A profile of nonurgent emergency department use in an urban pediatric hospital

Immigrant Latino parents demonstrated high interactivity with pediatric primary care text messaging intervention

BACKGROUND

The majority of Latino immigrants have been shown to have a mobile phone. Cellular phones offer a low-cost method of reaching larger populations and have the potential for increased tailoring and interactivity. This supports the development of mHealth interventions to address healthcare disparities in this population. In this study we sought to evaluate the feasibility and acceptability of interactive Spanish-language text messages sent throughout a child's first year of life in a low-income, limited-English proficient (LEP) Latino population to support families in accessing and using pediatric primary care more effectively.

METHODS

Participants (n=79) received interactive text messages over a period of 12 months as a part of a multi-modal mHealth intervention conducted at an urban academic pediatric primary care practice. Inclusion criteria were: singleton infant <2 months of age, enrollment in public health insurance, parent age >18, parent preferred healthcare language of Spanish, and at least one household cellular phone. Interactive text messages were designed to promote increased healthcare engagement and prompted participant responses through preprogramed algorithms. Text message sequences included clinic appointment reminders, support for obtaining medicine and completing referral appointments, monitoring of illness care needs and use, and parent support program reminders. Descriptive analyses were used to examine text message volume, usability, and participant response to text sequences.

RESULTS

Among participants, mean parent age was 30.1 years (SD: 6.1 years); mean years in the US was 7.5 years (SD: 5.1 years). 63.3% of parents had less than a high school education and 84.8% of parents had possible/high likelihood of limited health literacy. Participants completed the majority of sequences with appointment reminder sequences having the quickest response time. The top quartile of responders completed 88.3% of sequences; lower educational attainment was associated with lower text message sequence completion. Participants rated the program positively, especially the appointment reminders.

CONCLUSIONS

LEP Latino parents successfully engaged with interactive Spanish-language text sequences and parent acceptability was high. This study demonstrates feasibility for interventions employing this technology. Text message interventions may be a feasible approach to reduce healthcare disparities and costs for vulnerable populations.

A Texting Intervention in Latino Families to Reduce ED Use: A Randomized Trial

BACKGROUND AND OBJECTIVES

Latino children in immigrant families experience health care disparities. Text messaging interventions for this population may address disparities. The objective of this study was to evaluate the impact of a Spanish-language text messaging intervention on infant emergency department use and well care and vaccine adherence.

METHODS

The Salud al Día intervention, an educational video and interactive text messages throughout the child's first year of life, was evaluated via randomized controlled trial conducted in an urban, academic pediatric primary care practice from February 2016 to December 2017. Inclusion criteria were publicly insured singleton infant <2 months of age; parent age >18, with Spanish as the preferred health care language; and at least 1 household cellular phone. Primary outcomes were abstracted from the electronic medical record at age 15 months. Intention-to-treat analyses were used.

RESULTS

A total of 157 parent-child dyads were randomly assigned to Salud al Día (n = 79) or control groups (n = 78). Among all participants, mean parent age was 29.3 years (SD: 6.2 years), mean years in the United States was 7.3 (SD: 5.3 years), and 87% of parents had limited or marginal health literacy. The incidence rate ratio for emergency department use for the control versus intervention group was 1.48 (95% confidence interval: 1.04-2.12). A greater proportion of intervention infants received 2 flu vaccine doses compared with controls (81% vs 67%; P = .04).

CONCLUSIONS

This Spanish-language text messaging intervention reduced emergency department use and increased flu vaccine receipt among a population at high risk for health care disparities. Tailored text message interventions are a promising method for addressing disparities.

Use of Emergency Departments for Preventative Care Among Adults in the United States: Estimates From the 2017 National Health Interview Survey

BACKGROUND

Use of the emergency department (ED) for routine or preventative care has been an abiding concern for policy makers and public health practitioners.

OBJECTIVES

We utilized recent data to examine health-related, socioeconomic, and demographic factors associated with use of the ED for routine or preventative care using a national sample of adults.

METHODS

Data from the 2017 National Health Interview Survey, a nationally representative sample of 26,742 adults ≥18 years of age was used for this investigation. Bivariate and multivariate analyses were used to assess the association between reported use of EDs as a usual source of preventative care and health-related, socioeconomic, and demographic factors.

RESULTS

In 2017, approximately 2 million adults nationwide reported the ED as their usual source of preventative health care. Individuals experiencing ≥2 health care-related barriers were more likely to use the ED as a source of usual preventative care (odds ratio = 2.78 [95% confidence interval 1.64-4.72]). Individuals without insurance had higher odds (odds ratio = 9.52 [95% confidence interval 5.60-16.19]) of using the ED for care compared with those who were privately insured. In addition, those using the ED for preventative care were more likely to be younger, poorer, less educated, to identify as Asian or African American, and to reside in the Northeast United States.

CONCLUSION

This study provides a current perspective into characteristics and factors contributing to use of the ED for preventative care. Overall, our findings suggest that the ED continues to provide crucial safety net services to a small subset of the population experiencing significant barriers to timely medical care.

Racial Differences in Sepsis Recognition in the Emergency Department

OBJECTIVES

We assessed racial differences in sepsis recognition in a pediatric emergency department (ED) with an established electronic sepsis alert system.

METHODS

Quality-improvement data from June 1, 2016 to May 31, 2017 was used in this retrospective cohort study. All ED visits were included for non-Hispanic black (NHB) and non-Hispanic white (NHW) patients. The sepsis pathway was activated through the alert, 2 stages and a huddle, or outside of the alert using clinician judgment alone. We evaluated racial differences in the frequency of alerts and sepsis pathway activation within and outside of the alert. Multivariable regression adjusted for high-risk condition, sex, age, and insurance.

RESULTS

There were 97 338 ED visits: 56 863 (58.4%) and 23 008 (23.6%) from NHBs and NHWs, respectively. NHWs were more likely than NHBs to have a positive second alert (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.1-2.8). NHWs were more likely than NHBs to have the sepsis pathway activated (aOR 1.4; 95% CI 1.02-2.1). Of those treated within the alert, there was no difference in pathway activation (aOR 0.93; 95% CI 0.62-1.4). Of those recognized by clinicians when the alert did not fire, NHWs were more likely than NHBs to be treated (aOR 3.4; 95% CI 1.8-6.4).

CONCLUSIONS

NHWs were more likely than NHBs to be treated for sepsis, although this difference was specifically identified in the subset of patients treated for sepsis outside of the alert. This suggests that an electronic alert reduces racial differences compared with clinician judgment alone.

