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Heyming TW, Knudsen-Robbins C, Feaster W, Ehwerhemuepha L. Criticality index conducted in pediatric emergency department triage. Am J Emerg Med 2021; 48:209-217. [PMID: 33975133 DOI: 10.1016/j.ajem.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/27/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To develop and analyze the performance of a machine learning model capable of predicting the disposition of patients presenting to a pediatric emergency department (ED) based on triage assessment and historical information mined from electronic health records. METHODS We retrospectively reviewed data from 585,142 ED visits at a pediatric quaternary care institution between 2013 and 2020. An extreme gradient boosting machine learning model was trained on a randomly selected training data set (50%) to stratify patients into 3 classes: (1) high criticality (patients requiring intensive care unit [ICU] care within 4 h of hospital admission, patients who died within 4 h of admission, and patients who died in the ED); (2) moderate criticality (patients requiring hospitalization without the need for ICU care); and (3) low criticality (patients discharged home). Variables considered during model development included triage vital signs, aspects of triage nursing assessment, demographics, and historical information (diagnoses, medication use, and healthcare utilization). Historical factors were limited to the 6 months preceding the index ED visit. The model was tested on a previously withheld test data set (40%), and its performance analyzed. RESULTS The distribution of criticality among high, moderate, and low was 1.5%, 7.1%, and 91.4%, respectively. The one-versus-all area under the receiver operating characteristic (AUROC) curve for high and moderate criticality was 0.982 (95% CI 0.980, 0.983) and 0.968 (0.967, 0.969). The multi-class macro average AUROC and area under the receiver operating characteristic curve were 0.976 and 0.754. The features most integral to model performance included history of intravenous medications, capillary refill, emergency severity index level, history of hospitalization, use of a supplemental oxygen device, age, and history of admission to the ICU. CONCLUSION Pediatric ED disposition can be accurately predicted using information available at triage, providing an opportunity to improve quality of care and patient outcomes.
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Affiliation(s)
- Theodore W Heyming
- Children's Hospital of Orange County, Orange, CA, United States; Department of Emergency Medicine, University of California, Irvine, United States.
| | | | - William Feaster
- Children's Hospital of Orange County, Orange, CA, United States
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Schoppel KA, Stapleton S, Florian J, Whitfill T, Walsh BM. Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees? AEM EDUCATION AND TRAINING 2021; 5:e10509. [PMID: 33898912 PMCID: PMC8052997 DOI: 10.1002/aet2.10509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training. METHODS This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument. RESULTS A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%). CONCLUSIONS This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.
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Affiliation(s)
| | | | | | - Travis Whitfill
- Department of Pediatrics and Emergency MedicineYale UniversityNew HavenCTUSA
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Claiborne DM, Kelekar U, Shepherd JG, Naavaal S. Emergency department use for nontraumatic dental conditions among children and adolescents: NEDS 2014-2015. Community Dent Oral Epidemiol 2021; 49:594-601. [PMID: 33755217 DOI: 10.1111/cdoe.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Despite great efforts to improve paediatric dental care access in the last two decades, the use of emergency departments (ED) for dental conditions among children that are more appropriately addressed in dental offices remains a public health concern in the United States. We examined factors associated with ED visits for nontraumatic dental conditions or NTDCs and ED visits for any other reason among children and adolescents. METHODS A retrospective secondary data analysis of ED visits was conducted using the 2014-2015 Nationwide Emergency Department Sample (NEDS) data. NTDCs were further categorized as diseases of hard tissue (eg dental caries), pulp/periapical (eg root canal infections), gingival/periodontal (eg conditions that affect the supporting tissues) and other. We included patient/socioeconomic characteristics, disposition, time of visit, and the Grouped Charlson Comorbidity Index (GRPCI) in our analysis. Bivariate associations were tested using chi-squared test (α = 0.05). RESULTS There were 70 616 194 ED visits in 2014-15, with 465 353 (0.7%) visits for NTDCs. Statistically significant differences were observed for all patient characteristics tested, except for gender when comparing children visiting the ED for NTDCs and children visiting for any other reason. Medicaid was the expected payer for nearly 60% of all ED visits, and the uninsured shared a larger proportion of NTDC visits (19.4%) than other visits (8.8%). Late adolescents (aged 18-21) accounted for over 50% of NTDC visits but only one-fifth of all other types of ED visits. Late adolescents (18-21 years old) who were uninsured had a significantly higher proportion of NTDC visits. Of all NTDC visits, 19.1% were related to hard tissue disease, 25.3% pulp/periapical, 7.9% periodontal disease, and the remaining were grouped as other dental diseases. CONCLUSIONS The ED use for NTDCs is more common among late adolescents, Medicaid and uninsured groups. Examining and implementing new approaches that improve access to routine dental care for these groups may help in reducing inefficient ED use related to NTDCs.
