Revisiting predictors of parental health care-seeking behaviors for nonurgent conditions at one inner-city hospital

Caregiver alignment with triage acuity levels and drivers for discrepancy between caregiver assessment and triage acuity levels: a cross-sectional questionnaire based study

BACKGROUND

Caregiver concern is the main driver to paediatric emergency departments visits. Understanding caregiver worries is crucial to guide patients to the most appropriate healthcare setting. Previous research shows mixed findings on the accordance between caregiver assessment and professional triage.

METHODS

We assessed data from two questionnaire-based studies conducted over 27 months in two tertiary paediatric emergency departments in Switzerland to compare caregiver perception of their child's medical acuity and standard nurse triage. Furthermore, we examined socioeconomic factors associated with caregiver perception.

RESULTS

Our study of 2,126 children seen in the two paediatric emergency departments showed that caregiver assessment aligned well with the acuity assigned by professional triage in 89% (1,901/2,126) of cases. In 142 cases (7%, 142/2,126), caregivers rating their child's severity higher than nurse's triage while in 83 cases (4%, 83/2,126), they rated it lower. In an univariable analysis, we found that family's difficulties paying bills (20% vs. 12%) and low maternal education (19% vs. 10%) were associated with a higher percentage of caregiver rating their child's severity higher than nurse's triage. Fever as the main complaint was associated with caregiver rating their child's severity lower than nurse's triage.

CONCLUSIONS

This questionnaire-based study shows that caregiver's assessment of the severity of the child and nurse triage are concordant in most situations. Our study sheds light on the association between caregiver assessment and professional triage in two paediatric emergency departments in Switzerland, revealing some of the factors leading to discordance. These factors most probably reflect health illiteracy. It is important that healthcare professionals recognize and address factors influencing caregiver assessments to facilitate accurate decision-making and enhanced paediatric emergency care outcomes.

Sport culture and communication among middle school athletes, parents, and staff: A qualitative study

Middle school (MS) is an intermediary level of education between elementary and secondary school that typically includes students aged 10-15 years. There is limited research within the MS sport setting, particularly related to sport-related injury prevention. This qualitative study aimed to better understand the sport culture within MS sports and the communication strategies used among invested groups (i.e., athletes, parents, staff inclusive of coaches and school nurses). Semi-structured interviews were conducted with 19 athletes, 20 parents, and 18 staff (e.g., coaches, school nurses) from seven MS in two school districts during the 2018/19 and 2019/20 school years. Topics focused on understanding school- and sport-related factors related to education, safety, and communication. Analysis used a consensual qualitative research tradition, in which the research team discussed individually developed themes and categories from transcribed interviews, with the goal of coming to a consensus and creating a codebook. Throughout the coding process, the research team would reconvene to discuss coding decisions until consensus was reached. This study focuses on the themes of sport culture and communication. Dominant categories identified within sport culture related to participants noting why they were interested in MS sports, and their struggles with their perceived roles and engagement (e.g., helping parents stay engaged, finding coaches, oversight of school nurses). Competitiveness and safety could have conflicting roles and priority. Dominant categories identified within communication centered around limited communication between coaches and parents. Technological assistance (e.g., phone apps, websites) was available, but often varied by school and sport. Concussions were seldom discussed unless during the preseason meeting or when one occurred. Findings highlight that the MS sport settings may struggle with incorporating primary prevention into their cultures and ensuring reliable communication among individuals. Novel and tailored approaches to injury prevention are needed to help ensure buy-in and proper implementation.

Use of sport-related concussion information sources among parents of United States middle school children

OBJECTIVE

Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school children (age: 10-15 years).

METHODS

A panel of 1083 randomly selected U.S. residents, aged ≥18 years and identifying as parents of middle school children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (95%CIs) excluding 1.00 were deemed significant.

RESULTS

Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized ≥1 of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (OR_adjusted) = 1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (OR_adjusted = 1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (OR_adjusted = 0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (OR_adjusted = 0.64, 95%CI: 0.44-0.93) were lower among parents whose middle school children had concussion histories versus the parents of children who did not have concussion histories.

CONCLUSION

One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with underutilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information.

Burden of Pediatric Functional Gastrointestinal Disorder in an Emergency Department-A Single-Center Experience

OBJECTIVES

Functional gastrointestinal disorders (FGIDs) are recurrent or chronic gastrointestinal signs and symptoms in the absence of anatomical or biochemical alterations. They are commonly treated in outpatient setting but often present to emergency departments. We aimed to estimate the burden of pediatric FGID on a busy accident and emergency (A&E) department.

