Figures
Abstract
Background
Implementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children.
Methods
We conducted a scoping review using Arksey and O’Malley’s framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies.
Results
We included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%).
Conclusions
Studies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that ‘dissemination’ is the most common strategy used, and ‘capacity building and scale-up’ are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.
Citation: Aregbesola A, Abou-Setta AM, Okoli GN, Jeyaraman MM, Lam O, Kasireddy V, et al. (2021) Implementation strategies in emergency management of children: A scoping review. PLoS ONE 16(3): e0248826. https://doi.org/10.1371/journal.pone.0248826
Editor: Ahmed Negida, Zagazig University, EGYPT
Received: September 4, 2020; Accepted: March 7, 2021; Published: March 24, 2021
Copyright: © 2021 Aregbesola et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: The Children’s Hospital Foundation of Manitoba supported this study. The grant was awarded to TPK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
While it would be ideal, not all hospitals have a separate pediatric emergency department (ED), and a significant number of children present at the general EDs [1, 2]. The requirements to manage pediatric emergencies differ from adults because of their unique needs in medication, equipment, staff, and pediatric-specific policies and protocols [3]. As new evidence is developed from well-designed research studies aimed at improving the health outcomes of children visiting EDs, it is critical to identify effective strategies to help implement new research findings to improve health outcomes [4].
In brief, implementation strategies are methods or techniques used to enhance the uptake and sustainability of research findings into routine practice [4]. They can be categorized into the following classes: (1) dissemination strategies: actions that target healthcare providers’ awareness, knowledge, attitudes, and intention to adopt an evidence-based intervention (EBI) [5], (2) process strategies: activities or processes related to quality improvement in planning, selecting and integrating EBI into practice [6], (3) integration strategies: activities or actions taken to address factors that positively or negatively influence optimal integration of specific EBI into practice [5], and (4) capacity building and scale-up strategies: strategies that target the general capacity of individuals to execute implementation process strategies [5]. These include training, technical assistance, tools, and opportunities for peer networking. An implementation strategy is described as being successful or effective when it leads to an increase in the uptake or utilization of guidelines, protocols or evidence into routine practice [7]. However, it remains unclear if study designs play a role in determining the effectiveness of implementation.
Accumulating implementation studies have continued to report on various implementation strategies used in the emergency management of children with inconclusive evidence on the effectiveness of the strategy used [8–12]. Apart from patient-measured outcomes, implementation studies are expected to also focus on healthcare professional and organizational behavior to accept or utilize evidence-based practices [7], but some studies neither investigated nor reported on it [13]. It is unclear what the characteristics of successful implementation strategies in EDs are. Thus, the aim of this scoping review is to identify and map the characteristics of implementation strategies in the emergency management of children.
Methods
We used Arksey and O’Malley’s 5-stage framework to conduct our scoping review [14]. An a priori protocol of this study is available on the Open Science Framework platform (https://osf.io/h6jv2). Our review question was: What are the characteristics of successful implementation strategies used in the emergency management of children? We reported this review in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Review Checklist (S1 Table) [15].
Study eligibility criteria
This review included implementation studies conducted in EDs managing children (e.g., ≤21 years) [16]. Our intervention of interest was the use of any of the implementation strategies described earlier [5, 6]. We focused on controlled studies, defined in this case as studies that applied at least a guideline, protocol or a specific treatment plan compared to before implementation or to another setting in which the implementation strategy was not applied. Citations were limited to peer-reviewed, full-text articles published in English. There was no limit on the date of publication.
Search strategy
A medical librarian (N.A.) designed and executed a literature search strategy in MEDLINE (Ovid) from inception through May 2019 (S2 Table). The search strategy was adapted for other bibliographic databases: Embase (Ovid), Cochrane Central (Wiley), and Cinahl (Ebsco). All retrieved citations were imported into an Endnote X8 (Clarivate Analytics, Philadelphia, PA).
Study selection
Two pairs of reviewers (A.A., G.N.O., M.M.J., and O.L.) independently screened the identified citations for eligibility using a two-stage sifting approach to review the title, abstract, and full-text article. Disagreements between reviewers were observed on a few studies (<1%), which was resolved by a discussion between reviewers or by involving another reviewer (A.M.A.S.), on two occasions. We have reported the study selection process using the PRISMA flow diagram (Fig 1).