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Affiliation(s)
- Denise M Claiborne
- Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk, VA, USA
| | - Uma Kelekar
- School of Business, Innovation, Leadership and Technology, Marymount University, Arlington, VA, USA
| | | | - Shillpa Naavaal
- Dental Public Health and Policy, School of Dentistry, Virginia Commonwealth University, Richmond, VA, USA.,Oral Health in Childhood and Adolescence Core, Institute for Inclusion, Inquiry and Innovation, Virginia Commonwealth University, Richmond, VA, USA
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Abulebda K, Whitfill T, Montgomery EE, Thomas A, Dudas RA, Leung JS, Scherzer DJ, Aebersold M, Van Ittersum WL, Kant S, Walls TA, Sessa AK, Janofsky S, Fenster DB, Kessler DO, Chatfield J, Okada P, Arteaga GM, Berg MD, Knight LJ, Keilman A, Makharashvili A, Good G, Bingham L, Mathias EJ, Nagy K, Hamilton MF, Vora S, Mathias K, Auerbach MA. Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study. J Pediatr 2021; 230:230-237.e1. [PMID: 33137316 DOI: 10.1016/j.jpeds.2020.10.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs). STUDY DESIGN A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers. RESULTS Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P < .001) from a baseline of 62.4 (SEM = 2.2) to 78.7 (SEM = 2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol, and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline. CONCLUSIONS Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in WPRS when disseminated to a diverse group of general EDs partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.
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Affiliation(s)
- Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Anita Thomas
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Robert A Dudas
- Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - James S Leung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Daniel J Scherzer
- Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | | | - Wendy L Van Ittersum
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Northeast Ohio Medical University, Akron, OH
| | - Shruti Kant
- Department of Emergency Medicine and Pediatrics, University of California San Francisco, San Francisco, CA
| | - Theresa A Walls
- Department of Pediatrics, Division of Emergency Medicine, The Children's Hospital of Philadelphia at the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anna K Sessa
- Office of Emergency Medical Services, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Stephen Janofsky
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Daniel B Fenster
- Department of Emergency Medicine, Morgan Stanley Children's Hospital of New York Presbyterian at Columbia University Medical Center, New York, NY
| | - David O Kessler
- Department of Emergency Medicine, Morgan Stanley Children's Hospital of New York Presbyterian at Columbia University Medical Center, New York, NY
| | - Jenny Chatfield
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Pamela Okada
- Department of Pediatrics, University of Texas Southwestern School of Medicine, Dallas, TX
| | - Grace M Arteaga
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, MN
| | - Marc D Berg
- Davison of Critical Care Medicine, Lucile Packard children's Hospital Stanford, Stanford University College of Medicine, Palo Alto, CA
| | - Lynda J Knight
- Davison of Critical Care Medicine, Lucile Packard children's Hospital Stanford, Stanford University College of Medicine, Palo Alto, CA
| | - Ashley Keilman
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Ana Makharashvili
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Grace Good
- Department of Pediatrics, Division of Emergency Medicine, The Children's Hospital of Philadelphia at the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ladonna Bingham
- Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Emily J Mathias
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kristine Nagy
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Northeast Ohio Medical University, Akron, OH
| | - Melinda F Hamilton
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Marc A Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
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Abulebda K, Thomas A, Whitfill T, Montgomery EE, Auerbach MA. Simulation Training for Community Emergency Preparedness. Pediatr Ann 2021; 50:e19-e24. [PMID: 33450035 DOI: 10.3928/19382359-20201212-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most infants and children who are ill and injured are cared for in community-based settings across the emergency continuum. These settings are often less prepared for pediatric patients than dedicated pediatric settings such as academic medical centers. Disparities in health outcomes exist and are associated with gaps in community emergency preparedness. Simulation is an effective technique to enhance emergency preparedness to ensure the highest quality of care is provided to all pediatric patients. In this article, we summarize the pediatric emergency care provided across the emergency continuum and outline the key features of simulation used to measure and improve pediatric preparedness in community settings. First, we discuss the use of simulation as a training tool and as an investigative methodology to enhance emergency preparedness across the continuum. Next, we present two examples of successful simulation-based programs that have led to improved emergency preparedness. [Pediatr Ann. 2021;50(1):e19-e24.].
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Cortellazzo Wiel L, Poropat F, Barbi E, Cozzi G. Is opioid analgesia superior to NSAID analgesia in children with musculoskeletal trauma? Arch Dis Child 2020; 105:1229-1232. [PMID: 32819915 DOI: 10.1136/archdischild-2020-319359] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 01/10/2023]
Affiliation(s)
| | - Federico Poropat
- Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Egidio Barbi
- Pediatrics, University of Trieste, Trieste, Italy.,Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Giorgio Cozzi
- Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
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Abulebda K, Lutfi R, Petras EA, Berrens ZJ, Mustafa M, Pearson KJ, Kirby ML, Abu-Sultaneh S, Montgomery EE. Evaluation of a Nurse Pediatric Emergency Care Coordinator-Facilitated Program on Pediatric Readiness and Process of Care in Community Emergency Departments After Collaboration With a Pediatric Academic Medical Center. J Emerg Nurs 2020; 47:167-180. [PMID: 33036776 DOI: 10.1016/j.jen.2020.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/18/2020] [Accepted: 06/14/2020] [Indexed: 11/26/2022]
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Mitzman J, Bank I, Burns RA, Nguyen MC, Zaveri P, Falk MJ, Madhok M, Dietrich A, Wall J, Waseem M, Wu T, McQueen A, Peng CR, Phillips B, Bullaro FM, Chang CD, Shahid S, Way DP, Auerbach M. A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs. AEM EDUCATION AND TRAINING 2020; 4:369-378. [PMID: 33150279 PMCID: PMC7592831 DOI: 10.1002/aet2.10412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs. METHODS Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items. RESULTS A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs. CONCLUSIONS The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.
