Organisation et moyens de l’accueil des urgences pédiatriques : enquête nationale française en 2008

Pediatric emergency room visits for neurological conditions: Description and use of pediatric neurologist advice

INTRODUCTION AND OBJECTIVE

Information on the spectrum and frequencies of pediatric neurological presentations to emergency departments is vital to optimize quality of care. The objective of this study was to determine the incidence of pediatric neurological emergencies and to analyze the impact of specialist neurological advice in emergency care.

PATIENTS AND METHODS

We performed a retrospective descriptive study of pediatric emergency room visits for neurological reasons at the Timone University Hospital in Marseille over a 6-month period (from October 2017 to March 2018).

RESULTS

Of the 14,572 emergencies analyzed, 370 (2.5%) were for neurological conditions. These were most commonly seizures (56.7% of cases), headache (19.7%), and motor or sensory deficits (5.1%). The most frequent diagnosis was epileptic seizure (30%), followed by febrile seizure (26.1%) and migraine (15%). Around two in every five patients (37.6%) required hospitalization. Neurological emergencies requiring critical care occurred at a frequency of about one per month (1.6% of cases). A pediatric neurologist was consulted in 37.3% of cases, resulting in a modification of the diagnosis or treatment in 66% of these referrals.

CONCLUSION

The results of this study suggest that a formal referral system between the emergency department and pediatric neurologists would be useful.

Pediatric Readiness in the Emergency Department and Its Association With Patient Outcomes in Critical Care: A Prospective Cohort Study

OBJECTIVES

Pediatric mortality in Latvia remains one of the highest among Europe. The purpose of this study was to assess the quality of pediatric acute care and pediatric readiness and determine their association with patient outcomes using a patient registry.

DESIGN

This was a prospective cohort study. Pediatric readiness was measured using the weighted pediatric readiness score based on a 100-point scale. The processes of care were measured using in situ simulations to generate a composite quality score. Clinical outcome data-including PICU and hospital length of stay as well as 6-month mortality-were collected from the Pediatric Intensive Care Audit Network registry. The associations between composite quality score and weighted pediatric readiness score on patient outcomes were explored with mixed-effects regressions.

SETTING

This study was conducted in all Latvian Emergency Departments and in the national PICU.

PATIENTS

All patients who were transferred into the national PICU were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All (16/16) Latvian Emergency Departments participated with a mean composite quality score of 35.3 of 100 and a median weighted pediatric readiness score of 31 of 100. A total of 254 patients were included in the study and followed up for a mean of 436 days, of which nine died (3.5%). Higher weighted pediatric readiness score was associated significantly with lower length of stay in both the PICU and hospital (adjusted ß, -0.06; p = 0.021 and -0.36; p = 0.011, respectively) and lower 6-month mortality (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98).

CONCLUSIONS

These data provide a national assessment of pediatric emergency care in a European country. Pediatric readiness in the emergency department was associated with patient outcomes in this population of pediatric patients transferred to the national PICU.

Descriptif de l'activité des structures des urgences en Île-de-France à l'aide du questionnaire « National Emergency Department Inventory » (NEDI) appliqué au système français

Introduction : La base de données NEDI (National Emergency Department Inventory) repose sur un descriptif de l'activité des structures des urgences (SU). Elle rend compte de la diversité de ces structures au niveau national et international. L'objectif de cette étude NEDI-Paris était de décrire l'organisation des SU en Île-de-France et les moyens à disposition, selon le statut public ou privé.

Méthode : Les SU ouvertes 24 heures/24 et 7 jours/7 ont été inclus. Un questionnaire comprenant 29 items a permis de recueillir les caractéristiques de ces services et les données relatives à l'activité de l'année 2015. Un taux de participation de 80 % était souhaité dans le cadre des enquêtes NEDI pour assurer une exhaustivité des résultats.

