Factors associated with emergency department utilization for nonurgent pediatric problems

Low-Acuity Pediatric Emergency Department Utilization: Caregiver Motivations

OBJECTIVES

Proper emergency department (ED) utilization is a hallmark of population health. Emergency department overcrowding due to nonurgent visits causes increased stress to healthcare staff, higher costs, and longer wait times for more urgent cases. This study sought to better understand post pandemic reasons caregivers have when bringing in their children for nonurgent visits and devise effective interventions to improve caregiver choice for non-ED care for nonurgent conditions.

METHODS

Surveys were conducted at an urban pediatric hospital for Emergency Severity Index (ESI) level 3 to 5 visits. A total of 602 surveys were completed with 8 being excluded from analysis. Survey responses and anonymized demographic information were collected. Responses were compared between surveys grouped by respondent age category, relation to child, child's race, insurance type, and ESI levels.

RESULTS

Primary reasons given for nonurgent ED visits were perceived urgency (74.2%, n = 441), ED superiority to other locations (23.9%, n = 142), and referral to the ED by a third party (17.7%, n = 105). Of those who cited perceived urgency as a reason, 80.5% (n = 355) wanted to lessen their child's pain/discomfort as soon as possible, but only 13.6% said that their child was too ill to be seen anywhere else (n = 60). Demographic differences occurred in the proportions of respondents citing some of the primary and secondary reasons for bringing their child to the ED.

CONCLUSIONS

This study highlights 3 key findings. An immediate desire for care plays a key role in caregiver decision making for low-acuity visits. There is potential socioeconomic and racial bias in where care is recommended that needs to be further explored in this region. Cross community interventions that target key reasons for seeking low-acuity care have the highest likelihood of impacting the use of the ED for low-acuity conditions.

Community healthcare appointments as an alternative to emergency department assessment: an exploration of family acceptability and preferences

PURPOSE

Pediatric emergency departments are overcrowded, in part due to many non-emergent visits. We aimed to assess the proportion of parents interested in leaving the pediatric emergency department (ED) prior to physician assessment if they could be offered a scheduled community healthcare appointment. We explored differences in care children received in the ED stratified by interest in a community healthcare appointment and parents' reasons when they were not interested.

METHODS

We conducted a 14-item survey within the pediatric ED at a Canadian tertiary care teaching hospital to assess parents' interest if a program offered community healthcare appointments and we determined preferred appointment characteristics. All parents presenting with children triaged as CTAS 2-5 who met eligibility criteria were approached by a research assistant prior to physician assessment. Surveys were paired with the medical chart outlining the care received. Descriptive statistics and a regression model were used to describe characteristics of families and care received among those who were and were not interested in a community healthcare appointment.

RESULTS

In total, 403 surveys were completed. Overall, 236 participants (58.6%; 95% CI 53.8-63.4) were interested in a community healthcare appointment. In general, parents who were interested in a community healthcare appointment were younger and presented with younger children compared to those who were not interested. Among those interested, there was a preference to have the appointment with a pediatrician or family physician, timely access to an appointment, and appointments scheduled outside of regular business hours.

CONCLUSION

Our study provides evidence that there is interest in an alternative care access model positioned to reduce pediatric ED congestion. We found that parents would be interested in leaving the pediatric ED in favor of a community healthcare appointment, provided it was with a physician and available in a timely manner.

Effect of triage training on the knowledge application and practice improvement among the practicing nurses of the emergency departments of the National Referral Hospitals, 2018; a pre-post study in Asmara, Eritrea

BACKGROUND

Triage starts at the front door of the Emergency Department (ED), and repeatedly performed by the responsible duty nurses with the aim of facilitating a timely and appropriate treatment of patients. A triage system called the Orotta Triage System was implemented in the emergency settings of the selected hospitals in 2006, with the emergency nurses trained to triage using the system. Since the introduction, a majority of nurses have been replaced by new untrained nurses. This study was conducted to assess the impact of an educational intervention on the triage nurses knowledge and performance.

METHODS

A single group pre-posttest study design was performed in the adult EDs of the National Referral Eritrean Referral Hospitals, from January to July of 2018. All staff members in the ED were involved. Data collection tools utilized were, a self-administered knowledge assessing questionnaire and a practice observation checklist. Analysis was done in SPSS (version 22) using repeated measures ANOVA. Statistical significance level was set at P < 0.05.

RESULTS

The mean knowledge scores at Time 1(prior to the intervention), Time 2 (following the intervention) and Time 3 (three month follow up) were 6.23 (SD = 2.29), 10.55 (SD = 1.79), and 9.39(SD = 2.67) respectively. During the pre-intervention phase, only one (3%) nurse was determined to have adequate knowledge. Two days post training (immediate post-intervention), the percentage possessing adequate knowledge increased to 39% but dropped back to 19% three months later. Mean knowledge difference scores (95% CI) of immediate post and pre-intervention (Diff. = 4.32, 1 95%CI: 3.08-5.56), three months later and pre-intervention (Diff. = 3.16, 95%CI: 1.71-4.62) and immediate post and three months later (Diff. = 1.16, 95%CI: 0.12-2.20) were found to be statistically significant. The median score of appropriate triage practice at pre-intervention (Md = 6, IQR = 3) was not significantly different (p = 0.053) from that at post-intervention (Md = 8, IQR = 5).

CONCLUSION

The level of triage knowledge and appropriate application was low among the emergency nurses prior to training. The training provided an initial improvement in knowledge, but no significant improvement in triage nursing performance. To optimize ED triage performance, appropriate, timely in-service training is required to ensure new staff are educated and experienced staff have their knowledge and skills refreshed.

Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation

OBJECTIVES

Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity.

METHODS

Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department.

RESULTS

Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity.

CONCLUSIONS

Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.

Racial/Ethnic Differences in Pediatric Emergency Department Wait Times

OBJECTIVES

Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences.

METHODS

We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure.

RESULTS

Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)].

CONCLUSIONS

In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

Characteristics of pediatric emergency patients in a Turkish tertiary-level hospital: A 1-year cross-sectional study

Objectives:

Overcrowding in pediatric emergency departments negatively affects the quality of care. Investigating the characteristics of the patients admitted to PEDs will provide valuable information to increase the satisfaction of patients and healthcare staff. This research aimed to investigate the characteristics of pediatric emergency patients in a foundation university hospital in Ankara.

Methods:

This is a retrospective, descriptive, single-center, cross-sectional study, which was conducted with 6550 patients who were admitted to the pediatric emergency department of a foundation university hospital in Ankara, and got diagnosed with one of the 15 most common diseases between 1 August 2017 and 31 July 2018. The associations between the demographics and clinical features of the patients and their diagnoses were evaluated. For comparisons, frequencies, percentages, crosstabs, and chi-square tests were used.

Results:

While none of the patients had a red triage level, 19% had a yellow triage level, and 81% had a green triage level. The three most common diagnoses were fever of unknown origin, cough, and nausea and vomiting. Despite the 0–28 days of age group having the lowest admission rate of 5%, they had the highest usage rate of yellow triage level (66.5%). However, it was the opposite for the 19 months to 5 years of age group with the highest rate of admissions of 49% and the lowest usage rate of yellow triage level (12.8%).

Conclusion:

The reasons for admitting to pediatric emergency department differ according to some contextual variables. Being aware of the current situation is the first step in planning for better pediatric emergency service.

Patient Ethnicity and Pediatric Visits to the Emergency Department for Fever

OBJECTIVES

Previous research has identified ethnic differences in parents' beliefs about fever, but whether patient ethnicity is associated with health care use for fever is uncertain. Our objectives were to describe the national rate of pediatric visits to the emergency department (ED) for fever and to determine whether there is variation in this rate by patient ethnicity.

METHODS

Using the National Hospital Ambulatory Medical Care Survey between 2012 and 2015, we estimated the proportion of ED visits with a complaint of fever by patients 0 to 18 years old and compared this proportion across patient ethnicity. We performed multivariable logistic regression controlling for sociodemographic characteristics and visit acuity to determine whether patient ethnicity was independently associated with visits for fever.

RESULTS

Fever was the reason for 19% [95% confidence interval (CI), 18%-20%] of pediatric visits to the ED, and the proportion of visits for fever was highest among Hispanic patients (25%; 95% CI, 23%-27%) and lowest among non-Hispanic white patients (15%; 95% CI, 14%-17%). In multivariable analysis, the adjusted odds of visits for fever were greater for Hispanic patients (odds ratio, 1.56; 95% CI, 1.38-1.83) and non-Hispanic non-black patients of other races (1.34; 95% CI, 1.02-1.77) compared with non-Hispanic white patients.

CONCLUSIONS

There is significant ethnic variation in the use of emergency medical services for fever in the United States, and these disparities are not fully explained by differences in the acuity of illness or differences in socioeconomic status. Interventions to empower parents to manage nonurgent pediatric fever should incorporate ethnocultural differences in parents' understanding of fever.

Healthcare Utilization Patterns Among Children With a History of Child Protective Services Investigations

PURPOSE

Examine whether children with a prior child protective services (CPS) investigation had different healthcare utilization compared to children without a history of CPS investigations.

METHODS

The Children's Health Assessment and Planning Survey assessed 6,492 primary caregivers of children ages 0-17 years residing in North Texas in 2015. Caregivers reported prior CPS investigations and child healthcare utilization (emergency department [ED] use, unmet medication needs, and unmet medical care needs).

PRINCIPLE FINDINGS

A total of 408 (5%) caregivers reported their child had a CPS investigation. Children with CPS investigations had greater odds of visiting the ED (OR = 1.9; 95% CI: 1.4, 2.5) and not receiving necessary medical care (OR = 1.9; 95% CI: 1.4, 2.8) compared to children without a CPS investigation.

CONCLUSIONS

Prior CPS investigation was associated with disparities in receipt of necessary medical care and ED utilization for children.

Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review

INTRODUCTION

Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?"

METHOD

Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data.

RESULTS

Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP.

CONCLUSION

Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.

Randomized Controlled Trial of Acute Illness Educational Intervention in the Pediatric Emergency Department: Written Versus Application-Based Education

OBJECTIVES

The aim of this study was to determine the (1) feasibility, (2) demand, (3) acceptability, and (4) usefulness of a mobile health (mHealth) application (app) compared with a written intervention distributed in a pediatric emergency department (ED).

METHODS

This was a randomized controlled trial with parents of children 12 years or younger presenting to the ED for nonurgent complaints. Parents were randomized to receive a (1) low literacy pediatric health book with video, (2) pediatric mHealth app, (3) both 1 and 2, or (4) car-seat safety video and handout (control). Demand, acceptability, and usefulness were assessed at 1-, 3-, and 6-month follow-ups. Modified intention-to-treat analysis was completed for proportional data.