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Affiliation(s)
- Jennifer Mitzman
- The Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOH
| | - Ilana Bank
- Institute of Health Sciences EducationSteinberg Centre for Simulation and Interactive Learning/Institute of Pediatric SimulationMontreal Children's HospitalMcGill UniversityMontrealQuebecCanada
| | - Rebekah A. Burns
- Seattle Children's HospitalUniversity of Washington School of MedicineSeattleWA
| | | | - Pavan Zaveri
- George Washington University School of Medicine and Health Sciences/Children's National Health SystemWashingtonDC
| | - Michael J. Falk
- George Washington University School of Medicine and Health Sciences/Children's National Health SystemWashingtonDC
| | | | - Ann Dietrich
- College of MedicineOhio University HeritageDublinOH
| | - Jessica Wall
- Seattle Children's HospitalUniversity of Washington School of MedicineSeattleWA
| | | | - Teresa Wu
- College of Medicine‐PhoenixUniversity of ArizonaPhoenixAZ
- Banner University Medical Center–PhoenixPhoenixAZ
| | - Alisa McQueen
- Comer Children's HospitalThe University of ChicagoChicagoIL
| | | | | | | | | | - Sam Shahid
- American College of Emergency PhysiciansIrvingTX
| | - David P. Way
- The Ohio State University Wexner Medical CenterColumbusOH
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Lahmini W, Bourrous M. Mortality at the pediatric emergency unit of the Mohammed VI teaching hospital of Marrakech. BMC Emerg Med 2020; 20:57. [PMID: 32703150 PMCID: PMC7376937 DOI: 10.1186/s12873-020-00352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/09/2020] [Indexed: 12/04/2022] Open
Abstract
Background The death of a child at the emergency ward is one of the most difficult problems that the clinicians of these wards have to deal with. In our country the published data concerning the causes and the factors related to pediatric mortality especially in the pediatric emergency wards is very rare. This study aimed to study the epidemiology of the pediatric mortality in the pediatric emergency department (PED), to determine its rate and identify its most frequent causes. Methods It is a retrospective and descriptive study, over five years (1st January 2012 and 31st December 2016) including all children aged from 0 to 15 years old who died at the PED in the Mohamed VI Hospital in Marrakech. Results During the period of the study a total of 172.691 patients presented to the PED, among which 628 died (pediatric mortality rate: 3.63%). The masculine gender was predominant (n = 383) with a gender ratio of 1.59. Two-thirds of the patients died in the first 24 h (n = 421). The median of time from admission to death was around 12 h. Majority of the deceased children (n = 471, 75%) were from a low socioeconomic status. The most frequent cause of admissions for deceased patients in the PED was respiratory distress (n = 296, 47%) followed by neurological disorders (n = 70, 11%). Neonatal mortality (≤ 1 month of age) was predominant (n = 472, 75.1%), followed by postnatal mortality (1 month to 1 year old) (n = 73, 11.6%). The most frequent causes of pediatric mortality, whatever the age range, were dominated by neonatal pathologies (n = 391, 62.3%), followed by infecious causes bronchopulmonary infections included (n = 49, 7.7%), birth deformities (n = 46, 7.3%) while traumas were merely at 0.9% (n = 6). The most frequent causes of neonatal mortality were neonatal infections (n = 152, 32.2%) and prematurity (n = 115, 24.4%). Conclusion Our data once again underline the crucial importance of prevention. This requires correct follow-up of the pregnancies, an adequate assistance of births, and perfecting healthcare provision to newborns in order to attain proper assistance.
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Affiliation(s)
- W Lahmini
- Department of Paediatric Emergency, UHC Mohamed VI, Cadi Ayyad University, PO Box: 7010, Sidi Abbad Street, 40000, Marrakech, Morocco
| | - M Bourrous
- Department of Paediatric Emergency, UHC Mohamed VI, Cadi Ayyad University, PO Box: 7010, Sidi Abbad Street, 40000, Marrakech, Morocco.
