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Dholakia A, Burdick KJ, Kreatsoulas C, Monuteaux MC, Tsai J, Subramanian SV, Fleegler EW. Historical Redlining and Present-Day Nonsuicide Firearm Fatalities. Ann Intern Med 2024. [PMID: 38648643 DOI: 10.7326/m23-2496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation. OBJECTIVE To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities. DESIGN Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference. SETTING 202 cities with areas graded by the HOLC in the 1930s. PARTICIPANTS Population of the 8597 areas assessed by the HOLC. MEASUREMENTS Nonsuicide firearm fatalities. RESULTS From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively. LIMITATION The Gun Violence Archive relies on media coverage and police reports. CONCLUSION Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today. PRIMARY FUNDING SOURCE Fred Lovejoy Housestaff Research and Education Fund.
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Affiliation(s)
- Ayesha Dholakia
- Department of Pediatrics, Boston Children's Hospital, and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts (A.D., K.J.B.)
| | - Kendall J Burdick
- Department of Pediatrics, Boston Children's Hospital, and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts (A.D., K.J.B.)
| | | | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts (M.C.M.)
| | - Jennifer Tsai
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut (J.T.)
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, and Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (S.V.S.)
| | - Eric W Fleegler
- Department of Emergency Medicine, Massachusetts General Hospital, and Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts (E.W.F.)
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Hoffmann RM, Neal JT, Arichai P, Gravel CA, Neuman MI, Monuteaux MC, Levy JA, Miller AF. Test Characteristics of Cardiac Point-of-Care Ultrasound in Children With Preexisting Cardiac Conditions. Pediatr Emerg Care 2024; 40:307-310. [PMID: 37678275 DOI: 10.1097/pec.0000000000003050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The aim of the study is to assess diagnostic performance of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians in children with preexisting cardiac disease. METHODS We evaluated the use of cardiac POCUS performed by PEM physicians among a convenience sample of children with preexisting cardiac disease presenting to a tertiary care pediatric ED. We assessed patient characteristics and the indication for POCUS. The test characteristics of the sonologist interpretation for the assessment of both pericardial effusion as well as left ventricular systolic dysfunction were compared with expert POCUS review by PEM physicians with POCUS fellowship training. RESULTS A total of 104 children with preexisting cardiac disease underwent cardiac POCUS examinations between July 2015 and December 2017. Among children with preexisting cardiac disease, structural defects were present in 72%, acquired conditions in 22%, and arrhythmias in 13% of patients. Cardiac POCUS was most frequently obtained because of chest pain (55%), dyspnea (18%), tachycardia (17%), and syncope (10%). Cardiac POCUS interpretation compared with expert review had a sensitivity of 100% (95% confidence interval [CI], 85.7-100) for pericardial effusion and 100% (95% CI, 71.5-100) for left ventricular systolic dysfunction; specificity was 97.5% (95% CI, 91.3.1-99.7) for pericardial effusion and 98.9% (95% CI, 93.8-99.8) for left ventricular systolic dysfunction. CONCLUSIONS Cardiac POCUS demonstrates good sensitivity and specificity in diagnosing pericardial effusion and left ventricular systolic dysfunction in children with preexisting cardiac conditions when technically adequate studies are obtained. These findings support future studies of cardiac POCUS in children with preexisting cardiac conditions presenting to the ED.
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Freiman EC, Monuteaux MC, Michelson KA. Variation and Drivers of Costs for Emergency Department Visits Among Children in 8 States. Hosp Pediatr 2024; 14:258-264. [PMID: 38505934 PMCID: PMC11015896 DOI: 10.1542/hpeds.2023-007417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To describe variation in costs for emergency department (ED) visits among children and to assess hospital and regional factors associated with costs. METHODS Cross-sectional study of all ED encounters among children under 18 years in 8 states from 2014 to 2018. The primary outcome was each hospital's mean inflation-adjusted ED costs. We evaluated variability in costs between hospitals and determined factors associated with costs using hierarchical linear models at the state, region, and hospital levels. Models adjusted for pediatric case mix, regional wages, Medicaid share, trauma status, critical access status, ownership, and market competitiveness. RESULTS We analyzed 22.9 million ED encounters across 713 hospitals. The median ED-level cost was $269 (range 99-1863). There was a 5.1-fold difference in median ED-level costs between the lowest- and highest-cost regions (range 119-605). ED-level costs were associated with case mix index (+38% per 10% increase, 95% confidence interval [CI] 30 to 47); wages [+7% per 10% increase, 95% CI 5 to 9]); critical access (adjusted costs, +24%, 95% CI 13 to 35); for profit status (-20%, 95% CI -26 to -14) compared with nonprofit, lowest trauma designation (+17%, 95% CI 5 to 30); teaching hospital status (+7%, 95% CI 1 to 14); highest number of inpatient beds (+13%, 95% CI 4 to 23); and Medicaid share versus quarter (Q)1 (Q2: -12%, 95% CI -18 to -7; Q3: -13%, 95% CI -19 to -7; Q4: -11%, 95% CI -17 to -4). CONCLUSIONS Our results suggest nonclinical factors are important drivers of pediatric health care costs.
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Affiliation(s)
- Eli C Freiman
- Division of Emergency Medicine, Newton Wellesley Hospital, Newton, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth A Michelson
- Division of Emergency Medicine, Lurie Children's Hospital of Chicago, Chicago, Illinois
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Burdick KJ, Coughlin CG, D'Ambrosi GR, Monuteaux MC, Economy KE, Mannix RC, Lee LK. Abortion Restrictiveness and Infant Mortality: An Ecologic Study, 2014-2018. Am J Prev Med 2024; 66:418-426. [PMID: 37844712 DOI: 10.1016/j.amepre.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION The U.S. has the highest infant mortality rate among peer countries. Restrictive abortion laws may contribute to poor infant health outcomes. This ecological study investigated the association between county-level infant mortality and state-level abortion access legislation in the U.S. from 2014 to 2018. METHODS A multivariable regression analysis with the outcome of county-level infant mortality rates, controlling for the primary exposure of state-level abortion laws, and county-level factors, county-level distance to an abortion facility, and state Medicaid expansion status was performed. Incidence rate ratios and 95% CIs were reported. Analyses were conducted in 2022-2023. RESULTS There were 113,397 infant deaths among 19,559,660 live births (infant mortality rate=5.79 deaths/1,000 live births; 95% CI=5.75, 5.82). Black infant mortality rate (10.69/1,000) was more than twice the White infant mortality rate (4.87/1,000). In the multivariable model, increased infant mortality rates were seen in states with ≥8 restrictive laws, with the most restrictive (11-12 laws) having a 16% increased infant mortality level (adjusted incidence rate ratios=1.162; 95% CI=1.103, 1.224). Increased infant mortality rates were associated with increased county-level Black race individuals (adjusted incidence rate ratios=1.031; 95% CI=1.026, 1.037), high school education (adjusted incidence rate ratios=1.018; 95% CI=1.008, 1.029), maternal smoking (adjusted incidence rate ratios=1.025; 95% CI=1.018, 1.033), and inadequate prenatal care (adjusted incidence rate ratios=1.045; 95% CI=1.036, 1.055). CONCLUSIONS State-level abortion law restrictiveness is associated with higher county-level infant mortality rates. The Supreme Court decision on Dobbs versus Jackson and changes in state laws limiting abortion may affect future infant mortality.
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Affiliation(s)
- Kendall J Burdick
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Catherine G Coughlin
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Gabrielle R D'Ambrosi
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Katherine E Economy
- Department of Obstetrics Gynecology & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.
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Monuteaux MC, Du M, Neuman MI. Evaluation of Insurance Type as a Proxy for Socioeconomic Status in the Pediatric Emergency Department: A Pilot Study. Ann Emerg Med 2024:S0196-0644(23)01436-1. [PMID: 38244029 DOI: 10.1016/j.annemergmed.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024]
Abstract
STUDY OBJECTIVE To determine whether insurance status can function as a sufficient proxy for socioeconomic status in emergency medicine research by examining the concordance between insurance status and direct socioeconomic status measures in a sample of pediatric patients. METHODS We conducted a cross-sectional pilot study of patients aged 5 to 17 years in the emergency department of a quaternary care children's hospital. Socioeconomic status was measured using the highest level of the caregiver's education (low: less than bachelor's degree; high: bachelor's or greater) and previous year household income (low: <$75,000; high: ≥$75,000). We calculated the misclassification rate of insurance status (low: public; high: private) using education and income as reference standards. Results were expressed as percentages with 95% confidence intervals. RESULTS In total, 300 patients were enrolled (median age 11 years, 44% female). Insurance status misclassified 23% (95% CI 18% to 28%) and 14% (95% CI 10% to 19%) of patients when using caregiver education and income, respectively, as reference standards. CONCLUSIONS Insurance status misclassified socioeconomic status in up to 23% of pediatric patients, as measured by caregivers' education and income. Emergency medicine studies of pediatric patients using insurance as a covariate to adjust for socioeconomic status may need to consider this misclassification and the resulting potential for bias. These findings require confirmation in larger, more diverse samples, including adult patients.
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Affiliation(s)
| | - Michelle Du
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Michelson KA, Bachur RG, Rangel SJ, Finkelstein JA, Monuteaux MC, Goyal MK. Disparities in Diagnostic Timeliness and Outcomes of Pediatric Appendicitis. JAMA Netw Open 2024; 7:e2353667. [PMID: 38270955 PMCID: PMC10811560 DOI: 10.1001/jamanetworkopen.2023.53667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/06/2023] [Indexed: 01/26/2024] Open
Abstract
This cohort study compares rates of delayed diagnosis and complications of appendicitis by race and ethnicity and Child Opportunity Index among children in 8 states.
