The overall goal of this project is to further validate a quality of care instrument which can be used to measure and improve the quality of care delivered to children in emergency departments (ED). To help achieve this goal, we will collaborate with national experts across a large Pediatric ED research network, the Pediatric Emergency Care Applied Research Network (PECARN). The quality of care instrument, based on expert physician review, will be applied to a sample of 600 children treated in 12 heterogeneous PECARN hospital EDs. With this instrument, we expect to identify differences in quality of care across different settings including different types of EDs, differently trained physicians, and several patient factors, including gender, patient race/ethnicity, and payer source. Once these factors are identified, best practices can be identified and policy recommendations made to improve the quality of care delivered to children presenting to EDs across the country. Objective and Goals: Our long-term objective is to create a generalizable quality of care instrument that can be used to improve the quality of care provided to children in the ED. The short- term objective is to reassess the consistency, reliability and construct validity of a structured implicit review instrument that measures the quality of care provided to children presenting to EDs, and to identify modifiable factors (hospital, ED, physician, patient and presentation factors) associated with differences in quality of ED care delivered to acutely ill and injured children across the U.S. Study design: The proposed study will be a retrospective cross-sectional study of 600 children who present to 12 selected EDs in the PECARN. Each de-identified medical record will be reviewed by four physician expert reviewers randomly selected from a pool of 8 reviewers. To validate the instrument, we will compare our results to objective measures developed from evidence-based guidelines and expert consensus (Gausche-Hill Instrument) for patients treated for asthma, febrile seizure, gastroenteritis, and head trauma. We will also validate the instrument by comparing groups based on appropriateness of disposition (using Re-PEAT and PRISA II), and cross validation with other reviewers. We will then examine several hospitals, ED, physician, patient and presentation factors associated with quality of care using standard multivariable regression methods and multi-level modeling. Conclusion: Our findings and the implicit review quality of care instrument established in this study will help researchers, providers, and healthcare policy makers identify best practices and make recommendations, standards and policies aimed at addressing disparities in care to improve the quality of care delivered to children presenting to EDs across the country. PUBLIC HEALTH RELEVANCE: Our proposed study will validated a structured implicit quality instrument and results of this study could be used by healthcare academicians, researchers, providers, and policy makers in developing recommendations for quality benchmarks, standards and policies targeted at improving the quality of care delivered to children presenting to EDs across the country