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Carlson JN, Zocchi MS, Allen C, Denmark TK, Fisher JD, Wilkinson M, Remick K, Sullivan A, Pines JM, Venkat A. Critical procedure performance in pediatric patients: Results from a national emergency medicine group. Am J Emerg Med 2020; 38:1703-1709. [PMID: 32721781 DOI: 10.1016/j.ajem.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 11/30/2022] Open
Abstract
STUDY OBJECTIVE We sought to examine the frequency of pediatric critical procedures performed in a national group of emergency physicians. METHODS We performed a retrospective analysis of an administrative billing and coding dataset for procedural performance documentation verification from 2014 to 2018. We describe and compare incident rates of pediatric (age <18 years) patient critical procedure performance by emergency physicians in general emergency departments (EDs), pediatric EDs, and freestanding ED/urgent care centers. Critical procedures were endotracheal intubation, electrical cardioversion, central venous placement, intraosseous access, and chest tube insertion. RESULTS Among 2290 emergency physicians working in 186 EDs (1844 working in 129 general EDs, 125 in 8 pediatric EDs, and 321 in 49 freestanding EDs/urgent cares), a total of 2233 pediatric critical procedures were performed during the study period. Many physicians at general EDs and freestanding EDs/urgent cares performed zero pediatric procedures per year (53.9% and 89% respectively). Per 1000 ED visits seen (All patient ages), physicians working in general EDs performed fewer pediatric critical procedures than physicians in pediatric EDs (0.12/1000 visits vs 0.68/1000 visits; rate difference = 0.56, 95% confidence interval [CI] 0.51-0.61). Per 1000 clinical hours worked, physicians working in general EDs performed 0.26 procedures compared to 1.66 for physicians in pediatric EDs (rate difference = 1.39; 95% CI 1.27-1.52). CONCLUSION Pediatric critical procedures are rarely performed by emergency physicians and are exceedingly rare in general EDs and freestanding EDs/urgent cares. The rarity of performance of these skills has implications for ED pediatric readiness.
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Affiliation(s)
- Jestin N Carlson
- US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America
| | - Mark S Zocchi
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | - Coburn Allen
- US Acute Care Solutions, Canton, OH, United States of America; Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX, United States of America
| | - T Kent Denmark
- US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Oklahoma State University, Tulsa, OK, United States of America
| | - Jay D Fisher
- US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency, University of Nevada, Las Vegas School of Medicine, Las Vegas, NV, United States of America
| | - Matthew Wilkinson
- US Acute Care Solutions, Canton, OH, United States of America; Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX, United States of America
| | - Katherine Remick
- US Acute Care Solutions, Canton, OH, United States of America; Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX, United States of America; Department of Surgery and Perioperative Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, United States of America; Emergency Medical Services for Children Innovation and Improvement Center, Baylor College of Medicine, Houston, TX, United States of America
| | - Abbie Sullivan
- US Acute Care Solutions, Canton, OH, United States of America
| | - Jesse M Pines
- US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America
| | - Arvind Venkat
- US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America.
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Lo CB, Bridge JA, Shi J, Ludwig L, Stanley RM. Children's Mental Health Emergency Department Visits: 2007-2016. Pediatrics 2020; 145:peds.2019-1536. [PMID: 32393605 DOI: 10.1542/peds.2019-1536] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Emergency department (ED) visits for children seeking mental health care have increased. Few studies have examined national patterns and characteristics of EDs that these children present to. In data from the National Pediatric Readiness Project, it is reported that less than half of EDs are prepared to treat children. Our objective is to describe the trends in pediatric mental health visits to US EDs, with a focus on low-volume, nonmetropolitan EDs, which have been shown to be less prepared to provide pediatric emergency care. METHODS Using 2007 to 2016 Nationwide Emergency Department Sample databases, we assessed the number of ED visits made by children (5-17 years) with a mental health disorder using descriptive statistics. ED characteristics included pediatric volume, children's ED classification, and location. RESULTS Pediatric ED visits have been stable; however, visits for deliberate self-harm increased 329%, and visits for all mental health disorders rose 60%. Visits for children with a substance use disorder rose 159%, whereas alcohol-related disorders fell 39%. These increased visits occurred among EDs of all pediatric volumes, regardless of children's ED classification. Visits to low-pediatric-volume and nonmetropolitan areas rose 53% and 41%, respectively. CONCLUSIONS Although the total number of pediatric ED visits has remained stable, visits among children with mental health disorders have risen, particularly among youth presenting for deliberate self-harm and substance abuse. The majority of these visits occur at nonchildren's EDs in both metropolitan and nonurban settings, which have been shown to be less prepared to provide higher-level pediatric emergency care.