RESULTS

Ninety-eight parents completed randomization (83% approached). One or more follow-up was completed for 80.6% of parents. Only 57.1% downloaded the app. Parents used the app less than the book (35.1% vs 73.0%, P < 0.01), found the app to be harder to understand (26.0% vs 94.6%, P < 0.001) and less useful (37.8% vs 70.3%, P < 0.01), and were less likely to recommend the app to others (48.7% vs 100%, P < 0.01). No parent who received both book and app would prefer to have only the app; 88.9% of parents wanted either the book or both.

CONCLUSIONS

There was low demand for an mHealth app with parents who prefer, accept, and use the book more. Giving written health information to vulnerable populations in a pediatric ED has the capacity to empower parents with knowledge to care for a child and potentially decrease future nonurgent ED use with translation into a larger study.

Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore

INTRODUCTION

Inappropriate attendances (IAs) at emergency departments (ED) are contributed by patients with mild or moderate medical conditions that can be effectively managed by primary care physicians. IAs strain limited ED resources and have an adverse impact on efficiency. This study aimed to identify factors associated with IA at the ED of a tertiary hospital in Singapore.

METHODS

We conducted a retrospective cohort study of all eligible visits to the aforementioned ED between 1 January 2015 and 31 December 2015. The appropriateness of each attendance was estimated using criteria based on investigations or procedures that were performed on the attendee and the discharge type of that attendance. IAs were then compared against appropriate attendances in these areas: attendee demographics; referral source; time of ED visit; proximity to ED and 24-hour general practitioner clinics; and history of ED visits in 2014. Multivariate analysis was performed on significant variables associated with IAs.

RESULTS

Among 120,606 attendances, 11,631 (9.6%) were IAs. Multivariate analysis showed that gender, ethnicity, referral source, time of ED visit, nationality and history of frequent visits to the ED were factors associated with IAs. Moreover, the odds of IA were found to be higher among attendees who were younger, were self-referred, or had at least one IA in 2014.

CONCLUSION

This study identified subgroups in the population who were more likely to contribute to IAs at the ED. These findings offer relevant insights into future research directions and strategies that might potentially reduce avoidable IAs.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

BACKGROUND

Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France.

METHOD

The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs.

RESULTS

Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density.

CONCLUSION

Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.

The Effect of a Primary Care Provider Incentive Program on Pediatric Emergency Medicine Visits

OBJECTIVE

The aim of the study was to analyze the effect of a financial incentive program targeting primary care providers (PCPs) with the goal of decreasing emergency department (ED) utilization.

METHODS

We performed a retrospective cohort analysis in a single health maintenance organization comparing ED visit/1000 member-months before and after the physician incentive program in 2009. We compared the median ED visit rate between physicians who did (PIP) and did not participate (non-PIP) from 2009 to 2012. We used 2008 data as a baseline study period to compare the ED visit rate between PIP and non-PIP providers to detect any inherent difference between the 2 groups.

RESULTS

A total of 1376 PCPs were enrolled. A total of US $18,290,817 was spent in total on incentives. Overall, the median ED visit rate for all providers was statistically significantly lower during the study period (baseline period, study period: 56.36 ED visits/1000 member-months vs 45.82, respectively, P < 0.001). During the baseline period in our fully adjusted linear regression for degree, specialty, education, and board status, PIP versus non-PIP visits were not statistically significantly different (P = 0.17). During the study period in our fully adjusted model, we found that PIP had statistically significant fewer ED visits compared with non-PIP (P = 0.02). In a subgroup analysis of providers who did and did not receive an incentive payment, in the fully adjusted linear regression, providers who received any payment had statistically significant fewer ED visits/1000 member-months (P < 0.001). In addition, we found in the fully adjusted analysis that those providers who received at least 1 incentive payment for meeting after-hours criteria had statistically significantly fewer ED visits/1000 member-months (P < 0.001).

CONCLUSIONS

A financial incentive program to provide PCPs with specific targets and goals to decrease pediatric ED utilization can decrease ED visits.

Non-urgent paediatric emergency department presentation: A systematic review

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.

Risk Factors for Delayed Antimicrobial Treatment in Febrile Children with Urinary Tract Infections

OBJECTIVES

To identify factors associated with delayed antimicrobial treatment in febrile children with urinary tract infection (UTI).

STUDY DESIGN

We reviewed data from 802 children with UTI enrolled in 2 previously conducted prospective studies (Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation) and extracted data on possible predictors of delayed treatment including age, sex, history of UTI, ethnicity, race, primary caregiver's education level, insurance, and income. We used univariate and multivariable analyses to investigate the relationship between these predictors and treatment delay.

RESULTS

We included 660 febrile patients with a mean age of 17.0 months old. Older age and commercial insurance were associated with delayed treatment on univariate analysis. Compared with younger children, treatment was delayed by an average of 26.2 hours in children ≥12 months of age. This relationship remained significant on multivariable analysis. Treatment also was delayed by an average of 12.6 hours in patients with commercial insurance. Race, ethnicity, primary caregiver's education level, and income were not associated with delayed treatment.

CONCLUSIONS

Older age was a consistent predictor of delayed antimicrobial treatment. Delays in the initiation of antimicrobial therapy for UTI has previously been associated with renal scarring. Educating parents with older children regarding the management of fever as well as providers regarding prompt evaluation and management may help to reduce renal scarring.

Why Parents Use the Emergency Department Despite Having a Medical Home

Despite having a medical home, pediatric patients continue emergency department (ED) utilization for various reasons. This study examines parental reasons associated with the decision to seek ED care in a group of low-income, inner-city, publicly insured children. Surveys were conducted with parents of children (age = 0-19 years) presenting to a community-based clinic, which has an established medical home model with enhanced access. Most patients (88.3%) had a pediatrician, and nearly all (93.3%) reported a visit to the ED; most (75.7%) were aware of clinic walk-in hours, but less than half (42.6%) were aware of an after-hours phone line. There was no difference in those who were aware of walk-in hours or an after-hours phone line and a reported ED visit. Half of the parents (52.5%) thought their child's medical problem was serious. In addition to providing enhanced efforts, medical homes should strive to make families aware of increased access.

