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Slemmer A, Klamer B, Schmerge C, Lauden S, Texler C, Fennell M, Lowing D, Leyenaar JK, Bode RS. Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia. Hosp Pediatr 2024; 14:421-429. [PMID: 38766712 DOI: 10.1542/hpeds.2023-007527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVES Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. METHODS Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. RESULTS A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. CONCLUSIONS Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.
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Affiliation(s)
- Ashleigh Slemmer
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Brett Klamer
- Biostatistics Resource at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio &The Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | - Christine Schmerge
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Stephanie Lauden
- Department of Pediatrics, The University of Colorado, Denver, Colorado
| | - Cara Texler
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Meghan Fennell
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Dena Lowing
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - JoAnna K Leyenaar
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ryan S Bode
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical Excellence at Nationwide Children's Hospital, Columbus, Ohio
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Shapiro DJ, Hall M, Ramgopal S, Alpern ER, Chaudhari PP, Eltorki M, Badaki-Makun O, Bergmann KR, Macy ML, Foster CC, Neuman MI. Acute care utilization for ambulatory care-sensitive conditions among publicly insured children. Acad Emerg Med 2024; 31:346-353. [PMID: 38385565 PMCID: PMC11014776 DOI: 10.1111/acem.14867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home. METHODS We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care. RESULTS Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting. CONCLUSIONS Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.
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Affiliation(s)
- Daniel J Shapiro
- Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Hospital Minnesota, South Minneapolis, Minnesota, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carolyn C Foster
- Division of Advanced Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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3
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Uzsen H, Tural Buyuk E, Odabasoglu E, Koyun M. The effects of vibration and pressure interventions on children's pain, fear and anxiety: A randomized controlled trial. J Pediatr Nurs 2024; 75:196-204. [PMID: 38171061 DOI: 10.1016/j.pedn.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
AIM The effects of vibration and pressure methods on the level of fear, anxiety, and pain of pediatric patients who were admitted to the emergency department for intramuscular injection were evaluated. METHODS This was a parallel group and a randomized controlled study conducted in Turkey. The study sample consisted of 114 children aged between 5 and 10 years who presented to the emergency department to receive intramuscular ceftriaxone injection as part of their treatment. The children were randomized into three groups: Vibration Intervention Group (n = 38), Pressure Intervention Group (n = 38) and Control Group (n = 38). Before the procedure, the level of anxiety and fear of the children were evaluated, and the level of perceived pain during the procedure was immediately evaluated after the intervention. Parents and nurses also rated the level of pain. Data were analyzed with non-parametric tests using SPSS version 26.0. RESULTS According to the evaluations made by children, mothers, and nurses, there was a significant difference between pain scores of children in the vibration and pressure intervention groups during the procedure and children in the control group (p < 0.000). There was a significant difference between anxiety and fear scores of children in the vibration and pressure groups and children in the control group before and after the intervention according to the evaluations of the children, mothers, and nurses (p < 0.000). CONCLUSION Vibration and pressure interventions used during intramuscular injections administered to children in the emergency department were found to reduce pain, anxiety, and fear based on the evaluations of children, mothers, and nurses. PRACTICE IMPLICATIONS Vibration and pressure are effective and useful in relieving pain associated with intramuscular injections in children aged between 5 and 10 years.
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Affiliation(s)
- Hatice Uzsen
- Nursing Department, Pediatric Nursing, Health Sciences Faculty, Ondokuz Mayis University, Samsun, Turkey
| | - Esra Tural Buyuk
- Nursing Department, Pediatric Nursing, Health Sciences Faculty, Ondokuz Mayis University, Samsun, Turkey
| | - Emel Odabasoglu
- Pediatric Nursing Department, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Merve Koyun
- Nursing Department, Pediatric Nursing, Health Sciences Faculty, Ondokuz Mayis University, Samsun, Turkey.
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AlSaeed H, Sucha E, Bhatt M, Mitsakakis N, Bresee N, Bechard M. Rates of pediatric emergency department visits vary according to neighborhood marginalization in Ottawa, Canada. CAN J EMERG MED 2024; 26:119-127. [PMID: 38117415 DOI: 10.1007/s43678-023-00625-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES To determine the association between neighborhood marginalization and rates of pediatric ED visits in Ottawa, Ontario. Secondary objectives investigated if the association between neighborhood marginalization and rates varied by year, acuity, and distance to hospital. METHODS We calculated rates of pediatric ED visits per 1000 person-years for census dissemination areas within 100 km of the Children's Hospital of Eastern Ontario for patients < 18 years old from January 2018 through December 2020. The 2016 Ontario Marginalization Index categorized neighborhoods along quintiles of residential instability, material deprivation, ethnic concentration, and dependency. Generalized mixed-effects models determined the incidence rate ratios of pediatric ED visits for each quintile of marginalization; multivariate models were used to control for year of presentation and distance to hospital. Analysis was repeated for low versus high acuity ED visits. RESULTS There were 154,146 ED visits from patients in 2055 census dissemination areas within 100 km of CHEO from 2018 to 2020. After controlling for year and distance from hospital in multivariate analyses, there were higher rates of pediatric ED visits for dissemination areas with high residential instability, high material deprivation, and low ethnic concentration. These findings did not change according to visit acuity. CONCLUSIONS Neighborhood residential instability and material deprivation should be considered when locating alternatives to emergency care.
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Affiliation(s)
- Habeeb AlSaeed
- Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
| | - Ewa Sucha
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, Canada
| | - Maala Bhatt
- Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, Canada
| | - Natalie Bresee
- Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
| | - Melanie Bechard
- Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada.
- University of Ottawa, Ottawa, ON, Canada.
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5
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Leung S, McDonald E, Watson A, Doan Q, Desai N. Community healthcare appointments as an alternative to emergency department assessment: an exploration of family acceptability and preferences. CAN J EMERG MED 2023; 25:984-991. [PMID: 37851318 DOI: 10.1007/s43678-023-00605-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Pediatric emergency departments are overcrowded, in part due to many non-emergent visits. We aimed to assess the proportion of parents interested in leaving the pediatric emergency department (ED) prior to physician assessment if they could be offered a scheduled community healthcare appointment. We explored differences in care children received in the ED stratified by interest in a community healthcare appointment and parents' reasons when they were not interested. METHODS We conducted a 14-item survey within the pediatric ED at a Canadian tertiary care teaching hospital to assess parents' interest if a program offered community healthcare appointments and we determined preferred appointment characteristics. All parents presenting with children triaged as CTAS 2-5 who met eligibility criteria were approached by a research assistant prior to physician assessment. Surveys were paired with the medical chart outlining the care received. Descriptive statistics and a regression model were used to describe characteristics of families and care received among those who were and were not interested in a community healthcare appointment. RESULTS In total, 403 surveys were completed. Overall, 236 participants (58.6%; 95% CI 53.8-63.4) were interested in a community healthcare appointment. In general, parents who were interested in a community healthcare appointment were younger and presented with younger children compared to those who were not interested. Among those interested, there was a preference to have the appointment with a pediatrician or family physician, timely access to an appointment, and appointments scheduled outside of regular business hours. CONCLUSION Our study provides evidence that there is interest in an alternative care access model positioned to reduce pediatric ED congestion. We found that parents would be interested in leaving the pediatric ED in favor of a community healthcare appointment, provided it was with a physician and available in a timely manner.