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Affiliation(s)
- Kenneth A. Michelson
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts
| | - Jonathan A. Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Monika K. Goyal
- Division of Emergency Medicine, Department of Pediatrics, Children’s National Hospital, George Washington University, Washington, DC
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Meyer EJ, Correa ET, Monuteaux MC, Mannix R, Hatoun J, Vernacchio L, Lyons TW. Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study. Acad Pediatr 2024; 24:51-58. [PMID: 37148968 DOI: 10.1016/j.acap.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To characterize types, duration, and intensity of health care utilization following pediatric concussion and to identify risk factors for increased post-concussion utilization. METHODS A retrospective cohort study of children 5 to 17 years old diagnosed with acute concussion at a quaternary center pediatric emergency department or network of associated primary care clinics. Index concussion visits were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We analyzed patterns of health care visits 6 months before and after the index visit using interrupted time-series analyses. The primary outcome was prolonged concussion-related utilization, defined as having ≥1 follow-up visits with a concussion diagnosis more than 28 days after the index visit. We used logistic regressions to identify predictors of prolonged concussion-related utilization. RESULTS Eight hundred nineteen index visits (median [interquartile range] age, 14 [11-16] years; 395 [48.2%] female) were included. There was a spike in utilization during the first 28 days after the index visit compared to the pre-injury period. Premorbid headache/migraine disorder (adjusted odds ratio (aOR) 2.05, 95% confidence interval [CI] 1.09-3.89) and top quartile pre-injury utilization (aOR 1.90, 95% CI 1.02-3.52) predicted prolonged concussion-related utilization. Premorbid depression/anxiety (aOR 1.55, 95% CI 1.31-1.83) and top quartile pre-injury utilization (aOR 2.29, 95% CI 1.95-2.69) predicted increased utilization intensity. CONCLUSIONS Health care utilization is increased during the first 28 days after pediatric concussion. Children with premorbid headache/migraine disorders, premorbid depression/anxiety, and high baseline utilization are more likely to have increased post-injury health care utilization. This study will inform patient-centered treatment but may be limited by incomplete capture of post-injury utilization and generalizability.
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Affiliation(s)
- Erin J Meyer
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass.
| | - Emily Trudell Correa
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass
| | - Michael C Monuteaux
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
| | - Rebekah Mannix
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
| | - Jonathan Hatoun
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass; Department of Pediatrics (J Hatoun and L Vernacchio), Boston Children's Hospital and Harvard Medical School, Mass
| | - Louis Vernacchio
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass; Department of Pediatrics (J Hatoun and L Vernacchio), Boston Children's Hospital and Harvard Medical School, Mass
| | - Todd W Lyons
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
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Rosen RH, Monuteaux MC, Stack AM, Michelson KA, Fine AM. Impact of a Bronchiolitis Clinical Pathway on Management Decisions by Preferred Language. Pediatr Qual Saf 2024; 9:e714. [PMID: 38322294 PMCID: PMC10843310 DOI: 10.1097/pq9.0000000000000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Background Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care. Methods We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition. Results There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022). Conclusions A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity.
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Affiliation(s)
- Robert H. Rosen
- From the Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
| | - Michael C. Monuteaux
- From the Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
| | - Anne M. Stack
- From the Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
| | - Kenneth A. Michelson
- From the Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
| | - Andrew M. Fine
- From the Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
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Michelson KA, Bachur RG, Rangel SJ, Monuteaux MC, Mahajan P, Finkelstein JA. Emergency Department Volume and Delayed Diagnosis of Pediatric Appendicitis: A Retrospective Cohort Study. Ann Surg 2023; 278:833-838. [PMID: 37389457 PMCID: PMC10756921 DOI: 10.1097/sla.0000000000005972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To determine the association of emergency department (ED) volume of children and delayed diagnosis of appendicitis. BACKGROUND Delayed diagnosis of appendicitis is common in children. The association between ED volume and delayed diagnosis is uncertain, but diagnosis-specific experience might improve diagnostic timeliness. METHODS Using Healthcare Cost and Utilization Project 8-state data from 2014 to 2019, we studied all children with appendicitis <18 years old in all EDs. The main outcome was probable delayed diagnosis: >75% likelihood that a delay occurred based on a previously validated measure. Hierarchical models tested associations between ED volumes and delay, adjusting for age, sex, and chronic conditions. We compared complication rates by delayed diagnosis occurrence. RESULTS Among 93,136 children with appendicitis, 3,293 (3.5%) had delayed diagnosis. Each 2-fold increase in ED volume was associated with a 6.9% (95% CI: 2.2, 11.3) decreased odds of delayed diagnosis. Each 2-fold increase in appendicitis volume was associated with a 24.1% (95% CI: 21.0, 27.0) decreased odds of delay. Those with delayed diagnosis were more likely to receive intensive care [odds ratio (OR): 1.81, 95% CI: 1.48, 2.21], have perforated appendicitis (OR: 2.81, 95% CI: 2.62, 3.02), undergo abdominal abscess drainage (OR: 2.49, 95% CI: 2.16, 2.88), have multiple abdominal surgeries (OR: 2.56, 95% CI: 2.13, 3.07), or develop sepsis (OR: 2.02, 95% CI: 1.61, 2.54). CONCLUSIONS Higher ED volumes were associated with a lower risk of delayed diagnosis of pediatric appendicitis. Delay was associated with complications.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jonathan A Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Michelson KA, Bachur RG, Cruz AT, Grubenhoff JA, Reeves SD, Chaudhari PP, Monuteaux MC, Dart AH, Finkelstein JA. Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data. Diagnosis (Berl) 2023; 10:383-389. [PMID: 37340621 PMCID: PMC10679849 DOI: 10.1515/dx-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVES To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis. METHODS Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined. RESULTS Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2-89.9) and specificity of 61.3 % (95 % confidence interval 56.0-65.4). CONCLUSIONS Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review.
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Affiliation(s)
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A. Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
| | - Scott D. Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | - Arianna H. Dart
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
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Simpson MD, Watson CJ, Whitledge JD, Monuteaux MC, Burns MM. Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications. Pediatr Crit Care Med 2023; 24:893-900. [PMID: 37133321 DOI: 10.1097/pcc.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications. DESIGN Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022. SETTING International multicenter research network of 40 sites. PATIENTS Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied. CONCLUSIONS PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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Affiliation(s)
- Michael D Simpson
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - C James Watson
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - James D Whitledge
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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12
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Truschel LL, Fong HF, Stoklosa HM, Monuteaux MC, Lee L. Poverty and Health Inequities in Children Investigated by Child Protective Services. Clin Pediatr (Phila) 2023; 62:1398-1406. [PMID: 36951369 DOI: 10.1177/00099228231161472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The objective of our study was to examine the association between poverty and child health outcomes in school-age children referred to child protective services. We conducted a secondary analysis of children aged 5 to 9 years in the Second National Survey of Child and Adolescent Well-Being, a nationally representative longitudinal observational data set of children referred to protective services for maltreatment (2008-2012). We analyzed the association of poverty, defined as family income below the federal poverty level (FPL), with caregiver report of the child's overall health, primary care, and emergency department visits using Pearson's chi-squared test. Children below FPL compared with children above it had poorer overall health (29.8% vs 18.0%, P = .03). We also conducted a longitudinal multivariable logistic regression analysis and found poverty was associated with the child's poorer overall health at 36 months (odds ratios 2.78, 95% confidence interval 1.55-5.01). Future studies and interventions to improve health in this at-risk population should target poverty.
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Affiliation(s)
| | - Hiu-Fai Fong
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Hanni M Stoklosa
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Lois Lee
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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13
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Burdick KJ, Rees CA, Lee LK, Monuteaux MC, Mannix R, Mills D, Hirsh MP, Fleegler EW. Racial & ethnic disparities in geographic access to critical care in the United States: A geographic information systems analysis. PLoS One 2023; 18:e0287720. [PMID: 37910455 PMCID: PMC10619775 DOI: 10.1371/journal.pone.0287720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/23/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVE It is important to identify gaps in access and reduce health outcome disparities, understanding access to intensive care unit (ICU) beds, especially by race and ethnicity, is crucial. Our objective was to evaluate the race and ethnicity-specific 60-minute drive time accessibility of ICU beds in the United States (US). DESIGN We conducted a cross-sectional study using road network analysis to determine the number of ICU beds within a 60-minute drive time, and calculated adult intensive care bed ratios per 100,000 adults. We evaluated the US population at the Census block group level and stratified our analysis by race and ethnicity and by urbanicity. We classified block groups into four access levels: no access (0 adult intensive care beds/100,000 adults), below average access (>0-19.5), average access (19.6-32.0), and above average access (>32.0). We calculated the proportion of adults in each racial and ethnic group within the four access levels. SETTING All 50 US states and the District of Columbia. PARTICIPANTS Adults ≥15 years old. MAIN OUTCOME MEASURES Adult intensive care beds/100,000 adults and percentage of adults national and state) within four access levels by race and ethnicity. RESULTS High variability existed in access to ICU beds by state, and substantial disparities by race and ethnicity. 1.8% (n = 5,038,797) of Americans had no access to an ICU bed, and 26.8% (n = 73,095,752) had below average access, within a 60-minute drive time. Racial and ethnic analysis showed high rates of disparities (no access/below average access): American Indians/Alaskan Native 12.6%/28.5%, Asian 0.7%/23.1%, Black or African American 0.6%/16.5%, Hispanic or Latino 1.4%/23.0%, Native Hawaiian and other Pacific Islander 5.2%/35.0%, and White 2.1%/29.0%. A higher percentage of rural block groups had no (5.2%) or below average access (41.2%), compared to urban block groups (0.2% no access, 26.8% below average access). CONCLUSION ICU bed availability varied substantially by geography, race and ethnicity, and by urbanicity, creating significant disparities in critical care access. The variability in ICU bed access may indicate inequalities in healthcare access overall by limiting resources for the management of critically ill patients.