Data extraction
Data were extracted using standardized pilot-tested forms, entered into MS Excel (Microsoft Corporation, Redmond, WA, USA) by one reviewer (A.A., G.N.O., M.M.J., or O.L.), and verified for accuracy and completeness by a second reviewer. Disagreements were resolved by discussion between reviewers or by involving another reviewer (A.M.A.S.), when necessary. We extracted data on the study details: first author, year of publication, study period, country, study design, study objective, area of study, and the intervention: use of any of the implementation strategies described earlier [5, 6], the effectiveness of the implementation strategies as it relates to healthcare provider-measured and patient-measured outcomes, and the number of strategies used.
Risk of bias assessment
We did not appraise the risk of bias of the included studies, which is consistent with established scoping review methods [17].
Data analysis
We performed screening and data management using MS Excel (Microsoft Corporation, Redmond, WA, USA). A descriptive analysis of different implementation strategies and the effectiveness was conducted and presented in tabular and narrative formats. We determined the effectiveness of the implementation strategy of the included studies based on the positive change reported in the outcomes of studies. We labelled the studies accordingly in cases where no change or negative change was observed in the outcomes. The effectiveness (%) of an implementation strategy was computed by dividing the number of studies that reported a positive effect (on the study outcome using the strategy) by the total number of studies that used the strategy [18, 19].
Results
From 9,607 retrieved citations from four bibliographic databases, we included 87 studies [8–13, 20–100] (Fig 1). The detailed characteristics of the included studies are summarized in Table 1. Most of the included studies were from North America (n = 63, 70%) and Australia (n = 21, 11%). Before and after study design (n = 68, 61%) was the most common study design, and only (n = 7, 8%) were randomized controlled trials (RCTs) (S1 Fig).
Included studies adopted one (n = 27, 31%), two (n = 27, 31%) or three (n = 27, 31%) implementation strategies, while less than one-tenth of the studies used four strategies (n = 6, 7%). The details of the number and how these strategies were used in each included study are presented in S3 Table. Dissemination strategies were utilized by most studies (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%) (Fig 2).
Studies that adopted capacity building and scale-up as part of the implementation strategies were most effective (100%) compared to dissemination (90%), process (88%), and integration (85%) (Table 2). A similar pattern of effectiveness was observed when each strategy was adopted alone. Compared to other strategies (dissemination, 92%, process, 90%, integration, 87%), the highest level of effectiveness was observed in non-randomized studies, which focused on healthcare provider-related outcomes that used capacity building and scale-up (100%) (Table 3). In contrast, the effectiveness of these strategies was low in RCTs on patient-measured outcomes.
On average, the effectiveness of strategies was higher in studies conducted on healthcare provider-measured outcomes versus patient-measured outcomes for both RCTs (29.3% versus 8.3%) and non-randomized studies (92.3% versus 38.3%). Reduction in the effectiveness of strategies between healthcare provider-measured outcome and patient-measured outcome, however, was higher in RCTs versus non-randomized studies. The change in the number of participants or effect estimates or both following an implementation strategy intervention in each included study is summarized in the S4 Table.
Discussion
This review is the first systematic scoping review that identified the various implementation strategies in the emergency management of children to the best of our knowledge. Most evidence on implementation strategies came from non-randomized studies showing that dissemination strategies were most commonly used, but capacity building and scale-up strategies were the most effective implementation strategies in emergency management of children. About a third of the included studies used one implementation strategy, while two-thirds of the studies used two and three strategies, and less than 10% used four strategies. The effectiveness of the implementation strategies varied by study design and study outcome (e.g. healthcare provider-measured versus patient-measured outcomes). We observed a higher level of effectiveness of strategies in non-randomized studies that used capacity building and scale-up with a focus on healthcare provider-measured outcomes.
A timely intervention in the emergency management of children is crucial to attaining an optimal level of care. The skills and resources needed to manage children, especially in EDs require the rapid implementation of up-to-date research. Different types of implementation strategies have been used in emergency management of children [4–6], but the questions remain as to which ones are effective and how many strategies are needed in the real world.
Although dissemination strategies were most used in the included studies, capacity building and scale-up were most effective. A before and after study [9] investigated the effect of implementing a simulation-based training program on healthcare provider confidence in team-based management of severely injured pediatric trauma patients and found a positive response as the healthcare provider confidence on long-term exposure was improved. They used dissemination strategies in which healthcare providers underwent a 40-minute structured debriefing with trained debriefers after a training session. They also adopted capacity building and scale-up strategies in which various pediatric simulators and tools were used to support the implementation process to achieve a positive effect on healthcare providers.