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Affiliation(s)
- Charmaine B Lo
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey A Bridge
- Centers for Suicide Prevention and Research.,Departments of Pediatrics.,Psychiatry, and Behavioral Health, College of Medicine, The Ohio State University, Columbus, Ohio; and
| | - Junxin Shi
- Pediatric Trauma Research, and.,Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lorah Ludwig
- Emergency Medical Services for Children, Division of Child, Adolescent, and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - Rachel M Stanley
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio; .,Departments of Pediatrics
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Pediatric Readiness in the Emergency Department and Its Association With Patient Outcomes in Critical Care: A Prospective Cohort Study. Pediatr Crit Care Med 2020; 21:e213-e220. [PMID: 32132503 DOI: 10.1097/pcc.0000000000002255] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric mortality in Latvia remains one of the highest among Europe. The purpose of this study was to assess the quality of pediatric acute care and pediatric readiness and determine their association with patient outcomes using a patient registry. DESIGN This was a prospective cohort study. Pediatric readiness was measured using the weighted pediatric readiness score based on a 100-point scale. The processes of care were measured using in situ simulations to generate a composite quality score. Clinical outcome data-including PICU and hospital length of stay as well as 6-month mortality-were collected from the Pediatric Intensive Care Audit Network registry. The associations between composite quality score and weighted pediatric readiness score on patient outcomes were explored with mixed-effects regressions. SETTING This study was conducted in all Latvian Emergency Departments and in the national PICU. PATIENTS All patients who were transferred into the national PICU were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All (16/16) Latvian Emergency Departments participated with a mean composite quality score of 35.3 of 100 and a median weighted pediatric readiness score of 31 of 100. A total of 254 patients were included in the study and followed up for a mean of 436 days, of which nine died (3.5%). Higher weighted pediatric readiness score was associated significantly with lower length of stay in both the PICU and hospital (adjusted ß, -0.06; p = 0.021 and -0.36; p = 0.011, respectively) and lower 6-month mortality (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98). CONCLUSIONS These data provide a national assessment of pediatric emergency care in a European country. Pediatric readiness in the emergency department was associated with patient outcomes in this population of pediatric patients transferred to the national PICU.
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Boyle TP, Macias CG, Wu S, Holmstrom S, Truschel LL, Espinola JA, Sullivan AF, Camargo CA. Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis. Hosp Pediatr 2020; 10:415-423. [PMID: 32269075 PMCID: PMC7187394 DOI: 10.1542/hpeds.2019-0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The appropriateness of interfacility transfer admissions for bronchiolitis to pediatric centers is uncertain. We characterized avoidable transfer admissions for bronchiolitis. We hypothesized that a higher proportion of hospitalized infants transferred from a community emergency department (ED) or hospital (transfer admission) would be discharged within 48 hours with little or no intervention, compared with direct admissions from an enrolling ED (nontransfer admission). METHODS We analyzed a 17-center, prospective infant cohort (age <1 year) hospitalized for bronchiolitis (2011-2014). An avoidable transfer admission (primary outcome) was hospitalization for <48 hours without an intervention for severe illness in which a pediatric specialist could be beneficial (oxygen, advanced airway management, life support). Parenteral fluids and routine medications were excluded. We compared admissions by patient, ED, inpatient, and transferring hospital characteristics to identify factors associated with avoidable transfer admissions. Multivariable logistic regression was used to identify predictors of avoidable transfer admission. RESULTS Among 1007 infants, 558 (55%) were nontransfer admissions, 164 (16%) were transfer admissions, and 204 (20%) were referrals from clinics; 81 (8%) were missing referral type. Significantly fewer transferred infants were hospitalized for <48 hours with little or no intervention (40 of 164; 24% [95% confidence interval 18%-32%]) than nontransferred infants (199 of 558; 36% [95% confidence interval 32%-40%]; P = .007). Avoidable transfer admissions were more likely to be children of color, have nonprivate insurance, receive fewer ED interventions, and originate from small EDs. A multivariable model revealed that minority race and/or ethnicity, normal oxygenation, and small ED transfers increased odds of avoidable transfer admission. CONCLUSIONS Although most transferred infants hospitalized for bronchiolitis required interventions for severe illness, 1 in 4 admissions were potentially avoidable.
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Affiliation(s)
| | | | - Susan Wu
- Children's Hospital Los Angeles, Los Angeles, California
| | - Sara Holmstrom
- Boston Children's Hospital, Boston, Massachusetts
- Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
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Rees CA, Monuteaux MC, Raphael JL, Michelson KA. Disparities in Pediatric Mortality by Neighborhood Income in United States Emergency Departments. J Pediatr 2020; 219:209-215.e3. [PMID: 31610934 DOI: 10.1016/j.jpeds.2019.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/03/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate emergency department (ED) pediatric mortality by patient neighborhood income. STUDY DESIGN We calculated the incidence of ED pediatric mortality via a cross-sectional study of children <18 years who died in an ED using the Nationwide Emergency Department Sample and US Census from 2012 to 2016. The main exposure was median income for the patient's zip code tabulation area quartile. To determine factors associated with ED mortality, we modeled mortality using negative binomial regression. We used an interaction term between neighborhood income and insurance type to evaluate their relationship to mortality. RESULTS There were 64 893 ED deaths during the study period (incidence 17.3 per 100 000 person-years). The incidence of ED mortality increased with decreasing neighborhood income: compared with the wealthiest income quartile, the poorest, second, and third quartiles had adjusted incidence rate ratios (aIRRs) of 1.79 (95% CI 1.63-1.96), 1.42 (95% CI 1.29-1.55), and 1.23 (95% CI 1.12-1.36), respectively. The incidence of ED mortality was greater among uninsured children (aIRR 4.96, 95% CI 4.55-5.41) and publicly insured children (aIRR 2.69, 95% CI 2.51-2.88) compared with privately insured children. The interaction term showed no consistent relationship between neighborhood income and insurance with ED mortality. CONCLUSIONS Children from poorer neighborhoods have greater ED mortality rates than children from greater-income neighborhoods. Improved access to health insurance in the US may lead to reduced pediatric mortality, as ED mortality was greatest in uninsured children. Development of interventions to improve upstream determinants of health that contribute to ED mortality are needed.