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Affiliation(s)
- Steve Leung
- Department of Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada
| | - Erica McDonald
- Department of Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada.
| | - Amy Watson
- Department of Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada
| | - Quynh Doan
- Department of Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Neil Desai
- Department of Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada
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Wolfe I, Forman J, Cecil E, Newham J, Hu N, Satherley R, Soley-Bori M, Fox-Rushby J, Cousens S, Lingam R. Effect of the Children and Young People's Health Partnership model of paediatric integrated care on health service use and child health outcomes: a pragmatic two-arm cluster randomised controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:830-843. [PMID: 37866369 DOI: 10.1016/s2352-4642(23)00216-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/26/2023] [Accepted: 08/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Paediatric health systems across high-income countries are facing avoidable adverse outcomes and increasing demands and costs. The aim of this study was to compare the effect of an enhanced usual care model with that of an integrated health-care model that offers local health clinics for general paediatric problems and early intervention and care for children and young people with tracer conditions. METHODS In this pragmatic two-arm cluster randomised controlled trial, we compared the Children and Young People's Health Partnership (CYPHP) model of care versus enhanced usual care (EUC) among children registered at general practices in south London, UK. The CYPHP trial intervention was delivered between April 1, 2018, and June 30, 2021, and children younger than 16 years during the intervention period and registered at study practices on June 30, 2021, were included in the analysis. A restricted randomisation (1:1) following a computer-generated sequence was done by a masked independent statistician at the level of general practice cluster, stratified by borough (Lambeth or Southwark). Cluster allocation and data collection were masked, with unmasking of trial statisticians before analysis. The CYPHP model comprised all elements of EUC (electronic decision support, a primary care hotline, health checks, self-management support and health promotion, and resilience building and mental health first aid) plus local child health clinics delivered by paediatricians and general practitioners, and a nurse-led early intervention service for children with tracer conditions (asthma, eczema, and constipation). Primary outcomes were non-elective admissions (NELA; admissions coded as an emergency) among the whole trial population up to June 30, 2021, and paediatric quality of life (Pediatric Quality of Life Inventory [PedsQL]) among participants with tracer conditions at 6 months after recruitment. Secondary outcomes were primary and secondary care use, child mental health, parental wellbeing, standardised symptom scores for asthma, eczema, and constipation, health-care quality, and child absences from school and parent absences from work. The trial was registered on ClinicalTrials.gov, NCT03461848, and is complete. FINDINGS The trial was conducted between April 1, 2018, and Dec 31, 2021. In total, 23 general practice clusters, consisting of 70 practices with 97 970 registered children, were randomised to CYPHP (n=11) or EUC (n=12). We found no effect, at the population level, of CYPHP versus EUC on non-elective admissions during the intervention period (adjusted mean incidence rate ratio [IRR] 1·00 [95% CI 0·91 to 1·10], p=0·99). Among children with tracer conditions, we found no difference in paediatric quality of life (PedsQL score) at 6 months (adjusted mean difference -0·033 [95% CI -0·122 to 0·055], p=0·46). As a secondary outcome, among children with tracer conditions and requiring care, NELA rates at 12 months did not differ between the CYPHP and EUC groups (66·1 per 1000 person-years vs 75·3 per 1000 person-years; adjusted mean IRR 0·87 [0·61-1·22], p=0·42). In children requiring care, a statistically significant improvement was observed in eczema symptoms at 6 months from baseline in the CYPHP group versus the EUC group (adjusted mean difference -1·370 [-2·630 to -0·122], p=0·032). Quality of asthma care significantly improved among children in the CYPHP group compared with children in the EUC group. No significant improvement was seen for all other secondary outcomes. INTERPRETATION Although the CYPHP trial found a null effect for the primary outcomes, we found clinically important improvements in some secondary outcomes including care quality. Previous research has shown that large-scale system change requires time to observe a potential positive effect. FUNDING Guy's and St Thomas Charity, the Lambeth and Southwark Clinical Commissioning Groups, and Evelina London Children's Hospital.
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Affiliation(s)
- Ingrid Wolfe
- Department of Women and Children's Health, King's College London, London, UK.
| | - Julia Forman
- Department of Women and Children's Health, King's College London, London, UK
| | - Elizabeth Cecil
- Department of Women and Children's Health, King's College London, London, UK
| | - James Newham
- Department of Psychology, Northumbria University, Newcastle, UK
| | - Nan Hu
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Marina Soley-Bori
- Department of Population Health Sciences, King's College London, London, UK
| | - Julia Fox-Rushby
- Department of Population Health Sciences, King's College London, London, UK
| | - Simon Cousens
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Raghu Lingam
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
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Soriano P, Kanis J, Abulebda K, Schwab S, Coffee RL, Wagers B. Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations. Pediatr Emerg Care 2023; 39:848-852. [PMID: 36728549 DOI: 10.1097/pec.0000000000002900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding. METHODS A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups. RESULTS Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue. CONCLUSIONS Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.
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Affiliation(s)
- Pamela Soriano
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
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Pearce S, Marchand T, Shannon T, Ganshorn H, Lang E. Emergency department crowding: an overview of reviews describing measures causes, and harms. Intern Emerg Med 2023; 18:1137-1158. [PMID: 36854999 PMCID: PMC9974385 DOI: 10.1007/s11739-023-03239-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/17/2023] [Indexed: 03/02/2023]
Abstract
Crowding in Emergency Departments (EDs) has emerged as a global public health crisis. Current literature has identified causes and the potential harms of crowding in recent years. The way crowding is measured has also been the source of emerging literature and debate. We aimed to synthesize the current literature of the causes, harms, and measures of crowding in emergency departments around the world. The review is guided by the current PRIOR statement, and involved Pubmed, Medline, and Embase searches for eligible systematic reviews. A risk of bias and quality assessment were performed for each review, and the results were synthesized into a narrative overview. A total of 13 systematic reviews were identified, each targeting the measures, causes, and harms of crowding in global emergency departments. Key among the results is that the measures of crowding were heterogeneous, even in geographically proximate areas, and that temporal measures are being utilized more frequently. It was identified that many measures are associated with crowding, and the literature would benefit from standardization of these metrics to promote improvement efforts and the generalization of research conclusions. The major causes of crowding were grouped into patient, staff, and system-level factors; with the most important factor identified as outpatient boarding. The harms of crowding, impacting patients, healthcare staff, and healthcare spending, highlight the importance of addressing crowding. This overview was intended to synthesize the current literature on crowding for relevant stakeholders, to assist with advocacy and solution-based decision making.