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Affiliation(s)
- Kendall J. Burdick
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States of America
| | - Chris A. Rees
- Division of Emergency Medicine, Emory University, Atlanta, GA, United States of America
| | - Lois K. Lee
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
| | - David Mills
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Michael P. Hirsh
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States of America
| | - Eric W. Fleegler
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
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14
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Toce MS, Dorney K, D'Ambrosi G, Monuteaux MC, Paydar-Darian N, Raghavan VR, Bourgeois FT, Hudgins J. Resource utilization among children presenting with cannabis poisonings in the emergency department. Am J Emerg Med 2023; 73:171-175. [PMID: 37696075 DOI: 10.1016/j.ajem.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Exploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings. METHODS This is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0-10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named "ancillary testing" was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time. RESULTS A total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2-6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12]). CONCLUSIONS We found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation.
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America.
| | - Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Niloufar Paydar-Darian
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Vidya R Raghavan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America; Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA, United States of America
| | - Joel Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
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15
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Watson CJ, Monuteaux MC, Burns MM. Characterization of pediatric beta-adrenergic antagonist ingestions reported to the National Poison Data System from 2000 to 2020. Acad Emerg Med 2023; 30:1129-1137. [PMID: 37350748 DOI: 10.1111/acem.14769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND When ingested by children, small quantities of beta-adrenergic antagonists (BAA) are described as dangerous and even potentially lethal ("one pill can kill"). We characterize demographics, clinical characteristics, and the rate of serious outcomes among pediatric patients with reported BAA ingestions. METHODS This study was a retrospective review of U.S. patients <20 years old with reported single-agent BAA ingestions presenting to a health care facility between January 2000 and February 2020 for whom a poison control center was consulted. Data were abstracted from the National Poison Data System (NPDS). Medical outcomes were assessed by the NPDS scale of no effect, minor effect, moderate effect, major effect, and death. All relevant NPDS fatality narratives were reviewed. RESULTS A total of 35,436 reported exposures were identified. A total of 29,155 (82.3%) were <6 years old, of which 29,089 (99.8%) were unintentional. Twenty-five patients (<0.1%) <6 years old had major effects. A total of 2316 (8.8%) of patients with no/mild effects were admitted to a critical care unit. Of all cases, 1460 (4.1%) had hypotension and 1403 (4.0%) had bradycardia. One hundred nineteen (0.3%) developed hypoglycemia. The only four fatalities resulted from intentional ingestions in patients >10 years old who sustained cardiac arrest in the prehospital setting. CONCLUSIONS Reported BAA ingestions in this multiyear national pediatric cohort caused infrequent toxicity, and no fatalities resulted from an unintentional ingestion. The frequency of bradycardia, hypotension, and hypoglycemia were low. While severely poisoned patients require aggressive treatment, 8.8% of patients were admitted to a critical care unit despite having no or mild effects, which suggests an opportunity to reduce resource utilization.
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Affiliation(s)
- C James Watson
- Division of Medical Toxicology, Department of Emergency Medicine, Maine Medical Center, Portland, Maine, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michele M Burns
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, Massachusetts, USA
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16
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Cavallaro SC, Michelson KA, D'Ambrosi G, Monuteaux MC, Li J. Critical Revisits Among Children After Emergency Department Discharge. Ann Emerg Med 2023; 82:575-582. [PMID: 37462598 PMCID: PMC10889433 DOI: 10.1016/j.annemergmed.2023.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 08/11/2023]
Abstract
STUDY OBJECTIVE Identifying higher risk groups could reveal ways to prevent critical emergency department (ED) revisits. The study objectives were to determine the rate of critical ED revisits among children discharged from the ED and to identify factors associated with critical revisits. METHODS We performed a retrospective study using the Healthcare Cost and Utilization Project State ED Databases (SEDD) and the State Inpatient Databases (SID). We included data from 6 states from 2014 through 2017. Critical ED revisit was defined as either ICU admission or death within 3 days of the initial ED discharge. We included all patients younger than 21 years. The main outcome was the rate of critical ED revisit. We also determined the relative risk (RR) of a critical ED revisit for the most common index ED visit diagnoses. We used negative binomial regression to calculate incidence rate ratios (IRR) of a critical ED visit by pediatric volume and complex chronic conditions. RESULTS A total of 16.3 million children were discharged from an ED over the 4-year study period. There were 18,704 (0.1%) critical ED revisits, 180 (0.00001%) of whom died. Asthma (RR 2.24, 95% confidence interval [CI] [2.11 to 2.38) had the highest relative risk of a critical revisit among all ED diagnoses. Adjusting for hospital volume and patient age, patients with complex chronic conditions were also more likely to have a critical ED revisit (IRR 11.03, 95% CI, 7.76 to 15.67). CONCLUSIONS Critical revisits after ED discharge were uncommon among children in our study sample, with revisits resulting in patient death within 3 days of an ED discharge being rare. Given the short time interval between ED discharges, however, future research should focus on understanding higher risk patients among those with asthma and a history of complex chronic conditions.
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Affiliation(s)
- Sarah C Cavallaro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | | | | | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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17
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Wiener SJ, Porter JJ, Paydar-Darian N, Monuteaux MC, Hudgins JD. Emergency Care Utilization for Mental and Sexual Health Concerns Among Adolescents Following Sexual Assault: A Retrospective Cohort Study. J Adolesc Health 2023; 73:486-493. [PMID: 37294253 DOI: 10.1016/j.jadohealth.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE This study aimed to explore the health outcomes of adolescent survivors of sexual assault, as measured by subsequent emergency department (ED) utilization for mental and sexual health concerns. METHODS This retrospective cohort study used the Pediatric Health Information System (PHIS) database. We included patients aged 11-18 years seen at a PHIS hospital with a primary diagnosis of sexual assault. The control group included age- and sex-matched patients seen for an injury. Participants were followed in PHIS for 3-10 years; subsequent ED visits for suicidality, sexually transmitted infection, pelvic inflammatory disease (PID), or pregnancy were identified, and likelihoods of each were compared using Cox proportional hazards models. RESULTS The study population included 19,706 patients. ED return visit rates in the sexual assault and control groups were 7.9% versus 4.1% for suicidality, 1.8% versus 1.4% for sexually transmitted infection, 2.2% versus 0.8% for PID, and 1.7% versus 1.0% for pregnancy, respectively. Compared to controls, sexual assault patients were significantly more likely to return to the ED for suicidality throughout the follow-up period, with the highest hazard ratio of 6.31 (95% confidence interval 4.46-8.94) during the first 4 months. Sexual assault patients also had higher likelihood of returning for PID (hazard ratio 3.80, 95% confidence interval 3.07-4.71) throughout the follow-up period. DISCUSSION Adolescents seen in the ED for sexual assault were significantly more likely to return to the ED for suicidality and sexual health concerns, highlighting the need for increased allocation of research and clinical resources to improve their care.
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Affiliation(s)
- Susan J Wiener
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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18
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Miller KA, Cavallaro S, Hirsch A, Hudgins J, Levy J, Li J, Lipton G, Marchese A, Mannix RC, Monuteaux MC, Schutzman S, Miller AF. Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where. AEM Educ Train 2023; 7:e10903. [PMID: 37600855 PMCID: PMC10436031 DOI: 10.1002/aet2.10903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Abstract
Objectives Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions. Methods This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods. Results Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods. Conclusions Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.
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Affiliation(s)
- Kelsey A. Miller
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Sarah Cavallaro
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Alexander Hirsch
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Joel Hudgins
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Jason Levy
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Joyce Li
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Galina Lipton
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Ashley Marchese
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Rebekah C. Mannix
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | | | - Sara Schutzman
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Andrew F. Miller
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
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19
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Young AL, Monuteaux MC, Cooney TM, Michelson KA. Predictors of Delayed Diagnosis of Pediatric CNS Tumors in the Emergency Department. Pediatr Emerg Care 2023; 39:617-622. [PMID: 37079623 PMCID: PMC10527910 DOI: 10.1097/pec.0000000000002943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays. STUDY DESIGN We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit. RESULTS We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98). CONCLUSIONS Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs.
