Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium

Why Do Parents Bring Their Children to the Emergency Department? A Systematic Inventory of Motives

Parents frequently bring their children to general or pediatric emergency departments (EDs), even though many of these visits are judged by others to be "nonurgent" and inappropriate. This study examined the motives behind parents' decisions to take their children to a pediatric emergency department (PED). At a PED in Toulouse, France, 497 parents rated their level of agreement with each of 69 possible motives-representing all categories of human motivation-for coming to the PED that day. Exploratory and confirmatory factor analyses found evidence for six separable motives, called (in order of importance) (a) Seeking Quick Diagnosis, Treatment, and Reassurance; (b) PED as the Best Place to Go; (c) Empathic Concern for Child's Suffering; (d) Being Considered by Others as Responsible Parents; (e) External Factors; and (f) Dissatisfaction with Previous Consultation. Conclusions. Parents' motives in bringing their children to the PED are primarily serious and goal-oriented. They are also often emotion based, as would be expected in parents of ill children. The parents would be unlikely to agree that these visits were inappropriate.

Appropriateness of disposition following telemedicine consultations in rural emergency departments

OBJECTIVES

To compare the appropriateness of hospital admission in eight rural emergency departments among a cohort of acutely ill and injured children who receive telemedicine consultations from pediatric critical care physicians to a cohort of similar children who receive telephone consultations from the same group of physicians.

DESIGN

Retrospective cohort study between January 2003 and May 2012.

SETTING

Eight rural emergency departments in Northern California.

PATIENTS

Acutely ill and injured children triaged to the highest-level triage category who received either telemedicine or telephone consultations.

INTERVENTIONS

Telemedicine and telephone consultations.

MEASUREMENTS AND MAIN RESULTS

We compared the overall and stratified observed-to-expected hospital admission ratios between telemedicine and telephone cohorts by calculating the risk of admission using the second generation of Pediatric Risk of Admission score and the Revised Pediatric Emergency Assessment Tool. A total of 138 charts were reviewed; 74 children received telemedicine consultations and 64 received telephone consultations. The telemedicine cohort had fewer hospital admissions compared with the telephone cohort (59.5% vs 87.5%; p < 0.05). Although the telemedicine cohort had lower observed-to-expected admission ratios than the telephone cohort, these differences were not statistically different (Pediatric Risk of Admission II, 2.36 vs 2.58; Revised Pediatric Emergency Assessment Tool, 2.34 vs 2.57). This result did not change when the cohorts were stratified into low (below median) and high (above median) risk of admission cohorts, using either Pediatric Risk of Admission II (low risk, 18.25 vs 22.81; high risk, 1.40 vs 1.54) or Revised Pediatric Emergency Assessment Tool (low risk, 5.35 vs 5.94; high risk, 1.51 vs 1.81).

CONCLUSIONS

Although the overall admission rate among patients receiving telemedicine consultations was lower than that among patients receiving telephone consultations, there were no statistically significant differences between the observed-to-expected admission ratios using Pediatric Risk of Admission II and Revised Pediatric Emergency Assessment Tool. Our findings may be reassuring in the context of previous research, suggesting that telemedicine specialty consultations can aid in the delivery of more appropriate, safer, and higher quality of care.

[Travel distance and the utilisation of out-of-hours services]

BACKGROUND

It has been documented from a number of out-of-hours primary health care services that the utilisation of the services declines with increasing travel distances. In this study we have investigated the correlation between travel distances and the use of out-of-hours medical services for all Norwegian municipalities that provide such services at a single permanent casualty clinic round the clock. In addition, we have sought to reveal any differences in consultation rates between municipalities that maintain single-municipality or inter-municipal out-of-hours services, as well as between municipalities in which the casualty clinics are co-located with a hospital or located separately.

MATERIAL AND METHOD

Information on the types of out-of-hours services existing in 2011 was retrieved from the Norwegian Emergency Primary Health Care Registry, and 315 municipalities with single permanent casualty clinic premises were included. Rates for various types of utilisation of these clinics were calculated on the basis of statistics generated from reimbursement claims.

RESULTS

The number of medical consultations and house calls per inhabitant fell by 48 % and 55 % respectively when average travel distance increased from 0 to 50 kilometres. The use of telephone/letter contact was not significantly associated with distances. Single-municipality casualty clinics located outside hospitals had the highest consultation rate for out-of-hours medical services when adjusted for distance.

INTERPRETATION

This supports previous findings to the fact that distance is a crucial factor for the utilisation of out-of-hours medical services. Establishing inter-municipal casualty clinics and co-locating them with hospitals may contribute to a lower rate of use of out-of-hours medical services.