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Affiliation(s)
- Sabrina Pearce
- Faculty of Medicine, University of Calgary, University of Calgary Cumming School of Medicine, Calgary, Canada.
| | - Tyara Marchand
- Faculty of Medicine, University of Calgary, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Tara Shannon
- Faculty of Medicine, University of Calgary, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Heather Ganshorn
- Faculty of Medicine, University of Calgary, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Eddy Lang
- Faculty of Medicine, University of Calgary, University of Calgary Cumming School of Medicine, Calgary, Canada
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Freedman MS, Forno E. Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation. J Asthma 2023; 60:960-968. [PMID: 35943201 PMCID: PMC10027615 DOI: 10.1080/02770903.2022.2111686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission. METHODS We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission. RESULTS Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%). CONCLUSIONS A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.
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Affiliation(s)
- Michael S Freedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital
- Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, CA
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Kula R, Popela S, Klučka J, Charwátová D, Djakow J, Štourač P. Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040741. [PMID: 37189990 DOI: 10.3390/children10040741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.
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Affiliation(s)
- Roman Kula
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Stanislav Popela
- Emergency Department, University Hospital Olomouc and Faculty of Medicine, Palacký University, I.P. Pavlova 185/6, 779 00 Olomouc, Czech Republic
- Emergency Medical Service of the South Moravian Region, Kamenice 798, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Daniela Charwátová
- Department of Surgery, Vyškov Hospital, Purkyňova 235/36, 682 01 Vyškov, Czech Republic
| | - Jana Djakow
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Paediatric Intensive Care Unit, NH Hospital Inc., 268 01 Hořovice, Czech Republic
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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11
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Cushing AM, Liberman DB, Pham PK, Michelson KA, Festekjian A, Chang TP, Chaudhari PP. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr 2023; 177:168-176. [PMID: 36574251 PMCID: PMC9856860 DOI: 10.1001/jamapediatrics.2022.4885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/11/2022] [Indexed: 12/29/2022]
Abstract
Importance Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. Objective To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. Design, Setting, and Participants In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Exposures Characteristics of patients, encounters, hospitals, and communities. Main Outcomes and Measures The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. Results There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Conclusions and Relevance Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.
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Affiliation(s)
- Anna M. Cushing
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Danica B. Liberman
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Phung K. Pham
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Ara Festekjian
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Todd P. Chang
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
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12
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Hatachi T, Hashizume T, Taniguchi M, Inata Y, Aoki Y, Kawamura A, Takeuchi M. Machine Learning-Based Prediction of Hospital Admission Among Children in an Emergency Care Center. Pediatr Emerg Care 2023; 39:80-86. [PMID: 36719388 DOI: 10.1097/pec.0000000000002648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Machine learning-based prediction of hospital admissions may have the potential to optimize patient disposition and improve clinical outcomes by minimizing both undertriage and overtriage in crowded emergency care. We developed and validated the predictive abilities of machine learning-based predictions of hospital admissions in a pediatric emergency care center. METHODS A prognostic study was performed using retrospectively collected data of children younger than 16 years who visited a single pediatric emergency care center in Osaka, Japan, between August 1, 2016, and October 15, 2019. Generally, the center treated walk-in children and did not treat trauma injuries. The main outcome was hospital admission as determined by the physician. The 83 potential predictors available at presentation were selected from the following categories: demographic characteristics, triage level, physiological parameters, and symptoms. To identify predictive abilities for hospital admission, maximize the area under the precision-recall curve, and address imbalanced outcome classes, we developed the following models for the preperiod training cohort (67% of the samples) and also used them in the 1-year postperiod validation cohort (33% of the samples): (1) logistic regression, (2) support vector machine, (3) random forest, and (4) extreme gradient boosting. RESULTS Among 88,283 children who were enrolled, the median age was 3.9 years, with 47,931 (54.3%) boys and 1985 (2.2%) requiring hospital admission. Among the models, extreme gradient boosting achieved the highest predictive abilities (eg, area under the precision-recall curve, 0.26; 95% confidence interval, 0.25-0.27; area under the receiver operating characteristic curve, 0.86; 95% confidence interval, 0.84-0.88; sensitivity, 0.77; and specificity, 0.82). With an optimal threshold, the positive and negative likelihood ratios were 4.22, and 0.28, respectively. CONCLUSIONS Machine learning-based prediction of hospital admissions may support physicians' decision-making for hospital admissions. However, further improvements are required before implementing these models in real clinical settings.
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Affiliation(s)
- Takeshi Hatachi
- From the Department of Intensive Care Medicine, Osaka Women's and Children's Hospital
| | - Takao Hashizume
- Department of Pediatrics, SAKAI Children's Emergency Medical Center, Osaka
| | - Masashi Taniguchi
- From the Department of Intensive Care Medicine, Osaka Women's and Children's Hospital
| | - Yu Inata
- From the Department of Intensive Care Medicine, Osaka Women's and Children's Hospital
| | | | - Atsushi Kawamura
- From the Department of Intensive Care Medicine, Osaka Women's and Children's Hospital
| | - Muneyuki Takeuchi
- From the Department of Intensive Care Medicine, Osaka Women's and Children's Hospital
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13
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Akcan Yildiz L, Karaca Vural O, Tehci AK, Akca H, Kurt F, Akca Caglar A, Dibek Misirlioglu E. Pediatric emergency revisits of children with COVID-19. Postgrad Med 2022; 135:379-385. [PMID: 36516279 DOI: 10.1080/00325481.2022.2157634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study was conducted to reveal the characteristics of pediatric emergency revisits of children with COVID-19 and the factors associated with clinical worsening and hospitalization at the revisit. MATERIALS AND METHODS In pediatric emergency visits of children between July 2020 and March 2021 with COVID-19, the patients who had a revisit within 7 days were included in the study. Demographic and clinical characteristics, test results, and the relationship of these variables with clinical worsening and hospitalization at the revisit were investigated. RESULTS In 6779 children with COVID-19, 284 (4.1%) patients included in the study. 51.8% of the patients were male, the median age was 11.1 years, and median time to revisit time was 2.0 days. The rates of clinical worsening and hospitalization were 9.1% and 14.7%, respectively. Children younger than 24 months and those with chronic diseases were more commonly hospitalized at the revisit. Though the frequency of laboratory and radiologic testing at the revisit was significantly increased compared to the first presentation, tests did not play an important role in the decision-making processes. More than 85% of patients were clinically mild at the first presentation and revisit. CONCLUSIONS Children with a diagnosis of COVID-19 can revisit the emergency without evident clinical worsening. Since revisits cause increase in frequency of laboratory and radiological testing, preventing unnecessary revisits of children with COVID-19 can reduce the workload and cost of health care services. We may consider changing our perspective on revisit patients to make decisions based on clinical findings instead of obtaining for more laboratory tests.