Pediatric-Adapted Liking Survey (PALS): A Diet and Activity Screener in Pediatric Care

Clinical settings need rapid yet useful methods to screen for diet and activity behaviors for brief interventions and to guide obesity prevention efforts. In an urban pediatric emergency department, these behaviors were screened in children and parents with the 33-item Pediatric-Adapted Liking Survey (PALS) to assess the reliability and validity of a Healthy Behavior Index (HBI) generated from the PALS responses. The PALS was completed by 925 children (average age = 11 ± 4 years, 55% publicly insured, 37% overweight/obese by Body Mass Index Percentile, BMI-P) and 925 parents. Child–parent dyads differed most in liking of vegetables, sweets, sweet drinks, and screen time. Across the sample, child and parent HBIs were variable, normally distributed with adequate internal reliability and construct validity, revealing two dimensions (less healthy—sweet drinks, sweets, sedentary behaviors; healthy—vegetables, fruits, proteins). The HBI showed criterion validity, detecting healthier indexes in parents vs. children, females vs. males, privately- vs. publicly-health insured, and residence in higher- vs. lower-income communities. Parent’s HBI explained some variability in child BMI percentile. Greater liking of sweets/carbohydrates partially mediated the association between low family income and higher BMI percentile. These findings support the utility of PALS as a dietary behavior and activity screener for children and their parents in a clinical setting.

Identifying the Preferred Method to Educate Low Income Caregivers About Common Childhood Illnesses: A Step Toward Health Literacy Through a Focus Group Study

PURPOSE

The purpose of this focus group was to identify the preferred method of education for low-income caregivers to learn about common childhood illnesses in an effort to meet their health literacy needs.

METHODS

Focus group participants were recruited from two sources; caregivers who qualified for Women, Infants, and Children (WIC) Food and Nutrition Services and those attending a monthly prenatal health education program for low-income pregnant women. Participants were asked to rank in order of preference five educational options. The five options included a commonly used diagnosis-specific handout, a booklet of the most common childhood illnesses and symptoms, a comprehensive book of common childhood illness and symptoms, a 24-hour nurse call line, and a mobile application developed by the American Academy of Pediatrics. All options provided accurate information from professional sources.

RESULTS

The ranking of the five educational options identified the mobile application developed by the American Academy of Pediatrics, KidsDoc, to be the preferred method with the commonly used diagnosis-specific handout as the least favorite option.

CONCLUSION/PRACTICE IMPLICATIONS

The United States Department of Health and Human Services (USDHHS) has identified a need to change the way health information is designed and delivered. Identifying that materials should be redesigned using best practices to reduce health literacy demands and match consumer preferences, the USDHHS calls for periodic testing of materials with the intended consumers. This focus group provides valuable information and a step toward future research to address health literacy using materials identified by low-income consumers.

Tobacco Use Behaviors and Perceptions of Parental Smokers in the Emergency Department Setting

BACKGROUND

More information is needed about modifiable child tobacco smoke exposure (TSE) patterns in racially diverse parental smokers to tailor interventions designed to help parents quit smoking and reduce their child's TSE. Our objectives were to determine whether there were differences in smoking and TSE patterns based on parental race and child age and whether these patterns differed based on child age within black and white parental smokers. Secondary objectives were to assess the relationship between parental perceptions about the effects of smoking and the benefits of quitting on their child based on child age, race, and reported TSE patterns and to examine biochemically verified TSE levels by child age, race, and parent-reported TSE patterns.

METHODS

Participants (N = 415) were non-Hispanic black and non-Hispanic white parental smokers, mean age (standard deviation [SD]) = 31.2 (7.2) years, who visited the Pediatric Emergency Department (PED) or Urgent Care (UC) with their child, mean age (SD) = 4.7 (4.6) years. Parents reported sociodemographics, smoking, and child TSE patterns. We conducted chi-square tests, independent t-tests, and general linear regression models to answer our primary objectives and linear regression models to answer our secondary objectives.

RESULTS

Parents were 56.1% non-Hispanic black; 87.5% women; mean (SD) number of cigarettes smoked/day was 10.5(6.8). A higher proportion of parents with younger children <3 years old reported smoking bans compared with parents with older children ⩾3 to <18 years old (41.3% vs 19.7%, P < .0001). Subsequent analyses revealed this pattern for both black and white parents. A total of 212 (51%) of children had biochemical assessment of TSE; 89.6% had detectable TSE. Younger children had significantly higher cotinine levels than older children independent of their race (P < .001).

CONCLUSIONS

Children of parental smokers who visit the PED/UC were highly tobacco smoke exposed. Both black and white parental smokers with younger children were more likely to enforce smoking bans, but younger children had higher TSE levels than older children. Interventions that target this group of parental smokers with younger children may be more effective than interventions geared to all parental smokers.

Associations between self-harm and chronic disease among adolescents: Cohort study using statewide emergency department data

INTRODUCTION

We sought to understand the association between youthful self-harm and subsequent chronic disease-related healthcare utilization and whether self-harm reflects unique vulnerability in comparison with severe psychiatric disorders.

METHODS

We used a retrospective matched cohort design with statewide, all-payer, individually linked emergency department (ED) data from California, USA. Risk of future ED visits for common chronic conditions in adolescence (headaches, asthma, epilepsy, diabetes, and gastrointestinal disorders, assessed using ICD-9 diagnoses) were compared between three adolescent study groups presenting to an ED in 2010: self-harm patients (n = 5,484), patients with psychiatric complaints but no self-harm (n = 14,235), and patients with other complaints (n = 16,452). Cohort follow-up ended on Sept. 30, 2015. Analyses were adjusted for patients' prior histories of ED utilization for chronic conditions as well as patient- and area-level sociodemographic characteristics.

RESULTS

Risk of subsequent ED visits was higher among self-harm patients compared to non-psychiatric control patients for subsequent epilepsy- (aRR = 1.77, 95% CI [1.42, 2.21]). Risk of subsequent ED visits was higher among psychiatric patients compared to non-psychiatric control patients for subsequent headache- (aRR = 1.31, 95% CI [1.21, 1.42]), and epilepsy-related problems (aRR = 1.85, 95% CI [1.55, 2.21]). Self-harm patients were at higher risk than psychiatric patients for subsequent gastrointestinal disorder (aRR = 1.76, 95% CI [1.03, 3.01]).

CONCLUSIONS

Findings suggest that self-harm behavior and psychiatric disorders are associated with increased ED utilization for subsequent chronic disease-related ED utilization. Chronic disease among adolescent psychiatric patients should be attended to, potentially involving new models of clinical follow-up care.

