen, Claudia M / Macias, Charles G

Pediatric research

2022 Volume 93, Issue 4, Page(s) 789–796

Abstract: Sepsis remains the leading cause of childhood mortality worldwide. The evolving definition of pediatric sepsis is extrapolated from adult studies. Although lacking formal validation in the pediatric population, this working definition has historically ... ...

Abstract	Sepsis remains the leading cause of childhood mortality worldwide. The evolving definition of pediatric sepsis is extrapolated from adult studies. Although lacking formal validation in the pediatric population, this working definition has historically proven its clinical utility. Prompt identification of pediatric sepsis is challenging as clinical picture is often variable. Timely intervention is crucial for optimal outcome, thus biomarkers are utilized to aid in immediate, yet judicious, diagnosis of sepsis. Over time, their use in sepsis has expanded with discovery of newer biomarkers that include genomic bio-signatures. Despite recent scientific advances, there is no biomarker that can accurately diagnose sepsis. Furthermore, older biomarkers are readily available in most institutions while newer biomarkers are not. Hence, the latter's clinical value in pediatric sepsis remains theoretical. Albeit promising, scarce data on newer biomarkers have been extracted from research settings making their clinical value unclear. As interest in newer biomarkers continue to proliferate despite their ambiguous clinical use, the literature on older biomarkers in clinical settings continue to diminish. Thus, revisiting the evolving value of these earliest biomarkers in optimizing pediatric sepsis diagnosis is warranted. This review focuses on the four most readily available biomarkers to bedside clinicians in diagnosing pediatric sepsis. IMPACT: The definition of pediatric sepsis remains an extrapolation from adult studies. Older biomarkers that include C-reactive protein, procalcitonin, ferritin, and lactate are the most readily available biomarkers in most pediatric institutions to aid in the diagnosis of pediatric sepsis. Older biomarkers, although in varying levels of reliability, remain to be useful clinical adjuncts in the diagnosis of pediatric sepsis if used in the appropriate clinical context. C-reactive protein and procalcitonin are more sensitive and specific among these older biomarkers in diagnosing pediatric sepsis although evidence varies in different age groups and clinical scenarios.
MeSH term(s)	Adult ; Humans ; Child ; C-Reactive Protein/analysis ; Procalcitonin ; Reproducibility of Results ; Sepsis/diagnosis ; Biomarkers ; Lactic Acid
Chemical Substances	C-Reactive Protein (9007-41-4) ; Procalcitonin ; Biomarkers ; Lactic Acid (33X04XA5AT)
Language	English
Publishing date	2022-08-04
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	4411-8
ISSN	1530-0447 ; 0031-3998
ISSN (online)	1530-0447
ISSN	0031-3998
DOI	10.1038/s41390-022-02190-w
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Article: Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis.

Mullan, Paul C / Pruitt, Christopher M / Levasseur, Kelly A / Macias, Charles G / Paul, Raina / Depinet, Holly / Nguyen, Anh Thy H / Melendez, Elliot

Open access emergency medicine : OAEM

2022 Volume 14, Page(s) 375–384

Abstract: Purpose: Pediatric sepsis guidelines recommend rapid intravenous fluid (IVF) bolus administration rates (BAR). Recent sepsis studies suggest that rapid BAR may be associated with increased morbidity. We aimed to describe the association between ... ...