METHODS

Electronic patient records were used to retrospectively analyze the A&E attendances of 3866 patients presenting with either constipation or abdominal pain. Those found not to have a surgical/organic cause were assessed in terms of various parameters, that is, arrival times, wait times, and investigations performed.

RESULTS

A total of 91.31% of the attendances relating to constipation or nonsurgical, nonorganic causes of abdominal pain were self-referred with only 3.64% arriving via ambulance, an average wait time ranging between 138 and 156 minutes, and a total of 1008 investigations carried out on patients presenting with these symptoms. A total of 63.65% of the patients were discharged without follow-up.

CONCLUSIONS

Functional gastrointestinal disorders place considerable burden on the A&E, in terms of resource usage, time of clinicians, and financial strain. More education should be provided to families of those experiencing FGID in an outpatient setting to minimize A&E resource utilization. More research is needed to ascertain the true burden of FGIDs, both financially and in terms of time and resource.

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.

Healthcare utilisation and unmet health needs in children with intellectual disability: a propensity score matching approach using longitudinal cohort data

BACKGROUND

Health disparities for children with intellectual disabilities can be challenging to measure due to many other factors that can impact health and healthcare use. The aim of the current study was to use longitudinal cohort data to compare children with intellectual disability (ID) in Ireland between 2006 and 2014 on healthcare utilisation and unmet need, at ages 9 and 13, using a propensity score matching (PSM) approach.

METHODS

Using data from the Growing up in Ireland study, PSM was used to identify an appropriate control sample to compare with a sample of children with ID (n = 124). Participants were matched on variables that are known to influence healthcare utilisation to reduce the impact of confounding variables between groups so that differences between the groups can be estimated. Logistic regression was used to estimate effects at ages 9 and 13.

RESULTS

Children with ID were no more likely to have visited a general practitioner or emergency department in the past 12 months than children without ID. They did have a greater likelihood of visiting a doctor in a hospital in the past 12 months and of having an overnight stay in hospital by age 9. Primary caregivers of children with ID were more likely to report unmet health needs at ages 9 and 13.

CONCLUSIONS

This approach is a novel means of comparing healthcare use in this population by balancing the impact of other factors that may result in inequities, to which children with ID may be more vulnerable.

Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits

INTRODUCTION

Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits.

METHODS

This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables.

RESULTS

We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission.

CONCLUSIONS

In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.

Common diagnoses among pediatric attendances at emergency departments

BACKGROUND

Pediatric patients present to Emergency Departments (EDs) with a variety of medical conditions. An appreciation of the common presenting conditions can aid EDs in the provision of pediatric emergency care. In this study, we established the common pediatric diagnoses seen at the general EDs, with reference to a pediatric ED.

METHODS

A retrospective review of medical records was performed for patients less than 16 years old at a pediatric ED and two general EDs from 1 January to 31 December 2018. Information including patient demographics, triage category, case type and diagnoses were collected.

RESULTS

There were 159,040 pediatric attendances, of which 3477 (2.2%) were seen at the general EDs. Non-traumatic conditions were most prevalent at both general (N = 1933, 55.6%) and pediatric (N = 128,415, 82.5%) EDs. There was a higher proportion of trauma related conditions seen at the general EDs (N = 1544, 44.4%) compared to the pediatric ED (N = 27,148, 17.5%; p < 0.01). Across all EDs, upper respiratory tract infection, unspecified musculoskeletal pain and gastroenteritis were the three most common non-trauma related diagnoses, while fracture, wound and contusion were the three most common trauma related diagnoses. There was a greater proportion of emergent (P1) cases seen at the general EDs (N = 233, 6.7%) than the pediatric ED (N = 3821, 2.5%; p < 0.01). Respiratory conditions including bronchiolitis, asthma and bronchitis were the most common emergent (P1) diagnoses.

CONCLUSIONS

The common diagnoses among pediatric attendances varied between pediatric and general EDs. Therefore, general EDs should focus their efforts on these common diagnoses, especially the emergent (P1) ones, so that they can enhance their preparedness and work towards providing quality pediatric emergency care.

Comparing prevalence estimates of concussion/head injury in U.S. children and adolescents in national surveys

BACKGROUND AND OBJECTIVES

Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection.