It is crucial to identify implementation strategies, which may not produce desired results. As observed in our scoping review, a few implementation studies found no significant benefit following implementation. For example, Tavarez et al. [10] evaluated the effects of implementing e-mail-only, provider-level performance feedback on admission practice variation of physicians and reported no significant impact on management practices. They used integration strategies in which individual physician’s data/ performance was highlighted in red if it fell within the lowest quartile among all physicians and highlighted in blue if it fell within the highest quartile of performance.
The success of the implementation strategies appeared to be somewhat influenced by the study design. Our review showed that most of the included studies were non-randomized studies, and only less than one-tenth were RCTs. Arguably, the large number of study designs skewed towards the non-randomized studies may have powered the effectiveness of implementation strategies observed in non-randomized studies. That said, our review showed that the highest level of effectiveness was observed in capacity building and scale-up in non-randomized studies that focused on healthcare provider-measured outcomes. What appeared to be consistent for both RCTs and non-randomized studies was that the effectiveness of the strategies was higher in studies that focused on healthcare provider-measured outcomes versus patient-measured outcomes.
Although the ultimate goal of implementation research is to promote the overall quality of healthcare, the success of implementation strategies is in being able to influence healthcare professionals and organizational behavior positively to accept or utilize evidence-based practices [7]. Lee et al. [11] conducted a before and after study investigating the effect of implementing a clinical pathway to decrease the period of observation following the management of anaphylaxis at EDs to reduce the admission rate. They found a positive effect on the overall admission rate, which was reduced from 58 to 25% following the implementation. While they reported a positive outcome on healthcare provider-measured outcomes, they found no benefit on the patient-measured outcome (percentage of patients that returned to the ED within 72 hours) following the implementation. Their findings and that of other included studies in this review showed that perhaps the focus of implementation studies on patient-measured outcomes may not be a good marker of a successful implementation strategy. We also observed that the reduction in the effectiveness of strategies between healthcare provider-measured outcomes and patient-measured outcomes was higher in RCTs than non-randomized studies. This suggests that the effectiveness of the implementation strategies may be exaggerated in non-randomized studies.
The strengths of this review include using an a priori protocol that followed the standard accepted methods for scoping reviews, and reporting according to the PRISMA Extension for Scoping Review guidelines. The inclusion of a multidisciplinary team, including experienced systematic reviewers, experts in implementation science, clinical epidemiology, and pediatric emergency management, provided adequate guidance to the reviewers during study selection, data extraction, and interpretation of the results. Our study is not without limitations. Most of the included studies were from North America; thus, worldwide generalizability of our results may be difficult because of cultural variations, which may affect behavior towards implementing research evidence. We did not appraise the risk-of-bias of included studies, which is in keeping with scoping review methods [17]. Because most of the included studies were non-randomized studies with possible exaggeration of effectiveness of strategies, we acknowledged that more robust implementation RCTs with sophisticated methodological approaches are needed to accept or refute our findings. We only performed descriptive statistical analysis, which is consistent with our a priori protocol. Although we searched multiple bibliographic databases for completeness of the search, we acknowledged that we may not have captured all relevant studies due to our inclusion criteria.
Further research is needed to determine barriers to adopting other implementation strategies that appeared to be more effective but not commonly used. More data is also required to determine the optimal time to implement these strategies and their long term effects. Our scoping review has helped summarize the available evidence on implementation strategies in emergency management of children and highlighted the characteristics of successful ones.
In conclusion, studies on implementation strategies in emergency management of children have mostly been non-randomized study designs with possibly exaggerated effect sizes. Better study designs such as RCTs should be conducted more frequently when comparing implementation strategies. This review suggests that dissemination is the most common strategy, and capacity building and scale-up strategies are the most effective strategies.
Supporting information
S1 Table. PRISMA extension for scoping review checklist.
https://doi.org/10.1371/journal.pone.0248826.s001
(DOCX)
S3 Table. Summary of the number and type of implementation strategies used in the included studies.
https://doi.org/10.1371/journal.pone.0248826.s003
(DOCX)
S4 Table. Effect of implementation strategies on the number of participants or effect estimates measured in the included studies.
https://doi.org/10.1371/journal.pone.0248826.s004
(DOCX)
S1 Fig. Number (%) of included studies by study design.
RCT, Randomized controlled trial.
https://doi.org/10.1371/journal.pone.0248826.s005
(TIFF)
Acknowledgments
Authors thank Amanda Coyle for providing assistance in data cleaning and the design of the tables.
