#Notlittleadults might be the definitive hashtag for the field of paediatric emergency medicine. The unique differences in patterns of injury between children and adults are particularly obvious in the emergency department (ED). An elderly adult might break her hip falling out of bed. But a toddler may tumble down a full flight a steps and keep on playing! Even when adults and children are together in the same accident, such as a high-speed car crash, a properly-restrained child is not as vulnerable to major injury.

Professional societies began stressing differences in clinical guidelines for paediatric readiness in emergency care systems starting in the early 1990s. The most recent guidelines for the United States were released in 2018 and are the first to outline performance measures for paediatric clinical quality in the ED.¹ They highlight that >50% of emergency departments do not have a quality improvement plan which includes care for children. Unfortunately, as paediatric specialty care becomes more concentrated at regional centers, we risk moving resources for robust paediatric quality improvement farther from the hospitals where most children receive their emergency care.^2,3

Louie et al. tackle this disconnect between where paediatric emergency providers practice and where paediatric emergency care is delivered in their project to reduce unnecessary CT scanning in children with blunt head trauma.⁴ The overuse of diagnostic, ionizing radiation in children with non-life-threatening injuries remains pervasive in emergency departments without dedicated paediatric capabilities. Louie et al. describe their success providing tertiary paediatric outreach to a rural hospital within their health system in order to implement evidence-based screening and reduce unnecessary radiation exposure.

The outreach intervention included guideline dissemination, multiple education sessions with site staff, audit and feedback of CT use data by provider, and work-aids incorporated within the electronic medical record (EMR). Overall, the hospital reduced CT scans for paediatric patients with blunt head injuries or concussions from 41.8% pre-intervention to 27.7%, with the special cause improvements shown in their control charts (Figure 1) appearing to correlate with both implementation of EMR work-aids and provider-level audit and feedback. These last two interventions are well recognized as important to high reliability systems. However, several additional details are important to consider in seeking to scale the achievements to new settings.

First, the authors only describe one team member from the intervention setting, the local medical director. The local medical director is described as a champion for the project, but we don’t know more about the local context that can weigh heavily on a project’s success, such as the work culture, pre-existing attitudes, provider-perceived barriers and other stakeholders that may have helped or hindered the work.

Similarly, the authors do not describe any root cause analysis or problem investigation prior to their interventions. Spreading improvement work to new contexts, particularly those unfamiliar and less resourced, should be navigated with curiosity and inquiry. What were the theories for using the chosen interventions? The initial interventions targeted education and provider knowledge. Were there actual knowledge gaps? While education is often necessary and here seemed to lead to several months of reduced imaging rates, it is rarely sufficient to drive sustainable change.

Last, the authors transparently disclose their lack of near-time data, and hence, inability to perform data-driven rapid improvement. This is a challenge many improvement teams struggle to overcome. Despite this challenge, when the authors provided data-based feedback, it was associated with special cause improvement and no CT scans were performed in their population in the month following presentation of individual provider performance. This degree of improvement highlights the importance of data sharing and benchmarking to drive improvement outcomes. A further challenge is that improvement related to these audit-and-feedback methods might not prove sustainable. Potentially, this individual-level feedback may require a team member to compile and disseminate reports on a recurring basis, as the authors do not describe a system with ready access to automated data and management-level support such as protected time or administrative personnel.

An improvement infrastructure with resources for data access, expert QI coaching, and project management support may seem pie-in-the-sky for many community-based settings. Yet, with every telephone consult and trauma transfer with an unnecessary CT scan, academic faculty in paediatric emergency medicine ponder their role in ensuring safe, quality care for children in all emergency settings. Spreading improvement to new contexts requires rigorous preparation and investment of resources, including personnel, time, and access to data. So, what is the role for regional academic paediatric centers in community outreach and facilitating quality care for children in hospitals with fewer resources? How can we ensure quality care for all children is prioritized on the agenda of larger health organizations?

Finding sponsors for this type of important work across institutions is a big hurdle to clear, but essential to drive successful teams and achieve sustainable outcomes. The efforts of Louie et al. certainly required an investment of resources from the tertiary academic hospital, and they should be applauded for partnering with their wider community and taking the first steps. Ideally, more centers will partner with their referring facilities to improve paediatric emergency clinical quality. Hopefully, the hard work put in by Louie et al. will have reduced the use of ionizing radiation in many children in this community since the end of this study.

–Emily Sterrett

Dr. Emily C. Sterrett is an Assistant Professor of Paediatrics at Duke University School of Medicine and practicing Paediatric Emergency Medicine Physician.

¹Remick K et al. Pediatric Readiness in the Emergency Department. Ann Emerg Med. 2018 Dec; 72(6): e123-e136.

²Lorch SA et al. The regionalization of pediatric health care. Pediatrics. 2010 Dec; 126(6): 1182-90.

³Ames SG et al. Emergency Department Pediatric Readiness and Mortality in Critically Ill Children. Pediatrics. 2019 Sep;144(3): e20190568.

⁴Louie et al. Reduction of paediatric head CT utilisation at a rural general hospital emergency department. BMJ Qual Saf. 2020 Feb 28 [Epub ahead of print].