METHODS

Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health, the National Health Interview Survey, and the Monitoring the Future Survey were examined. Children were grouped by ages 3-17 years and adolescent ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH and NHIS) and adolescents (MTF survey). The primary outcome measure is an estimate of LCHI in children.

RESULTS

Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language.

CONCLUSIONS

Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

Association of Insurance With Use of Emergency Medical Services Among Children

OBJECTIVE

The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED).

METHODS

In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings.

RESULTS

Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results.

CONCLUSIONS

In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

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.

Using opinion leaders to address intervention gaps in concussion prevention in youth sports: key concepts and foundational theory

Behavioral interventions to increase disclosure and proper management of concussion in youth sports have unrealized potential when it comes to preventing concussion. Interventions have focused on changing individual athlete behavior and have fallen short of the potential for sustained systemic behavioral change. One potentially critical reason for this shortfall is that other key determinants of risk behaviors at all levels of the socio-ecological model (e.g. interpersonal, community, policy) are not addressed in extant programming. There is a critical need for theory-driven interventions that address concussion prevention and education at the community level and target sustainable culture change. The Popular Opinion Leader (POL) intervention, a multi-level intervention model previously successfully employed in multiple public health contexts, is theoretically well positioned to affect such change. POL is based on the Diffusion of Innovations framework and involves identifying, recruiting, and training well-respected and trusted individuals to personally endorse prevention and risk-reduction within their social networks. Critical behavioral changes related to concussion disclosure and management have been shown to diffuse to others if enough opinion leaders endorse and support the behaviors. This article summarizes the concepts and principles of POL and describes how it could be adapted for and implemented in youth sport settings. For optimal impact, POL needs to adapt to several factors unique to youth sports settings and culture. First, adult involvement may be important, given their direct involvement in the athlete's medical care. However, parents and coaches' opinions on injury care-seeking, competition, and safety may affect their perceptions of POL. Second, youth sports are structured settings both physically and socioculturally. Games and practices may provide opportunities for the informal interactions that are critical to the success of POL. However, youth sport setting membership is transient as players get older and move to other sport settings; POL approaches need to be self-sustaining despite this turnover. Moreover, stakeholder value placed on athlete development and competition, alongside safety, must be considered. Formative research is needed to ensure that POL principles are translated into the youth sport setting while maintaining fidelity to the concepts and principles that have made POL successful for other health outcomes.

Utilization of Antipyretics for Nonurgent Fever in a Pediatric Emergency Department

This retrospective cohort study aimed to describe antipyretic use among healthy patients in a pediatric emergency department (ED) with nonurgent fever defined as: triage level 4 or 5, chief complaint fever or temperature 38°C to 39°C, and otherwise normal vital signs, and determine if antipyretic administration is associated with increased ED length of stay (LOS). We compared continuous variables using Kruskal-Wallis and Wilcoxon rank sum testing. We adjusted confounding variables using logistic regression modeling. A total of 22 169 patients were included. Of these, 52% received antipyretic: acetaminophen (38%), ibuprofen (19%), or both antipyretics (5%). ED LOS (median hours) varied by number of antipyretic types given (none, 2.2; ibuprofen, 2.7; acetaminophen, 2.7; and both 3.4, P < .001) and number of doses (0 doses, 2.2, 1 dose, 2.7; 2 doses, 3.4, P < .001). Patients who received antipyretic were more likely to have ED LOS greater than 2 hours (adjusted odds ratio 1.99, 95% CI 1.88-2.11) compared with those with no antipyretic, controlling for age, imaging studies, laboratory studies, antibiotic administration, and disposition.

Severity of Oral Mucositis in Children following Chemotherapy and Radiotherapy and Its Implications at a Single Oncology Centre in Durango State, Mexico

BACKGROUND

Mucositis is an adverse effect of chemotherapy (QT) and/or radiotherapy (RT). The purpose of this study was to investigate the occurrence of oral mucositis in children undergoing cancer treatment.

METHODS

Fifty-one children with cancer who had received QT, RT, or both (QT-RT) underwent clinical evaluations; World Health Organization criteria were used to establish the degree and severity of mucositis. The correlations between the clinical data, type of cancer, and therapy were statistically analysed.

RESULTS

Mucositis was present in 88.23% of the patients; 57.78%, 7.78%, and 24.44% received QT, RT, and QT-RT, respectively. Severity scores of 1 and 2 were the most common; scores of 3-4 were observed in patients who received QT-RT or more than 7 treatment cycles. There was a significant association between mucositis, the type of treatment, and the number of cycles received (p < 0.05).