Racial and Ethnic Disparities in Emergency Department Care and Health Outcomes Among Children in the United States

Background: There is an incomplete understanding of disparities in emergency care for children across racial and ethnic groups in the United States. In this project, we sought to investigate patterns in emergency care utilization, disposition, and resource use in children by race and ethnicity after adjusting for demographic, socioeconomic, and clinical factors. Methods: In this cross-sectional study of emergency department (ED) data from the nationally representative National Hospital Ambulatory Medical Survey (NHAMCS), we examined multiple dimensions of ED care and treatment from 2005 to 2016 among children in the United States. The main outcomes include ED disposition (hospital admission, ICU admission, and in hospital death), resources utilization (medical imaging use, blood tests, and procedure use) and patient ED waiting times and total length of ED stay. The main exposure variable is race/ethnicity, categorized as non-Hispanic white (white), non-Hispanic black (Black), Hispanic, Asian, and Other. Analyses were stratified by race/ethnicity and adjusted for demographic, socioeconomic, and clinical factors. Results: There were 78,471 pediatric (≤18 years old) ED encounters, providing a weighted sample of 333,169,620 ED visits eligible for analysis. Black and Hispanic pediatric patients were 8% less likely (aOR 0.92, 95% CI 0.91-0.92) and 14% less likely (aOR 0.86, CI 0.86-0.86), respectively, than whites to have their care needs classified as immediate/emergent. Blacks and Hispanics were also 28 and 3% less likely, respectively, than whites to be admitted to the hospital following an ED visit (aOR 0.72, CI 0.72-0.72; aOR 0.97, CI 0.97-0.97). Blacks and Hispanics also experienced significantly longer wait times and overall visits as compared to whites. Conclusions: Black and Hispanic children faced disparities in emergency care across multiple dimensions of emergency care when compared to non-Hispanic white children, while Asian children did not demonstrate such patterns. Further research is needed to understand the underlying causes and long-term health consequences of these divergent patterns of racial disparities in ED care within an increasingly racially diverse cohort of younger Americans.

Socio-economic composition of low-acuity paediatric presentation at a regional hospital emergency department

AIM

Despite increasing rates of emergency department (ED) utilisation, little is known about low-acuity presentations in children ≤5 years. The aims of the study were to estimate the proportion and cost of low-acuity presentations in children ≤5 years presenting to the ED and to determine the relative effect of socio-economic status (SES) on paediatric low-acuity presentations at the ED.

METHODS

This is a retrospective observational study of children ≤5 years presenting to the Cairns Hospital ED over 4 years. A multivariate logistic regression model was used to assess the association between SES and low-acuity presentations. Cost of low-acuity presentations was calculated based on triage score and admission status, using costs obtained from the National Hospital Cost Data Collection.

RESULTS

A total of 23 086 children were included in the study, of whom 56.7% were male (mean age = 1.85 ± 1.63 years). Approximately one-third of ED visits were low-acuity presentations (32.4%), and low-acuity presentations increased progressively with SES. In multivariate analysis, children from families with very high SES were twice as likely to have a low-acuity presentation (odds ratio 2.17; 95% confidence interval, 1.66-2.85). Low-acuity ED presentations cost the health-care system in excess of A$895 000-A$1 110 000 per year.

CONCLUSIONS

These findings demonstrate that a significant proportion of paediatric ED visits are of low acuity and that these visits yield a substantial cost to the health system. Further research is required regarding care givers' rationale and potentially other reasons underlying these low-acuity ED presentations.

Emergency Department Utilization by Native American Children

OBJECTIVES

The aims of this study were to determine differences in emergency department (ED) use by Native American (NA) children in rural and urban settings and identify factors associated with frequent ED visits.

METHODS

This cross-sectional, cohort study examined visits to 6 EDs: 2 rural, 2 midsize urban, and 2 large urban EDs from June 2011 to May 2012. Univariate and multiple regression analyses were conducted. Frequent ED visitors had more than 4 visits in the study period.

RESULTS

We studied 8294 NA visits (5275 patients) and 44,503 white visits (33,945 patients). Rural EDs had a higher proportion of NA patients, those below 200% of the income poverty level, and those who traveled more than 10 miles from their residence to attend the ED (all P < 0.05) compared with midsize and urban EDs. Native American patients had a high proportion of mental health diagnoses compared with whites (4.9% vs 1.9%, P < 0.001). Frequent ED visitors had greater odds of NA race, age younger than 1 year, public insurance, female sex, residence within less than 5 miles from the ED, and chronic disease.

CONCLUSIONS

Native American children seem to have greater challenges compared with whites obtaining care in rural areas. Native American children were more likely to be frequent ED visitors, despite having to travel farther from their residence to the ED. Native American children visiting rural and midsize urban EDs had a much higher prevalence of mental health problems than whites. Additional efforts to provide both medical and mental health services to rural NA are urgently needed.

Mothers' experiences of managing their child's pain before and during attendance at the emergency department

AIMS AND OBJECTIVES

To explore mothers' experiences of managing their child's pain before and during attendance at the emergency department.

BACKGROUND

Pain accounts for 50%-80% of all visits to the emergency department. Historically paediatric pain has been poorly managed in the emergency department and there remains variability in practice. It is mothers who usually bring their child to the emergency department and as such it is important to explore their perspectives of how pain is managed.

DESIGN

Exploratory qualitative study.

METHODOLOGY

Semi-structured interviews were carried out with mothers (n = 10) of children who have attended the emergency department in one hospital in the East of England during April 2015.

RESULTS

Most mothers felt able to assess their child's pain and reported attending the emergency department when their normal pain-relieving strategies failed following an injury. Several mothers sought advice from elsewhere before bringing their child to the emergency department. The advice received was usually to take their child to the emergency department. Mothers welcomed the professional approach to pain management in the emergency department and valued being kept informed about their child's care. Mothers rated the care provided in the emergency department as good or very good.

CONCLUSIONS

Mothers attended the emergency department when their normal pain-relieving strategies failed. This suggests there is a need to provide additional resources to support parents in this context. Mothers often brought their child to the emergency department rather than their General Practitioner or other primary healthcare providers. The reasons for this need exploring further.

RELEVANCE TO CLINICAL PRACTICE

The results suggest that mothers need additional resources to enable them to manage their child's pain at home following an injury. The reasons mothers attend the emergency department rather than other healthcare providers need exploring in more depth.