Multicenter Evaluation of Emergency Department Treatment for Children and Adolescents With Crohn's Disease According to Race/Ethnicity and Insurance Payor Status

BACKGROUND

Racial and socioeconomic disparities exist in the treatment and outcomes of children and adults with Crohn's disease (CD). This study investigated the impact of race and insurance status on emergency department (ED) evaluation and treatment among children with CD in the United States.

METHODS

Data from the Pediatric Health Information System included ED visits between January 2007 and December 2013 for patients aged ≤21 years with a primary diagnosis of CD, or a secondary diagnosis of CD plus a primary CD-related diagnosis. Analyses were performed using mixed-effects logistic regression.

RESULTS

Subjects included 2618 unique patients (black, 612 [23%]; white, 2006 [77%]) with 3779 visits from 38 hospitals, a median age of 14.0 ± 4.0 years, and 50% male. White children had a higher median neighborhood income and were more likely to have private insurance (57% vs 30%; P < 0.001). Emergency department visits for privately insured patients had higher odds of complete blood count (odds ratio [OR], 1.43; 95% CI, 1.08-1.90) and C-reactive protein/erythrocyte sedimentation rate (OR, 1.39; 95% CI, 1.06-1.82) vs Medicaid insured. Visits for white children had higher odds of receiving antiemetics (OR, 1.52; 95% CI, 1.06-2.17) vs black children. The proportion of patients with repeat visits was greater for black children (33%) than white children (22%; P < 0.001) and greater for Medicaid-insured (27%) than privately insured patients (21%; P < 0.01).

CONCLUSIONS

This cross-sectional database study demonstrated that black children and those with Medicaid insurance made more ED visits and received somewhat fewer treatments, which may be explained by greater use of the ED for routine care. An opportunity exists for better outpatient management of children with IBD so that nonemergent problems are more effectively handled.

Cell Phone and Computer Use Among Parents Visiting an Urban Pediatric Emergency Department

OBJECTIVES

The objectives of this study were to estimate the prevalence of cell phone and computer use among urban families bringing their children to an emergency department and to determine which technologies parents prefer to use to receive health information.

METHODS

We visited 2 pediatric emergency departments in Baltimore, Md, and Little Rock, Ark. A convenience sample of parents of children 8 years old or younger completed a self-administered survey in the waiting area.

RESULTS

Two hundred thirty-eight surveys were completed. Respondents were primarily female (83%), less than 35 years old (74%), and had at least a high school diploma or General Educational Development (94%). Forty-three percent were employed full time. A majority (95%) of respondents reported owning a cell phone, with most (88%) owning a smartphone and 96% reported having some internet access. Of cell phone owners, 91% reported daily text messaging activity. Over half (63%) of respondents reported having computer internet access at home; 31% reported having internet access at work. Patterns of behavior and preferences emerged for both cell phone and computer use. Respondents were more likely to check their email (75% vs 50%, P < 0.0001) and access the internet (78% vs 67%, P = 0.002) with a smartphone rather than their computer.

CONCLUSIONS

Both cell phones and computers are prevalent and used among urban families seen in pediatric emergency departments, offering new ways to deliver health information to these often underserved populations. Providers aiming to deliver health information should consider smartphone applications, text message-based programs, and email to communicate with their patients.

Examining the Appropriateness and Motivations Behind Low-Acuity Pediatric Emergency Department Visits

OBJECTIVES

High patient volumes have a deleterious effect on care in the pediatric emergency department (PED). Our study assessed the motivation for PED visits that could have been assessed by a primary care physician.

METHODS

We identified a convenience sample of patients presenting to the SickKids Hospital PED in June and July 2011 with a Paediatric Canadian Triage and Acuity Score 4 or 5. Patients completed a forced answer yes/no survey describing potential motivators for visiting the PED. Visit appropriateness was determined by a modified version of the DeAngelis tool, an explicit criteria-based tool frequently used for this purpose.

RESULTS

Of the included 635 patients with Paediatric Canadian Triage and Acuity Score 4 and 5, 25% were truly inappropriate as per DeAngelis criteria. Of these, perceived expertise at the tertiary care hospital (93.1%) and ease of getting tests (80.8%) were the most common reasons behind PED presentation.

CONCLUSIONS

Patients presenting to our PED typically have primary care physicians; however, access to their physicians during off-hours and availability of off-site testing is limited. Public policy aimed at decreasing overcrowding in the PED should address these themes.

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.

Factors that Affect Nonurgent Emergency Department Visits in a Publicly Insured Pediatric Population: An Observational Study

BACKGROUND

Publicly insured children have high rates of nonurgent emergency department visits (LAVs). The factors that drive consumption of these services are unknown.

METHODS

Demographics, emergency department visits, hospitalizations, missed preventative care appointments, zip code, and asthma status as factors for LAVs were determined by univariate, multivariate, and classification/regression tree analysis. Subjects were publicly insured and received care between March 1 and December 31, 2011.