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Affiliation(s)
| | | | - Ali Kansu Tehci
- University of Health Sciences Ankara City Hospital Pediatrics
| | - Halise Akca
- University of Yildirim Beyazit Ankara City Hospital, Pediatric Emergency Clinic
| | - Funda Kurt
- Ankara City Hospital Pediatric Emergency Clinic
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14
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Plint AC, Newton AS, Stang A, Cantor Z, Hayawi L, Barrowman N, Boutis K, Gouin S, Doan Q, Dixon A, Porter R, Joubert G, Sawyer S, Crawford T, Gravel J, Bhatt M, Weldon P, Millar K, Tse S, Neto G, Grewal S, Chan M, Chan K, Yung G, Kilgar J, Lynch T, Aglipay M, Dalgleish D, Farion K, Klassen TP, Johnson DW, Calder LA. How safe are paediatric emergency departments? A national prospective cohort study. BMJ Qual Saf 2022; 31:806-817. [PMID: 35853646 PMCID: PMC9606537 DOI: 10.1136/bmjqs-2021-014608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/02/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department. METHODS Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred. RESULTS We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit. CONCLUSION In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.
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Affiliation(s)
- Amy C Plint
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amanda S Newton
- Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Antonia Stang
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Zach Cantor
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Lamia Hayawi
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kathy Boutis
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics and Child Health Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Serge Gouin
- Pediatric Emergency Department, CHU Sainte-Justine, Montreal, Québec, Canada
- Pediatrics, Université de Montreal, Montreal, Québec, Canada
| | - Quynh Doan
- Evidence to Innovations, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Dixon
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Porter
- Janeway Children's Health and Rehabilitation Centre, St John's, Newfoundland and Labrador, Canada
- Pediatrics, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Gary Joubert
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Scott Sawyer
- Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- Pediatric Emergency, Health Sciences Centre Winnipeg Children's Hospital, Winnipeg, Manitoba, Canada
| | - Tyrus Crawford
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Jocelyn Gravel
- Pediatric Emergency Department, CHU Sainte-Justine, Montreal, Québec, Canada
- Pediatrics, Université de Montreal, Montreal, Québec, Canada
| | - Maala Bhatt
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick Weldon
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kelly Millar
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sandy Tse
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gina Neto
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Simran Grewal
- Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Melissa Chan
- Emergency Medicine, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Kevin Chan
- Janeway Children's Health and Rehabilitation Centre, St John's, Newfoundland and Labrador, Canada
- Pediatrics, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Grant Yung
- Pediatric Emergency, Health Sciences Centre Winnipeg Children's Hospital, Winnipeg, Manitoba, Canada
| | - Jennifer Kilgar
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Tim Lynch
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Mary Aglipay
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Dale Dalgleish
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken Farion
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Pediatrics and Child Health, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - David W Johnson
- Paediatrics, Alberta Health Services, Edmonton, Alberta, Canada
| | - Lisa A Calder
- Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
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15
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Freire GC, Diong C, Gandhi S, Saunders N, Neuman MI, Freedman SB, Friedman JN, Cohen E. Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases. CMAJ Open 2022; 10:E889-E899. [PMID: 36220182 PMCID: PMC9578750 DOI: 10.9778/cmajo.20210140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty. METHODS This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED. RESULTS Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively). INTERPRETATION Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.
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Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Christina Diong
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sima Gandhi
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Natasha Saunders
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mark I Neuman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Stephen B Freedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jeremy N Friedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Eyal Cohen
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta.
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16
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Wilk P, Maltby A, Lau T, Gunz AC, Osornio-Vargas A, Yamamoto SS, Ali S, Lavigne É. Geographic inequalities in paediatric emergency department visits in Ontario and Alberta: a multilevel analysis of 2.5 million visits. BMC Pediatr 2022; 22:432. [PMID: 35858855 PMCID: PMC9297543 DOI: 10.1186/s12887-022-03485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/08/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Piotr Wilk
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. .,Department of Paediatrics, Western University, London, ON, Canada. .,Child Health Research Institute, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada. .,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 3rd Floor, Western Centre for Public Health and Family Medicine, 1465 Richmond St, ON, N6G 2M1, London, Canada.
| | - Alana Maltby
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Tammy Lau
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Anna C Gunz
- Department of Paediatrics, Western University, London, ON, Canada.,Child Health Research Institute, London, ON, Canada.,Division of Paediatric Critical Care, Children's Hospital, London Health Sciences Center, London, ON, Canada
| | | | - Shelby S Yamamoto
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Shehzad Ali
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Éric Lavigne
- Air Health Science Division, Health Canada, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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17
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Singh D, Nagaraj S, Mashouri P, Drysdale E, Fischer J, Goldenberg A, Brudno M. Assessment of Machine Learning-Based Medical Directives to Expedite Care in Pediatric Emergency Medicine. JAMA Netw Open 2022; 5:e222599. [PMID: 35294539 PMCID: PMC8928004 DOI: 10.1001/jamanetworkopen.2022.2599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Increased wait times and long lengths of stay in emergency departments (EDs) are associated with poor patient outcomes. Systems to improve ED efficiency would be useful. Specifically, minimizing the time to diagnosis by developing novel workflows that expedite test ordering can help accelerate clinical decision-making. OBJECTIVE To explore the use of machine learning-based medical directives (MLMDs) to automate diagnostic testing at triage for patients with common pediatric ED diagnoses. DESIGN, SETTING, AND PARTICIPANTS Machine learning models trained on retrospective electronic health record data were evaluated in a decision analytical model study conducted at the ED of the Hospital for Sick Children Toronto, Canada. Data were collected on all patients aged 0 to 18 years presenting to the ED from July 1, 2018, to June 30, 2019 (77 219 total patient visits). EXPOSURE Machine learning models were trained to predict the need for urinary dipstick testing, electrocardiogram, abdominal ultrasonography, testicular ultrasonography, bilirubin level testing, and forearm radiographs. MAIN OUTCOMES AND MEASURES Models were evaluated using area under the receiver operator curve, true-positive rate, false-positive rate, and positive predictive values. Model decision thresholds were determined to limit the total number of false-positive results and achieve high positive predictive values. The time difference between patient triage completion and test ordering was assessed for each use of MLMD. Error rates were analyzed to assess model bias. In addition, model explainability was determined using Shapley Additive Explanations values. RESULTS There was a total of 42 238 boys (54.7%) included in model development; mean (SD) age of the children was 5.4 (4.8) years. Models obtained high area under the receiver operator curve (0.89-0.99) and positive predictive values (0.77-0.94) across each of the use cases. The proposed implementation of MLMDs would streamline care for 22.3% of all patient visits and make test results available earlier by 165 minutes (weighted mean) per affected patient. Model explainability for each MLMD demonstrated clinically relevant features having the most influence on model predictions. Models also performed with minimal to no sex bias. CONCLUSIONS AND RELEVANCE The findings of this study suggest the potential for clinical automation using MLMDs. When integrated into clinical workflows, MLMDs may have the potential to autonomously order common ED tests early in a patient's visit with explainability provided to patients and clinicians.