Health Care Access Barriers Bring Children to Emergency Rooms More Frequently: A Representative Survey

Children may visit the emergency department (ED) regularly in part because they and their caregivers may be experiencing barriers to appropriate and timely pediatric care. However, assessing the wide range of potential barriers to access to care that children and their caregivers may experience is often a challenge. The objective of this study was to assess the barriers to pediatric health care reported by caregivers and to examine the association between those reported barriers to care with the frequency of children's ED visits in the past 12 months. Assessment of ED utilization and access to care barriers was made through a telephone interview survey conducted as part of a broader Community Health Needs Assessment in 2015. A weighted community sample of adult caregivers (N = 1057) of children between the ages of 0-17 residing in Miami-Dade, Broward, and Palm Beach counties, Florida were contacted. This study found that multiple ED visits (≥2 vs. 0) in the past 12 months by a child were most strongly associated with access to care barriers attributed to language and culture (relative risk [RR] = 2.51), trouble finding a doctor (RR = 1.86), scheduling an appointment (RR = 1.68), and transportation access (RR = 1.73). These findings suggest that access to care barriers experienced by households may exacerbate the risk of a child experiencing repeated visits to the ED in a year. Findings are discussed further in the context of actionable population health management strategies to reduce risk of frequent ED utilization by children.

Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey

BACKGROUND

Parents take neonates to the emergency department for many reasons, often nonurgent, pressuring an already burdened system. We aimed to characterize these visits and families to identify potential strategies to decrease neonatal emergency department visits.

METHODS

We developed and implemented a survey that explored characteristics of neonates and parents/guardians evaluated in the emergency department, perspectives of parents and use of health care services. Parents presenting with a neonate to the emergency department in 5 large academic hospitals in Ontario were surveyed between December 2013 and June 2015. We used descriptive statistics to report survey data and explored correlations between factors.

RESULTS

A total of 1533 surveys were completed. The most common reasons for presenting were jaundice (441 [28.8%]) and feeding issues (251 [16.4%]). The majority of respondents (73.9% [1104/1494]) had received advice before going to the emergency department. In most cases (86.4% [954/1104]), this was from a health care provider, who frequently advised going to the emergency department. Although most parents (86.8% [1280/1475]) reported high confidence in caring for a sick or injured child, 42.3% (643/1519) were unsure of the severity, and most (90.4% [578/639]) of these parents felt that the infant required assessment immediately or the same day. Of parents who felt the condition was not serious, 83.2% (198/238) thought that same-day evaluation was required. Nearly half of respondents (44.4% [621/1400]) said they would have gone to their health care provider with a same-day appointment, and 28.1% (344/1225) would have gone to their care provider with a next-day appointment.

INTERPRETATION

Parents' reported confidence in caring for sick or injured infants does not match the perceived urgency of neonatal conditions, which likely contributes to emergency department overuse. Any system to decrease nonurgent emergency department use by neonates would need to be immediately responsive, providing same-day help.

Barriers and enablers to a physician-delivered educational initiative to reduce low-acuity visits to the pediatric emergency department

BACKGROUND

Use of the pediatric emergency department (PED) for low-acuity health issues is a growing problem, contributing to overcrowding, longer waits and higher health system costs. This study examines an educational initiative aimed at reducing low-acuity PED visits. The initiative, implemented at an academic pediatric hospital, saw PED physicians share a pamphlet with caregivers to educate them about appropriate PED use and alternatives. Despite early impacts, the initiative was not sustained. This study analyzes the barriers and enablers to physician participation in the initiative, and offers strategies to improve implementation and sustainability of similar future initiatives.

METHODS

Forty-two PED physicians were invited to participate in a semi-structured individual interview assessing their views about low-acuity visits, their pamphlet use, barriers and enablers to pamphlet use, and the initiative's potential for reducing low-acuity visits. Suggestions were solicited for improving the initiative and reducing low-acuity visits. Constant comparative method was used during analysis. Codes were developed inductively and iteratively, then grouped according to the Theoretical Domains Framework (TDF). Efforts to ensure study credibility included seeking participant feedback on the findings.

RESULTS

Twenty-three PED physicians were interviewed (55%). Barriers and enablers for pamphlet use were identified and grouped according to five of the 14 TDF domains: social/professional role and identity; beliefs about consequences; environmental context and resources; social influences; and emotions.

CONCLUSIONS

The TDF provided an effective approach to identify the key elements influencing physician participation in the educational initiative. This information will help inform behavior change interventions to improve the implementation of similar future initiatives that involve physicians as the primary educators of caregivers.

The characteristics of pediatric emergency department visits in Korea: An observational study analyzing Korea Health Panel data

Objective

We investigated the characteristics of pediatric emergency department (ED) patients in Korea and determined factors associated with hospital admission after ED treatment.

Methods

Korea Health Panel data from 2008 through 2013 were analyzed retrospectively; we included patients under 18 years old who visited the ED at least once. We collected patient and household epidemiologic data such as sex, age group, region of residence, disability, chronic disease, household income quintile, national health insurance type, use of private insurance, and annual frequency of ED visits. We also examined data related to each ED visit, such as reason for visit, medical service provided, and hospital size/ownership. We then investigated which factors were correlated with case disposition (discharge home or hospital admission) after ED treatment.

Results

In total, 3,160 pediatric ED visits occurred during the six-year period. Males (57.5%) and children aged 0–5 years (47.7%) made more visits than females and older children, respectively. The proportion of ED visits for disease (67.7%) was much higher than for injury or poisoning (32.2%), and 452 cases (14.3%) required hospital admission. For hospital admission, the odds ratio (OR) of females was 0.73 compared to males, and the OR of children aged 6–11 was 0.68 compared to children aged 0–5. The OR of capital residents was 0.69 compared to province residents, and the OR of the highest income quintile was 0.51 compared to the lowest quintile. The OR of children with private insurance coverage was 0.49 compared to those lacking private insurance, and the OR of ED visits due to disease was 1.82 compared to visits due to injury/poisoning.

Conclusion

This analysis of clinical and demographic characteristics of pediatric ED visits and hospital admissions can serve as the foundation of future prospective studies required for establishing appropriate policies for the Korean pediatric emergency medical system.

Health Information Preferences of Parents in a Pediatric Emergency Department

Parents of children seeking nonurgent care in the emergency department completed surveys concerning media use and preferences for health education material. Results were compiled using descriptive statistics, compared by health literacy level with logistic regression, adjusting for race/ethnicity and income. Semistructured qualitative interviews to elicit reasons for preferences, content preference, and impact of health information were conducted and analyzed using content analysis. Surveys (n = 71) showed that despite equal access to online health information, parents with low health literacy were more likely to use the internet less frequently than daily ( P < .01). Surveys and interviews (n = 30) revealed that health information will be most effective when distributed by a health care professional and must be made available in multiple modalities. Parents requested general information about childhood illness, including diagnosis, treatment, and signs and symptoms. Many parents believed that appropriate health information would change their decision-making regarding seeking care during their child's next illness.