References
- 1.
Emergency Medical Services for Children—NPRP. Ensuring Pediatric Readiness for All Emergency Department. EMSC—NPRP 2017.
- 2.
Canadian Institute for Health Information. Sources of Potentially Avoidable Emergency Department Visits. Ottawa, ON. CIHI 2014;ISBN 978-1-77109-320-0.
- 3. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Yamamoto LG. Access to optimal emergency care for children. Pediatrics 2007 Jan;119(1):161–164. pmid:17200284
- 4. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci. 2013;8:139. pmid:24289295
- 5. Leeman J, Birken SA, Powell BJ, Rohweder C, Shea CM. Beyond "implementation strategies": classifying the full range of strategies used in implementation science and practice. Implement Sci. 2017;12(1): 017–0657. pmid:29100551
- 6. Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1): 4–23. pmid:21197565
- 7. Eccles MP, Armstrong D, Baker R, Cleary K, Davies H, Davies S, et al. An implementation research agenda. Implement Sci. 2009;4: 4–18.
- 8. McGrew PR, Chestovich PJ, Fisher JD, Kuhls DA, Fraser DR, Patel PP, et al. Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes. J Trauma Acute Care Surg. 2018;85(3): 451–458. pmid:29787555
- 9. McLaughlin CM, Wieck MM, Barin EN, Rake A, Burke RV, Roesly HB, et al. Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation. Pediatr Surg Int. 2018;34(12): 1353–1362. pmid:30324569
- 10. Tavarez MM, Ayers B, Jeong JH, Coombs CM, Thompson A, Hickey RW. Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department. Acad Emerg Med. 2017;24(8): 948–956. pmid:28470786
- 11. Lee J, Rodio B, Lavelle J, Lewis MO, English R, Hadley S, et al. Improving Anaphylaxis Care: The Impact of a Clinical Pathway. Pediatrics. 2018;141(5): 1616. pmid:29615480
- 12. Waddell D, McGrath I, Maude P. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int Emerg Nurs. 2014;22(3): 159–164. pmid:24210953
- 13. Johnson DP, Arnold DH, Gay JC, Grisso A, O’Connor MG, O’Kelley E, et al. Implementation and Improvement of Pediatric Asthma Guideline Improves Hospital-Based Care. Pediatrics. 2018;141(2): 1542–1630. pmid:29367203
- 14. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1): 19–32.
- 15. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–473 pmid:30178033
- 16. Hardin AP, Hackell JM, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE. Age Limit of Pediatrics. Pediatrics. 2017;140(3):10 pmid:28827380
- 17. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. pmid:30453902
- 18. Stegenga J. Measuring effectiveness. Stud Hist Philos Biol Biomed Sci. 2015;54: 62–71. pmid:26199055
- 19. Haynes B. Can it work? Does it work? Is it worth it? The testing of healthcare interventions is evolving. BMJ. 1999;319(7211):652–653. pmid:10480802
- 20. Puffenbarger MS, Ahmad FA, Argent M, Gu H, Samson C, Quayle KS, et al. Reduction of Computed Tomography Use for Pediatric Closed Head Injury Evaluation at a Nonpediatric Community Emergency Department. Acad Emerg Med. 2019;26(7): 784–795. pmid:30428150
- 21. Lukes T, Schjodt K, Struwe L. Implementation of a Nursing Based Order Set: Improved Antibiotic Administration Times for Pediatric ED Patients with Therapy-Induced Neutropenia and Fever. J Pediatr Nurs. 2019;46: 78–82. pmid:30856462
- 22. Carson SM. Implementation of a Comprehensive Program to Improve Child Physical Abuse Screening and Detection in the Emergency Department. J Emerg Nurs. 2018;44(6): 576–581. pmid:29779624
- 23. Libetta C, Burke D, Brennan P, Yassa J. Validation of the Ottawa ankle rules in children. J Accid Emerg Med. 1999;16(5): 342–344. pmid:10505914
- 24. Hendrickson MA, Wey AR, Gaillard PR, Kharbanda AB. Implementation of an Electronic Clinical Decision Support Tool for Pediatric Appendicitis Within a Hospital Network. Pediatr Emerg Care. 2018;34(1): 10–16. pmid:28277414
- 25. Norton SP, Pusic MV, Taha F, Heathcote S, Carleton BC. Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study. Arch Dis Child. 2007;92(1):60–66. pmid:16905562
- 26. Dona D, Zingarella S, Gastaldi A, Lundin R, Perilongo G, Frigo AC, et al. Effects of clinical pathway implementation on antibiotic prescriptions for pediatric community-acquired pneumonia. PLoS One. 2018;13(2):0193581. pmid:29489898
- 27. Mohan S, Nandi D, Stephens P, M’Farrej M, Vogel RL, Bonafide CP. Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department. Pediatr Emerg Care. 2018;34(11): 778–782. pmid:27649041
- 28. Jones PG, Kool B, Dalziel S, Shepherd M, Le Fevre J, Harper A, et al. Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand. J Paediatr Child Health. 2017;53(7): 685–690. pmid:28407334
- 29. Murray AL, Alpern E, Lavelle J, Mollen C. Clinical Pathway Effectiveness: Febrile Young Infant Clinical Pathway in a Pediatric Emergency Department. Pediatr Emerg Care. 2017;33(9): 33–37.