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Affiliation(s)
- Devin Singh
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sujay Nagaraj
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pouria Mashouri
- DATA Team, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Erik Drysdale
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jason Fischer
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anna Goldenberg
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario Canada
- Canadian Institute for Advanced Research, Toronto, Ontario Canada
| | - Michael Brudno
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- DATA Team, Techna Institute, University Health Network, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario Canada
- Canadian Institute for Advanced Research, Toronto, Ontario Canada
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Pediatric ED departmental complexity: a different approach to the concept of ED crowding. CAN J EMERG MED 2022; 24:318-324. [PMID: 35146700 DOI: 10.1007/s43678-022-00261-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 12/31/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Emergency department (ED) crowding is a significant problem in Canada and internationally and is associated with the potential for patient harm. Although pediatric patients represent a significant proportion of overall ED visits, there is limited research on pediatric ED crowding. The Canadian Association of Emergency Physicians defines department crowding as a mismatch between the required and available resources to provide timely emergency care. We propose that rather than crowding, it is better to think of ED patient populations as being more or less "complex" as defined by proxies of the human and physical resources needed for patient management. The study objectives are to explore the utility of a simple and easily available retrospective metric of ED complexity, and to assess the relationship this measure has on patient outcomes in a pediatric ED. METHODS Using administrative data from a tertiary care pediatric ED, we developed a departmental complexity score based on patient registration number, triage acuity, and departmental length of stay as a proxy for the resources necessary to provide ED care. We then explored the relationship between this departmental complexity score and clinical care indices. RESULTS The score shows a strong relationship with the number of patients who left without being seen by a physician, as well as time to initial MD assessment, both measures which have been used to represent ED crowding in previous research. We found no association between our departmental complexity score and adverse impacts on patient care outcomes of hospital admission, pediatric ICU admission, or patients returning to the ED within 72 h of leaving. CONCLUSIONS The departmental complexity score has promise as a retrospective measure of departmental resource requirement and may have a role in the ongoing assessment of patient flow.
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Michelson KA, Cushing AM, Bucholz EM. Association of County-Level Availability of Pediatricians With Emergency Department Visits. Pediatr Emerg Care 2022; 38:e953-e957. [PMID: 34282091 PMCID: PMC8770659 DOI: 10.1097/pec.0000000000002502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The relationship between pediatrician availability and emergency department (ED) attendance is uncertain. We determined whether children in counties with more pediatricians had fewer ED visits. METHODS We conducted a cross-sectional study of all ED visits among children younger than 18 years from 6 states. We obtained ED visit incidences by county and assessed the relationship to pediatrician density (pediatricians per 1000 children). Possible confounders included state, presence of an urgent care facility in the county, urban-rural status, and quartile of county-level characteristics: English-speaking, Internet access, White race, socioeconomic status, and public insurance. We estimated county-level changes in incidence by pediatrician density adjusting for state and separately for all possible confounders. RESULTS Each additional pediatrician per 1000 children was associated with a 13.7% (95% confidence interval, -19.6% to -7.5%) decrease in ED visits in the state-adjusted model. In the full model, there was no association (-1.4%, 95% confidence interval, -7.2% to 4.8%). The presence of an urgent care, higher socioeconomic status score, urban status, and higher proportions of White race and nonpublic insurance were each associated with decreased ED visit rates. CONCLUSIONS Pediatrician density is not associated with decreased ED visits after adjusting for other county demographic factors. Increasing an area's availability of pediatricians may not affect ED attendance.
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Affiliation(s)
| | - Anna M Cushing
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Emily M Bucholz
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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Rickard KN, Cohen JS, Chamberlain JM, Ong H, Dwyer M, Perritt A, McKinley KW. Validation of "Personal Protective Equipment Conservation Strategies Tool" to Predict Consumption of N95s, Facemasks, and Gowns During Pandemic-Related Shortages. Comput Inform Nurs 2022; 40:28-34. [PMID: 34508020 PMCID: PMC8745942 DOI: 10.1097/cin.0000000000000831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We sought to prospectively validate a model to predict the consumption of personal protective equipment in a pediatric emergency department during the COVID-19 pandemic. We developed the Personal Protective Equipment Conservation Strategies Tool, a Monte Carlo simulation model with input parameters defined by members of our emergency department personal protective equipment task force. Inputs include different conservation strategies that reflect dynamic reuse policies. Over the course of 4 consecutive weeks in April and May 2020, we used the model to predict the consumption of N95 respirators, facemasks, and gowns in our emergency department based on values for each input parameter. At the end of each week, we calculated the percent difference between actual consumption and predicted consumption based on model outputs. Actual consumption of personal protective equipment was within 20% of model predictions for each of the 4 consecutive weeks for N95s (range, -16.3% to 16.1%) and facemasks (range, -7.6% to 13.1%), using "maximum conservation" and "high conservation" strategies, respectively. Actual consumption of gowns was 11.8% less than predicted consumption for Week 1, gown resupply data were unavailable on Weeks 2-4. The Personal Protective Equipment Conservation Strategies Tool was prospectively validated for "maximum conservation" and "high conservation" models, with actual consumption within 20% of model predictions.
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21
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Almeida HS, Sousa M, Mascarenhas I, Russo A, Barrento M, Mendes M, Nogueira P, Trigo R. The Dynamics of Patient Visits to a Public Hospital Pediatric Emergency Department: A Time-Series Model. Pediatr Emerg Care 2022; 38:e240-e245. [PMID: 32925706 DOI: 10.1097/pec.0000000000002235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The overcrowding of emergency departments (EDs) is an increasingly relevant public health problem. The main aims of this study were to identify and analyze temporal periodicities of a self-referred pediatric ED (PED), correlate them with meteorological and calendar variables and build a robust forecasting model. METHODS An 8-year administrative data set (2010-2017) of the daily number of admissions to the PED of a public hospital in Lisbon, Portugal, was used (n = 670,379). A time-series model of the daily number of visits was built, including temporal periodicities, the Portuguese school calendar, and a meteorological comfort index (humidex). RESULTS Several temporal cycles were identified: 1 year (peak in January/February related to respiratory infections in younger children and infants), 6 months (peaks in May and October with an increase in the admissions of older children and adolescents with trauma, gastrointestinal infections and atopic symptoms), 4 months (related to annual school vacations), 1 week (lower admission values on Saturday), and half a week (low from Friday to Monday morning). School calendar and humidex were significantly correlated with daily admissions. The model yielded a mean absolute percentage error of 10.7% ± 1.10% when cross-validation was performed for the full data set. CONCLUSION Although PED visits are multifactorial, they may be predicted and explained by a relatively small number of variables. Such a model may be easily reproduced in different settings and represents a relevant tool to improve quality in EDs through correctly adapting human resources to ED demand.