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Affiliation(s)
- Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jean L Raphael
- Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Whitfill TM, Remick KE, Olson LM, Richards R, Brown KM, Auerbach MA, Gausche-Hill M. Statewide Pediatric Facility Recognition Programs and Their Association with Pediatric Readiness in Emergency Departments in the United States. J Pediatr 2020; 218:210-216.e2. [PMID: 31757472 DOI: 10.1016/j.jpeds.2019.10.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Accepted: 10/09/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To describe the relationship between statewide pediatric facility recognition (PFR) programs and pediatric readiness in emergency departments (EDs) in the US. STUDY DESIGN Data were extracted from the 2013 National Pediatric Readiness Project assessment (4083 EDs). Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) based on a 100-point scale. Descriptive statistics were used to compare WPRS between recognized and nonrecognized EDs and between states with or without a PFR program. A linear mixed model with WPRS was used to evaluate state PFR programs on pediatric readiness. RESULTS Eight states were identified with a PFR program. EDs in states with a PFR program had a higher WPRS compared with states without a PFR program (overall a 9.1-point higher median WPRS; P < .001); EDs recognized in a PFR program had a 21.7-point higher median WPRS compared with nonrecognized EDs (P < .001); and between states with a statewide PFR program, there was high variability of participation within the states. We found state-level PFR programs predicted a higher WPRS compared with states without a PFR program (β = 5.49; 95% CI 2.76-8.23). CONCLUSIONS Statewide PFR programs are based on national guidelines and identify those EDs that adhere to a standard level of readiness for children. These statewide PFR initiatives are associated with higher pediatric readiness. As scalable strategies are needed to improve emergency care for children, our study suggests that statewide PFR programs may be one way to improve pediatric readiness and underscores the need for further implementation and evaluation.
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Affiliation(s)
- Travis M Whitfill
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Katherine E Remick
- Office of the Medical Director, Austin-Travis County EMS System, Austin, TX; Dell Medical School at the University of Texas, Austin, TX; San Marcos/Hays County EMS System, San Marcos, TX; EMS for Children Innovation and Improvement Center, Houston, TX
| | - Lenora M Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Rachel Richards
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Kathleen M Brown
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC; Children's National Medical Center, Washington, DC
| | - Marc A Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics, Harbor-UCLA Medical Center, Torrance, CA; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA; Emergency Medical Services Agency, Department of Health Services, Los Angeles County, Los Angeles, CA
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
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Foster AA, Monuteaux MC, Li J. How ready are we? A statewide assessment of pediatric readiness policies. Am J Emerg Med 2020; 38:854.e1-854.e2. [PMID: 32059933 DOI: 10.1016/j.ajem.2020.01.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/18/2020] [Accepted: 01/27/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ashley A Foster
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America.
| | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America.
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Oglesbee SJ, Roberts MH, Sapién RE. Implementing lower-risk brief resolved unexplained events guideline reduces admissions in a modelled population. J Eval Clin Pract 2020; 26:343-356. [PMID: 31172653 DOI: 10.1111/jep.13211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 01/01/2023]
Abstract
RATIONALE American Academy of Pediatrics released a clinical practice guideline (CPG) in 2016 recommending the term apparent life-threatening events (ALTE) be replaced by brief resolved unexplained events (BRUE). The CPG provides recommendations for the clinical evaluation and management of infants with this condition based on the risk of a serious underlying disorder or repeat event. The lower-risk CPG was applied to a modelled population, studying predictors of hospital admission, defined as length of stay (LOS) ≥ 24 hours. METHODS An algorithm was derived using a Pediatric Emergency Care Applied Research Network database. Propensity score weighting, based on probability of following the CPG, determined the adjusted odds ratio (aOR) and 95% confidence interval (CI) of hospital admission. Multiple imputation allowed any missing data problems be addressed and a sensitivity analysis of database robustness. RESULTS Applying the modelling algorithm, 3116 observations were identified, among whom 1974 (63.4%) the CPG was followed and 1142 (36.6%) not followed. The CPG was followed for 60.1% of infants staying ≥24 hours compared with 76.6% of infants staying <24 hours (P < .001). After propensity score weighting and multiple imputation, the likelihood of hospital admission was significantly lower when the CPG was followed (aOR = 0.49; 95% CI, 0.39-0.62, P < .001). CONCLUSIONS Results suggest that use of the CPG under strict conditions would lead to fewer hospital admissions among infants with a lower-risk BRUE. Implementation of CPGs in modelled populations may help clinicians identify unanticipated factors and address these issues beforehand. We noted differences in care based on race, necessitating further investigation.