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Affiliation(s)
- Ann L Young
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Tabitha M Cooney
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Hospital, Boston, MA
| | - Kenneth A Michelson
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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20
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Kahane CG, Nigrovic LE, Kharbanda AB, Neville D, Thompson AD, Balamuth F, Chapman L, Levas MN, Branda JA, Kellogg MD, Monuteaux MC, Lyons TW. Biomarkers for Pediatric Bacterial Musculoskeletal Infections in Lyme Disease-Endemic Regions. Pediatrics 2023:e2023061329. [PMID: 37409396 DOI: 10.1542/peds.2023-061329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES Bacterial musculoskeletal infections (MSKIs) are challenging to diagnose because of the clinical overlap with other conditions, including Lyme arthritis. We evaluated the performance of blood biomarkers for the diagnosis of MSKIs in Lyme disease-endemic regions. METHODS We conducted a secondary analysis of a prospective cohort study of children 1 to 21 years old with monoarthritis presenting to 1 of 8 Pedi Lyme Net emergency departments for evaluation of potential Lyme disease. Our primary outcome was an MSKI, which was defined as septic arthritis, osteomyelitis or pyomyositis. We compared the diagnostic accuracy of routinely available biomarkers (absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and procalcitonin) to white blood cells for the identification of an MSKI using the area under the receiver operating characteristic curve (AUC). RESULTS We identified 1423 children with monoarthritis, of which 82 (5.8%) had an MSKI, 405 (28.5%) Lyme arthritis, and 936 (65.8%) other inflammatory arthritis. When compared with white blood cell count (AUC, 0.63; 95% confidence interval [CI], 0.55-0.71), C-reactive protein (0.84; 95% CI, 0.80-0.89; P < .05), procalcitonin (0.82; 95% CI, 0.77-0.88; P < .05), and erythrocyte sedimentation rate (0.77; 95% CI, 0.71-0.82; P < .05) had higher AUCs, whereas absolute neutrophil count (0.67; 95% CI, 0.61-0.74; P < .11) had a similar AUC. CONCLUSIONS Commonly available biomarkers can assist in the initial approach to a potential MSKI in a child. However, no single biomarker has high enough accuracy to be used in isolation, especially in Lyme disease-endemic areas.
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Affiliation(s)
- Caroline G Kahane
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Desiree Neville
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Chapman
- Division of Pediatric Emergency Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Mark D Kellogg
- Department of Laboratory Medicine, Boston Children's Hospital and Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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21
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Michelson KA, Bachur RG, Grubenhoff JA, Cruz AT, Chaudhari PP, Reeves SD, Porter JJ, Monuteaux MC, Dart AH, Finkelstein JA. OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS. J Emerg Med 2023; 65:e9-e18. [PMID: 37355425 PMCID: PMC10527892 DOI: 10.1016/j.jemermed.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/15/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Missed diagnosis can predispose to worse condition-specific outcomes. OBJECTIVE To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. RESULTS We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis. CONCLUSIONS Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Andrea T Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California; Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Scott D Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan A Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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22
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Foster AA, Saidinejad M, Duffy S, Hoffmann JA, Goodman R, Monuteaux MC, Li J. Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators. Acad Pediatr 2023; 23:988-992. [PMID: 36948291 DOI: 10.1016/j.acap.2023.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/09/2023] [Accepted: 03/12/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care. METHODS We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California. RESULTS PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%). CONCLUSIONS ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine (AA Foster), University of California San Francisco, Calif.
| | - Mohsen Saidinejad
- The Lundquist Institute for Biomedical Innovation at Harbor UCLA (M Saidinejad and R Goodman), Torrance, Calif; David Geffen School of Medicine at UCLA (M Saidinejad), Los Angeles, Calif; Department of Emergency Medicine (M Saidinejad), Harbor UCLA Medical Center, Torrance, Calif.
| | - Susan Duffy
- Department of Emergency Medicine (S Duffy), The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
| | - Jennifer A Hoffmann
- Division of Emergency Medicine (JA Hoffmann), Ann & Robert H. Lurie Children...s Hospital of Chicago, Ill; Feinberg School of Medicine (JA Hoffmann), Northwestern University, Chicago, Ill.
| | - Robin Goodman
- The Lundquist Institute for Biomedical Innovation at Harbor UCLA (M Saidinejad and R Goodman), Torrance, Calif.
| | - Michael C Monuteaux
- Division of Emergency Medicine (MC Monuteaux and J Li), Boston Children...s Hospital, Mass.
| | - Joyce Li
- Division of Emergency Medicine (MC Monuteaux and J Li), Boston Children...s Hospital, Mass; Department of Emergency Medicine (J Li), Harvard Medical School, Boston, Mass; Department of Pediatrics (J Li), Harvard Medical School, Boston, Mass.
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23
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Geanacopoulos AT, Neuman MI, Lipsett SC, Monuteaux MC, Michelson KA. Association of Chest Radiography With Outcomes in Pediatric Pneumonia: A Population-Based Study. Hosp Pediatr 2023:e2023007142. [PMID: 37340908 DOI: 10.1542/hpeds.2023-007142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Chest radiograph (CXR) is often performed for the evaluation of community-acquired pneumonia (CAP) in the ED setting. We sought to evaluate the association of undergoing CXR with 7-day hospitalization after emergency department (ED) discharge among patients with CAP. METHODS This was a retrospective cohort study including children 3 months to 17 years discharged from any ED within 8 states from 2014 to 2019. We evaluated the association of CXR performance with 7-day hospitalization at both the patient and ED levels using mixed-effects logistic regression models accounting for markers of illness severity. Secondary outcomes included 7-day ED revisits and 7-day hospitalization with severe CAP. RESULTS Among 206 694 children with CAP, rates of 7-day ED revisit, hospitalization, and severe CAP were 8.9%, 1.6%, and 0.4%, respectively. After adjusting for illness severity, CXR was associated with fewer 7-day hospitalizations (1.6% vs. 1.7%, adjusted odds ratio: [aOR] 0.82, 95% confidence interval [CI]: 0.73-0.92). CXR performance varied somewhat between EDs (median 91.5%, IQR: 85.3%-95.0%). EDs in the highest quartile had fewer 7-day hospitalizations (1.4% vs 1.9%, aOR: 0.78, 95% CI: 0.65-0.94), ED revisits (8.5% vs 9.4%, aOR: 0.88, 95% CI: 0.80-0.96) and hospitalizations for severe CAP (0.3% vs. 0.5%, aOR: 0.70, 95% CI: 0.51-0.97) as compared to EDs with the lowest quartile of CXR utilization. CONCLUSIONS Among children discharged from the ED with CAP, performance of CXR was associated with a small but significant reduction in hospitalization within 7 days. CXR may be helpful in the prognostic evaluation of children with CAP discharged from the ED.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth A Michelson
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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24
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McKay J, Wasserman M, Monuteaux MC, Hirsch AW, Nagler J. Just-in-time procedural training for pediatric emergency medicine trainees: A randomized educational interventional trial. AEM Educ Train 2023; 7:e10886. [PMID: 37361189 PMCID: PMC10287658 DOI: 10.1002/aet2.10886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023]
Abstract
Background Pediatric requirements include procedural skills training such as peripheral intravenous (PIV) catheter placement and bag-mask ventilation (BMV). Clinical experiences may be limited and temporally remote from scheduled teaching. Just-in-time (JIT) training prior to utilization can promote skill development and mitigate learning decay. Our objective was to assess the impact of JIT training on pediatric residents' procedural performance, knowledge, and confidence with PIV placement and BMV. Methods Residents received standardized baseline training in both PIV placement and BMV during scheduled educational programming. Between 3 and 6 months later, participants were randomized and received JIT training for either PIV placement or BMV. JIT training included a brief video and coached practice, totaling <5 min. Each participant was videotaped performing both procedures on skills trainers. Blinded investigators scored performance using skills checklists. Pre- and postintervention knowledge was assessed using multiple-choice and short-answer items, and confidence was reported using Likert scores. Results Seventy-two residents completed baseline training sessions: 36 were randomized to receive JIT training for PIV and 36 for BMV. Thirty-five residents in each cohort completed the curriculum. There were no significant differences between the cohorts with regard to demographics, baseline knowledge, or prior simulation experience. JIT training was associated with improved procedural performance for PIV (median 87% vs. 70%, p < 0.001) and for BMV (mean 83% vs. 57%, p < 0.001). Results remained significant after using regression models to adjust for differences in prior clinical experience. Improvements in knowledge or confidence were not associated with JIT training in either cohort. Conclusions JIT training resulted in a significant improvement in resident procedural performance with PIV placement and BMV in a simulated environment. There were no differences in outcome with regard to knowledge or confidence. Future work might explore how the demonstrated benefit translates into the clinical setting.