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Affiliation(s)
- Helena Seabra Almeida
- From the Pediatric Department, Hospital Professor Doutor Fernando Fonseca, EPE, Amadora
| | | | - Inês Mascarenhas
- From the Pediatric Department, Hospital Professor Doutor Fernando Fonseca, EPE, Amadora
| | - Ana Russo
- Instituto Dom Luíz, Faculdade de Ciências da Universidade de Lisboa
| | - Manuel Barrento
- Management and Planning Department, Hospital Professor Doutor Fernando Fonseca, EPE, Amadora
| | | | - Paulo Nogueira
- IMSP - Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Ricardo Trigo
- Instituto Dom Luíz, Faculdade de Ciências da Universidade de Lisboa
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22
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Osmanlliu E, Gagnon I, Weber S, Bach CQ, Turnbull J, Seguin J. The Waiting Room Assessment to Virtual Emergency Department pathway: Initiating video-based telemedicine in the pediatric emergency department. J Telemed Telecare 2021; 28:452-457. [PMID: 34636683 DOI: 10.1177/1357633x211044038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The COVID-19 pandemic has presented pediatric emergency departments with unique challenges, resulting in a heightened demand for adapted clinical pathways. In response to this need, the Montreal Children's Hospital pediatric emergency department introduced the WAVE (Waiting Room Assessment to Virtual Emergency Department) pathway, a video-based telemedicine pathway for selected non-critical patients, aiming to reduce safety issues related to emergency department overcrowding, while providing timely care to all children presenting and registering at our emergency department. The objective of the WAVE pilot phase was to evaluate the feasibility and acceptability of telemedicine in our pediatric emergency department, which was previously unfamiliar with this mode of care delivery. During the six-week, three-evening per week deployment, we conducted 18 five-hour telemedicine shifts. In total, 27 patients participated in the WAVE pathway. Results from this pilot phase met four of five a priori feasibility and acceptability criteria. Overall, participating families were satisfied with this novel care pathway and reported no disruptive technological barriers.
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Affiliation(s)
- Esli Osmanlliu
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada.,507266Research Institute of the McGill University Health Centre (RI-MUHC)
| | - Isabelle Gagnon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada.,507266Research Institute of the McGill University Health Centre (RI-MUHC)
| | - Saskia Weber
- Quality and Continuous Improvement Office, 10040Montreal Children's Hospital, Canada
| | - Chi Quan Bach
- Partnership Office, 54473McGill University Health Centre, Canada
| | - Jennifer Turnbull
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada
| | - Jade Seguin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada.,507266Research Institute of the McGill University Health Centre (RI-MUHC)
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23
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Heyming TW, Knudsen-Robbins C, Feaster W, Ehwerhemuepha L. Criticality index conducted in pediatric emergency department triage. Am J Emerg Med 2021; 48:209-217. [PMID: 33975133 DOI: 10.1016/j.ajem.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/27/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To develop and analyze the performance of a machine learning model capable of predicting the disposition of patients presenting to a pediatric emergency department (ED) based on triage assessment and historical information mined from electronic health records. METHODS We retrospectively reviewed data from 585,142 ED visits at a pediatric quaternary care institution between 2013 and 2020. An extreme gradient boosting machine learning model was trained on a randomly selected training data set (50%) to stratify patients into 3 classes: (1) high criticality (patients requiring intensive care unit [ICU] care within 4 h of hospital admission, patients who died within 4 h of admission, and patients who died in the ED); (2) moderate criticality (patients requiring hospitalization without the need for ICU care); and (3) low criticality (patients discharged home). Variables considered during model development included triage vital signs, aspects of triage nursing assessment, demographics, and historical information (diagnoses, medication use, and healthcare utilization). Historical factors were limited to the 6 months preceding the index ED visit. The model was tested on a previously withheld test data set (40%), and its performance analyzed. RESULTS The distribution of criticality among high, moderate, and low was 1.5%, 7.1%, and 91.4%, respectively. The one-versus-all area under the receiver operating characteristic (AUROC) curve for high and moderate criticality was 0.982 (95% CI 0.980, 0.983) and 0.968 (0.967, 0.969). The multi-class macro average AUROC and area under the receiver operating characteristic curve were 0.976 and 0.754. The features most integral to model performance included history of intravenous medications, capillary refill, emergency severity index level, history of hospitalization, use of a supplemental oxygen device, age, and history of admission to the ICU. CONCLUSION Pediatric ED disposition can be accurately predicted using information available at triage, providing an opportunity to improve quality of care and patient outcomes.
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Affiliation(s)
- Theodore W Heyming
- Children's Hospital of Orange County, Orange, CA, United States; Department of Emergency Medicine, University of California, Irvine, United States.
| | | | - William Feaster
- Children's Hospital of Orange County, Orange, CA, United States
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24
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Gorski JK, Arnold TS, Usiak H, Showalter CD. Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department. Am J Emerg Med 2021; 48:73-78. [PMID: 33845424 DOI: 10.1016/j.ajem.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/29/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Emergency Department (ED) patients who leave without being seen (LWBS) are associated with adverse safety and medico-legal consequences. While LWBS risk has been previously tied to demographic and acuity related factors, there is limited research examining crowding-related risk in the pediatric setting. The primary objective of this study was to determine the association between LWBS risk and crowding, using the National Emergency Department Overcrowding Score (NEDOCS) and occupancy rate as crowding metrics. METHODS We performed a retrospective observational study on electronic health record (EHR) data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period. NEDOCS and occupancy rate were calculated for 15-min windows and matched to patient arrival time. We leveraged multiple logistic regression analyses to demonstrate the relationship between patientlevel LWBS risk and each crowding metric, controlling for characteristics drawn from the pre-arrival state. We performed a chi-squared test to determine whether a difference existed between the receiver operating characteristic (ROC) curves in the two models. Finally, we executed a dominance analysis using McFadden's pseudo-R 2 to determine the relative importance of each crowding metric in the models. RESULTS A total of 54,890 patient encounters were studied, 1.22% of whom LWBS. The odds ratio for LWBS risk was 1.30 (95% CI 1.27-1.33) per 10-point increase in NEDOCS and 1.23 (95% CI 1.21-1.25). per 10% increase in occupancy rate. Area under the curve (AUC) was 86.9% for the NEDOCS model and 86.7% for the occupancy rate model. There was no statistically significant difference between the AUCs of the two models (p-value 0.27). Dominance analysis revealed that in each model, the most important variable studied was its respective crowding metric; NEDOCS accounted for 55.6% and occupancy rate accounted for 53.9% of predicted variance in LWBS. CONCLUSION Not only was ED overcrowding positively and significantly associated with individual LWBS risk, but it was the single most important factor that determined a patient's likelihood of LWBS in the pediatric ED. Because occupancy rate and NEDOCS are available in real time, each could serve as a monitor for individual LWBS risk in the pediatric ED.