Predicting Low-Resource-Intensity Emergency Department Visits in Children

OBJECTIVES

Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits.

METHODS

We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI.

RESULTS

Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74.

CONCLUSIONS

Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.

Why Parents Seek Care for Acute Illness in the Clinic or the ED: The Role of Health Literacy

OBJECTIVE

To explore the decision to seek care and decision-making regarding location of care among parents with low and adequate health literacy.

METHODS

Parents of children 8 years old or younger who presented for 'sick child' visits at a clinic or a nonurgent emergency department (ED) visit (triage level 5) were interviewed. The Newest Vital Sign was used to categorize parental health literacy. Interviewers followed a semistructured interview guide to understand: 1) care-seeking for current illness, and 2) choice of clinic or ED. Themes emerged using a grounded theory process, facilitated by NVivo version 10.0 software (QSR International, Melbourne, Australia). Themes included the experiences of low and adequate health literacy in the clinic as well as in the ED.

RESULTS

Fifty semistructured interviews were completed with parents who brought their child to the ED for a nonurgent visit (n = 30) and clinic parents (n = 20) with 56% possessing low health literacy. Parents with low health literacy were more inclined to overestimate severity of illness and seek care sooner to gain answers about the illness and treatment options, and visit the clinic only when an appointment was available within hours. Parents with adequate health literacy sought reassurance for their ongoing illness management and valued close relationships with their physician, and were willing to wait longer for an appointment. Fever, vomiting, and young child age prompted some parents to seek expedient care regardless of health literacy.

CONCLUSIONS

Caregiving skills (eg, assessing and treating illness, understanding illness severity, and navigating the health care system) in addition to physician-parent relationships and perception of care seem to influence the behavior of parents managing their child's mild acute illness. These factors might be amenable to a future health literacy intervention.

Urgent Care Transfers to an Academic Pediatric Emergency Department

OBJECTIVES

The aim of this study was to investigate the hypothesis that a significant percentage of urgent care center to pediatric ED transfers can be discharged home without emergency department (ED) resource utilization.

METHODS

A retrospective chart review was completed for a 6-month period on all patients transferred from urgent care centers. A data collection tool focusing on demographics, diagnoses, reason for transfer, ED resource utilization, ED disposition, and 72-hour ED return was used. Each encounter was classified as "urgent" or "nonurgent" based on resource utilization criteria. Descriptive statistics were reported for demographics, encounter data, and 72-hour ED return stratified by nonurgent versus urgent classification. Two-sample t, χ, and Fisher exact tests were used to assess differences in characteristics between the nonurgent and urgent groups.

RESULTS

One hundred nine patients met inclusion criteria. Of these, 93 (85%) were discharged from the ED. Twenty nine (27%) of the transferred patients were discharged without ED resource utilization. Seventy-two-hour return was noted for only 1 patient who was again discharged at the subsequent encounter.

CONCLUSIONS

A large proportion of patients transferred from urgent care centers were directly discharged from the ED without any ED resource utilization. Eliminating or reducing such transfers has the potential to limit the amount of nonurgent ED visits, thus producing cost savings and better patient care.

Influence of awareness and availability of medical alternatives on parents seeking paediatric emergency care

AIMS

Direct seeking of care at paediatric emergency departments may result from an inadequate awareness or a short supply of medical alternatives. We therefore evaluated the care-seeking patterns, availability of medical options and initial medical assessments - with overall reference to socioeconomic status - of parents at an urban paediatric emergency department in a Scandinavian country providing free paediatric healthcare.

METHODS

The parents of children assessed by paediatric emergency department physicians at a Swedish university hospital over a 25-day winter period completed a questionnaire on recent medical contacts and their reasons for attendance. Additional information was obtained from ledgers, patient records and population demographics.

RESULTS

In total, 657 of 713 eligible patients (92%) were included. Seventy-nine per cent of their parents either failed to or managed to establish medical contact before the emergency department visit, whereas 21% sought care with no attempt at recent medical contact. Visits with a failed telephone or primary care contact (18%) were more common outside office hours ( p=0.014) and were scored as less urgent ( p=0.014). A perceived emergency was the main reason for no attempt at medical contact before the visit. Direct emergency department care-seeking was more common from the city district with the lowest socioeconomic status ( p=0.027).

CONCLUSIONS

Although most parents in this Swedish study tried to seek medical advice before attending a paediatric emergency department, perceived emergency, a short supply of telephone health line or primary care facilities and lower socioeconomic status contributed to direct care-seeking by almost 40% of parents. Pre-hospital awareness and the availability of medical alternatives with an emphasis on major differences in socioeconomic status should therefore be considered to further optimize care-seeking in paediatric emergency departments.

[The Spanish triage system in the evaluation of neonates in paediatric emergency departments]

The triage system in the emergency department classifies patients according to priority levels of care. Neonates are a vulnerable population and require rapid assessment.

OBJECTIVE

To correlate the priority levels in newborns seen in the paediatric emergency department with admissions, resource consumption, and service times.

PATIENTS AND METHOD

Observational study, using the Andorran triage model (MAT-SET) with ePATV4 software database, in paediatric emergencies. Neonates were classified into 3 levels of care established for them as level I resuscitation, level II emergency, and level iii urgent. The correlation between levels of priority and admission and resource consumption were analysed, as well as the time spent on medical care and stay in the emergency department.

RESULTS

The study included 1103 infants. The highest priority level was positively correlated with hospital admission (r = 0.66, P<.005) and resource consumption (r = 0.59, P < .005). The medical care times were 126 ± 203, 119 ± 51, and 33 ± 81 min for levels i, ii, and iii, respectively and the stay in emergency department was 150 ± 203, 131 ± 80, and 55 ± 86 min, respectively for these levels (P < .05).

CONCLUSION

The higher level of priority in the care of neonates in the paediatric emergency department was positively correlated with increased need for hospital admission and resource consumption. They also required a longer time for medical care and stay in the emergency department.

Factors Determining Parents' Decisions to Bring Their Children to the Pediatric Emergency Department for a Minor Illness

Background

The number of children visiting Emergency Departments (EDs) is increasing in Lithuania; therefore, the aim of this study was to determine the factors influencing the parental decision to bring their child to the ED for a minor illness that could be managed in a primary healthcare setting, and to compare parents’ and medical professionals’ attitudes toward a child’s health status and need for urgent care.