- 30. Geurts D, de Vos-Kerkhof E, Polinder S, Steyerberg E, van der Lei J, Moll H, et al. Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department. Eur J Pediatr. 2017;176(2): 173–181. pmid:27933399
- 31. Ahmad FA, Storch GA, Miller AS. Impact of an Institutional Guideline on the Care of Neonates at Risk for Herpes Simplex Virus in the Emergency Department. Pediatr Emerg Care. 2017;33(6): 396–401. pmid:26308608
- 32. Gildenhuys J, Lee M, Isbister GK. Does implementation of a paediatric asthma clinical practice guideline worksheet change clinical practice? Int J Emerg Med 2009;2(1): 33–39. pmid:19390915
- 33. Rutman L, Atkins RC, Migita R, et al. Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care. Pediatrics. 2016;138(6):10. pmid:27940683
- 34. Lin GX, Yang YL, Kudirka D, Church C, Yong CK, Reilly F, et al. Implementation of a Pediatric Emergency Triage System in Xiamen, China. Chin Med J (Engl). 2016;129(20):2416–2421. pmid:27748332
- 35. Shah SR, Sinclair KA, Theut SB, Johnson KM, Holcomb GW 3rd, St Peter SD. Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm. Ann Surg. 2016;264(3):474–481. pmid:27433918
- 36. Dandoy CE, Hariharan S, Weiss B, Demmel K, Timm N, Chiarenzelli , et al. Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative. BMJ Qual Saf. 2016;25(2): 100–109. pmid:26341714
- 37. Cohen C, King A, Lin CP, Friedman GK, Monroe K, Kutny M. Protocol for Reducing Time to Antibiotics in Pediatric Patients Presenting to an Emergency Department With Fever and Neutropenia: Efficacy and Barriers. Pediatr Emerg Care. 2016 Nov;32(11): 739–745. pmid:25822237
- 38. Fallon SC, Orth RC, Guillerman RP, Munden MM, Zhang W, Elder SC, et al. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol. 2015;45(13): 1945–1952. pmid:26280638
- 39. Jeong JH, Hwang SS, Kim K, Lee JH, Rhee JE, Kang C, et al. Implementation of clinical practices to reduce return visits within 72 h to a paediatric emergency department. Emerg Med J. 2015;32(6): 426–432. pmid:24981010
- 40. Dexheimer JW, Abramo TJ, Arnold DH, Johnson K, Shyr Y, Ye F, et al. Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: a randomized clinical trial. Int J Med Inform. 2014;83(11): 805–813. pmid:25174321
- 41. Higginbotham N, Lawson KA, Gettig K, Roth J, Hopper E, Higginbotham E, et al. Utility of a child abuse screening guideline in an urban pediatric emergency department. J Trauma Acute Care Surg. 2014;76(3): 871–877. pmid:24553563
- 42. Geurts DH, Vos W, Moll HA, Oostenbrink R. Impact analysis of an evidence-based guideline on diagnosis of urinary tract infection in infants and young children with unexplained fever. Eur J Pediatr. 2014;173(4): 463–468. pmid:24221603
- 43. Boutis K, Grootendorst P, Willan A, et al. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ. 2013;185(15): 731–738. pmid:23939215
- 44. Taylor SE, Taylor DM, Jao K, Goh S, Ward M. Nurse-initiated analgesia pathway for paediatric patients in the emergency department: a clinical intervention trial. Emerg Med Australas. 2013;25(4): 316–323. pmid:23911022
- 45. Russell WS, Schuh AM, Hill JG, Hebra A, Cina RA, Smith CD, et al. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care. 2013;29(5): 568–573. pmid:23611916
- 46. Hack CM, Scarfi CA, Sivitz AB, Rosen MD. Implementing routine HIV screening in an urban pediatric emergency department. Pediatr Emerg Care. 2013;29(3): 319–323. pmid:23426243