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Affiliation(s)
- Jillian K Gorski
- Department of Pediatrics, Indiana University School of Medicine. 705 Riley Hospital Drive, Indianapolis, IN 46202, USA.
| | - Tyler S Arnold
- Department of Pediatrics, Indiana University School of Medicine. 705 Riley Hospital Drive, Indianapolis, IN 46202, USA; Department of Emergency Medicine, Indiana University School of Medicine. 720 Eskenazi Avenue, Fifth Third Bank Building 3rd Floor, Indianapolis, IN 46202, USA
| | - Holly Usiak
- Department of Emergency Medicine, Indiana University School of Medicine. 720 Eskenazi Avenue, Fifth Third Bank Building 3rd Floor, Indianapolis, IN 46202, USA
| | - Cory D Showalter
- Department of Pediatrics, Indiana University School of Medicine. 705 Riley Hospital Drive, Indianapolis, IN 46202, USA; Department of Emergency Medicine, Indiana University School of Medicine. 720 Eskenazi Avenue, Fifth Third Bank Building 3rd Floor, Indianapolis, IN 46202, USA
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25
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Maki K, Azizi H, Hans P, Doan Q. Adherence to national paediatric bronchiolitis management guidelines and impact on emergency department resource utilization. Paediatr Child Health 2021; 26:108-113. [DOI: 10.1093/pch/pxaa013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To evaluate the association between the use of nonrecommended pharmacology (salbutamol and corticosteroids) per national bronchiolitis guidelines, either during the index visit or at discharge, and system utilization measures (frequency of return visits [RTED] and on paediatric emergency department [PED] length of stay [LOS]).
Study Design
We conducted a retrospective case control study of 185 infants (≤12 months old) who presented to the PED between December 2014 and April 2017 and discharged home with a clinical diagnosis of bronchiolitis. Inclusion criteria included ≥ 1 viral prodromal symptom and ≥ 1 physical exam finding of respiratory distress. Cases were defined as infants who had ≥ 1 RTED within 7 days of their index visit and controls were matched for age and acuity but without RTED. Logistic regression analysis and multivariable linear regression were used to assess the odds of RTED and PED LOS associated with nonadherence to pharmaceutical recommendations per AAP and CPS bronchiolitis guidelines.
Results
Use of nonrecommended pharmacology per national bronchiolitis guidelines was documented among 39% of the 185 study participants. Adjusting for acuity of index visit, age, severe tachypnea, oxygen desaturation, and dehydration, use of nonrecommended pharmacology was not associated with RTED (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.47 to 2.03). Use of salbutamol and corticosteroids, however, were each independently associated with increased PED LOS (58.3 minutes [P=0.01] and 116.7 minutes [P<0.001], respectively).
Conclusion
Nonadherence to the pharmaceutical recommendations of national bronchiolitis guidelines was not associated with RTED but salbutamol and corticosteroid use increased PED LOS.
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Affiliation(s)
- Kate Maki
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
- BC Children’s Hospital Research Institute, Vancouver, British Columbia
| | - Hawmid Azizi
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Prabhjas Hans
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Quynh Doan
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
- BC Children’s Hospital Research Institute, Vancouver, British Columbia
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Abudan A, Merchant RC. Multi-dimensional Measurements of Crowding for Pediatric Emergency Departments: A Systematic Review. Glob Pediatr Health 2021; 8:2333794X21999153. [PMID: 33718529 PMCID: PMC7923972 DOI: 10.1177/2333794x21999153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/08/2021] [Indexed: 11/17/2022] Open
Abstract
The absence of accepted crowding measurement tools that encompass the unique characteristics of pediatric emergency departments (EDs) creates a deficit in advancing efforts to identify and evaluate solutions for this growing problem. In this systematic review, we examined 4 studies that reported on the development and testing of multidimensional pediatric ED crowding measurements. Two investigations involved models (PEDOCS, SOTU-PED) that measured factors indicative or contributory to crowding. A third investigation developed a model mapping the flow of patients through the pediatric ED. The final study modeled the magnitude of physician’s work load, particularly when this load is high when crowding is likely present, based on patient arrivals, presenting complaints and conditions, and tests ordered. These works from 4 studies on measuring crowding in pediatric EDs show promise, but this field is at an early stage. Future work should concentrate on comparing the utility of crowding measurements across multiple pediatric ED settings.
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Affiliation(s)
- Areej Abudan
- Ministry of Health, Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
| | - Roland C Merchant
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Loso JM, Filipp SL, Gurka MJ, Davis MK. Using Queue Theory and Load-Leveling Principles to Identify a Simple Metric for Resource Planning in a Pediatric Emergency Department. Glob Pediatr Health 2021; 8:2333794X20944665. [PMID: 33614834 PMCID: PMC7841236 DOI: 10.1177/2333794x20944665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/15/2020] [Accepted: 06/30/2020] [Indexed: 11/20/2022] Open
Abstract
Increased waiting time in pediatric emergency departments is a well-recognized
and complex problem in a resource-limited US health care system. Efforts to
reduce emergency department wait times include modeling arrival rates, acuity,
process flow, and human resource requirements. The aim of this study was to
investigate queue theory and load-leveling principles to model arrival rates and
to identify a simple metric for assisting with determination of optimal physical
space and human resource requirements. We discovered that pediatric emergency
department arrival rates vary based on time of day, day of the week, and month
of the year in a predictable pattern and that the hourly change in pediatric
emergency department waiting room census may be useful as a simple metric to
identify target times for shifting resources to better match supply and demand
at no additional cost.
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Virtual care in the pediatric emergency department: a new way of doing business? CAN J EMERG MED 2020; 23:80-84. [PMID: 33683615 PMCID: PMC7747474 DOI: 10.1007/s43678-020-00048-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/04/2020] [Indexed: 01/28/2023]
Abstract
Objectives To understand the feasibility, utilization rate, and satisfaction of the first Virtual Pediatric ED (V-PED) in Canada. Methods We conducted a prospective cohort study examining the feasibility and impact of virtual care as an adjunct to in-person emergency care at a tertiary pediatric hospital from May to July 2020. Children (< 18 years) from Ontario and Quebec seeking V-PED care were included. A secure, encrypted, video platform within the hospital’s electronic medical record was used. Caregivers self-determined appropriateness of V-PED using a standardized online triage questionnaire to request their appointment. The V-PED is directly launched from the patient’s chart and the family joins the portal via hyperlink. Outcome measures included the number of V-PED visits, hospital admission rates, and caregiver satisfaction using a 10-item voluntary post-visit online survey. Results A total of 1036 V-PED visits were seen of which 176 (17.0%) were referred for further in-person ED assessment, and 8 (0.8%) required hospital admission. Of the 107 completing patient experience surveys (10% response), most respondents (69%) endorsed they “very likely” or “definitely” would have presented in-person to the ED if V-PED were unavailable. Overall satisfaction was rated as excellent (9 or 10 out of 10) in 87% of respondents. Conclusion Our novel V-PED is feasible, has high caregiver satisfaction, and can reduce the burden of in-person ED visits. Future work must ensure the safety of emergency virtual care and examine how to increase capacity and integrate V-PED within traditional emergency medicine. Electronic supplementary material The online version of this article (10.1007/s43678-020-00048-w) contains supplementary material, which is available to authorized users.