RESULTS

A total of 4,387 children were identified; 856 (19.5%) had at least 1 nonurgent and 1,173 (26.7%) had at least 1 urgent emergency department visit; 526 (12%) missed ≥2 primary care appointments and 779 children had asthma. By univariate analysis, at least one high acuity emergency department visit, hospitalization during the study period, and asthma were directly associated with LAVs; age was inversely related. Multivariate and classification tree analyses identified children younger than 31.5 months with at least 1 high acuity emergency department visit as the highest risk group (0.807 visits per patient; 95% confidence interval: 0.699-0.916, p < .00001). Missed appointments, asthma status, hospitalizations, zip code of residence, and gender were not significant factors.

CONCLUSIONS

Young age and at least one high acuity emergency department visit are associated with high rates of nonurgent emergency department use among publicly insured children.

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.

The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period

As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.

Emergency department utilization and predictors of mortality for inpatient inguinal hernia repairs

BACKGROUND

Although inguinal hernias are common surgical diagnoses, minimally symptomatic patients are often not scheduled for repairs and are asked to seek medical attention if they develop symptoms. We investigated factors associated with emergency department (ED) utilization for inguinal hernia repairs and determined whether ED utilization affected mortality for this otherwise electively treated condition.

METHODS

We performed a retrospective analysis of the 2009-2013 Nationwide Inpatient Sample to identify patients who presented through the ED and were then admitted for unilateral inguinal hernia repairs. Multivariable logistic regressions that adjusted for several patient and hospital characteristics determined predictors of both ED admission and postoperative mortality.

RESULTS

There were 116,357 inpatient hospitalizations. The majority (57%) resulted from ED admissions, of which most (85%) had a diagnosis of obstruction or gangrene. Notable predictors of ED admission from the multivariable analysis included obstruction (odds ratio, 9.77 [95% confidence interval: 9.05-10.55]), gangrene (18.24 [13.00-25.59]), Black race (1.47 [1.29-1.69]), Hispanic ethnicity (1.35 [1.18-1.54]), self-pay (2.29 [1.97-2.66]) and Medicaid insurance (1.76 [1.50-2.06]). While overall mortality decreased from 2.03% in 2009 to 1.36% in 2013, admission through the ED was independently associated with higher mortality compared with elective repair (1.67 [1.21-2.29]), even after adjusting for the diagnosis of obstruction and gangrene. Other predictors of mortality included patient age and comorbidities.

CONCLUSIONS

In our study, Black, Hispanic, and self-pay patients were more likely to present through the ED. After adjusting for obstruction or gangrene, simply presenting through the ED was independently associated with a 67% higher postoperative mortality rate compared with that of an elective operation. Our findings suggest both a difference in ED utilization and subsequent difference in mortality by patient race and ethnicity and insurance for this common surgical condition.

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.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits

STUDY OBJECTIVE

We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low-acuity conditions.

METHODS

We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low-acuity conditions. Retail clinic "penetration" was measured as the percentage of the ED catchment area that overlapped with the 10-minute drive radius of a retail clinic. Rate ratios were calculated for a 10-percentage-point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012.

RESULTS

Among all patients, retail clinic penetration was not associated with a reduced rate of low-acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low-acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low-acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter.

CONCLUSION

With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low-acuity ED visits.

Federally Qualified Health Center Access and Emergency Department Use Among Children

OBJECTIVE

To determine whether increasing access to federally qualified health centers (FQHCs) in California was associated with decreased rates of emergency department (ED) use by children without insurance or insured by Medicaid.

METHODS

We combined several data sets to longitudinally analyze 58 California counties between 2005 and 2013. We defined access to FQHCs by county using 2 measures: FQHC sites per 100 square miles between 2005 and 2012 and percentage of Medicaid-insured and uninsured children served by FQHCs from 2008 to 2013. Our outcome was rates of ED use by uninsured or Medicaid-insured children ages 0 to 18 years. To determine the effect of changes in FQHC access on the outcome within a county over time, we used negative binomial models with county fixed effects and controls for preselected time-varying county characteristics and secular trends.

RESULTS

Increased geographic density of FQHC sites was associated with ≤18% lower rates of ED visits among Medicaid-insured children and ≤40% lower ED utilization among uninsured children (P = .05 and P < .01, respectively). However, the percentage of Medicaid-insured and uninsured children seen at FQHCs was not associated with any significant change in ED visit rates among Medicaid-insured or uninsured children.

CONCLUSIONS

Whereas increased geographic FQHC access was associated with lower rates of ED use by uninsured children, all other measures of FQHC access were not associated with statistically significant changes in pediatric ED use. These results provide community-level evidence that expanding FQHCs may have a limited impact on pediatric ED use, suggesting the need to explore additional factors driving ED utilization.

Does Nursery-Based Intensified Anticipatory Guidance Reduce Emergency Department Use for Nonurgent Conditions in the First Month of Life? A Randomized Controlled Trial

Objective. We aimed to evaluate the impact of an intensified anticipatory guidance program in the nursery on Emergency Department (ED) use for nonurgent conditions (NUCs) in the neonatal period. Methods. Parturient mothers of healthy newborns were randomized to an intervention group or control group. Baseline and 1-month follow-up knowledge surveys regarding newborn care were conducted. The primary outcome was the proportion of neonates who used the ED for a NUC. Secondary outcome was change in caregivers' knowledge on NUC. Results. Of a total of 594 mothers, 323 (54%) agreed to participate and were randomized to intervention (n = 170) or control (n = 153) group. Most were Hispanic (68%), single (61%), primiparous (39%), and without high school diploma (44%). 35 (21%) neonates in the intervention group and 41 (27%) in the control group were brought at least once for a NUC to the ED (p = 0.12). There was no statistically significant difference in within subject change on knowledge scores between the two study arms. Conclusions. Neonatal ED visits for NUCs occur frequently. This nursery-based intensified anticipatory guidance program had no statistically significant impact on neonatal ED use for NUC, nor on neonatal care-relevant knowledge among parturient mothers. Alternative modalities and timing of parental educational intervention may need to be considered. This trial is registered with Clinical Trials Number NCT01859065 (Clinicaltrials.gov).