The burden of inappropriate emergency department pediatric visits: why Italy needs an urgent reform

OBJECTIVE

To better understand the issue of inappropriate pediatric Emergency Department (ED) visits in Italy, including the impact of the last National Health System reform.

STUDY DESIGN

A retrospective cohort study was conducted with five health care providers in the Veneto region (Italy) in a 2-year period (2010-2011). ED visits were considered "inappropriate" by evaluating both nursing triage and resource utilization, as addressed by the Italian Ministry of Health in 2007. Factors associated with inappropriate ED visits were identified. The cost of each visit was calculated.

PRINCIPAL FINDINGS

In total, 134,358 ED visits with 455,650 performed procedures were recorded in the 2-year period; of these, 76,680 (57.1 percent) were considered inappropriate ED visits. Patients likely to make inappropriate ED visits were younger, female, visiting the ED during night or holiday, when the primary care provider (PCP) is not available.

CONCLUSION

The National Health System reform aims to improve efficiency, effectiveness, and costs by opening PCP offices 24 hours a day and 7 days a week. This study highlights the need for a deep reorganization of the Italian Primary Care System not only providing a larger time availability but also treating the parents' lack of education on children's health.

Screening for post-traumatic stress disorder after injury in the pediatric emergency department--a systematic review protocol

BACKGROUND

Pediatric injury is highly prevalent and has significant impact both physically and emotionally. The majority of pediatric injuries are treated in emergency departments (EDs), where treatment of physical injuries is the main focus. In addition to physical trauma, children often experience significant psychological trauma, and the development of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) is common. The consequences of failing to recognize and treat children with ASD and PTSD are significant and extend into adulthood. Currently, screening guidelines to identify children at risk for developing these stress disorders are not evident in the pediatric emergency setting. The goal of this systematic review is to summarize evidence on the psychometric properties, diagnostic accuracy, and clinical utility of screening tools that identify or predict PTSD secondary to physical injury in children. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with focus on ED suitability.

METHODS

Computerized databases including MEDLINE, EMBASE, CINAHL, ISI Web of Science and PsycINFO will be searched in addition to conference proceedings, textbooks, and contact with experts. Search terms will include MeSH headings (post-traumatic stress or acute stress), (pediatric or children) and diagnosis. All articles will be screened by title/abstract and articles identified as potentially relevant will be retrieved in full text and assessed by two independent reviewers. Quality assessment will be determined using the QUADAS-2 tool. Screening tool characteristics, including type of instrument, number of items, administration time and training administrators level, will be extracted as well as gold standard diagnostic reference properties and any quantitative diagnostic data (specificity, positive and negative likelihood/odds ratios) where appropriate.

DISCUSSION

Identifying screening tools to recognize children at risk of developing stress disorders following trauma is essential in guiding early treatment and minimizing long-term sequelae of childhood stress disorders. This review aims to identify such screening tools in efforts to improve routine stress disorder screening in the pediatric ED setting.

TRIALS REGISTRATION

PROSPERO registration: CRD42013004893.

Suitability of emergency department attenders to be assessed in primary care: survey of general practitioner agreement in a random sample of triage records analysed in a service evaluation project

OBJECTIVES

To assess the proportion of emergency department (ED) attendances that would be suitable for primary care and the inter-rater reliability of general practitioner (GP) assessment of primary care suitability.

DESIGN OF STUDY

Survey of GPs' agreement of suitability for primary care on a random anonymised sample of all ED patients attending over a 1-month period.

SETTING

ED of a UK Hospital serving a population of 600 000.

METHOD

Four GPs independently used data extracted from clinical notes to rate the appropriateness for management in primary care as well as need for investigations, specialist review or admission. Agreement was assessed using Cohen's κ.

RESULTS

The mean percentage of patients that GPs considered suitable for primary care management was 43% (range 38-47%). The κ for agreement was 0.54 (95% CI 0.44 to 0.64) and 0.47(95% CI 0.38 to 0.59). In patients deemed not suitable for primary care, GPs were more likely to determine the need for specialist review (relative risks (RR)=3.5, 95% CI 3.0 to 4.2, p<0.001) and admission (RR=3.9, 95% CI 3.2 to 4.7, p<0.001). In patients assessed as suitable for primary care, GPs would initiate investigations in 51% of cases. Consensus over primary care appropriateness was higher for paediatric than for adult attenders.

CONCLUSIONS

A significant number of patients attending ED could be managed by GPs, including those requiring investigations at triage. A stronger agreement among GPs over place of care may be seen for paediatric than for adult attenders. More effective signposting of patients presenting with acute or urgent problems and supporting a greater role for primary care in relieving the severe workflow pressures in ED in the UK are potential solutions.