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Affiliation(s)
- Jheanelle McKay
- Department of Pediatric Emergency MedicineJoe DiMaggio Children's HospitalHollywoodFloridaUSA
| | - Mollie Wasserman
- Division of Pediatric Hospital MedicineBoston Children's HospitalBostonMassachusettsUSA
| | | | - Alexander W. Hirsch
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
| | - Joshua Nagler
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
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25
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Junior JA, Lee LK, Fleegler EW, Monuteaux MC, Niescierenko ML, Stewart AM. Association of State-Level Tax Policy and Infant Mortality in the United States, 1996-2019. JAMA Netw Open 2023; 6:e239646. [PMID: 37093600 PMCID: PMC10126872 DOI: 10.1001/jamanetworkopen.2023.9646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Importance Infant mortality in the United States is highest among peer nations; it is also inequitable, with the highest rates among Black infants. The association between tax policy and infant mortality is not well understood. Objective To examine the association between state-level tax policy and state-level infant mortality in the US. Design, Setting, and Participants This state-level, population-based cross-sectional study investigated the association between tax policy and infant mortality in the US from 1996 through 2019. All US infant births and deaths were included, with data obtained from the National Center for Health Statistics. Data were analyzed from November 28, 2021, to July 9, 2022. Exposures State-level tax policy was operationalized as tax revenue per capita and tax progressivity. The Suits index was used to measure tax progressivity, with higher progressivity indicating increased tax rates for wealthier individuals. Main Outcomes and Measures The association between tax policy and infant mortality rates was analyzed using a multivariable, negative binomial, generalized estimating equations model. Since 6 years of tax progressivity data were available (1995, 2002, 2009, 2012, 2014, and 2018), 300 state-years were included. Adjusted incidence rate ratios (aIRRs) were calculated controlling for year, state-level demographic variables, federal transfer revenue, and other revenue. Secondary analyses were conducted for racial and ethnic subgroups. Results There were 148 336 infant deaths in the US from 1996 through 2019, including 27 861 Hispanic infants, 1882 non-Hispanic American Indian or Alaska Native infants, 5792 non-Hispanic Asian or Pacific Islander infants, 41 560 non-Hispanic Black infants, and 68 666 non-Hispanic White infants. The overall infant mortality rate was 6.29 deaths per 1000 live births. Each $1000 increase in tax revenue per capita was associated with a 2.6% decrease in the infant mortality rate (aIRR, 0.97; 95% CI, 0.95-0.99). An increase of 0.10 in the Suits index (ie, increased tax progressivity) was associated with a 4.6% decrease in the infant mortality rate (aIRR, 0.95; 95% CI, 0.91-0.99). Increased tax progressivity was associated with decreased non-Hispanic White infant mortality (aIRR, 0.95; 95% CI, 0.91-0.99), and increased tax revenue was associated with increased non-Hispanic Black infant mortality (aIRR, 1.04; 95% CI, 1.01-1.08). Conclusions and Relevance In this cross-sectional study, an increase in tax revenue and the Suits index of tax progressivity were both associated with decreased infant mortality. These associations varied by race and ethnicity. Tax policy is an important, modifiable social determinant of health that may influence state-level infant mortality.
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Affiliation(s)
- Jean A Junior
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michelle L Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Amanda M Stewart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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26
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Miller KA, Auerbach M, Bin SS, Donoghue A, Kerrey BT, Mittiga MR, D'Ambrosi G, Monuteaux MC, Marchese A, Nagler J. Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation. AEM Educ Train 2023; 7:e10846. [PMID: 36936084 PMCID: PMC10014969 DOI: 10.1002/aet2.10846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
Background Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.
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Affiliation(s)
- Kelsey A. Miller
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Steven S. Bin
- Departments of Pediatrics and Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Aaron Donoghue
- Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Benjamin T. Kerrey
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | | | - Ashley Marchese
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Joshua Nagler
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
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Toce MS, Michelson KA, Hudgins JD, Hadland SE, Olson KL, Monuteaux MC, Bourgeois FT. Association of Prescription Drug Monitoring Programs With Opioid Prescribing and Overdose in Adolescents and Young Adults. Ann Emerg Med 2023; 81:429-437. [PMID: 36669914 PMCID: PMC10091852 DOI: 10.1016/j.annemergmed.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE Prescription opioid use is associated with substance-related adverse outcomes among adolescents and young adults through a pathway of prescribing, diversion and misuse, and addiction and overdose. Assessing the effect of current prescription drug monitoring programs (PDMPs) on opioid prescribing and overdoses will further inform strategies to reduce opioid-related harms. METHODS We performed interrupted time series analyses to measure the association between state-level implementation of PDMPs with annual opioid prescribing and opioid-related overdoses in adolescents (13 to 18 years) and young adults (19 to 25 years) between 2008 and 2019. We focused on PDMPs that included mandatory reviews by providers. Data were obtained from a commercial insurance company. RESULTS Among 9,344,504 adolescents and young adults, 1,405,382 (15.0%) had a dispensed opioid prescription, and 6,262 (0.1%) received treatment for an opioid-related overdose. Mandated PDMP review was associated with a 4.2% (95% CI, 1.9% to 6.4%) reduction in annual opioid dispensations among adolescents and a 7.8% (95% CI, 4.7% to 10.9%) annual reduction among young adults. For opioid-related overdoses, mandated PDMP review was associated with a 16.1% (95% CI, 3.8 to 26.7) and 15.9% (95% CI, 7.6 to 23.4) reduction in annual opioid overdoses for adolescents and young adults, respectively. CONCLUSION PDMPs were associated with sustained reductions in opioid prescribing and overdoses in adolescents and young adults. Although these findings support the value of mandated PDMPs as part of ongoing strategies to reduce opioid overdoses, further studies with prospective study designs are needed to characterize the effect of these programs fully.
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Scott E Hadland
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Adolescent and Young Adult Medicine, MassGeneral Hospital for Children, Boston, MA
| | - Karen L Olson
- Department of Pediatrics, Harvard Medical School, Boston, MA; Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA
| | | | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA
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28
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Toce MS, Michelson KA, Hudgins JD, Olson KL, Monuteaux MC, Bourgeois FT. Association of prescription drug monitoring programs with benzodiazepine prescription dispensation and overdose in adolescents and young adults. Clin Toxicol (Phila) 2023; 61:234-240. [PMID: 36919488 DOI: 10.1080/15563650.2023.2181092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Prescription drug monitoring programs are state-run databases designed to support safe prescribing of controlled substances and reduce prescription drug misuse. We analyzed healthcare claims data to determine the association between prescription drug monitoring programs with mandated provider review and adolescent and young adult benzodiazepine prescription dispensing and overdose. METHODS We performed a state-level retrospective cohort study to evaluate the association between implementation of prescription drug monitoring programs with mandated provider review and benzodiazepine prescription dispensing and benzodiazepine-related overdoses among adolescents (13-18 years) and young adults (19-25 years) between 1 January 2008 and 31 December 2019. Data were obtained from a United States commercial health insurance company. RESULTS There were 74,539 (1.8%) adolescents and 246,760 (4.0%) young adults with at least one benzodiazepine prescription dispensed. Benzodiazepine overdoses occurred among 1,569 (0.04%) and 3,202 (0.05%) adolescents and young adults, respectively. Implementation of a prescription drug monitoring program with mandated provider review was associated with a 6.8% (95% CI, 1.6-11.8) yearly reduction in benzodiazepine prescription dispensing among adolescents and a 12.5% (95% CI, 9.3-15.5) yearly reduction among young adults. There was no decrease in benzodiazepine overdoses in either age group (-15.4% [95% CI, -21.5 to 3.0] and -8.0% [95% CI, -18.0 to 3.2] yearly change in adolescents and young adults, respectively). DISCUSSION Consistent with prior work, our study did not find an association between prescription drug monitoring program implementation and reduction in benzodiazepine-related overdoses among adolescents and young adults. However, the substantial reduction in benzodiazepine prescription dispensing is encouraging. CONCLUSION Prescription drug monitoring programs were associated with decreases in benzodiazepine prescription dispensing, but not benzodiazepine-related overdoses in this cohort of adolescents and young adults. These findings serve to inform development of further policies to address rising rates of benzodiazepine misuse and overdose in this patient population.
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Karen L Olson
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA, USA
| | | | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA, USA
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29
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Li J, Baker AL, D'Ambrosi G, Monuteaux MC, Chung S. A Statewide Assessment of Pediatric Emergency Care Surge Capabilities. Pediatrics 2023; 151:190814. [PMID: 36872285 DOI: 10.1542/peds.2022-059459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Pediatric surge planning is critical in the setting of decreasing pediatric inpatient capacity. We describe a statewide assessment of pediatric inpatient bed capacity, clinical care therapies, and subspecialty availability during standard and disaster operations in Massachusetts. METHODS To assess pediatric (<18 years old) inpatient bed capacity during standard operations, we used Massachusetts Department of Public Health data from May 2021. To assess pediatric disaster capacity, therapies, and subspecialty availability in standard and disaster operations, we performed a state-wide survey of Massachusetts hospital emergency management directors from May to August 2021. From the survey, we calculated additional pediatric inpatient bed capacity during a disaster and clinical therapy and subspecialty availability during standard and disaster operations. RESULTS Of 64 Massachusetts acute care hospitals, 58 (91%) completed the survey. Of all licensed inpatient beds in Massachusetts (n = 11 670), 19% (n = 2159) are licensed pediatric beds. During a disaster, 171 pediatric beds could be added. During standard and disaster operations, respiratory therapies were available in 36% (n = 21) and 69% (n = 40) of hospitals, respectively, with high flow nasal cannula being most common. The only surgical subspecialist available in the majority of hospitals (>50%) during standard operations is general surgery (59%, n = 34). In a disaster, only orthopedic surgery could additionally provide services in the majority hospitals (76%; n = 44). CONCLUSIONS Massachusetts pediatric inpatient capacity is limited in a disaster scenario. Respiratory therapies could be available in more than half of hospitals in a disaster, but the majority of hospitals lack surgical subspecialists for children under any circumstance.
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Burdick KJ, Lee LK, Mannix R, Monuteaux MC, Hirsh MP, Fleegler EW. Racial and Ethnic Disparities in Access to Pediatric Trauma Centers in the United States: A Geographic Information Systems Analysis. Ann Emerg Med 2023; 81:325-333. [PMID: 36328848 DOI: 10.1016/j.annemergmed.2022.08.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Injury is the leading cause of death and disability for children, making access to pediatric trauma centers crucial to pediatric trauma care. Our objective was to describe the pediatric population with timely access to a pediatric trauma center by demographics and geography in the United States. METHODS Level 1, 2, and 3 pediatric trauma center locations were provided by the American Trauma Society. Geographic information systems road network and rotor wing analysis determined US Census Block Groups with the ground and/or air access to a pediatric trauma center within a 60-minute transport time. We then described, at the national and state levels, the 2020 pediatric population (< 15 years old) with and without pediatric trauma center access by ground and air, stratified by race, ethnicity, and urbanicity. RESULTS There were 157 pediatric trauma centers (82 Level 1, 64 Level 2, 11 Level 3). Of the 2020 US pediatric population, 33,352,872 (54.5%) had timely access to Level 1-3 pediatric trauma centers by ground and 45,431,026 (74.1%) by air. The percentage of children with access by race and ethnicity were (by ground, by air): American Indian/Alaskan Native (31.0%, 43.5%), White (48.7%, 71.3%), Native Hawaiian/Pacific Islander (59.3%, 61.0%), Hispanic (60.2%, 76.9%), Black (64.2%, 78.0%), and Asian (76.5%, 89.5%). Only 48.2% of children living in rural block groups had access, compared with 83.6% in urban block groups. CONCLUSION Significant disparities in current access to pediatric trauma centers exist by race and ethnicity, and geography, leaving some children at risk for poor trauma outcomes.
