Maternal Confidence and Emergency Department Utilization Among Infants

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport

OBJECTIVES

Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol.

METHODS

We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight.

CONCLUSIONS

EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Pediatric ED Utilization in a Destination City: Demographic, Clinical, and Temporal Trends

OBJECTIVES

Seasonal variation in emergency department (ED) visits has been shown for a variety of pediatric conditions, but previous studies have not considered how geographic location may also influence when and why these patients present to the ED. Our study examined the demographic and clinical characteristics as well as the seasonal variation among 3 patient populations (locals, in-state nonlocals, and out-of-state visitors) presenting to our pediatric ED (PED), which is located in a coastal, destination city.

METHODS

This was a retrospective chart review of PED visits from June 2014 to June 2019 at the Medical University of South Carolina Children's Hospital, a tertiary care facility located in Charleston, SC. Pediatric ED encounters were divided into 3 groups, depending on the patient's home address: local patients residing in the 3 surrounding metro counties, in-state but nonlocal patients, and out-of-state patients. Demographic and clinical information was abstracted for each visit and compared among the 3 patient groups. Seasonal variation among PED visits was determined by recording the week of the year during which each visit occurred.

RESULTS

Local patients accounted for more than 90% of PED visits with increases in visits from October to April. In-state nonlocal patients presented at consistent rates throughout the year, whereas out-of-state ED utilization peaked significantly during the summer months, Spring Break, Thanksgiving, and Christmas. Our local patient population was majority African American; our in-state nonlocal patients roughly matched our state's racial demographics, and our out-of-state population was predominantly White. Compared with in-state nonlocal patients, our local patients were more likely to present with an infection-related complaint and be diagnosed with lower-acuity conditions such as viral infection, otitis media, upper respiratory infection, cough, fever, and gastroenteritis. In-state nonlocal patients had the highest average triage acuity, more frequently had laboratory tests and imaging ordered, and were more than 4.5 times as likely to be admitted to the hospital compared with our local patients. In-state nonlocal patients were also more likely to present with a psychiatric chief complaint compared with our local patients. Out-of-state patients had a similar overall acuity to local patients but were more likely to have imaging ordered and be diagnosed with injuries such as fractures.

CONCLUSION

At our institution, local patients, in-state nonlocal patients, and out-of-state patients exhibited 3 distinct patterns of PED utilization. Knowledge of these trends can be used to optimize resource allocation and follow-up planning, particularly for our out-of-state patient population.