Why Do Parents Bring Their Children to the Emergency Department? A Systematic Inventory of Motives

Reframing the Narrative: An Exploratory Study of the Concerns, Expectations and Experiences of Parents Who Bring Their Child to an Emergency Department with Non-Urgent Illness

Parenthood inevitably includes caring for a child suffering from mild-moderate illness requiring access to health care. Most childhood illnesses can be managed in the community, and parents are encouraged to attend the most suitable primary care service for their needs. Yet the number of children visiting emergency departments with non-urgent illness continues to rise annually, with child attendance representing over 25% of the total workload. This study investigated why parents chose to bring their child to an emergency department and explored the concerns, expectations and experiences of parents when making this decision. Parents of children aged 0-16 years presenting with non-urgent conditions were approached over an 18-month period to participate. Prior to discharge, focused interviews were used to explore the antecedent decision-making factors leading up to attendance, and parents' experiences of urgent care were explored. Parents often experienced complex journeys prior to attending the emergency department following multiple health care contacts and referrals from other providers. For most parents, attending the department was a considered decision, often prompted by their experience of interaction with professionals. Health professionals were powerful agents controlling resources and knowledge, but they were influenced by pressures and targets within the health service. The NHS is a complicated system that parents tried to navigate, but they were thwarted by its complexity and conflicting messages. When their child was unwell parents wanted a service that was simple to access, and that would offer a standard of care that would reassure and empower them to continue to care for their child. The findings challenge assumptions that lead nurses to criticize parents for misuse of emergency care, and highlight the culpability of health professionals and systems in generating increased demand for urgent care. It is important for nurses and others to reframe their perception of parental decision-making.

Children accessing accident and emergency department for non-urgent consultations: A cross-sectional study about parents' use of primary care services

INTRODUCTION

Parents often take their children to the Paediatric Accident and Emergency Department (A&E) for non-urgent consultations rather than using community-based primary care services. This study describes the use of primary care services in parents taking their children to the A&E for non-urgent consultations.

METHODS

A cross-sectional study was conducted from July 2018 to June 2019, in a second-level Italian paediatric A&E of a tertiary-level children's academic research and hub hospital. Parents of children aged between 3 months and 6 years assigned with a white code at the triage were asked to complete a paper-and-pencil 40-item questionnaire after accessing the A&E for a non-urgent consultation.

RESULTS

The questionnaire was completed by the parents of 237 children (males 58 %; median age = 2.3 years). Overall, 48.1 % (n = 114) of the parents reported consulting 'often/always' the primary care paediatrician, mainly when their child was sick and for check-ups (n = 182, 76.8 %). However, only 7.2 % (n = 17) of the parents 'often/always' used any other health service in the community. Most of them (n = 191, 82 %) did not even know where the community health centre was located.

CONCLUSION

Parents accessing the A&E for non-urgent consultations should be better informed/educated on how to use community health services.

Clinical decision support system in emergency telephone triage: A scoping review of technical design, implementation and evaluation

OBJECTIVES

Emergency department overcrowding could be improved by upstream telephone triage. Emergency telephone triage aims at managing and orientating adequately patients as early as possible and distributing limited supply of staff and materials. This complex task could be improved with the use of Clinical decision support systems (CDSS). The aim of this scoping review was to identify literature gaps for the future development and evaluation of CDSS for Emergency telephone triage.

MATERIALS AND METHODS

We present here a scoping review of CDSS designed for emergency telephone triage, and compared them in terms of functional characteristics, technical design, health care implementation and methodologies used for evaluation, following the PRISMA-ScR guidelines.

RESULTS

Regarding design, 19 CDSS were retrieved: 12 were knowledge based CDSS (decisional algorithms built according to guidelines or clinical expertise) and 7 were data driven (statistical, machine learning, or deep learning models). Most of them aimed at assisting nurses or non-medical staff by providing patient orientation and/or severity/priority assessment. Eleven were implemented in real life, and only three were connected to the Electronic Health Record. Regarding evaluation, CDSS were assessed through various aspects: intrinsic characteristics, impact on clinical practice or user apprehension. Only one pragmatic trial and one randomized controlled trial were conducted.

CONCLUSION

This review highlights the potential of a hybrid system, user tailored, flexible, connected to the electronic health record, which could work with oral, video and digital data; and the need to evaluate CDSS on intrinsic characteristics and impact on clinical practice, iteratively at each distinct stage of the IT lifecycle.