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Affiliation(s)
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
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Michelson KA, Bachur RG, Dart AH, Chaudhari PP, Cruz AT, Grubenhoff JA, Reeves SD, Monuteaux MC, Finkelstein JA. Identification of delayed diagnosis of paediatric appendicitis in administrative data: a multicentre retrospective validation study. BMJ Open 2023; 13:e064852. [PMID: 36854600 PMCID: PMC9980351 DOI: 10.1136/bmjopen-2022-064852] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE To derive and validate a tool that retrospectively identifies delayed diagnosis of appendicitis in administrative data with high accuracy. DESIGN Cross-sectional study. SETTING Five paediatric emergency departments (EDs). PARTICIPANTS 669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis. OUTCOME Delayed diagnosis was defined as appendicitis being present but not diagnosed at the first ED encounter based on standardised record review. The cohort was split into derivation (2/3) and validation (1/3) groups. We derived a prediction rule using logistic regression, with covariates including variables obtainable only from administrative data. The resulting trigger tool was applied to the validation group to determine area under the curve (AUC). Test characteristics were determined at two predicted probability thresholds. RESULTS Delayed diagnosis occurred in 471 (70.4%) patients. The tool had an AUC of 0.892 (95% CI 0.858 to 0.925) in the derivation group and 0.859 (95% CI 0.806 to 0.912) in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% (95% CI 78.2% to 89.8%) and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% (95% CI 87.4% to 98.6%) and identified 46.8% of delayed cases. CONCLUSIONS This tool accurately identified delayed diagnosis of appendicitis. It may be used to screen for potential missed diagnoses or to specifically identify a cohort of children with delayed diagnosis.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Scott D Reeves
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand T, Goldman MP, Prieto MM, Wing R, Breuer R, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes. Ann Emerg Med 2023; 81:113-122. [PMID: 36253297 DOI: 10.1016/j.annemergmed.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | | | - Andrew F Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Phillip M Thomas
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Tara Neubrand
- Department of Emergency Medicine - Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Ryan Breuer
- Department of Pediatrics - Pediatric Critical Care, Oishei Children's Hospital, Buffalo, NY
| | - Jenn D'Mello
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Dorney K, Monuteaux MC, Nigrovic LE, Lipsett SC, Nelson KA, Neuman MI. Trends in the Use of Procalcitonin at US Children's Hospital Emergency Departments. Hosp Pediatr 2023; 13:24-30. [PMID: 36530152 DOI: 10.1542/hpeds.2022-006792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing. METHODS We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count). RESULTS The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%). CONCLUSIONS PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses.
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Kanak MM, Fleegler EW, Chang L, Curt AM, Burdick KJ, Monuteaux MC, Deane M, Warrington P, Stewart AM. Mobile Social Screening and Referral Intervention in a Pediatric Emergency Department. Acad Pediatr 2023; 23:93-101. [PMID: 36075518 DOI: 10.1016/j.acap.2022.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/15/2022] [Accepted: 08/28/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Many families in pediatric emergency departments (PED) have unmet social needs, which may be detected and addressed with the use of a digital social needs intervention. Our objective was to characterize the feasibility and effectiveness of utilizing personal phones or a PED tablet for screening and referral to social services. METHODS We conducted a prospective single-arm intervention study using a convenience sample of caregivers and adult patients in an urban PED between May 2019 and October 2020. Participants chose either their personal phone or a PED-provided tablet to use an app, "HelpSteps." Participants self-selected need(s) then referrals to service agencies. Participants completed a 1-month follow-up. Clinicians were surveyed about screening and impact on visit. RESULTS Of 266 participants enrolled, 55% of participants elected to use their personal phone. Of all participants, 67% self-selected at least 1 health-related social need; 34% selected 3 or more. The top 3 "most important" needs were housing (14%), education (12%), and fitness (12%). At one month follow-up, 44% of participants reported their top need was "completely" or "somewhat" solved. For 95% of encounters, clinicians reported the intervention did not increase length of stay. CONCLUSIONS A mobile social needs intervention was feasible and effective at identifying and referring participants in the PED setting. While more than half of participants used their personal phones, several smartphone owners cited barriers and elected to use a tablet. Overall, participants found the app easy to use, appropriate for the PED, and the intervention had minimal impact on clinical flow.
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Affiliation(s)
- Mia M Kanak
- Children's Hospital Los Angeles (MM Kanak), Division of Emergency Medicine and Transport Medicine, Los Angeles, Calif.
| | - Eric W Fleegler
- Boston Children's Hospital (EW Fleegler, L Chang, MC Monuteaux, M Deane, and AM Stewart), Division of Emergency Medicine, Boston, Mass; Harvard Medical School (EW Fleegler, L Chang, AM Curt, MC Monuteaux, and A M Stewart), Boston, Mass
| | - Lawrence Chang
- Boston Children's Hospital (EW Fleegler, L Chang, MC Monuteaux, M Deane, and AM Stewart), Division of Emergency Medicine, Boston, Mass; Harvard Medical School (EW Fleegler, L Chang, AM Curt, MC Monuteaux, and A M Stewart), Boston, Mass
| | - Alexa M Curt
- Harvard Medical School (EW Fleegler, L Chang, AM Curt, MC Monuteaux, and A M Stewart), Boston, Mass
| | - Kendall J Burdick
- University of Massachusetts Medical School (KJ Burdick), Worcester, Mass
| | - Michael C Monuteaux
- Boston Children's Hospital (EW Fleegler, L Chang, MC Monuteaux, M Deane, and AM Stewart), Division of Emergency Medicine, Boston, Mass; Harvard Medical School (EW Fleegler, L Chang, AM Curt, MC Monuteaux, and A M Stewart), Boston, Mass
| | - Melissa Deane
- Boston Children's Hospital (EW Fleegler, L Chang, MC Monuteaux, M Deane, and AM Stewart), Division of Emergency Medicine, Boston, Mass
| | | | - Amanda M Stewart
- Boston Children's Hospital (EW Fleegler, L Chang, MC Monuteaux, M Deane, and AM Stewart), Division of Emergency Medicine, Boston, Mass; Harvard Medical School (EW Fleegler, L Chang, AM Curt, MC Monuteaux, and A M Stewart), Boston, Mass
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Genadry KC, Monuteaux MC, Neuman MI, Lowe DA, Lee LK. Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19. Acad Pediatr 2023; 23:76-84. [PMID: 35609775 DOI: 10.1016/j.acap.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management. METHODS We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79). CONCLUSIONS Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.
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Affiliation(s)
- Katia C Genadry
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass.
| | - Michael C Monuteaux
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| | - Mark I Neuman
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| | - David A Lowe
- Department of Emergency Medicine, Nicklaus Children's Hospital (DA Lowe), Miami, Fla
| | - Lois K Lee
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
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36
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Foster AA, Porter JJ, Monuteaux MC, Hoffmann JA, Li J, Lee LK, Hudgins JD. Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments. Pediatrics 2023; 151:190312. [PMID: 36530158 DOI: 10.1542/peds.2022-056667] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described. METHODS This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint. RESULTS Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25). CONCLUSIONS For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco, California
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Emergency Medicine.,Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Emergency Medicine.,Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Emergency Medicine.,Pediatrics, Harvard Medical School, Boston, Massachusetts
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Baker AH, Monuteaux MC, Michelson KA, Neuman MI. Acetaminophen Versus Ibuprofen for Fever Reduction in the Pediatric Emergency Department. Clin Pediatr (Phila) 2022:99228221144116. [PMID: 36503309 DOI: 10.1177/00099228221144116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Neal JT, Monuteaux MC, Porter JJ, Hudgins JD. The Effect of COVID-19 Stay-At-Home Orders on the Rate of Pediatric Foreign Body Ingestions. J Emerg Med 2022; 63:729-737. [PMID: 36289021 PMCID: PMC9472683 DOI: 10.1016/j.jemermed.2022.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Foreign body ingestions are a common presentation in the emergency department (ED), particularly in young children. OBJECTIVE We sought to determine whether the COVID-19 pandemic lockdowns had an effect on the proportion of foreign body ingestions. METHODS We performed a retrospective review of the Pediatric Health Information System for patients younger than 19 years who were identified by International Classification of Diseases, Tenth Revision codes for foreign body ingestion. We analyzed patients in the following three groups: young children (younger than 5 years), school-aged children (5-12 years), and adolescents (13 years and older), using an interrupted time series analysis. Our primary outcome was the difference in proportion of foreign body ingestions. We compared 1 year after the declaration of the COVID-19 pandemic (March 13, 2020 to March 31, 2021) with the previous 3 years (March 1, 2017 to March 12, 2020). RESULTS Total pediatric ED encounters decreased in the post period (p < 0.01); 4902 patients per year presented for foreign body ingestion pre-COVID-19 shutdown vs. 5235 patients per year post-COVID-19 shutdown. In all three age groups (young children, school-age children, and adolescents), there was a higher proportion of foreign body ingestions post-COVID-19 shutdown (p < 0.01, p < 0.01, and p = 0.028, respectively), driven primarily by the decrease in total ED encounters. In the youngest age group (younger than 5 years), there was also a significant increase in slope for foreign body ingestions post-COVID-19 (p = 0.010). CONCLUSIONS The proportion of foreign body ingestions increased after the declaration of the COVID-19 pandemic, primarily driven by an overall decrease in total ED volume.