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Affiliation(s)
- Scott J Oglesbee
- Division of Pediatric Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Melissa H Roberts
- College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Robert E Sapién
- Division of Pediatric Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Chasle V, de Giorgis T, Guitteny MA, Desgranges M, Metreau Z, Herve T, Longuet R, Farges C, Ryckewaert A, Violas P. Evaluation of an oral analgesia protocol for upper-limb fracture reduction in the paediatric emergency department: Prospective study of 101 patients. Orthop Traumatol Surg Res 2019; 105:1199-1204. [PMID: 31447399 DOI: 10.1016/j.otsr.2019.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/15/2019] [Accepted: 06/11/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Upper limb injuries are common in children. When required, closed fracture reduction can be performed in the emergency department without general anaesthesia but causes pain. The primary objective of this study was to assess an oral analgesia protocol for fracture reduction without general anaesthesia. The secondary objectives were to look for associations linking pain intensity to age, sex, and waiting time and to determine the frequency of secondary displacement requiring closed reduction or internal fixation under general anaesthesia at the 1-week follow-up visit. HYPOTHESIS An oral analgesia protocol combining a loading dose of morphine with other medications would provide sufficient pain control to obviate the need for general anaesthesia. MATERIAL AND METHODS A prospective observational single-centre study was conducted over a 15-month period (July 2017-October 2018) in consecutive patients younger than 16 years who required reduction of a displaced upper-limb fracture. All patients received the same oral combination of paracetamol (15mg/kg), ibuprofen (7.5-10mg/kg), and a loading morphine dose (0.5mg/kg, up to 20mg) 1hour before the procedure. Patients given morphine more than 2hours before the procedure and those with persistent pain were given an additional morphine dose (0.2mg/kg, up to 10mg). An equimolar mixture of oxygen and nitrous oxide was administered during reduction. An appropriate scale was used to measure pain intensity before, during, and 15minutes after the procedure. Cases of secondary displacement requiring further reduction or internal fixation under general anaesthesia at the 1-week follow-up visit were recorded. RESULTS The 101 study patients (73 male and 28 female) had a mean age of 9.4 years (range, 2-15 years). Mean pain scores were 5.0±2.6 at admission and 2.1±2.3, 2.6±3.3, and 1.3±2.2 before, during, and after reduction, respectively. Pain intensity during reduction was significantly associated with age. The analgesia was deemed satisfactory by 94 patients and 90 parents. General anaesthesia for further treatment was required in 10 (9.9%) patients, either on the day after the initial treatment, due to inadequate reduction (n=8), or at the 1-week visit, due to secondary displacement (n=2). DISCUSSION Oral morphine in a sufficient dosage given in combination with other medications was effective and well tolerated when used to control pain during upper-limb fracture reduction. Pain intensity was not significantly associated with sex. In contrast, pain was significantly more severe in the patients older than 10 years of age. The proportions of patients requiring further reduction or internal fixation were consistent with previously published data. Most patients and parents were satisfied with the analgesia protocol. CONCLUSION A multimodal oral analgesia protocol provides sufficient pain relief to allow closed reduction of upper-limb fractures in children at the emergency department. This management strategy provided high satisfaction rates in both the patients and their parents. LEVEL OF EVIDENCE II, prospective observational study.
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Affiliation(s)
- Véronique Chasle
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Tommaso de Giorgis
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Marie-Aline Guitteny
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Marie Desgranges
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Zofia Metreau
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Tiphaine Herve
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Romain Longuet
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Céline Farges
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Amélie Ryckewaert
- Service des Urgences Médicochirurgicales Pédiatriques, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France
| | - Philippe Violas
- Service de Chirurgie Pédiatrique, Hôpital Sud, Rennes University Hospital, 16 Boulevard de Bulgarie, 35200 Rennes, France.
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Merritt C, Dietrich AM, Bogie AL, Wu F, Khanna K, Ballasiotes MK, Gerardi M, Ishimine PT, Denninghoff KR, Saidinejad M. 2018 Academic Emergency Medicine Consensus Conference: A Workforce Development Research Agenda for Pediatric Care in the Emergency Department. Acad Emerg Med 2019; 26:1063-1073. [PMID: 30338608 DOI: 10.1111/acem.13638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
Each year, more than 30 million children visit U.S. emergency departments (EDs). Although the number of pediatric emergency medicine specialists continues to rise, the vast majority of children are cared for in general EDs outside of children's hospitals. The diverse workforce of care providers for children must possess the knowledge, experience, skills, and systemic support necessary to deliver excellent pediatric emergency care. There is a crucial need to understand the factors that drive the professional development and support systems of this diverse workforce. Through the iterative process culminating with the 2018 Academic Emergency Medicine consensus conference, we have identified five key research themes and prioritized a specific research agenda. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce and allow for a prioritization of future research efforts. Only by more fully understanding the gaps in workforce needs, and the necessary steps to address these gaps, can outcomes be optimized for children in need of emergency care.