Understanding decisions leading to nonurgent visits to the paediatric emergency department: caregivers' perspectives

INTRODUCTION

A significant percentage of paediatric emergency department (ED) attendances worldwide are nonurgent, adversely affecting patient outcomes and healthcare systems. This study aimed to understand the reasons behind nonurgent ED visits, in order to develop targeted and effective preventive interventions.

METHODS

In-depth interviews were conducted with 49 caregivers to identify the decision-making factors related to taking children to the ED of KK Women's and Children's Hospital, Singapore. Interviews were carried out in the emergency room of the hospital after the children had been diagnosed with nonurgent conditions by the attending physician. Interview transcripts were analysed based on grounded theory principles.

RESULTS

The demographics of our study cohort were representative of the target population. The main reasons given by the caregivers for attending paediatric EDs included perceived severity of the child's symptoms, availability of after-hours care, perceived advantage of a paediatric specialist hospital and mistrust of primary care physicians' ability to manage paediatric conditions. Insurance or welfare was a contributing factor for only a small portion of caregivers.

CONCLUSION

The reasons provided by Singaporean caregivers for attending paediatric EDs were similar to those reported in studies conducted in Western countries. However, the former group had a unique understanding of the local healthcare system. The study's findings may be used to develop interventions to change the knowledge, attitudes and behaviours of caregivers in Singapore.

Paediatric emergency department referrals from primary care

Background Over the last decade, paediatric referrals from general practitioners (GPs) to the emergency department (ED) have increased by 60% in Australia. Objective To investigate the characteristics of Victorian children referred by GPs to the ED with lower-urgency conditions. Method Data were collected from four hospital EDs in Victoria, May–November 2014. Parents attending the ED with their child triaged as lower urgency were surveyed. Descriptive, frequency, and bivariate analyses were performed. Results Of the 1150 responses, 28% (320) visited their GP before attending ED. Of these 66% (212), were referred by their GP. A greater proportion with injury than illness (84% vs 59%; P < 0.0001) was referred to the ED if they had first visited their GP. Conclusion Motivations of GPs to send lower-urgency injured and ill children to ED are not well understood. The high number of referrals from GPs to the ED for lower urgency conditions suggests attention by policy makers and health professionals must be paid to the current patterns of care of children in general practice. What is known about the topic? Paediatric referrals in Australia from GPs to EDs have increased in the last decade, along with the absolute number of children in Victoria presenting to the ED. What does this paper add? A significant number of children (66%) who attend the GP before visiting the ED are referred to the ED for their lower urgency condition. What are the implications for practitioners? It may be appropriate for GPs to be further supported to manage lower urgency conditions, through better resources or education.

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.

Reconnecting patients with their primary care provider: an intervention for reducing nonurgent pediatric emergency department visits

OBJECTIVE

Intervention to reduce nonurgent pediatric emergency department (PED) visits over a 12-month follow-up.

METHODS

Prospective, randomized, controlled trial enrolled children seen in the PED for nonurgent concerns. Intervention subjects received a structured session/handout specific to their primary care provider (PCP), which outlined ways to obtain medical advice. Visitation to the PED and PCP were followed over 12 months.

RESULTS

A total of 164 patients were assigned to the intervention and 168 patients to the control. At 12-month follow-up, the intervention group had a lower rate of nonurgent PED utilization compared with the control group (70 [43%] patients in the intervention compared with 91 [54%] in the control; P = .047). At 12 months, there was an increase in the rate of sick visits to PCP in the intervention group when compared with the control (P = .036).

CONCLUSIONS

Intervention designed in cooperation with pediatricians was able to decrease nonurgent PED utilization and redirect patients to their PCP for future sick visits over a 12-month period.

Emergency department and urgent care for children excluded from child care

BACKGROUND

Children in child care are frequently unnecessarily excluded for illness. We investigated parental use of urgent medical evaluation for sick children unable to attend child care.

METHODS

In May 2012, authors conducted a nationally representative survey of parents, who completed online questions regarding child illness causing absence from child care and their medical care-seeking behavior. Main outcome was parents' use of emergency department or urgent care (ED/UC).

RESULTS

Overall survey participation rate was 62%. Of participating parent cohort with children 0 to 5 years old, 57% (n = 357) required child care, of which 84% (n = 303) required out-of-home child care. Over 88% of parents sought acute medical care for their sick children unable to attend child care. Approximately one-third of parents needed a doctor's note for employers and/or child care. Parents sought medical evaluation (>1 option possible) from primary care (81%), UC (26%), or ED (25%). ED/UC use was most common for rash (21%) and fever (15%). Logistic regression indicated ED/UC use was significantly higher among single/divorced parents (odds ratio [OR] = 4.3; 95% confidence interval [CI]: 2.5-13.5); African American parents (OR = 4.2; 95% CI: 1.2-14.6); parents needing a doctor's note (OR = 4.2; 95% CI: 1.5-11.7); and those with job concerns (OR = 3.4; 95% CI: 1.2-9.7).

CONCLUSIONS

A substantial proportion of parents whose sick children cannot attend child care seek care in ED/UC. Training child care professionals regarding appropriate illness exclusions may decrease ED/UC visits by lowering child care exclusions.

Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent?

PURPOSE

Adolescents frequently rely on emergency medical care, rather than using primary care providers (PCPs). Our objectives were to characterize a population of adolescents presenting to a large, urban emergency department (ED) and to examine the reasons why they present to the ED, rather than to their PCP's office.

METHODS

Adolescents ages 12 to 21 years and their parents/guardians were invited to participate and asked to complete a brief online survey. Demographic data and triage information were collected from electronic medical records.

RESULTS

Of 203 participants, 66% (n = 134) had public insurance, and 40% (n = 82) were triaged as nonurgent. Nearly all (93%, n = 189) reported having a PCP or primary clinic. The most common reasons given for presenting to the ED were participant perception of illness requiring immediate care (34%), followed by PCP referral to the ED (21%). Those with public insurance (odds ratio = 4.44; 95% CI 2.01 to 9.81) or no insurance/unknown insurance status (odds ratio = 4.77; 95% CI 1.34 to 17.01) were more likely to be triaged as nonurgent than those with private insurance.

CONCLUSIONS

Many adolescents in this study were triaged as nonurgent, with several participants perceiving they were acutely ill requiring immediate physician care. Further analyses revealed that private insurance was significantly associated with urgent triage status. Future studies could educate adolescents and families about appropriate use of the ED or examine PCP offices directly to determine practices for phone triage and ED referrals of adolescents.

Presentation to either the pediatric emergency department or primary care clinic for acute illness: the caregivers' perspective

OBJECTIVES

This study aimed to understand and compare caregivers' perceptions of and attitudes toward care received in a primary care clinic (PCC) versus that received in the pediatric emergency department (PED) as well as the reasons for selecting either location to receive care for their child.

METHODS

Surveys were administered to caregivers of children who receive their primary care at the same location who presented for a nonurgent sick visit to either the PCC or PED during regular PCC hours.

RESULTS

One hundred fifty-one caregivers in the PCC and 83 in the PED completed the survey. Compared with caregivers who brought their child to the PED, those who presented to the PCC were more likely to report that the child had been sick for more than 2 days (P < 0.001), indicate that the child could wait more than 3 hours to be seen (P < 0.001), have called the PCC for advice (odds ratio [OR], 5.2; 95% confidence interval [CI], 2.9-9.2), have spoken with a nurse (OR, 3.7; 95% CI, 2.0-6.7), be satisfied with their phone call to the PCC (OR, 12.2; 95% CI, 6.4-23.1), and report that they could easily get in touch with the PCC (OR, 3.6; 95% CI, 1.8-7.3). Most caregivers who went to the PCC felt that it was more convenient (98.6%) and they would be seen more quickly (95.8%).

CONCLUSIONS

Although all children had the same medical home, caregivers who presented to the PCC were more likely to have called the clinic, spoken with a nurse, and reported greater satisfaction with the PCC than those who brought their child to the PED.

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.

Factors associated with nonurgent use of pediatric emergency care among Latino families

OBJECTIVE

This study investigates Latino parents' decision to seek pediatric emergency care for nonurgent health conditions.

METHODS

Three focus groups were conducted with Spanish-speaking parents. Eligible families had a pediatric primary care provider, and their child received emergency treatment for a nonurgent health condition in the previous year. Transcripts were transcribed, translated, and thematically coded.

RESULTS

Parents shared a heightened concern about symptoms such as fever or diminished energy. Many related experiences where delay resulted in serious illness or death. Other factors included low utilization of telephone triage and long clinic wait times. Nearly every family had managed the child's illness at home prior to seeking care, employing medical and natural remedies.

CONCLUSIONS

The study findings suggest that strengthening the connection with a child's medical home, eliminating barriers to receiving primary care in urgent situations and educating parents about management of common illnesses may improve care for Latino children.

Daycaritis

Healthy infants and toddlers who attend day care centers are at increased risk for contracting common childhood illnesses such as viral upper and lower respiratory illnesses, viral gastrointestinal infections, and acute and chronic otitis media. The author proposes that this high frequency of common infections be termed daycaritis. Daycaritis imposes significant social and economic burdens on both the family and the health care system. This review describes the most common infections seen in day care attendees, preventative measures to decrease the rates of illness, and a practical approach to diagnosis and management in the emergency department.

Primary care spatial density and nonurgent emergency department utilization: a new methodology for evaluating access to care

OBJECTIVE

To determine the spatial and demographic characteristics of pediatric patients who make nonurgent visits (NUVs) to an urban pediatric emergency department (ED). We hypothesized that the rate of NUVs would be inversely associated with the spatial density of primary care providers (PCPs).

METHODS

A retrospective, cross-sectional analysis was conducted for all visits to Washington, DC's principal pediatric ED between 2003 and 2006. NUVs were defined by a unique algorithm combining resource allocation, ambulatory-sensitive diagnoses, and billing data. Multivariate linear regression analysis was used to determine the association of PCP density and demographic variables on the spatial rate of NUVs.

RESULTS

Over the 4-year period, 35.1% (52,110) of the 148,314 ED visits by Washington, DC, residents were nonurgent. NUVs were most associated with neighborhood median household income <$40,000 and low spatial density of PCPs. For every 1-unit increase in PCP density, the spatial rate of NUVs decreased by 9%. The odds of a visit being nonurgent were significantly higher for African Americans and Hispanics than for whites (odds ratio [OR] 2.4, 95% confidence interval [CI] 2.19-2.64; and OR 2.6, 95% CI 2.36-2.86, respectively), for patients using public insurance versus private (OR 1.46, 95% CI 1.42-1.50), and for patients age <5 years (OR 2.66, 95% CI 2.60-2.72).