Material/Methods

A prospective observational study was performed at the tertiary-level teaching Children’s Hospital in Vilnius. A total of 381 patients’ parents were interviewed using an original questionnaire based on Andersen’s behavioral model of healthcare utilization; in addition, the medical records of patients were reviewed to identify factors that might have an impact on parental decisions to bring their child to the ED for a minor health problem. The study participants were enrolled from October 1, 2013 to August 31, 2014. The urgency of medical care needed to be provided to the patients was evaluated by a tertiary-level triage system.

Results

Based on the assessment of the triage nurses, the need for emergency care to patients was distributed as follows: 298 patients (78.2%) needed non-urgent care and 83 patients (21.8%) needed urgent care. More than one-third (38.8%) of the parents reported that they came to the ED due to their child’s urgent care need and worsened child’s health; however, the opinion of ED professionals indicated only a fifth of patients required urgent care. Parents who brought their children to the ED without physician referral were five times more likely to visit the ED during evening hours and on weekends (OR=5.416; 95% CI, 3.259–8.99; p<0.001). The decision to come to the ED without visiting a primary care physician was made more often by parents with a higher income (OR=2.153; 95% CI, 1.167–3.97) and those who came due to children having rash (OR=4.303; 95% CI, 1.089–16.995) or fever (OR=3.463; 95% CI, 1.01–11.876). Older parents were 2.07 (95% CI, 1.1224–3.506) times more likely to evaluate their child’s health unfavorably than younger parents.

Conclusions

We identified predisposing, enabling, and need factors that influenced the parents’ decision to bring their child to the ED for minor health problems that could be managed by a primary care physician. Parents assessed their child’s condition more critically and thought that their child required urgent medical aid more frequently than healthcare professionals.

Evaluating the Impact of the Healthy Beginnings System of Care Model on Pediatric Emergency Department Utilization

OBJECTIVE

The aim of this study was to evaluate whether enrollment in the Healthy Beginnings System of Care (SOC) model is associated with a decrease in emergency department (ED) visits among children aged 6 months to 5.5 years.

METHODS

A retrospective, longitudinal study of ED utilization was conducted among children enrolled in the Healthy Beginnings SOC model between February 2011 and May 2013. Using medical records obtained from a children's hospital in Atlanta, the rate of ED visits per quarter was examined as the main outcome. A multilevel, multivariate Poisson model, with family- and child-level random effects, compared ED utilization rates before and after enrollment. Adjusted rate ratios and 95% confidence intervals were calculated after controlling for sociodemographic confounders.

RESULTS

The effect of SOC enrollment on the rate of ED visits differed by income level of the primary parent. The rate of ED visits after enrollment was not significantly different than the rate of ED visits before enrollment for children whose primary parent had an annual income of less than $5000 (P = 0.298), $20,000 to $29,999 (P = 0.199), or $30,000 or more (P = 0.117). However, for the children whose primary parent's annual income was $5000 to $19,999, the rate of ED visits after enrollment was significantly higher than the rate of ED visits before enrollment (adjusted rate ratio, 1.48; 95% confidence interval, 1.17-1.87).

CONCLUSIONS

Enrollment in the SOC model does not appear to decrease the rate of ED visits among enrolled children. Additional strategies, such as education sessions on ED utilization, are needed to reduce the rate of ED utilization among SOC-enrolled children.

The "Battle" of Managing Language Barriers in Health Care

Providing safe and high-quality health care for children whose parents have limited English proficiency (LEP) remains challenging. Reports of parent perspectives on navigating language discordance in health care are limited. We analyzed portions of 48 interviews focused on language barriers from 2 qualitative interview studies of the pediatric health care experiences of LEP Latina mothers in 2 urban US cities. We found mothers experienced frustration with health care and reported suboptimal accommodation for language barriers. Six themes emerged relevant to health care across settings: the "battle" of managing language barriers, preference for bilingual providers, negative bias toward interpreted encounters, "getting by" with limited language skills, fear of being a burden, and stigma and discrimination experienced by LEP families. Parents' insights highlight reasons why effective language accommodation in health care remains challenging. Partnering with families to address the management of language barriers is needed to improve health care quality and safety for LEP patients and families.

Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis: A Systematic Review and Meta-analysis

BACKGROUND

An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7%-23% of cases. Despite national guidelines stating "current evidence does not support routine radiography in children with bronchiolitis"; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia.

OBJECTIVES

We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis.

METHODS

We searched the medical literature from 1965 to June 2015 in PubMed/EMBASE using the following PICO formulation of our clinical question, "What characteristic(s) of history/physical examination (H&P) and vital signs (VS) in a child with bronchiolitis should prompt the physician to order a CXR?": Patients-pediatric emergency department (ED) patients (<2 years) with clinical bronchiolitis; Intervention-H&P and VS; Comparator-a CXR positive for airspace disease (+CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome-operating characteristics of H&P and VS predicting an +CXR were calculated: sensitivity, specificity, and likelihood ratios (LR+ or LR-). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). We created a test-treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection.

RESULTS

We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a +CXR ranged from 7% to 23%. An oxygen saturation < 95% was the predictor with highest LR+ of 2.3 (95% confidence interval = 1.3 to 3.07) to predict a +CXR. None of the H&P and VS variables were found to have sufficiently low LR- to significantly decrease the pretest probability of finding a +CXR. Our test-treatment threshold model showed that hypoxia (O₂ Sat < 95%) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O₂ Sat < 95%) and respiratory failure requiring ventilatory support.

CONCLUSION

No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.

Nonurgent Use of the Emergency Department by Pediatric Patients: A Theory-Guided Approach for Primary and Acute Care Pediatric Nurse Practitioners

Providing quality, cost-effective care to children and their families in the appropriate setting is the goal of nurse practitioners in primary and acute care. However, increased utilization of the emergency department (ED) for nonurgent care threatens cost-effective quality care, interrupts continuity of care, and contributes to ED overcrowding. To date, descriptive research has identified demographics of those using the ED for nonurgent care, the chief complaints of children seeking nonurgent care, the cost to the health care system of pediatric nonurgent care, and characteristics of associated primary care settings. Using Donabedian's Model of Quality of Healthcare and a Theory of Dependent Care by Taylor and colleagues, acute and primary care pediatric nurse practitioners can incorporate interventions that will channel care to the appropriate setting and educate caregivers regarding common childhood illnesses and the value of continuity of care. By using a theoretical framework as a guide, this article will help both acute and primary care pediatric nurse practitioners understand why parents seek nonurgent care for their children in the ED and actions they can take to ensure that care is provided in an optimal setting.