Rapid detection of gastrointestinal pathogens using a multiplex polymerase chain reaction gastrointestinal panel and its role in antimicrobial stewardship

OBJECTIVES

The FilmArray gastrointestinal panel (FAGIP) is widely used to detect infectious diarrhoea due to its outstanding sensitivity compared to conventional methods, but there is geographic variation, such as in the distribution of pathogens, among populations.

METHODS

This was a retrospective study that analysed patients with acute diarrhoea who underwent FAGIP tests from all age groups during 2022. We compared positive rates of FAGIP between paediatric (n = 245) and adult patients (n = 242) of different origins. The targeted therapy rate and antimicrobial agent use rate were also analysed.

RESULTS

Among the 487 stool samples evaluated, the overall, community-origin (CO), and nosocomial (NC) positivity rates of paediatric patients were significantly higher than those of adults (73.9 % vs. 43.0 %, p = 0.000; 76.2 % vs. 51.7 %, p = 0.000; 50.0 % vs. 19.7 %, p = 0.000). Salmonella was the most frequently detected pathogen (35.9 %) in children, while the predominant pathogen in adult patients was toxin A/B-genic Clostridioides difficile (13.2 %). There was a significantly lower antimicrobial agent use rate after FAGIP results were available (79.1 % vs. 64.5 %, p = 0.000) and a higher rate of targeted therapy towards C. difficile infection in adults than in children (84.4 % vs. 69.0 %, p = 0.011).

CONCLUSION

Paediatric diarrhoea patients showed higher positivity rates than adult patients. Application of FAGIP for acute diarrhoea might lower unnecessary antimicrobial use.

The Association of Emergency Severity Index Score and Patient and Family Experience in a Pediatric Emergency Department

The study aim was to determine the relationship between a patient's Emergency Severity Index (ESI) score and their or their family's response to the key performance indicator (KPI) question on the post-visit patient and family experience (PFE) survey. Retrospective review of patients presenting to the Pediatric Emergency Department between July 1, 2021, and June 30, 2022, who completed the KPI question on an associated post-visit survey. We performed univariate analyses on all candidate variables; multivariable linear regression identified independent predictors of KPI on the PFE survey. A total of 8136 patients were included in the study. Although ESI score was significantly associated with PFE in univariate analysis, this association was lost in the multivariable model. Independent associations were appreciated with race/ethnicity, time to provider, length of stay, and procedure performance during the visit. Although ESI is not independently associated with PFE in this study, its interaction with factors such as time to provider, length of stay, and procedure performance may be important for emergency department providers creating interventions to impact experience during low acuity visits.

Parental perspectives on emergency health service use during the first wave of the COVID-19 pandemic in the United Kingdom: A qualitative study

UK 'Lockdown' measures introduced in March 2020 aimed to mitigate the spread of COVID-19. Although seeking healthcare was still permitted within restrictions, paediatric emergency department attendances reduced dramatically and led to concern over risks caused by delayed presentation. Our aim was to gain insight into healthcare decisions faced by parents during the first wave of the COVID-19 pandemic and to understand if use of urgent healthcare, self-care, and information needs differed during lockdown as well as how parents perceived risks of COVID-19. We undertook qualitative telephone interviews with a purposive sample of parents living in the North East of England recruited through online advertising. We used a semi-structured interview schedule to explore past and current healthcare use, perceptions of risk and the impact of the pandemic on healthcare decisions. Interviews were transcribed and analysed using Thematic Analysis. Three major themes were identified which concerned (i) how parents made sense of risks posed to, and by their children, (ii) understanding information regarding health services and (iii) attempting to make the right decision. These themes contribute to the understanding of the initial impact of COVID-19 and associated restrictions on parental decisions about urgent healthcare for children. These findings are important to consider when planning for potential future public health emergencies but also in the wider context of encouraging appropriate use of urgent healthcare.

Caregiver perceptions and experiences of paediatric emergency department attendance during the COVID-19 pandemic: A mixed-methods study

Background

During the early stages of the COVID-19 pandemic, concerns were raised about reduced attendance at hospitals, particularly in paediatric emergency departments, which could result in preventable poorer outcomes and late presentations among children requiring emergency care. We aimed to investigate the impact of COVID-19 on health-seeking behaviour and decision-making processes of caregivers presenting to paediatric emergency services at a National Health Service (NHS) Trust in London.

Materials and methods

We conducted a mixed-methods study (survey and semi-structured interviews) across two hospital sites between November-December 2020. Data from each study were collected concurrently followed by data comparison.