- 47. Wolff M, Schinasi DA, Lavelle J, Boorstein N, Zorc JJ. Management of neonates with hyperbilirubinemia: improving timeliness of care using a clinical pathway. Pediatrics. 2012; 130: 1688–1694. pmid:23147974
- 48. Doyle SL, Kingsnorth J, Guzzetta CE, Jahnke SA, McKenna JC, Brown K. Outcomes of implementing rapid triage in the pediatric emergency department. J Emerg Nurs. 2012;38(1):30–35. pmid:22226134
- 49. Waseem M, McInerney JE, Perales O, Leber M. Impact of operational staging to improve patient throughput in an inner-city emergency department during the novel H1N1 influenza surge: a descriptive study. Pediatr Emerg Care. 2012;28(1): 39–42. pmid:22193699
- 50. Hendrickson JE, Shaz BH, Pereira G, Parker PM, Jessup P, Atwell F, et al. Implementation of a pediatric trauma massive transfusion protocol: one institution’s experience. Transfusion. 2012;52(6): 1228–1236. pmid:22128884
- 51. Crocker PJ, Higginbotham E, King BT, Taylor D, Milling TJ Jr. Comprehensive pain management protocol reduces children’s memory of pain at discharge from the pediatric ED. Am J Emerg Med. 2012;30(6): 861–871. pmid:22030197
- 52. Angoulvant F, Skurnik D, Bellanger H, Abdoul H, Bellettre X, Morin L, et al. Impact of implementing French antibiotic guidelines for acute respiratory-tract infections in a paediatric emergency department, 2005–2009. Eur J Clin Microbiol Infect Dis. 2012;31(7): 1295–1303. pmid:22002230
- 53. Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011;127(6): 1585–1592. pmid:21576304
- 54. Cruz AT, Perry AM, Williams EA, Graf JM, Wuestner ER, Patel B. Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. Pediatrics. 2011;127(3): 758–766. pmid:21339277
- 55. Iyer SB, Schubert CJ, Schoettker PJ, Reeves SD. Use of quality-improvement methods to improve timeliness of analgesic delivery. Pediatrics. 2011;127(1): 219–225. pmid:21149422
- 56. Fagbuyi DB, Brown KM, Mathison DJ, Kingsnorth J, Morrison S, Saidinejad M, et al. A rapid medical screening process improves emergency department patient flow during surge associated with novel H1N1 influenza virus. Ann Emerg Med. 2011;57(1): 52–59. pmid:20947207
- 57. Fein JA, Pailler ME, Barg FK, Wintersteen MB, Hayes K, Tien AY, et al. Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department. Arch Pediatr Adolesc Med. 2010;164(12): 1112–1117. pmid:21135339
- 58. Babl FE, Krieser D, Belousoff J, Theophilos T. Evaluation of a paediatric procedural sedation training and credentialing programme: sustainability of change. Emerg Med J. 2010; 27(8): 577–581. pmid:20688936
- 59. To T, Wang C, Dell SD, Fleming-Carroll B, Parkin P, Scolnik D, et al. Can an evidence-based guideline reminder card improve asthma management in the emergency department? Respir Med 2010;104(9): 1263–1270. pmid:20434896
- 60. Trottier ED, Bailey B, Dauphin-Pierre S, Doray JP, Dusseault M, Gravel J. Practice variation after implementation of a protocol for migraines in children. Eur J Emerg Med. 2010;17(5): 290–292. pmid:19864956
- 61. Cruz AT, Patel B, DiStefano MC, Codispoti CR, Shook JE, Demmler-Harrison GJ, et al. Outside the box and into thick air: implementation of an exterior mobile pediatric emergency response team for North American H1N1 (swine) influenza virus in Houston, Texas. Ann Emerg Med. 2010;55(1): 23–31. pmid:19837479
- 62. Burnette K, Ramundo M, Stevenson M, Beeson MS. Evaluation of a web-based asynchronous pediatric emergency medicine learning tool for residents and medical students. Acad Emerg Med. 2009;16: 46–50.