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Affiliation(s)
- Chris Merritt
- Department of Emergency Medicine & Pediatrics Alpert Medical School of Brown University Rhode Island Hospital/Hasbro Children's Hospital Providence RI
| | - Ann M. Dietrich
- Department of Pediatrics Ohio University Heritage College of Medicine Dublin OH
| | - Amanda L. Bogie
- Department of Pediatric Emergency Medicine University of Oklahoma College of Medicine The Children's Hospital at OU Medical Center Oklahoma City OK
| | - Fred Wu
- Department of Emergency Medicine University of California San Francisco–Fresno Fresno CA
| | - Kajal Khanna
- Department of Emergency Medicine Stanford University Stanford Health Care Stanford CA
| | | | - Michael Gerardi
- Morristown Medical Center & Goryeb Children's Hospital Morristown NJ
| | - Paul T. Ishimine
- Departments of Emergency Medicine and Pediatrics School of Medicine University of California at San Diego Rady Children's Hospital–San Diego San Diego CA
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center Department of Emergency Medicine College of Medicine University of Arizona Tucson AZ
| | - Mohsen Saidinejad
- David Geffen School of Medicine at UCLA Institute for Health Services and Outcomes Research The Los Angeles Biomedical Research Institute Department of Emergency Medicine Harbor UCLA Medical Center TorranceCA
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Lutfi R, Montgomery EE, Berrens ZJ, Yabrodi M, Yuknis ML, Kirby ML, Pearson KJ, Abu-Sultaneh S, Abulebda K. Improving Adherence to a Pediatric Advanced Life Support Supraventricular Tachycardia Algorithm in Community Emergency Departments Following in Situ Simulation. J Contin Educ Nurs 2019; 50:404-410. [DOI: 10.3928/00220124-20190814-06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 04/24/2019] [Indexed: 12/27/2022]
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Barata I, Auerbach M, Badaki‐Makun O, Benjamin L, Joseph MM, Lee MO, Mears K, Petrack E, Wallin D, Ishimine P, Denninghoff KR. A Research Agenda to Advance Pediatric Emergency Care Through Enhanced Collaboration Across Emergency Departments. Acad Emerg Med 2018; 25:1415-1426. [PMID: 30353946 DOI: 10.1111/acem.13642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/06/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022]
Abstract
In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.
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Affiliation(s)
- Isabel Barata
- Department of Pediatrics and Emergency Medicine Northwell Health System Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Marc Auerbach
- Pediatrics and Emergency Medicine Yale University School of Medicine New Haven CT
| | | | - Lee Benjamin
- Pediatric Emergency Center Saint Joseph Mercy Health System Department of Emergency Medicine University of Michigan Ann Arbor MI
| | - Madeline M. Joseph
- Department of Emergency Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Moon O. Lee
- Department of Emergency Medicine Stanford University School of Medicine Stanford CA
| | | | | | - Dina Wallin
- Division of Pediatric Emergency Medicine Department of Emergency Medicine University of California at San Francisco San Francisco CA
| | | | - Kurt R. Denninghoff
- Department of Emergency Medicine University of Arizona College of Medicine Tucson AZ
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Auerbach M, Brown L, Whitfill T, Baird J, Abulebda K, Bhatnagar A, Lutfi R, Gawel M, Walsh B, Tay KY, Lavoie M, Nadkarni V, Dudas R, Kessler D, Katznelson J, Ganghadaran S, Hamilton MF. Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study. Acad Emerg Med 2018; 25:1396-1408. [PMID: 30194902 DOI: 10.1111/acem.13564] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. METHODS This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800-4,999; medium-high 5,000-9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. RESULTS A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800-4,999/year), 24 medium-high (5,000-9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0-78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high-volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. CONCLUSIONS This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high-volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.
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Affiliation(s)
- Marc Auerbach
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Linda Brown
- Department of Emergency Medicine, Alpert School of Medicine at Brown University, Providence, RI
| | - Travis Whitfill
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Janette Baird
- Department of Emergency Medicine, Alpert School of Medicine at Brown University, Providence, RI
| | - Kamal Abulebda
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Ambika Bhatnagar
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Riad Lutfi
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Marcie Gawel
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Barbara Walsh
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Boston University, Boston, MA
| | - Khoon-Yen Tay
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Megan Lavoie
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robert Dudas
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Kessler
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Jessica Katznelson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sandeep Ganghadaran
- Department of Critical Care Medicine and Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - Melinda Fiedor Hamilton
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
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Nuño M, Ugiliweneza B, Zepeda V, Anderson JE, Coulter K, Magana JN, Drazin D, Boakye M. Long-term impact of abusive head trauma in young children. CHILD ABUSE & NEGLECT 2018; 85:39-46. [PMID: 30144952 DOI: 10.1016/j.chiabu.2018.08.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/14/2018] [Accepted: 08/17/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs). METHODS We used the Truven Health MarketScan Research Claims Database (2000-2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes. RESULTS The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance. CONCLUSION AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.
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Affiliation(s)
- Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA.
| | | | - Veronica Zepeda
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA
| | - Jamie E Anderson
- Department of Surgery, University of California, Davis Medical Center, Sacramento, USA
| | - Kevin Coulter
- Department of Pediatrics, University of California, Davis Medical Center, Sacramento, USA
| | - Julia N Magana
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, USA
| | | | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
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