Results

Overall, 100 caregivers participated in our study; 80 completed the survey only, two completed the interview only and 18 completed both. Our quantitative study found that almost two-thirds (63%, n = 62) of caregivers attended the department within two days of their child becoming ill. Our qualitative study identified three major themes which were underpinned by concepts of trust, safety and uncertainty and were assessed in relation to the temporal nature of the pandemic and the caregivers’ journey to care. We found most caregivers balanced their concerns of COVID-19 and a perceived “overwhelmed” NHS by speaking to trusted sources, predominantly general practitioners (GPs).

Conclusion

Caregivers have adapted their health-seeking behaviour throughout the pandemic as new information and guidance have been released. We identified several factors affecting decisions to attend; some existed before the pandemic (e.g., concerns for child’s health) whilst others were due to the pandemic (e.g., perceived risks of transmission when accessing healthcare services). We recommend trusted medical professionals, particularly GPs, continue to provide reassurance to caregivers to seek emergency paediatric care when required. Communicating the hospital safety procedures and the importance of early intervention to caregivers could additionally provide reassurance to those concerned about the risks of accessing the hospital environment.

Exploring nursing presence as experienced by parents in pediatric oncology

BACKGROUND

Nursing presence has been viewed as a valuable way to create therapeutic relationships and has been linked to better health outcomes for patients and families. However, whether nursing presence can be described and how parents in pediatric oncology experience this phenomenon remains unanswered. Therefore, the purpose of this study was to explore how parents of children with cancer describe and experience nursing presence.

METHODS

This study used Giorgi's phenomenological approach to explore nursing presence as experienced by parents of children with cancer. Ten participants from a pediatric oncology clinic in Canada were interviewed. Giorgi's approach was used to analyze these data.

FINDINGS

Based upon participants' descriptions, a structure of nursing presence emerged which included six constituent features: An attitude of presence, a source of encouragement, clinical experience and expertise, therapeutic communication, family involvement, and a sense of home away from home. Most notably, nursing presence as experienced by parents was characterized by the 'being' and 'doing' of presence which were equally important.

CONCLUSION

The experiences described by parents provided rich and nuanced insights into what it meant to experience nursing presence in a pediatric oncology setting. This study provides a structure for this meaning making and expounds on its constituent features, describing what nursing presence resembles when experienced by parents of children with cancer.

PRACTICE IMPLICATIONS

This study informs nursing practice, policy, and education in ways that are likely to enhance care and the subsequent well-being of pediatric oncology patients and families.

Geographic inequalities in paediatric emergency department visits in Ontario and Alberta: a multilevel analysis of 2.5 million visits

Background

Research on intra- and inter-regional variations in emergency department (ED) visits among children can provide a better understanding of the patterns of ED utilization and further insight into how contextual features of the urban environment may be associated with these health events. Our objectives were to assess intra-urban and inter-urban variation in paediatric emergency department (PED) visits in census metropolitan areas (CMAs) in Ontario and Alberta, Canada and explore if contextual factors related to material and social deprivation, proximity to healthcare facilities, and supply of family physicians explain this variation.

Methods

A retrospective, population-based analysis of data on PED visits recorded between April 1, 2015 and March 31, 2017 was conducted. Random intercept multilevel regression models were constructed to quantify the intra- (between forward sortation areas [FSAs]) and inter- (between CMAs) variations in the rates of PED visits.

Results

In total, 2,537,442 PED visits were included in the study. The overall crude FSA-level rate of PED visits was 415.4 per 1,000 children population. Across CMAs, the crude rate of PED visits was highest in Thunder Bay, Ontario (771.6) and lowest in Windsor, Ontario (237.2). There was evidence of substantial intra- and inter-urban variation in the rates of PED visits. More socially deprived FSAs, FSAs with decreased proximity to healthcare facilities, and CMAs with a higher rate of family physicians per 1,000 children population had higher rates of PED visits.

Conclusions

The variation in rates of PED visits across CMAs and FSAs cannot be fully accounted for by age and sex distributions, material and social deprivation, proximity to healthcare facilities, or supply of family physicians. There is a need to explore additional contextual factors to better understand why some metropolitan areas have higher rates of PED visits.

Pediatric patients accessing Accident and Emergency Department (A&E) for non-urgent treatment: Why do parents take their children to the A&E?

INTRODUCTION

About 20-30% of children access the Pediatric Accident and Emergency Department (A&E) for non-urgent health care that should normally follow other health care paths. This study aimed to investigate why parents take their children to the A&E for non-urgent visits rather than using primary care services.