CONCLUSIONS

Low spatial density of primary care is strongly associated with nonurgent ED utilization. Improving spatial distribution of primary care may decrease ED misuse and improve access to the medical home.

Health-Compromising Behaviors Among Young Adults in the Urban Emergency Department

Emergency departments (ED) are a point of care for many young adults and may provide a teachable moment leading to behavioral change. We determined the descriptive epidemiology of health-compromising behaviors in the young adult ED population by computing demographic-adjusted estimates of prevalence and frequency of hazardous drinking, risky driving, cigarette smoking, fast-food consumption, lack of exercise, and sleep deficit. We screened 8,815 young adults during an ED visit. Younger males had higher levels of fast-food and cigarette consumption. Non-Whites and females reported more days of little to no exercise. Whites and older individuals reported more nights of less sleep. Younger Whites reported consuming the most alcohol, with males consuming more than females. Risky driving was more frequent among younger males. Prevalence of health-compromising behaviors varied by demographics, but was higher than in the general population. Prevention strategies such as implementing a teachable moment in the ED may hold promise to reduce health-compromising behaviors.

Self-Report of Child Care Directors Regarding Return-to-Care

BACKGROUND

The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors' practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines.

METHODS

A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations.

RESULTS

A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis-antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms-physician visit (45.6%), antibiotics (10%), and symptom resolution (25%).

CONCLUSIONS

Directors' self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.

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

INTRODUCTION

The nonurgent use of the emergency department (ED) for pediatric patients is an increasing problem facing healthcare systems worldwide. To evaluate the magnitude of the phenomenon and to identify associated factors, an observational prospective survey was performed including all patients (<15 years) attending the ED in 12 Belgian hospitals during 2 weeks in autumn 2010. Use of ED was considered appropriate if at least one of the following criteria was met: child referred by doctor or police, brought by ambulance, in need for short stay, technical examination or orthopedic treatment, in-patient admission, or death. Among the 3,117 children, attending ED, 39.9 % (1,244) of visits were considered inappropriate. Five factors were significantly associated with inappropriate use: age of child, distance to ED, having a registered family doctor, out-of-hours visit, and geographic region. The adjusted odds ratio and 95 % confidence intervals are respectively-1.7 (1.3-2.0), 1.7 (1.3-2.2), 1.5 (1.1-2.2), 1.5 (1.2-1.9), and 0.6 (0.5-0.8).

CONCLUSIONS

Almost 40 % of all paediatric ED attendances did not require hospital expertise. The risk of an inappropriate use of ED by pediatrician patients is predominantly associated with organizational and cultural factors. Access, equity, quality of care, and medical human resources availability have to be taken into account to design financially sustainable model of care for those patients. Furthermore, future research is needed to explain reasons why parents visit ED rather than using of primary-care services.

Comparison of primary physician patterns of and attitudes on emergency department use

OBJECTIVE

This study aimed to compare physician viewpoints and clinic patterns between primary care providers (PCPs) with high patient emergency department (ED) use (HU) and PCPs with low patient ED use (LU).

METHODS

We conducted a mixed methods descriptive study of quantitative and qualitative data of 22 practices. We compared admission rates, American Academy of Pediatrics guideline adherence, efficiency, medical complexity, and patient satisfaction. Primary care provider interviews regarding ED use practices and perspectives were coded and inductively analyzed using Atlas 6.0 for themes.

RESULTS

Compared with LU, the HU group had a higher admission rate (92 vs 41 admissions per 1000 members, P = 0.005), lower scores in adherence to American Academy of Pediatrics guidelines, and higher scores in satisfaction overall. There were no significant differences in efficiency, medical complexity, PCP communications, timeliness for appointment, satisfaction with after-hour care or likelihood of PCP referral. All PCPs described the EDs' purpose as for things they "cannot handle." The LU group was more likely to identify the ED for emergencies, whereas the HU group had a broader, more ambiguous definition of what they "cannot handle," with parental anxiety identified as a significant factor. In addition, the LU group recognized the need for more parental education about ED use.

CONCLUSIONS

Primary care providers with low patient ED use were more likely to describe the EDs' purpose as being for emergencies and to recognize a need for more parental education about the use of the ED. All physicians struggled with reassuring parents.

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

OBJECTIVES

This study was designed to develop a descriptive profile of parents and caregivers who bring their children to the emergency department (ED) for nonurgent issues and to explore the reasons for presenting to an urban hospital pediatric ED for nonurgent conditions. Such work is necessary to develop effective interventions.

METHODS

A total of 106 parents/caregivers whose child was triaged with a nonemergent/urgent condition completed a 15- to 20-minute computerized survey (English and Spanish) in an urban pediatric ED.

RESULTS

Most respondents described themselves as Latino (76%) and foreign born (62%). About one half (49%) reported having an annual income of less than $20,000, and 43% of respondents did not have health insurance for themselves. Almost all (95%) of the index children had a primary care physician and health insurance. Despite being triaged as nonurgent, more than one half (63%) described their child's condition as "very" or "extremely" urgent. About one half of the respondents reported not receiving basic information on childhood illnesses from their child's physician. Reasons for nonurgent visits seemed to revolve around issues of convenience and perception of quality of care.

CONCLUSIONS

Interventions should focus on health literacy and ensure that parents are provided relevant and accurate education on pediatric illnesses and common safety concerns; by increasing parental education on pediatric health, parents may be better able to assess acuity of their child's health issues.