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Affiliation(s)
- Jeffrey T. Neal
- Reprint Address: Jeffrey T. Neal, MD, Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand TL, Goldman MP, Prieto MM, Wing R, Breuer RK, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine. AEM Educ Train 2022; 6:e10830. [PMID: 36562026 PMCID: PMC9763969 DOI: 10.1002/aet2.10830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 06/17/2023]
Abstract
Background Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. Methods This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. Results There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. Conclusions The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.
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Affiliation(s)
- Kelsey A. Miller
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Andzelika Dechnik
- Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Andrew F. Miller
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Phillip M. Thomas
- Division of Emergency Medicine, Department of PediatricsCincinnati Children'sCincinnatiOhioUSA
| | - Benjamin T. Kerrey
- Division of Emergency Medicine, Department of PediatricsCincinnati Children'sCincinnatiOhioUSA
| | - Tara Lynn Neubrand
- Department of Pediatrics – Emergency MedicineChildren's Hospital ColoradoAuroraColoradoUSA
| | - Michael Paul Goldman
- Departments of Pediatrics and Emergency MedicineYale‐New Haven Children's HospitalNew HavenConnecticutUSA
| | - Monica M. Prieto
- Department of Pediatrics – Emergency MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Robyn Wing
- Department of Emergency Medicine – Pediatric Emergency MedicineHasbro Children's HospitalProvidenceRhode IslandUSA
| | - Ryan K. Breuer
- Department of Pediatrics – Pediatric Critical CareOishei Children's HospitalBuffaloNew YorkUSA
| | - Jenn D'Mello
- Department of PediatricsUniversity of CalgaryCalgary, AlbertaCaliforniaUnited States
| | - Andy Jakubowicz
- Department of Emergency MedicineWakeMedRaleighNorth CarolinaUSA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
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Baker AH, Monuteaux MC, Michelson KA, Neuman MI. Resolution of Fever in the Pediatric Emergency Department and Bacteremia. Clin Pediatr (Phila) 2022; 62:474-480. [PMID: 36401509 DOI: 10.1177/00099228221138212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
To determine whether a lack of response to antipyretics was associated with bacteremia, we performed a cross-sectional study involving children with an initial temperature ≥38°C presenting to a pediatric emergency department (ED) from 2012 to 2020 who received an antipyretic and had a blood culture obtained. We assessed the association of resolution of fever at specific time points after antipyretic administration with bacteremia adjusting for age, complex chronic condition, blood culture source, type of antipyretic, and height of temperature. Among 6319 febrile children, 242 (3.8%) had bacteremia. The adjusted odds ratio of bacteremia was 1.6 (95% confidence interval: 1.2-2.2) among children who remained febrile at 180 minutes and 1.7 (1.2-2.4) among children who remained febrile at 240 minutes. Among febrile children presenting to a tertiary care ED for whom a blood culture was obtained, the response to an antipyretic varies based on the presence or absence of bacteremia.
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Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Abstract
IMPORTANCE Firearm fatality rates in the United States have reached a 28-year high. Describing the evolution of firearm fatality rates across intents, demographics, and geography over time may highlight high-risk groups and inform interventions for firearm injury prevention. OBJECTIVE To understand variations in rates of firearm fatalities stratified by intent, demographics, and geography in the US. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed firearm fatalities in the US from 1990 to 2021 using data from the Centers for Disease Control and Prevention. Heat maps, maximum and mean fatality rate graphs, and choropleth maps of county-level rates were created to examine trends in firearm fatality rates by intent over time by age, sex, race, ethnicity, and urbanicity of individuals who died from firearms. Data were analyzed from December 2018 through September 2022. MAIN OUTCOMES AND MEASURES Rates of firearm fatalities by age, sex, race, ethnicity, urbanicity, and county of individuals killed stratified by specific intent (suicide or homicide) per 100 000 persons per year. RESULTS There were a total of 1 110 421 firearm fatalities from 1990 to 2021 (952 984 among males [85.8%] and 157 165 among females [14.2%]; 286 075 among Black non-Hispanic individuals [25.8%], 115 616 among Hispanic individuals [10.4%], and 672 132 among White non-Hispanic individuals [60.5%]). All-intents total firearm fatality rates per 100 000 persons declined to a low of 10.1 fatalities in 2004, then increased to 14.7 fatalities (45.5% increase) by 2021. From 2014 to 2021, male and female firearm homicide rates per 100 000 persons per year increased from 5.9 to 10.9 fatalities (84.7% increase) and 1.1 to 2.0 fatalities (87.0% increase), respectively. Firearm suicide rates were highest among White non-Hispanic men aged 80 to 84 years (up to 46.8 fatalities/100 000 persons in 2021). By 2021, maximum rates of firearm homicide were up to 22.5 times higher among Black non-Hispanic men (up to 141.8 fatalities/100 000 persons aged 20-24 years) and up to 3.6 times higher among Hispanic men (up to 22.8 fatalities/100 000 persons aged 20-24 years) compared with White non-Hispanic men (up to 6.3 fatalities/100 000 persons aged 30-34 years). Males had higher rates of suicide (14.1 fatalities vs 2.0 fatalities per 100 000 persons in 2021) and homicide (10.9 fatalities vs. 2.0 fatalities per 100 000 persons in 2021) compared with females. Metropolitan areas had higher homicide rates than nonmetropolitan areas (6.6 fatalities vs 4.8 fatalities per 100 000 persons in 2021). Firearm fatalities by county level increased over time, spreading from the West to the South. From 1999 to 2011 until 2014 to 2016, fatalities per 100 000 persons per year decreased from 10.6 to 10.5 fatalities in Western states and increased from 12.8 to 13.9 fatalities in Southern states. CONCLUSIONS AND RELEVANCE This study found marked disparities in firearm fatality rates by demographic group, which increased over the past decade. These findings suggest that public health approaches to reduce firearm violence should consider underlying demographic and geographic trends and differences by intent.
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Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Division of Emergency Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lois K. Lee
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jefferson T. Barrett
- Division of Pediatric Emergency Medicine, Children’s Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, New York, New York
| | - Eric W. Fleegler
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Shanahan KH, Subramanian SV, Burdick KJ, Monuteaux MC, Lee LK, Fleegler EW. Association of Neighborhood Conditions and Resources for Children With Life Expectancy at Birth in the US. JAMA Netw Open 2022; 5:e2235912. [PMID: 36239940 PMCID: PMC9568807 DOI: 10.1001/jamanetworkopen.2022.35912] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
Importance To address inequities in life expectancy, we must understand the associations of modifiable socioeconomic and structural factors with life expectancy. However, the association of limited neighborhood resources and deleterious physical conditions with life expectancy is not well understood. Objective To evaluate the association of community social and economic conditions and resources for children with life expectancy at birth. Design, Setting, and Participants This cross-sectional study examined neighborhood child opportunity and life expectancy using data from residents of 65 662 US Census tracts in 2015. The analysis was conducted from July 6 to October 1, 2021. Exposures Neighborhood conditions and resources for children in 2015. Main Outcomes and Measures The primary outcome was life expectancy at birth at the Census tract level based on data from the US Small-Area Life Expectancy Estimates Project (January 1, 2010, to December 31, 2015). Neighborhood conditions and resources for children were quantified by Census tract Child Opportunity Index (COI) 2.0 scores for 2015. This index captures community conditions associated with children's health and long-term outcomes categorized into 5 levels, from very low to very high opportunity. It includes 29 indicators in 3 domains: education, health and environment, and social and economic factors. Mixed-effects and simple linear regression models were used to estimate the associations between standardized COI scores (composite and domain-specific) and life expectancy. Results The study included residents from 65 662 of 73 057 US Census tracts (89.9%). Life expectancy at birth across Census tracts ranged from 56.3 years to 93.6 years (mean [SD], 78.2 [4.0] years). Life expectancy in Census tracts with very low COI scores was lower than life expectancy in Census tracts with very high COI scores (-7.06 years [95% CI, -7.13 to -6.99 years]). Stepwise associations were observed between COI scores and life expectancy. For each domain, life expectancy was shortest in Census tracts with very low compared with very high COI scores (education: β = -2.02 years [95% CI, -2.12 to -1.92 years]); health and environment: β = -2.30 years [95% CI, -2.41 to -2.20 years]; social and economic: β = -4.16 years [95% CI, -4.26 to -4.06 years]). The models accounted for 41% to 54% of variability in life expectancy at birth (R2 = 0.41-0.54). Conclusions and Relevance In this study, neighborhood conditions and resources for children were significantly associated with life expectancy at birth, accounting for substantial variability in life expectancy at the Census tract level. These findings suggest that community resources and conditions are important targets for antipoverty interventions and policies to improve life expectancy and address health inequities.