Résultats : Sur 117 services éligibles, 97 ont participé à l'étude, soit un taux de réponse de 83 %. L'ensemble de ces services était localisé dans des établissements hospitaliers. Le service était sur un seul site géographique dans 86 % des cas. Le nombre annuel médian de visites était de 34 000 (interquartile : 23 000–56 000). Soixante-six centres (68 %) appartenaient au système public, dont 22 centres universitaires et 31 centres (32 %) étaient des services privés. Les urgences adultes, pédiatriques et mixtes représentaient respectivement 54, 26 et 20 % de l'offre de soins. Un temps d'attente inférieur à une heure était rapporté par 25 % des services : 42 % pour les services privés versus 17 % dans le public (p = 0,01). Un taux d'hospitalisation inférieur à 20 % était rapporté par 54 % des centres, similaire entre public et privé (60 vs 50 % ; p = 0,40). Parmi les services interrogés, 22 % ont déclaré fonctionner en surcharge, plus fréquemment dans le public comparativement aux services privés (27 vs 10 %). La gestion 24 heures/24 et 7 jours/7 de certaines pathologies de même que la disponibilité de certains spécialistes étaient le plus souvent observées dans les hôpitaux publics, notamment universitaires.

Conclusion : L'enquête NEDI en Île-de-France a montré une hétérogénéité dans les caractéristiques et les moyens à disposition des SU. Un déterminant majeur de ces disparités repose sur le statut public versus privé. Une réflexion peut être menée à partir de ces résultats.

[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.

[A short track to relieve pediatric emergency department overload]

INTRODUCTION

The number of emergency pediatric consultations continues to rise in France. The pediatric emergency department (PED) introduced relocated consultations (RlCs) for unwarranted visits to relieve the overload of emergency medical consultations. The objective of this study was to assess the advantages of implementing these RlCs.

METHODS

A single-center prospective study was undertaken from 21st January to 18 March 2012, with RlCs opened on weekends from 1 to 8 pm in the PED of the Nice Lenval University Hospital Center. All children referred for medical reasons during this period were included. One out of two children labeled stage 5 were transferred to the RlCs. The data evaluated were waiting time, duration of the medical consultation, transit time, and patient and medical staff satisfaction.

RESULTS

Eight hundred and seventy-five patients were included. All patients in stages 1-2, 3, 4, and 5, relocated or not, had a mean waiting time before the medical consultation lasting 39.1, 57.7, 54.8, 70.5, and 52.7 min, respectively. The mean duration of the medical consultation was longer for stages 1-2 (61.6 min). The total time spent in the PED did not differ between stage 5 patients who were not relocated (121.3 min) and stages 1-2 (118 min), but both were longer than stage 5 patients who were relocated (90.3 min). Patients and medical staff expressed overall satisfaction during this period.

DISCUSSION

By relocating one out of two stage 5 children, waiting times and consultation times decreased for all patients consulting at the PED. These results confirm that implementing RlCs has improved working conditions and quality of patient management.

Effectiveness of multifunction paediatric short-stay units: a French multicentre study

AIM

To describe the characteristics of the activities of multifunction paediatric 'short-stay units' (SSU) including observation unit (OU), medical assessment and planning unit (MAPU) and holding unit (HU), to evaluate their effectiveness and to explore predictors of inappropriate admissions for OU patients.

METHODS

Admissions to nine French paediatric SSUs were analysed. The main outcome measures were SSU length of stay with associated outcome for all patients and appropriate admission rate for OU patients.

RESULTS

Of 1084 patients included in the study, 66% were OU patients (n = 718), 21% MAPU patients (n = 225) and 13% HU patients (n = 141). The OU patients constituted the majority of the SSU admissions. The appropriate OU admission rates ranged from 52% to 86%. Head trauma and seizure were the conditions with the highest appropriate OU admission rates (82%). Age <1 year, and need for IV fluids or medications, CT-Scan or MRI and cardiorespiratory monitoring were associated with an increased risk of inappropriate OU admission. Eighteen per cent of the MAPU patients and 5% of the HU patients were discharged home within 24 h.

CONCLUSION

By providing extended and easily available facilities for diagnostics and early treatment for a wide range of sick children, the French paediatric SSU is an effective model for 'observation medicine' in emergency department-managed units. The experience and principles may be applicable to similar units in other health care systems.