CONCLUSION

It is important to implement therapeutic protocols that help maintain excellent oral health and reduce the risk of oral mucositis. Stomatologists should be consulted to assess patients' oral cavities and provide preventive treatment prior to QT and/or RT administration. It is important to integrate a stomatologist into the oncological working group to focus on preventing and managing oral mucositis.

An investigation of factors related to the use of respite care services for children with severe motor and intellectual disabilities (SMID) living at home in Japan

Limited time away from the child is cited as the main factor that increases the burden for the primary caregiver of severely disabled children. The aim of this study was to quantitatively elucidate the factors related to the desire to use social services and the actual use of respite care services by the primary caregivers of severely disabled children in Japan. In this study, we investigated the use of respite care services in accordance with the primary caregivers' wishes by examining inhibiting or promoting factors associated with respite care service use only among those who wished to use social services. A total of 169 Japanese mothers participated and answered the questionnaires. We conducted a logistic regression analysis and a multiple regression analysis to investigate the factors related to respite care service use. The most important factors affecting a primary caregiver's desire to use social services were the belief that the child would enjoy using social services and the family's approval of the social service use. The most important factors affecting respite care service use were the family's approval of the use and a large care burden on the primary caregiver. Respite care services should be sought out before the care burden becomes too great to enable the primary caregiver to more easily contribute to the continuation of home care. A background of mother-child separation anxiety disrupted the use of respite care. However, believing that the child enjoys using social services may reduce primary caregivers' psychological resistance to being separated from their child, which is supported by tradition. Thus, it is also important for respite care service providers to provide information about the children to their primary caregivers and families while they are using respite care services.

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.

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).

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.

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.

The impact of limited English proficiency on asthma action plan use

OBJECTIVE

The goal of this study was to compare rates of asthma action plan use by limited English proficiency (LEP) caregivers to English proficient (EP) caregivers.

METHODS

A cross-sectional bilingual survey was distributed at an urban, academic, pediatric emergency department (PED). Surveys were completed by adult caregivers of children with asthma who sought PED care for asthma related chief complaints. LEP was defined as caregiver ability to speak English less than "very well". Data were analyzed using Fisher's exact test and odds ratios (OR).

RESULTS

One hundred seven surveys were completed and analyzed. Fifty-one surveys (48%) were completed by LEP caregivers and 56 (52%) by EP caregivers. A 25% difference (p = .01) in action plan use rates between LEP caregivers (39%) and EP caregivers (64%) was observed. EP alone was associated with action plan use (OR 2.8 [95% CI 1.3-6.1]). Variables not associated with plan use included mother acting as caregiver (OR 2.1 [95% CI 0.7-7.0]), age of child >7 years (OR 1.0 [95% CI 0.5-2.4]), caregiver education  ≥  associate degree (OR 1.4 [95% CI 0.6-3.0]), private insurance (OR 0.7 [95% CI 0.3-1.8]), White race (OR 0.7 [95% CI 0.2-2.2]), Latino ethnicity (OR 0.5 [95% CI 0.2-1.3]) and a federally qualified health center (OR 0.8 [95% CI 0.3-2.0]). The main caregiver reasons for plan use were feeling that a plan works/gets results, helps with symptom management and appreciation towards physician attentiveness when a plan is prescribed. The main caregiver reasons for non plan use were they were not informed/given an action plan or perceived the child's asthma as mild/well controlled.

CONCLUSION

Compared with EP caregivers, those with LEP experience disparate rates of asthma action plan use.

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.

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.

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.

Mother-child interactions and the associations with child healthcare utilization in low-income urban families

Studies have demonstrated that low-income families often have disproportionately high utilization of emergency department (ED) and hospital services, and low utilization of preventive visits. A possible contributing factor is that some mothers may not respond optimally to their infants' health needs, either due to their own responsiveness or due to the child's ability to send cues. These mother-child interactions are measurable and amenable to change. We examined the associations between mother-child interactions and child healthcare utilization among low-income families. We analyzed data from the Nurse-Family Partnership trial in Memphis, TN control group (n = 432). Data were collected from child medical records (birth to 24 months), mother interviews (12 and 24 months postpartum), and observations of mother-child interactions (12 months postpartum). We used logistic and ordered logistic regression to assess independent associations between mother-child interactions and child healthcare utilization measures: hospitalizations, ED visits, sick-child visits to primary care, and well-child visits. Better mother-child interactions, as measured by mother's responsiveness to her child, were associated with decreased hospitalizations (OR: 0.51; 95% CI: 0.32, 0.81), decreased ambulatory-care-sensitive ED visits (OR: 0.65, 95% CI: 0.44, 0.96), and increased well-child visits (OR: 1.55, 95% CI: 1.06, 2.28). Mother's responsiveness to her child was associated with child healthcare utilization. Interventions to improve mother-child interactions may be appropriate for mother-child dyads in which child healthcare utilization appears unbalanced with inadequate primary care and excess urgent care. Recognition of these interactions may also improve the care clinicians provide for families.