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Affiliation(s)
- Kristen H. Shanahan
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - S. V. Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lois K. Lee
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Eric W. Fleegler
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Rees CA, Neuman MI, Monuteaux MC, Michelson KA, Duggan CP. Mortality During Readmission Among Children in United States Children's Hospitals. J Pediatr 2022; 246:161-169.e7. [PMID: 35364094 PMCID: PMC9233053 DOI: 10.1016/j.jpeds.2022.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify demographic, clinical, and hospital factors associated with mortality on readmission within 180 days following an inpatient hospitalization. STUDY DESIGN We conducted a retrospective cohort study including 33 US children's hospitals in the Pediatric Health Information System from January 2010 to June 2020. Our primary outcome was death during readmission within 180 days of an index hospitalization among children aged 0-18 years. Illness severity during the index hospitalization was defined according to the All Patient-Refined Diagnosis-Related Group-categorized illness severity (ie, minor, moderate, or major/extreme). We performed multivariable logistic regression analysis to identify factors during the index hospitalization associated with mortality during readmission. RESULTS Among 2 677 111 children discharged, 337 385 (12.6%) were readmitted within 180 days of the index hospitalization and 2913 (0.8%) died during readmission. More than one-quarter (26.2%) of deaths among children who were readmitted and died occurred within 10 days after discharge from the index hospitalization. Factors independently associated with mortality during readmission included multiple complex chronic conditions, index admissions lasting >7 days, moderate or severe/extreme illness during the index hospitalization, and public insurance. Children whose race was reported as Black had greater odds of mortality during readmission compared with children of other races. CONCLUSIONS Among hospitalized children, several demographic and clinical factors present during index hospitalizations were associated with mortality during readmission. Greater odds of mortality during readmission among children whose race was reported as Black likely reflects disparities in social determinants of health and clinical care. Interventions to reduce mortality during readmission may target high-risk populations in the period immediately following discharge.
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Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America,Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher P. Duggan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America,Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
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Shanahan KH, Monuteaux MC, Nagler J, Bachur RG. The authors reply. Crit Care Med 2022; 50:e654-e655e. [PMID: 35726991 DOI: 10.1097/ccm.0000000000005552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kristen H Shanahan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Harvard Pediatric Health Services Research Fellowship, Cambridge, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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45
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Farrell C, Hannon M, Monuteaux MC, Mannix R, Lee LK. Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization. Pediatr Emerg Care 2022; 38:e1342-e1347. [PMID: 35686967 DOI: 10.1097/pec.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fractures are common childhood injuries that result in emergency department (ED) visits. National trends in pediatric fracture epidemiology and resource utilization are not well described. Our objective is to analyze national trends in pediatric fracture epidemiology, ED disposition, and ED resource utilization from 2010 to 2015. METHODS This is an epidemiological study of fracture care in US EDs from 2010 to 2015 for children 0 to 18 years old using the Nationwide Emergency Department Sample. We calculated frequencies and national rates using weighted analyses and census data. We used the test for linear trend to analyze incidence, hospital admission, transfer, and procedural sedation over time. Multivariate logistic regression analyses identified encounter- and hospital-level predictors of transfer, admission, operative care, and use of procedural sedation. RESULTS During the study period, from 2010 to 2015, a total of 5,398,827 children received ED care for fractures. The pediatric fracture rate was 11.5 ED visits/1000 persons (95% confidence interval [CI], 10.6-12.5) and decreased over time. The admission rate for pediatric fracture patients was 5% and stable over time. The transfer rate increased from 3.3 to 4.1/100 fracture visits (linear trend: odds ratio, 1.06; 95% CI, 1.03-1.09). Utilization of procedural sedation increased from 1.5% to 2.9% of fracture visits (linear trend: odds ratio, 1.17; 95% CI, 1.09-1.25). Predictors associated with disposition and resource utilization include patient age, fracture location, insurance type, hospital type, and region. CONCLUSIONS The national incidence rate of pediatric fractures decreased slightly. Emergency department resource utilization increased over time. With high national volume, understanding pediatric fracture epidemiology and resource utilization is important to the health care system.
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Rosman SL, Daneau Briscoe C, Rutare S, McCall N, Monuteaux MC, Unyuzumutima J, Uwamaliya A, Hitayezu J. The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting. PLoS One 2022; 17:e0270253. [PMID: 35731748 PMCID: PMC9216488 DOI: 10.1371/journal.pone.0270253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings. Methods The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from “strongly disagree” to “strongly agree”). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC. Results Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the “share information” item was statistically significant. Conclusion Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.
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Affiliation(s)
- Samantha L. Rosman
- Division of Pediatric Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- * E-mail: (SLR); (CDB)
| | - Christine Daneau Briscoe
- Division of Hematology, Boston Children’s Hospital, Boston, MA, United States of America
- * E-mail: (SLR); (CDB)
| | - Samuel Rutare
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | - Natalie McCall
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States of America
| | - Michael C. Monuteaux
- Division of Pediatric Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
| | - Juliette Unyuzumutima
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | - Agnes Uwamaliya
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | - Janvier Hitayezu
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
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Geanacopoulos AT, Lipsett SC, Hirsch AW, Monuteaux MC, Neuman MI. Impact of Viral Radiographic Features on Antibiotic Treatment for Pediatric Pneumonia. J Pediatric Infect Dis Soc 2022; 11:207-213. [PMID: 35020928 DOI: 10.1093/jpids/piab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED). METHODS Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR. RESULTS Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia. CONCLUSIONS Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Abstract
BACKGROUND AND OBJECTIVES Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking. METHODS We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis. RESULTS We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period. CONCLUSIONS NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.
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Affiliation(s)
- Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kristen H Shanahan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Tolliver DG, Lee LK, Patterson EE, Monuteaux MC, Kistin CJ. Disparities in School Referrals for Agitation and Aggression to the Emergency Department. Acad Pediatr 2022; 22:598-605. [PMID: 34780998 DOI: 10.1016/j.acap.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/01/2021] [Accepted: 11/06/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Describe the demographic and clinical characteristics of children presenting to the emergency department (ED) for agitation and aggression from school versus other sites. METHODS We performed a retrospective cross-sectional study of children 5 to 18 years old who were evaluated in an urban tertiary care pediatric ED with a chief complaint of agitation or aggression. We examined demographics, disposition, and payments for children presenting from school versus other sites. We conducted multivariable logistic regression to identify predictors of referral site (school versus all other sites, school versus home) and discharge status (home versus higher level of psychiatric care). RESULTS Of the 513 included children, 147 (29%) presented from school. Children were more likely to present from school versus other sites if they were Black (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.32, 3.88), Latinx (aOR 2.91, 95% CI 1.42, 5.97), or had special educational needs (aOR 2.55, 95% CI 1.64, 3.97). These associations persisted in the analysis of school versus home referrals. Children presenting from school versus all other sites were more likely to be discharged home (aOR 1.60, 95% CI 1.05, 2.44), although this difference did not persist when comparing school versus only home referral. A total of $154,269 (median $367 per encounter) was paid for school referrals to the ED. CONCLUSIONS Children with agitation and aggression referred from school were more likely to be Black, Latinx, or have special educational needs. Future efforts should identify and address root causes of this disparity to decrease ED referrals, reduce healthcare spending, and address inequities.
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Affiliation(s)
- Destiny G Tolliver
- Department of Pediatrics (DG Tolliver), Boston Children's Hospital, Boston, Mass.
| | - Lois K Lee
- Division of Emergency Medicine (LK Lee, EE Patterson, and MC Monuteaux), Boston Children's Hospital, Boston, Mass
| | - Emma E Patterson
- Division of Emergency Medicine (LK Lee, EE Patterson, and MC Monuteaux), Boston Children's Hospital, Boston, Mass
| | - Michael C Monuteaux
- Division of Emergency Medicine (LK Lee, EE Patterson, and MC Monuteaux), Boston Children's Hospital, Boston, Mass
| | - Caroline J Kistin
- Division of General Pediatrics (CJ Kistin), Boston Medical Center, Boston, Mass
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50
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Shanahan KH, Monuteaux MC, Bachur RG. Severity of Illness in Bronchiolitis Amid Unusual Seasonal Pattern During the COVID-19 Pandemic. Hosp Pediatr 2022; 12:e119-e123. [PMID: 35352128 DOI: 10.1542/hpeds.2021-006405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We aimed to characterize recent trends in bronchiolitis at US children's hospitals and to compare severity of illness in bronchiolitis in the most recent year to the previous seasonal epidemics. METHODS This is a cross-sectional study of visits for bronchiolitis in infants <24 months old from October 2016 to September 2021 at 46 US children's hospitals participating in the Pediatric Health Information Systems database. Study years were defined by 12-month periods beginning in October to account for typical winter epidemics that crossover calendar years. We used logistic and Fourier Poisson regression models to examine trends in outcomes and compare seasonality, respectively. RESULTS The study included 389 411 emergency visits for bronchiolitis. Median age of infants with bronchiolitis was higher in October 2020 to September 2021 compared to previous epidemics (8 and 6 months, respectively, P < .001) The odds of hospitalization, ICU admission, invasive mechanical ventilation, and noninvasive ventilation did not differ in October 2020 to September 2021 compared to previous epidemics from October 2016 to September 2020 (all P > .05 for unadjusted models and models adjusted for age). Seasonality varied significantly among these 2 periods (P < .001). CONCLUSIONS Although the seasonality of bronchiolitis differed in October 2020 to September 2021, severity of illness in infants with bronchiolitis was consistent with previous epidemics.
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Affiliation(s)
- Kristen H Shanahan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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