Abstract	Purpose: Pediatric sepsis guidelines recommend rapid intravenous fluid (IVF) bolus administration rates (BAR). Recent sepsis studies suggest that rapid BAR may be associated with increased morbidity. We aimed to describe the association between emergency department (ED) IVF BAR and clinical outcomes in pediatric sepsis. Patients and methods: Secondary post-hoc analysis of retrospective cohort data from 19 hospitals in the Pediatric Septic Shock Collaborative (PSSC) database. Patients with presumed septic shock were defined by severe sepsis/septic shock diagnostic codes, receipt of septic shock therapies, or floor-to-ICU transfers within 12 hours from ED admission for septic shock. Patients (2 months-21 years) with complete data on weight, antibiotic receipt, bolus timing, and bolus volumes were included. The primary outcome was 30-day mortality. Associations between BAR and mortality and secondary (intubation or non-invasive positive pressure ventilation = NIPPV) outcomes were assessed using unadjusted and adjusted logistic regression. Results: The PSSC database included 6731 patients; 3969 met inclusion and received a median ED volume of 40.2 mL/kg. Seventy-six (1.9%) patients died, 151 (3.8%) were intubated, and 235 (5.9%) had NIPPV administered. The median BAR was 25.7 mL/kg/hr. For each 20 mL/kg/hr increase in BAR, the adjusted odds ratio (aOR) for 30-day mortality [aOR = 1.11 (95% CI 1.01, 1.23)], intubation [aOR = 1.25 (95% CI 1.09, 1.44)], and NIPPV [aOR = 1.20 (95% CI 1.05, 1.38)] significantly increased. Conclusion: Faster ED IVF bolus administration rates in this pediatric sepsis database were associated with higher adjusted odds of death, intubation and NIPPV. Controlled trials are needed to determine if these associations are replicable.
Language	English
Publishing date	2022-07-28
Publishing country	New Zealand
Document type	Journal Article
ZDB-ID	2520704-0
ISSN	1179-1500
ISSN	1179-1500
DOI	10.2147/OAEM.S368442
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Article ; Online: Establishing national stakeholder priorities for quality improvement in pediatric trauma care: Consensus results using a modified Delphi process.

Melhado, Caroline G / Yorkgitis, Brian K / Patel, Bhavin / Remick, Katherine / Macias, Charles G / Dingeldein, Michael W / Gray, Lisa / Jensen, Aaron R

The journal of trauma and acute care surgery

2022 Volume 93, Issue 4, Page(s) 467–473

Abstract: Background: Quality improvement efforts within pediatric trauma centers (PTCs) are robust, but the majority of children do not receive initial postinjury care at PTCs. Disparities in access to quality trauma care remain, particularly for children who ... ...

Abstract	Background: Quality improvement efforts within pediatric trauma centers (PTCs) are robust, but the majority of children do not receive initial postinjury care at PTCs. Disparities in access to quality trauma care remain, particularly for children who initially access the trauma system outside of a PTC. The purpose of this project was to identify unmet needs for injured children within the pediatric emergency care system and to determine national priorities for quality improvement across the continuum of pediatric trauma care. Methods: A panel of delegates representing patients and families, prehospital providers, federal funding partners, nurses, and physicians was recruited from 10 national stakeholder organizations. Potential targets were identified using an initial stakeholder meeting followed by a free text response survey. Free text items were coded and condensed as themes and then ranked by the panel using a modified Delphi approach to determine consensus priorities. Items not achieving >35% prioritization on a given iteration were dropped from subsequent iterations. Consensus was defined as 75% of members designating an item as a top-four priority. Results: Nineteen themes were identified as potential targets for QI initiatives. Four iterations of panel ranking were used to achieve consensus, with four priorities identified: (1) creation of a toolkit and standard provider training for pediatric trauma triage, shock recognition, and early recognition for need to transfer to higher level of care; (2) development of minimum standards for pediatric trauma resuscitation and stabilization capability in nonpediatric centers; (3) facilitating creation of local nursing and physician champions for pediatric trauma; and (4) development and dissemination of best-practice guidelines to improve imaging practices for injured children. Conclusion: System-level quality improvement priorities for pediatric trauma care should focus resources on developing and implementing minimum pediatric standards for injury care, frontline provider training, stabilization protocols, imaging guidelines, and local pediatric champions. Level of evidence: Therapeutic/Care Management; Level IV.
MeSH term(s)	Child ; Consensus ; Delphi Technique ; Emergency Medical Services ; Humans ; Quality Improvement ; Triage
Language	English
Publishing date	2022-06-17
Publishing country	United States
Document type	Journal Article ; Research Support, U.S. Gov't, P.H.S.
ZDB-ID	2651070-4
ISSN	2163-0763 ; 2163-0755
ISSN (online)	2163-0763
ISSN	2163-0755
DOI	10.1097/TA.0000000000003731
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Article: Recognition and Management of Sepsis in Children: Practice Patterns in the Emergency Department.