A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial

OBJECTIVE

The goal of this study was to examine the effects of a new model for well-child care (WCC), the Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT), on WCC quality and health care utilization among low-income families.

METHODS

PARENT includes 4 elements designed by using a stakeholder-engaged process: (1) a parent coach (ie, health educator) to provide anticipatory guidance, psychosocial screening and referral, and developmental/behavioral guidance and screening at each well-visit; (2) a Web-based tool for previsit screening; (3) an automated text message service to provide periodic, age-specific health messages to families; and (4) a brief, problem-focused encounter with the pediatric clinician. The Promoting Healthy Development Survey-PLUS was used to assess receipt of recommended WCC services at 12 months' postenrollment. Intervention effects were examined by using bivariate analyses.

RESULTS

A total of 251 parents with a child aged ≤12 months were randomized to receive either the control (usual WCC) or the intervention (PARENT); 90% completed the 12-month assessment. Mean child age at enrollment was 4.5 months; 64% had an annual household income less than $20,000. Baseline characteristics for the intervention and control groups were similar. Intervention parents scored higher on all preventive care measures (anticipatory guidance, health information, psychosocial assessment, developmental screening, and parental developmental/behavioral concerns addressed) and experiences of care measures (family-centeredness, helpfulness, and overall rating of care). Fifty-two percent fewer intervention children had ≥2 emergency department visits over the 12-month period. There were no significant differences in WCC or sick visits/urgent care utilization.

CONCLUSIONS

A parent coach-led model for WCC may improve the receipt of comprehensive WCC for low-income families, and it may potentially lead to cost savings by reducing emergency department utilization.

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.

Opportunities for Nurses to Increase Parental Health Literacy: A Discussion Paper

Most families can access a range of health information and advice. Information and advice sources often include nurses, the Internet, social media, books, as well as family and friends. While the immediate aim may be to find information, it can also be to assist with parenting skills, solve parenting problems or as part of decision-making processes about their child's health. These processes are strongly influenced by the parent's level of health literacy. Health literacy describes a person's capacity to obtain and utilize health related information. Although there are numerous health literacy definitions all have clearly defined steps. These steps are: obtaining relevant information; then understanding this information; and finally being able to use the information to achieve the expected outcome. Previous research has linked low levels of parental health literacy with poorer child health outcomes. Given this link, increasing health literacy levels would be advantageous for both families and health services. Nurses working with families are in a position to support the family to increase their health literacy through the use of a variety of strategies. This article outlines how health literacy can influence the way parents seek help when they are concerned about child health issues, the relevance of parental health literacy for nurses and suggests some tools that could be used to support the increase of health literacy.

Factors Influencing the Decision to Attend a Pediatric Emergency Department for Nonemergent Complaints

OBJECTIVE

The objective of this study was to explore the factors associated with parents' decisions to bring their children to the pediatric emergency department (PED) for nonemergent concerns.

METHODS

We conducted a cross-sectional survey at a tertiary-care, pediatric referral center emergency department. We surveyed caregivers of children triaged to low-acuity levels using the Pediatric Canadian Triage and Acuity Scale. We used descriptive statistics to report the proportion of patients who have a primary care physician, who attempted to contact any health care providers prior to coming to the PED, and other factors surrounding the decision to come to the PED.

RESULTS

We approached 340 families, of which 300 were enrolled (uptake rate, 88.2%). We found that 32% (95% confidence interval, 0.26-0.37) attempted to contact another health care provider prior to coming to the PED, and 59% (95% confidence interval, 0.48-0.69) of those respondents were specifically instructed to come to the PED. The top 3 reasons for coming to the British Columbia Children's Hospital PED were (1) that it specializes in children, (2) child has medical issues previously managed at the same hospital, and (3) closest location to patient.

CONCLUSIONS

Despite the majority of patients having a primary care physician, less than half of them actually contacted these providers (or another health care provider) before presenting to the PED for their nonurgent illness or injury. Of these, nearly two thirds were specifically instructed to come to the PED by the health care provider in the community.

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.

[Ethics in pediatric emergencies: Care access, communication, and confidentiality]

Children suffer most from today's increasing precariousness. In France, access to care is available for all children through various structures and existing measures. The support for foreign children is overseen by specific legislation often unfamiliar to caregivers. Pediatric emergencies, their location, organization, actors, and patient flow are a particular environment that is not always suitable to communication and may lead to situations of abuse. Communication should not be forgotten because of the urgency of the situation. The place of the child in the dialogue is often forgotten. Considering the triangular relationship, listening to the child and involving the parents in care are the basis for a good therapeutic alliance. Privacy and medical confidentiality in pediatric emergencies are governed by law. However, changes in treatments and medical practices along with the variety of actors involved imply both individual and collective limitations, to the detriment of medical confidentiality.

Non-urgent accident and emergency department use as a socially shared custom: a qualitative study

Objective

We explored attitudes of non-urgent accident and emergency department (AED) patients in the middle-income healthcare setting Saint Vincent and the Grenadines (SVG) in the Caribbean to understand how and why they decide to seek emergency care and resist using primary care facilities.

Methods

In 2013, we conducted 12 semistructured interviews with a purposive sample of non-urgent AED users from a variety of social backgrounds. Verbatim transcripts were analysed with a grounded theory approach.

Results

In this study, we found, first, that participants automatically chose to visit the AED and described this as a locally shared custom. Second, the healthcare system in SVG reinforced this habitual use of the AED, for example, by health professionals routinely referring non-urgent cases to the AED. Third, there was also some deliberate use; patients took convenience and the systemic encouragement into account to determine that the AED was the most appropriate choice for healthcare.

Conclusions

We conclude that the attitudes and habits of the Vincentian non-urgent patient are major determinants of their AED use and are intricately linked to local, socially shared practices of AED use. Findings show that health services research should reconsider rational choice behaviour models and further explore customs of health-seeking.

Utilization of emergency service of obstetrics and gynecology: a cross-sectional analysis of a training hospital

BACKGROUND

Overutilization and inappropriate use of emergency departments (EDs) by patients with non-urgent health problems has become a major concern worldwide. This study aims to describe the characteristics of obstetric and gynecologic patients admitted to the Department of Emergency Obstetric and Gynecology.