- 63. Gauthier M, Chevalier I, Gouin S, Lamarre V, Abela A. Ceftriaxone for refractory acute otitis media: impact of a clinical practice guideline. Pediatr Emerg Care. 2009;25(11): 739–743. pmid:19864968
- 64. Minniear TD, Gilmore B, Arnold SR, Flynn PM, Knapp KM, Gaur AH. Implementation of and barriers to routine HIV screening for adolescents. Pediatrics. 2009;124(4): 1076–1084. pmid:19752084
- 65. Kozer E, Bar-Hamburger R, Rosenfeld N, Dalal I, Landu O, Fainmesser P, et al. Strategy for increasing detection rates of drug and alcohol abuse in paediatric emergency departments. Acta Paediatr. 2009;98(10): 1637–1640. pmid:19555445
- 66. Hayden G, Hewson PH, Eddey D, Smith D, Vuillermin PJ. Implementation of a checklist to assist in the rapid identification of seriously ill children in the emergency department: an observational study. J Paediatr Child Health. 2009;45(5): 274–278. pmid:19493119
- 67. Callegaro S, Titomanlio L, Donega S, Tagliaferro T, Andreola B, Gibertini GG, et al. Implementation of a febrile seizure guideline in two pediatric emergency departments. Pediatr Neurol. 2009;40(2): 78–83. pmid:19135618
- 68. Morrissey LK, Shea JO, Kalish LA, Weiner DL, Branowicki P, Heeney MM. Clinical practice guideline improves the treatment of sickle cell disease vasoocclusive pain. Pediatr Blood Cancer. 2009;52(3): 369–372. pmid:19023890
- 69. Roukema J, Steyerberg EW, van der Lei J, Moll HA. Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source. J Am Med Inform Assoc. 2008;15(1): 107–113. pmid:17947627
- 70. Doherty S, Jones P, Stevens H, Davis L, Ryan N, Treeve V. ’Evidence-based implementation’ of paediatric asthma guidelines in a rural emergency department. J Paediatr Child Health. 2007;43(9): 611–616. pmid:17688645
- 71. Boychuk RB, Demesa CJ, Kiyabu KM, Yamamoto F, Yamamoto LG, Sanderson R, et al. Change in approach and delivery of medical care in children with asthma: results from a multicenter emergency department educational asthma management program. Pediatrics. 2006;117(4 Pt 2):145–551. pmid:16777830
- 72. De Marco G, Mangani S, Correra A, Di Caro S, Tarallo L, De Franciscis A, et al. Reduction of inappropriate hospital admissions of children with influenza-like illness through the implementation of specific guidelines: a case-controlled study. Pediatrics. 2005;116(4): 506–511. pmid:16199678
- 73. Buckmaster A, Boon R. Reduce the rads: a quality assurance project on reducing unnecessary chest X-rays in children with asthma. J Paediatr Child Health. 2005;41(3): 107–111. pmid:15790320
- 74. Buller-Close K, Schriger DL, Baraff LJ. Heterogeneous effect of an Emergency Department Expert Charting System. Ann Emerg Med. 2003;41(5): 644–652. pmid:12712031
- 75. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38(3): 358–362. pmid:12632349
- 76. Perlstein PH, Lichtenstein P, Cohen MB, Ruddy R, Schoettker PJ, Atherton HD, et al. Implementing an evidence-based acute gastroenteritis guideline at a children’s hospital. Jt Comm J Qual Improv. 2002;28(1): 20–30. pmid:11787237
- 77. Sharieff GQ, Hoecker C, Silva PD. Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy. J Emerg Med. 2001;21(1): 1–6. pmid:11399380
- 78. Gazarian M, Henry RL, Wales SR, Micallef BE, Rood EM, O’Meara MW, et al. Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma. Med J Aust. 2001 Apr 16;174(8): 394–397.
- 79. Schriger DL, Baraff LJ, Buller K, Shendrikar MA, Nagda S, Lin EJ, et al. Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age. J Am Med Inform Assoc. 2000;7(2): 186–195. pmid:10730602
- 80. Lavelle JM, Shaw KN. Evaluation of head injury in a pediatric emergency department: pretrauma and posttrauma system. Arch Pediatr Adolesc Med. 1998;152(12): 1220–1224. pmid:9856433
- 81. Rooholamini SN, Clifton H, Haaland W, McGrath C, Vora SB, Crowell CS, et al. Outcomes of a Clinical Pathway to Standardize Use of Maintenance Intravenous Fluids. Hosp Pediatr. 2017;7(12): 703–709. pmid:29162640
- 82. Hall RT, Domenico HJ, Self WH, Hain PD. Reducing the blood culture contamination rate in a pediatric emergency department and subsequent cost savings. Pediatrics. 2013;131(1): 292–297.