Child, caregiver, and family characteristics associated with emergency department use by children who remain at home after a child protective services investigation

OBJECTIVES

To examine emergency department (ED) use among children involved with child protective services (CPS) in the US but who remain at home, and to determine if ED use is related to child, caregiver and family characteristics as well as receipt of CPS services.

METHOD

We analyzed data on 4,001 children in the National Survey of Child and Adolescent Well-being. Multivariate models compared rates of ED use for whether the family received CPS services or did not receive CPS services as well as child characteristics, caregiver characteristics and caregiver/family psychological variables.

RESULTS

ED use among children who remained at home receiving CPS services was similar to that of children who did not receive CPS services (35.6% and 37.4%, respectively). In multivariate modeling, children with families who received CPS services, children 6 years or older, and children without a chronic health problem were less likely to use the ED. Children who remained at home in families identified with numerous stressors and, therefore, likely at high risk for future abuse and neglect were 1.73 times (95% CI, 1.14-2.63) more likely to have repeat ED use than children in low risk families.

CONCLUSION

Children who remain at home after a CPS evaluation are at high risk for ED use. Future research should focus on the health problems that precipitate an ED visit as well as the relationship between primary care and ED use.

Nonurgent emergency-department care: analysis of parent and primary physician perspectives

OBJECTIVE

To better understand parental decisions to seek care for their children and physician perceptions of parents' decisions to seek nonurgent emergency-department care.

PATIENTS AND METHODS

In-depth interviews of 26 parents of children and 20 primary care physicians of the same children presenting for nonurgent care at a children's hospital emergency department were completed. Parent accounts of events that preceded the emergency-department visit were coded and qualitatively analyzed for themes. Physician evaluations of the accounts of events and parental decisions were ascertained through interviews with primary care physicians, who also described their practice characteristics. The parent/physician analyses allowed for an investigation of all aspects of the child's care and were designed to reveal differences between parent and physician beliefs.

RESULTS

Parents believed that they acted appropriately, and physicians approved of parents' decisions. Four main themes emerged: (1) immediate reassurance that their children are safe from harm is critical to parents' decisions; (2) primary care offices lack specific tests and treatments that parents and physicians believe may be necessary, regardless of whether they are actually needed; (3) discrepancies exist between physician and parent perceptions of adequate communication and access; and (4) nonurgent emergency-department visits are not perceived as a significant enough breach in continuity of care by physicians and parents to warrant any concern.

CONCLUSIONS

When individual interviews were evaluated, neither parents nor primary care physicians saw nonurgent emergency-department visits as a significant enough problem to warrant any change in physician care practices or parent care-seeking behavior.

The impact of race and ethnicity on care in the pediatric emergency department

PURPOSE OF REVIEW

To review healthcare disparities encountered by pediatric patients in the emergency department. The discussion focuses on recent research that is relevant to the field of pediatric emergency medicine.

RECENT FINDINGS

The majority of recent research focuses on healthcare disparities affecting black and Hispanic children and adolescents. Disparities are identified in the areas of emergency department utilization, the provision of effective interpreter services, and the epidemiology and management of specific illnesses, including asthma, adolescent sexual health, and mental health. The findings suggest that disparities persist after controlling for socioeconomic factors and that the effect on healthcare outcomes is measurable. Interventions to mitigate healthcare disparities have shown mixed results. There is some evidence that disparity reduction is possible.

SUMMARY

Recent research demonstrates that healthcare disparities exist in several areas affecting the delivery of quality pediatric emergency care. These disparities are shaped by a complex interaction of social, cultural, behavioral, educational, and financial factors. More research is needed to increase the body of knowledge as to why disparities exist. The success of this future research may require an interdisciplinary approach incorporating experts from multiple scientific fields.