METHODS

A retrospective and cross-sectional study was designed at our Emergency Service of Obstetrics and Gynecology of Kayseri Education and Research Hospital of Medicine between January 1 and December 31, 2013. A total of 30,853 patients applying to emergency service were retrospectively analyzed from the admission charts, patient files and hospital automation system. Patients were assessed in terms of demographic features, presentation times, complaints, admission type (with own facilities, with consultation or with ambulance), diagnoses (urgent or non-ergent), discharge rates, clinical admission, rejection rate of examination, and rejection rate of hospitalization.

RESULTS

A total of 30,853 patients were analyzed retrospectively. The mean age of patients was 27.69 ± 8.44 years; 51% of patients were between 20 and 29 years old. The categories of patients in urgent and non-urgent were 69% and 31% respectively. Most common presentation time period was between 19:00 and 21:00. Labor pain, pain and bleeding during pregnency, routine antenatal control, pelvic pain and menstrual irregularity were the most common complaints. Labor pain with the rate of 21% was the most common cause of ED admission. All patients who presented with labor pain were hospitalized. Patients hospitalized for labor constituted 56% of all hospitalized patients. Among patients, 62% were treated on an outpatient basis and 38% were hospitalized. Of patients, 3.54% refused to hospitalization. The cases using the ambulance to admission constituted 1.07% of all ED patients. Of these patients who have used ambulance 3.65% refused to the patient examination.

CONCLUSIONS

To improve the obstetric and gynecologic emergency medical care in Turkey, demographic properties and other characteristics of patients should be analyzed in detail. Detailed analysis of the data contributes to the further design and perspective of the EDs.

Low caregiver health literacy is associated with higher pediatric emergency department use and nonurgent visits

OBJECTIVE

We sought to determine the association between low caregiver health literacy and child emergency department (ED) use, both the number and urgency of ED visits.

METHODS

This year long cross-sectional study utilized the Newest Vital Sign questionnaire to measure the health literacy of caregivers accompanying children to a pediatric ED. Prior ED visits were extracted from a regional database. ED visit urgency was classified by resources utilized during the index ED visit. Regression analyses were used to model 2 outcomes-prior ED visits and ED visit urgency-stratified by chronic illness. Analyses were weighted by triage level.

RESULTS

Overall, 503 caregivers completed the study; 55% demonstrated low health literacy. Children of caregivers with low health literacy had more prior ED visits (adjusted incidence rate ratio 1.5; 95% confidence interval 1.2, 1.8) and increased odds of a nonurgent index ED visit (adjusted odds ratio 2.4; 95% confidence interval 1.3, 4.4). Among children without chronic illness, low caregiver health literacy was associated with an increased proportion of nonurgent index ED visits (48% vs. 22%; adjusted odds ratio 3.2; 1.8, 5.7).

CONCLUSIONS

Over half of caregivers presenting with their children to the ED have low health literacy. Low caregiver health literacy is an independent predictor of higher ED use and use of the ED for nonurgent conditions. In children without a chronic illness, low health literate caregivers had more than 3 times greater odds of presenting for a nonurgent condition than those with adequate health literacy.

Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness

OBJECTIVE

To examine the association between caregiver health literacy and the likelihood of a nonurgent emergency department (ED) visit in children presenting for fever.

METHODS

This cross-sectional study used the Newest Vital Sign to assess the health literacy of caregivers accompanying children with fever to the ED. Visit urgency was determined by resources utilized during the ED visit. Findings were stratified by race and child age. Chi-square and logistic regression analysis controlling for race were conducted to determine the association between low health literacy and ED visit urgency.

RESULTS

A total of 299 caregivers completed study materials. Thirty-nine percent of ED visits for fever were nonurgent, and 63% of caregivers had low health literacy. Low health literacy was associated with a higher proportion of nonurgent ED visits for fever (44% vs 31%, odds ratio 1.8, 95% confidence interval [CI] 1.1, 2.9). Low health literacy was associated with higher odds of a nonurgent visit in white and Hispanic caregivers but not in black caregivers. In regression analysis, children ≥ 2 years old had higher odds of a nonurgent visit if caregivers had low health literacy (adjusted odds ratio 2.0; 95% CI 1.1, 4.1); this relationship did not hold for children <2 years old (adjusted odds ratio 0.8; 95% CI 0.4, 1.8).

CONCLUSIONS

Nearly two-thirds of caregivers with their child in the ED for fever have low health literacy. Caregiver low health literacy is associated with nonurgent ED utilization for fever in children over 2 years of age. Future interventions could target health literacy skills regarding fever in caregivers of children ≥ 2 years.

Effects of immigrant status on Emergency Room (ER) utilisation by children under age one: a population-based study in the province of Reggio Emilia (Italy)

BACKGROUND

The primary aim of this study was to assess the effect of immigrant status on Emergency Room (ER) utilisation by children under age one, considering all, non-urgent, very urgent, and followed by hospitalisation visits. The second aim was to investigate the role played by mother's educational level in the relationship between citizenship and ER utilisation.

METHODS

The cohort study included all healthy singleton live births in the years 2008-2009 and residing in the province of Reggio Emilia, followed for the first year of life in order to study their ER visits. The outcomes were the ER utilisation rate for all, non-urgent, very urgent, and followed by hospitalisation visits. The main explanatory variable was mother's citizenship. Other covariates were mother's educational level, maternal age, parity, and child gender. Multivariate analyses (negative binomial regression and zero inflated when appropriate) were performed. Adjusted utilisation Rate Ratios (RR) and their 95% Confidence Intervals (95% CI) were calculated. Trend for age in months by citizenship is depicted.

RESULTS

There were 3,191 children (36.4%) with at least one ER visit in the first year of life. Adjusted RR show a significantly greater risk of ER visit for immigrants than for Italians: (RR 1.51; 95% CI 1.39-1.63). Immigrants also had a higher risk of non-urgent visits (RR 1.72; 95% CI 1.48-2.00) and for visits followed by hospitalizations (RR 1.58; 95% CI 1.33-1.89). For very urgent visits, the immigrants had a slightly higher risk compared to Italians (RR 1.25; 95% CI 0.98-1.59).The risk of ER visits is higher in the first two months of life (RR(1st vs 3rd-12th) 2.08; 95% CI 1.93-2.24 and RR(2nd vs 3rd-12th) 1.45; 95% CI 1.33-1.58, respectively). Considering all visits, the ER utilisation rate was inversely related with maternal education only for Italians (low educational level 44.0 and high educational level 73.9 for 100 children; p value for trend test < 0.001).

CONCLUSIONS

Our study observed a higher use of ER services by immigrant children and, to a lesser extent, by children of less educated Italian mothers. In immigrants, the excess is mostly due to non-urgent visits and only slightly to high acute conditions.