Thompson, Graham C / Macias, Charles G

The Journal of emergency medicine

2015 Volume 49, Issue 4, Page(s) 391–399

Abstract: Background: Pediatric sepsis remains a leading cause of morbidity and mortality. Understanding current practice patterns and challenges is essential to inform future research and education strategies.: Objective: Our aim was to describe the practice ... ...

Abstract	Background: Pediatric sepsis remains a leading cause of morbidity and mortality. Understanding current practice patterns and challenges is essential to inform future research and education strategies. Objective: Our aim was to describe the practice patterns of pediatric emergency physicians (PEPs) in the recognition and management of sepsis in children and to identify perceived priorities for future research and education. Methods: We conducted a cross-sectional, internet-based survey of members of the American Academy of Pediatrics, Section on Emergency Medicine and Pediatric Emergency Research Canada. The survey was internally derived, externally validated, and distributed using a modified Dillman methodology. Rank scores (RS) were calculated for responses using Likert-assigned frequency values. Results: Tachycardia, mental-status changes, and abnormal temperature (RS = 83.7, 80.6, and 79.6) were the highest ranked clinical measures for diagnosing sepsis; white blood cell count, lactate, and band count (RS = 73.5, 70.9, and 69.1) were the highest ranked laboratory investigations. The resuscitation fluid of choice (85.5%) was normal saline. Dopamine was the first-line vasoactive medication (VAM) for cold (57.1%) and warm (42.2%) shock with epinephrine (18.5%) and norepinephrine (25.1%) as second-line VAMs (cold and warm, respectively). Steroid administration increased with complexity of presentation (all-comers 3.8%, VAM-resistant shock 54.5%, chronic steroid users 72.0%). Local ED-specific clinical pathways, national emergency department (ED)-specific guidelines, and identification of clinical biomarkers were described as future priorities. Conclusions: While practice variability exists among clinicians, PEPs continue to rely heavily on clinical metrics for recognizing sepsis. Improved recognition through clinical biomarkers and standardization of care were perceived as priorities. Our results provide a strong framework to guide future research and education strategies in pediatric sepsis.
MeSH term(s)	Adult ; Child ; Child, Preschool ; Critical Care/methods ; Critical Care/statistics & numerical data ; Cross-Sectional Studies ; Disease Management ; Emergency Service, Hospital/statistics & numerical data ; Female ; Fluid Therapy/methods ; Humans ; Male ; Middle Aged ; Pediatrics ; Practice Patterns, Physicians'/statistics & numerical data ; Resuscitation/statistics & numerical data ; Sepsis/diagnosis ; Sepsis/therapy ; United States ; Vasodilator Agents/therapeutic use
Chemical Substances	Vasodilator Agents
Language	English
Publishing date	2015-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	605559-x
ISSN	0736-4679
ISSN	0736-4679
DOI	10.1016/j.jemermed.2015.03.012
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Article ; Online: Anaphylaxis on the other front line: perspectives from the emergency department.

Nowak, Richard M / Macias, Charles G

The American journal of medicine

2014 Volume 127, Issue 1 Suppl, Page(s) S34–44

Abstract: Although most cases of anaphylaxis are treated in the emergency department (ED), personnel may not immediately recognize anaphylaxis based on presenting symptoms because it has a wide range of clinical manifestations and variable progression. When ... ...