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Ehwerhemuepha L, Yu PT, Guner YS, Wallace E, Feaster W. A Nested Mixed Effects Multicenter Model Examining the Risk Factors for Pediatric Trauma Return Visits Within 72 Hours. J Surg Res 2020; 257:370-378. [PMID: 32892133 DOI: 10.1016/j.jss.2020.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Return visits within 72 h are an important metric in evaluating the performance of emergency rooms. This has not been well studied in the pediatric trauma population. We sought to determine novel risk factors for return visits to the emergency department (ED) after trauma that may assist in identifying patients most at risk of revisit. METHODS We used the Cerner Health Facts Database to retrieve data from 34 EDs across the United States that care for pediatric trauma patients aged <15 y. The data consist of 610,845 patients and 816,571 ED encounters. We retrieved variables encompassing demographics, payor, current and past health care resource utilization, trauma diagnoses, other diagnoses/comorbidities, medications, and surgical procedures. We built a nested mixed effects logistic regression model to provide statistical inference on the return visits. RESULTS Traumas resulting from burns and corrosion, injuries to the shoulder and arms, injuries to the hip and legs, and trauma to the head and neck are all associated with increased odds of returning to the ED. Patients suffering from poisoning relating to drugs and other biological substances and patients with trauma to multiple body regions have reduced odds of returning to the ED. Longer ED length of stay and prior health care utilization (ED or inpatient) are associated with increased odds of a return visit. The sex of the patient and payor had a statistically significant effect on the risk of a return visit to the ED within 72 h of discharge. CONCLUSIONS Certain traumas expose patients to an increased risk for return visits to the ED and, as a result, provide opportunity for improved quality of care. Targeted interventions that include education, observation holds, or a decision to hospitalize instead of discharge home may help improve patient outcomes and decrease the rate of ED returns. LEVEL OF EVIDENCE III (Prognostic and Epidemiology).
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Affiliation(s)
- Louis Ehwerhemuepha
- CHOC Children's, Orange, California; Chapman University School of Computational and Data Science, Orange, California.
| | - Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County and Department of Surgery, University of California Irvine, Orange, California
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County and Department of Surgery, University of California Irvine, Orange, California
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Cushing AM, Bucholz E, Michelson KA. Trends in Regionalization of Emergency Care for Common Pediatric Conditions. Pediatrics 2020; 145:peds.2019-2989. [PMID: 32169895 PMCID: PMC7236317 DOI: 10.1542/peds.2019-2989] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis. METHODS We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes. RESULTS Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings. CONCLUSIONS Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions.
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Affiliation(s)
- Anna M Cushing
- Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Emily Bucholz
- Boston Children's Hospital, Boston, Massachusetts; and
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Millar R, Palmer B, Chiappazzo A. Informing diversion strategy: A comparison of parent and general practitioner-referred paediatric patients presenting to a metropolitan hospital. Emerg Med Australas 2020; 32:494-498. [PMID: 32180341 DOI: 10.1111/1742-6723.13499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/08/2020] [Accepted: 02/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether the characteristics and outcomes of parent-referred children differ substantially from general practitioner (GP)-referred children attending a metropolitan ED. METHODS Prospective cross-sectional observational study of consecutive patients aged less than 16 years of age attending a mixed adult and paediatric metropolitan teaching hospital ED in Melbourne. Data collected included patient characteristics (age, sex, arrival mode and triage category) and outcomes (admission, specialty consultation, treatment time >1 h, intravenous or nasogastric therapy, procedural sedation, procedures, imaging studies and pathology collection). RESULTS The outcome data of 4580 patients was analysed. Patients brought by parents directly to the ED did not differ from patients referred by their GP in age, sex, or triage category, but were more likely to arrive by ambulance (13% vs 2%, P < 0.01). Low-urgency GP-referred children were more likely to require a procedure (22% vs 15%, risk difference [RD] 0.07, 95% confidence interval [CI] 0.02-0.13) and pathology tests (13% vs 8%, RD 0.05, 95% CI 0.01-0.1) than parent-referred children, but were similar for other outcomes. The proportion of low-urgency children who had no ED-specific care interventions was not significantly different between the groups (27% vs 32%, RD -0.06, 95% CI -0.11 to 0). CONCLUSIONS Children brought to ED directly by their parents or carers did not differ substantially from GP-referred children in their characteristics or outcomes. The use of referral source and triage categories to determine patient suitability for diversion to general practice may need to be reconsidered.
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Affiliation(s)
- Robert Millar
- The University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Austin Hospital, Melbourne, Victoria, Australia
| | - Bethany Palmer
- The University of Melbourne, Melbourne, Victoria, Australia
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Amaniyan S, Faldaas BO, Logan PA, Vaismoradi M. Learning from Patient Safety Incidents in the Emergency Department: A Systematic Review. J Emerg Med 2019; 58:234-244. [PMID: 31843322 DOI: 10.1016/j.jemermed.2019.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/01/2019] [Accepted: 11/10/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patient safety incidents are commonly observed in critical and high demanding care settings, including the emergency department. There is a need to understand what causes patient safety incidents in emergency departments and determine the implications for excellence in practice. OBJECTIVE Our aim was to systematically review the international literature on patient safety incidents in emergency departments and determine what can be learned from reported incidents to inform and improve practice. DISCUSSION Patient safety incidents in emergency departments have a number of recognized contributing factors. These can be used as groundwork for the development of effective tools to systematically identify incident risk. Participation in efforts to diminish risk and improve patient safety through appropriate incident reporting is critical for removing barriers to safe care. CONCLUSIONS This review enhances our awareness of contributing factors to patient safety incidents within emergency departments and encourages researchers from different disciplines to investigate the causes of practice errors and formulate safety improvement strategies.
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Affiliation(s)
- Sara Amaniyan
- Student Research Committe, Semnan University of Medical Sciences, Semnan, Iran
| | - Bjørn Ove Faldaas
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Patricia A Logan
- Faculty of Science, Charles Sturt University, Bathurst Campus, New South Wales, Australia
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Moylan A, Maconochie I. Demand, overcrowding and the pediatric emergency department. CMAJ 2019; 191:E625-E626. [PMID: 32392478 DOI: 10.1503/cmaj.190610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Alexander Moylan
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, UK
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, UK
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