METHODS

A one-year cross-sectional study was conducted in a large pediatric A&E in Italy. A paper-and-pencil 40-item questionnaire was administered to parents of children aged between 3 months to 6 years who accessed the A&E for non-urgent visits between July 2018 and June 2019.

RESULTS

Parents of 238 children completed the questionnaire (mean age = 2.6 years; male 58%). The most common symptoms were fever (n = 105; 44.1%) and skin rash (n = 63; 26.5%); symptoms usually started more than 24 h earlier (n = 163; 69.4%). Reasons for accessing the A&E for non-urgent visits included the availability of rapid medical tests (n = 71; 29.8%), deterioration of the clinical conditions after the pediatrician's visit (n = 67; 28.2%), and the perceived need for urgent care (n = 65; 27.3%). Besides, 26.6% (n = 63) of parents reported not being able to contact their pediatrician before accessing A&E.

CONCLUSION

Parents may need further education to distinguish between urgent and non-urgent pediatric health conditions.

Use and Misuse of Emergency Room for Children: Features of Walk-In Consultations and Parental Motivations in a Hospital in Southern Italy

Objective: Inappropriate use of the emergency department (ED) represents a major worldwide issue both in pediatric and adult age. Herein, we aim to describe features of pediatric visits to the ED of Salerno University Hospital and to evaluate parental reasons behind the decision to walk in. Materials and Methods: We performed a retrospective observational study evaluating ED encounters for children from January 2014 to December 2019. The appropriateness of visits was measured with a national tool assessing every ED encounter, namely, "the Mattoni method," which consists of the combination of the triage code assigned, the diagnostic resources adopted, and the consultation outcomes. Moreover, 64 questionnaires were collected from a sample of parents in the waiting rooms in January 2020. Results: A total number of 42,507 visits were recorded during the study period (19,126 females; mean age ± SD: 4.3 ± 3.8 years), the majority of whom were inappropriate (75.8% over the considered period; 73.6% in 2014; 74.6% in 2015; 76.3% in 2016; 76.7% in 2017; 77.9% in 2018; 75.5% in 2019). Most of the inappropriate consultations arrived at the ED by their own vehicle (94.4%), following an independent decision of the parents (97.2%), especially in the evening and at night on Saturdays/Sundays/holidays (69.7%). A multivariate analysis revealed the following: patients of younger age (OR: 1.11, 95% C.I. 1.06-1.16; p < 0.0019), night visits (OR 1.39; 95% C.I.: 1.32-1.47; p < 0.001), patients living in the municipality of Salerno (OR 1.28; 95% C.I.: 1.22-1.34; p < 0.001), weekend day visits (OR 1.48; 95% C.I.: 1.41-1.56; p < 0.001), and independent parental decision without previous contact with primary care pediatrician (OR 3.01; 95% C.I.: 2.64-3.44; p < 0.001) were all significant independent predictors of inappropriate consultation. The most frequent trigger of ED encounters was fever (51.4%). Hospital admission made up 17.6% of all consultations. The questionnaire showed that most parents were aware of the lack of urgency (20.3%) or minor urgency (53.1%) of the visit. The reasons for walking in were the impossibility to receive a home consultation (70%), the difficulty of contacting their family pediatrician during weekends and holidays (54.4%), as well as the search for a quick, effective, diagnosis and therapy (48.4%). Conclusions: The study suggests a highly inappropriate use of ED for children in our region. This issue deserves considerable attention by health care system leaders in order to optimally integrate hospitals and primary care.

Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: a systematic review and narrative synthesis

BACKGROUND

Clinical guidelines are integral to a general practitioner's decision to refer a paediatric patient to emergency care. The influence of non-clinical factors must also be considered. This review explores the non-clinical factors that may influence general practitioners (GPs) when deciding whether or not to refer a paediatric patient to the Emergency Department (ED).

METHODS

A systematic review of peer-reviewed literature published from August 1980 to July 2019 was conducted to explore the non-clinical factors that influence GPs' decision-making in referring paediatric patients to the emergency department. The results were synthesised using a narrative approach.

RESULTS

Seven studies met the inclusion criteria. Non-clinical factors relating to patients, GPs and health systems influence GPs decision to refer children to the ED. GPs reported parents/ caregivers influence, including their perception of severity of child's illness, parent's request for onward referral and GPs' appraisal of parents' ability to cope. Socio-economic status, GPs' aversion to risk and system level factors such as access to diagnostics and specialist services also influenced referral decisions.