Abstract	Although most cases of anaphylaxis are treated in the emergency department (ED), personnel may not immediately recognize anaphylaxis based on presenting symptoms because it has a wide range of clinical manifestations and variable progression. When symptoms happen to be atypical or mild and when no trigger is identified, the diagnosis of anaphylaxis can be challenging. Underdiagnosis of anaphylaxis can lead to delayed use of appropriate first-line epinephrine in favor of treatments that should be used as adjunctive only. Even when anaphylaxis is recognized, the choice between an epinephrine autoinjector or epinephrine ampule can still present a challenge. Treatment of anaphylaxis in the ED should include a combination of intramuscular epinephrine, supplemental oxygen, and intravenous fluids. If there is an incomplete response to the initial dose of epinephrine, additional doses or other measures may be considered. The most important management consideration is avoiding treatment delays, because symptoms can progress rapidly. Upon discharge from the ED, all patients with anaphylaxis should be given a prescription for at least 2 epinephrine autoinjectors, an initial emergency action plan, education about avoidance of triggers, and a referral to an allergist. A significant limitation of current studies is that clinical outcomes in anaphylaxis associated with established poor rates of diagnosis and use of recommended treatments are unclear; such trials must be conducted as supporting evidence for ED management guidelines for anaphylaxis.
MeSH term(s)	Anaphylaxis/diagnosis ; Anaphylaxis/drug therapy ; Anaphylaxis/epidemiology ; Anaphylaxis/etiology ; Anaphylaxis/therapy ; Delayed Diagnosis ; Diagnosis, Differential ; Drug Hypersensitivity/complications ; Emergency Medicine/standards ; Emergency Service, Hospital ; Epinephrine/administration & dosage ; Fluid Therapy ; Food Hypersensitivity/complications ; Humans ; Injections, Intramuscular/instrumentation ; Oxygen/administration & dosage ; Patient Discharge/standards ; Patient Education as Topic/standards ; United States/epidemiology ; Venoms/adverse effects
Chemical Substances	Venoms ; Oxygen (S88TT14065) ; Epinephrine (YKH834O4BH)
Language	English
Publishing date	2014-01
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80015-6
ISSN	1555-7162 ; 1873-2178 ; 0002-9343 ; 1548-2766
ISSN (online)	1555-7162 ; 1873-2178
ISSN	0002-9343 ; 1548-2766
DOI	10.1016/j.amjmed.2013.09.012
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Article ; Online: Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting.

Hewes, Hilary A / Genovesi, Andrea L / Codden, Rachel / Ely, Michael / Ludwig, Lorah / Macias, Charles G / Schmuhl, Patricia / Olson, Lenora M

Prehospital emergency care

2021 Volume 26, Issue 4, Page(s) 503–510

Abstract: ... ...

Abstract	Objectives
MeSH term(s)	Child ; Emergency Medical Services ; Humans ; Surveys and Questionnaires
Language	English
Publishing date	2021-07-12
Publishing country	England
Document type	Journal Article ; Research Support, U.S. Gov't, P.H.S.
ZDB-ID	1461751-1
ISSN	1545-0066 ; 1090-3127
ISSN (online)	1545-0066
ISSN	1090-3127
DOI	10.1080/10903127.2021.1942340
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Article ; Online: Pediatric emergency medicine fellowships adopt a new application process.

Macias, Charles G

Pediatric emergency care

2005 Volume 21, Issue 6, Page(s) 413–414

Abstract: The growth of the subspecialty of pediatric emergency medicine has created a subsequent growth in the demands of pediatric emergency medicine fellowship training. To facilitate the application process for both applicants and fellowship training programs, ...

Abstract	The growth of the subspecialty of pediatric emergency medicine has created a subsequent growth in the demands of pediatric emergency medicine fellowship training. To facilitate the application process for both applicants and fellowship training programs, a uniform application and uniform deadlines have been adopted by the Pediatric Emergency Medicine Fellowship Director's Subcommittee. The Electronic Residency Application Service will provide online support necessary for the implementation of this new process. A description of the new process and a description of theoretical benefits from this change are described. Pediatric emergency medicine fellowship applicants should be encouraged to investigate resources describing the new application process.
MeSH term(s)	Emergency Medicine/education ; Fellowships and Scholarships/methods ; Humans ; Job Application ; Online Systems ; Pediatrics/education ; United States
Language	English
Publishing date	2005-06
Publishing country	United States
Document type	Journal Article
ZDB-ID	632588-9
ISSN	1535-1815 ; 0749-5161
ISSN (online)	1535-1815
ISSN	0749-5161
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