- 83. Zeretzke CM, McIntosh MS, Kalynych CJ, Wylie T, Lott M, Wood D. Reduced use of occult bacteremia blood screens by emergency medicine physicians using immunization registry for children presenting with fever without a source. Pediatr Emerg Care. 2012;28(7): 640–645. pmid:22743750
- 84. Volpe D, Harrison S, Damian F, Rachh P, Kahlon PS, Morrissey L, et al. Improving timeliness of antibiotic delivery for patients with fever and suspected neutropenia in a pediatric emergency department. Pediatrics. 2012;130(1): 201–210.
- 85. Pakakasama S, Surayuthpreecha K, Pandee U, Anurathapan U, Maleewan V, Udomsubpayakul U, et al. Clinical practice guidelines for children with cancer presenting with fever to the emergency room. Pediatr Int. 2011;53(6): 902–905. pmid:21418423
- 86. Quint DM, Teach JS. IMPACT DC: Reconceptualizing the Role of the Emergency Department for Urban Children with Asthma. Clin Ped Emerg Med. 2009;10: 115–121.
- 87. Michalowski W, Slowinski R, Wilk S. MET system: a new approach to m-health in emergency triage. Stud Health Technol Inform. 2004;103: 101–108. pmid:15747911
- 88. Muething S, Schoettker PJ, Gerhardt WE, Atherton HD, Britto MT, Kotagal UR. Decreasing overuse of therapies in the treatment of bronchiolitis by incorporating evidence at the point of care. J Pediatr. 2004;144(6): 703–710. pmid:15192613
- 89. Melzer-Lange MD, Walsh-Kelly CM, Lea G, Hillery CA, Scott JP. Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department. Pediatr Emerg Care. 2004;20(1):2–4. pmid:14716157
- 90. Dexheimer JW, Abramo TJ, Arnold DH, Johnson K, Shyr Y, Ye F, et al. Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: a randomized clinical trial. Int J Med Inform. 2014;83(11): 805–813. pmid:25174321
- 91. Jain S, Hegenbarth MA, Humiston SG, Gunter E, Anson L, Giovanni JE. Increasing ED Use of Jet Injection of Lidocaine for IV-Related Pain Management. Pediatrics. 2017;139(4):10. pmid:28280209
- 92. Fraser JA, Flemington T, Doan D, Hoang V, Doan B, Ha T. Professional self-efficacy for responding to child abuse presentations. Journal of children’s services. 2018;13:81–92.
- 93. Gillespie GL, Leming-Lee TS, Crutcher T, Mattei J. Chart It to Stop It: A Quality Improvement Study to Increase the Reporting of Workplace Aggression. J Nurs Care Qual. 2016;31(3):254–261. pmid:26796974
- 94. Qazi K, Altamimi SA, Tamim H, Serrano K. Impact of an emergency nurse-initiated asthma management protocol on door-to-first-salbutamol-nebulization-time in a pediatric emergency department. J Emerg Nurs. 2010;36(5): 428–433. pmid:20837211
- 95. Hughes JL, Asarnow JR. Enhanced Mental Health Interventions in the Emergency Department: Suicide and Suicide Attempt Prevention in the ED. Clin Pediatr Emerg Med. 2013;14(1): 28–34. pmid:25904825
- 96. Meunier-Sham J, Ryan K. Reducing pediatric pain during ED procedures with a nurse-driven protocol: an urban pediatric emergency department’s experience. J Emerg Nurs. 2003;29(2): 127–132. pmid:12660694
- 97. Cunningham RM, Walton MA, Goldstein A, Chermack ST, Shope JT, Bingham CR, et al. Three-month follow-up of brief computerized and therapist interventions for alcohol and violence among teens. Acad Emerg Med. 2009;16(11): 1193–1207. pmid:20053240
- 98. Einfeld S, Tobin M, Beard J, Evans E, Dudley M. Sustaining evidence-based practice for young people who self-harm: a 4-year follow-up. Aust Health Rev. 2004;27(2): 94–99. pmid:15525242
- 99. Lemberg DA, Day AS, Brydon M. The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis. Am J Med Qual. 2005;20(2): 83–89. pmid:15851386
- 100. Fox L, Timm N. Pediatric issues in disaster preparedness: meeting the educational needs of nurses-are we there yet? J Pediatr Nurs. 2008;23(2): 145–152. pmid:18339341