CONCLUSIONS

A myriad of non-clinical factors influence GP referrals of children to the ED. Further research on the impact of non-clinical factors on clinical decision-making can help to elucidate patterns and trends of paediatric healthcare and identify areas for intervention to utilise resources efficiently and improve healthcare delivery.

A systematic review of the organizational, environmental, professional and child and family factors influencing the timing of admission to hospital for children with serious infectious illness

Background

Infection, particularly in the first 5 years of life, is a major cause of childhood deaths globally, many deaths from infections such as pneumonia and meningococcal disease are avoidable, if treated in time. Some factors that contribute to morbidity and mortality can be modified. These include organisational and environmental factors as well as those related to the child, family or professional.

Objective

Examine what organizational and environmental factors and individual child, family and professional factors affect timing of admission to hospital for children with a serious infectious illness.

Design

Systematic review.

Data sources

Key search terms were identified and used to search CINAHL Plus, Medline, ASSIA, Web of Science, The Cochrane Library, Joanna Briggs Institute Database of Systematic Review.

Study appraisal methods

Primary research (e.g. quantitative, qualitative and mixed methods studies) and literature reviews (e.g., systematic, scoping and narrative) were included if participants included or were restricted to children under 5 years of age with serious infectious illnesses, included parents and/or first contact health care professionals in primary care, urgent and emergency care and where the research had been conducted in OECD high income countries. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies.

Main findings

Thirty-six papers were selected for full text review; 12 studies fitted the inclusion criteria. Factors influencing the timing of admission to hospital included the variability in children’s illness trajectories and pathways to hospital, parental recognition of symptoms and clinicians non-recognition of illness severity, parental help-seeking behaviour and clinician responses, access to services, use and non-use of ‘gut feeling’ by clinicians, and sub-optimal management within primary, secondary and tertiary services.

Conclusions

The pathways taken by children with a serious infectious illness to hospital are complex and influenced by a variety of potentially modifiable individual, organisational, environmental and contextual factors. Supportive, accessible, respectful services that provide continuity, clear communication, advice and safety-netting are important as is improved training for clinicians and a mandate to attend to ‘gut feeling’.

Implications

Relatively simple interventions such as improved communication have the potential to improve the quality of care and reduce morbidity and mortality in children with a serious infectious illness.

Knowledge and Acceptability of Human Papillomavirus Vaccination and Text Message Reminders for Adolescents in Urban Emergency Departments: A Pilot Study

Purpose

Cervical, oropharyngeal and anogenital cancers are vaccine-preventable diseases, but human papillomavirus (HPV) vaccination coverage in the US remains poor overall with regional variations in vaccination rates. We explore the acceptability by adolescents and their parents of HPV vaccination and text message reminders in the non-traditional setting of the emergency department (ED).

Patients and Methods

The modified validated Carolina HPV Attitudes and Beliefs Scale (CHIAS) survey was administered at two urban EDs to adolescents aged 13–18 years and their parents. Demographic information was collected for each participating adolescent. Recruitment occurred with consecutive eligible participants on the ED census list approached within 4-hour blocks from 8am to 8pm.

Results

Ninety-six adolescents completed the survey. The mean adolescent and parental knowledge scores were 63% (SD=29.7) and 60% (SD=22.1), respectively. The higher the HPV knowledge score among both adolescents and parents, the more likely they were to accept HPV vaccine in ED. Among the 10 cases where the parents disagreed to the HPV vaccine and the adolescents agreed to the HPV vaccine, the mean knowledge score among parents disagreeing was 47 compared to 62 among the remaining parents (p=0.04). Sixty-seven percent of adolescents and 68% of parents were agreeable to the adolescent receiving vaccination in the ED (kappa = 0.24). Seventy-five percent of adolescents and 71% of parents reported being agreeable to receiving text reminders for HPV vaccines (kappa = 0.20). Adolescent agreement with receiving a text message reminder corresponded with an increased willingness to be vaccinated (OR=3.21, 95% CI=1.07–9.57, p-value=0.0368). Sexually active adolescents were older (mean age, 17 years) than those who reported no sexual activity (mean age, 15 years) (p<0.0001).

Conclusion

Increased knowledge about HPV influences vaccine acceptance. Parents and adolescents may disagree in accepting HPV vaccination. A majority of adolescents and their parents were agreeable to receiving HPV vaccination in the ED and subsequent text message reminders. The ED should be explored further as a non-traditional healthcare setting for HPV vaccination of adolescents.

Influence of social characteristics on use of paediatric emergency care in Sweden - a questionnaire based study

Background

Parental social characteristics influence the use of emergency departments (ED) in the USA, but less is known about paediatric ED care-seeking in countries with national health insurance. This prospective study was designed to evaluate associations between parental care-seeking and social characteristics, with emphasis on impact of non-native origin, at a paediatric ED in Sweden, a European country providing paediatric healthcare free of charge.

Methods

Parents attending a paediatric ED at a large urban university hospital filled out a questionnaire on social characteristics and reasons for care-seeking. Information on patient characteristics and initial management was obtained from ED registers and patient records. Paediatric ED physicians assessed the medical appropriateness of each patient visit triaged for ED care.

Results

In total, 962 patient visits were included. Telephone healthline service before the paediatric ED visit was less often used by non-native parents (63/345 vs. 249/544, p < 0.001). Low-aquity visits, triaged away from the ED, were more common among non-native parents (80/368 vs. 67/555, OR = 1.66; p = 0.018), and among those reporting lower abilities in the Swedish language (23/82 vs. 120/837, OR = 2.66; p = 0.003). Children of non-native parents were more often assessed by physicians not to require ED care (122/335 vs. 261/512, OR = 0.70; p = 0.028).

Conclusions

This study confirms more direct and less urgent use of paediatric ED care by parents of non-native origin or with limited abilities in the Swedish language, proposing that parental social characteristics influence paediatric ED care-seeking, also in a country with healthcare free of charge, and that specific needs of these groups should be better met by prehospital medical services.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0210-5) contains supplementary material, which is available to authorized users.

Health Information Preferences of Parents in a Pediatric Emergency Department

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

Referral patterns from emergency department to otolaryngology clinic

OBJECTIVES/HYPOTHESIS

Patients who present to the emergency department (ED) with various otolaryngologic disorders are frequently referred to an otolaryngologist for follow-up care. Our aim was to further characterize this group as it has not been well described in the literature.

STUDY DESIGN

Cross-sectional retrospective study.

METHODS

We reviewed the charts of patients seen during an 18-month period in an urban public hospital trauma center adult ED and referred to an otolaryngology clinic for follow-up care.

RESULTS

Seven hundred thirty-eight patients were seen and referred; the most common diagnoses made by ED providers were peripheral vertigo (12%), otitis externa (8%), and nasal fractures (8%). Nine percent of patients were evaluated during their ED visit by an otolaryngology provider. Three hundred seventy-two (50%) patients returned for their otolaryngology clinic visit; facial trauma patients were least likely to return. The most common diagnoses made by otolaryngology providers were otitis externa (12%), peripheral vertigo (12%), and nasal fractures (7%). There was 50% concordance between patients' diagnoses made by ED and otolaryngology providers. The most common differences were otitis media versus otitis externa (10%) and acute pharyngitis versus laryngopharyngeal reflux (8%). During 37% of follow-up visits, an in-office procedure was performed, most commonly flexible fiberoptic laryngoscopy, cerumen removal, and nasal endoscopy.

CONCLUSIONS

Our analysis reports comprehensive characteristics of this referral group, identifying potential areas for improvement in patient management, resident education and efficiency. Otolaryngologists covering EDs should be familiar with this population in terms of types of cases that may affect their practices.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1062-1067, 2018.

Secondary Prevention of Childhood Arterial Ischemic Stroke

This study aimed to know how frontline physicians in France, Belgium, and Switzerland implement guidelines regarding the secondary prevention of childhood arterial ischemic stroke and to introduce physicians' point of view on a clinical trial assessing the efficacy of aspirin as a preventive strategy. The authors conducted an online survey directed at specialists throughout dedicated networks and used a mixed method for data analysis. Overall, 63 physicians responded, and 88% prescribe aspirin when sickle cell disease, cardio-embolic stroke, and dissection of cervical arteries are excluded. Prescribing habits vary among respondents with respect to their specialty. A majority would choose placebo or a treatment given to historical controls to compare with an aspirin arm in a trial. In studied countries, there seems to be good adherence to guidelines regarding the secondary prevention of childhood stroke. A trial assessing the efficacy of aspirin could be well accepted if several factors regarding study design were taken into account.

Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization

STUDY OBJECTIVE

We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma.

METHODS

This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit.

RESULTS

A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit.

CONCLUSION

Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort.