Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children

Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children.

Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children

Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Guidance for Structuring a Pediatric Intermediate Care Unit

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

Alpha2-adrenoceptor modulation of cortical acetylcholine release in vivo

Acetylcholine release in the rat cortex in vivo has been shown to be modulated by alpha2-adrenoceptor ligands. We have previously reported that the systemic administration of selective alpha2-antagonists including (+)-efaroxan increase, while alpha2-adrenoceptor agonists such as UK-14304 reduce the release of acetylcholine in the medial prefrontal cortex of conscious rats as measured by microdialysis. To evaluate the extent to which noradrenergic afferent inputs are required for the expression of these different effects, the present study examined the drug-induced changes in cortical acetylcholine release in rats which had undergone prior noradrenergic deafferentation. Rats were pretreated with the noradrenergic neurotoxin N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine (40 mg/kg, i.p.), which after three days had reduced noradrenaline levels in the medial prefrontal cortex by 84%. At that time, slices of cortex were incubated with [3H]choline, superfused and stimulated by consecutive exposures to increasing concentrations of K+. In N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine pretreated tissue, the [3H] outflows evoked by 20, 35 and 45 mM K+ were lower by 12%, 22% and 43%, respectively, in comparison to slices prepared from vehicle-pretreated control animals. For in vivo microdialysis experiments, rats were pretreated as above with N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine, or prepared seven to eight days in advance with bilateral 6-hydroxydopamine lesions of the locus coeruleus. Neither of these lesioning procedures significantly affected the basal outflow of endogenous acetylcholine in the cortex. In control rats, cortical acetylcholine outflow was increased by up to 300% of baseline values by (+)-efaroxan (0.63 mg/kg, i.p.), and was reduced to 21% of baseline by UK-14304 (2.5 mg/kg, i.p.), confirming our previous findings. In N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine pretreated rats, the inhibitory effect of UK-14304 on acetylcholine outflow persisted, while the ability of (+)-efaroxan to increase outflow was essentially eliminated. In locus coeruleus-lesioned rats, where cortical noradrenaline levels were reduced by 64%, (+)-efaroxan still increased acetylcholine outflow, but this effect was significantly attenuated and less sustained in comparison to sham-operated control rats. Viewed together with complimentary biochemical, electrophysiological and neuroanatomical evidence in the literature, a model is presented to account for these findings, and indicates that alpha2-adrenoceptors both on noradrenergic neurons (autoreceptors) and on non-noradrenergic cells (heteroreceptors) can participate in mediating drug-induced changes in medial prefrontal cortical acetylcholine release in vivo. The acetylcholine release-enhancing effect of (+)-efaroxan appears to be dependent on at least a partially intact cortical noradrenergic innervation.

Acetylcholine release in the rat prefrontal cortex in vivo: modulation by alpha 2-adrenoceptor agonists and antagonists

We have previously shown that the release of acetylcholine (ACh) in the medial prefrontal cortex of the conscious rat, as measured by microdialysis, is increased following intraperitoneal injection of the selective alpha 2-adrenoceptor antagonist (+)-efaroxan. To characterize further the receptor pharmacology of this response, the effects of other selective alpha 2-adrenoceptor ligands were examined. The alpha 2-adrenoceptor antagonists idazoxan (2.5 and 20 mg/kg), atipamezole (2.5 mg/kg), and fluparoxan (10 mg/kg) increased ACh outflow by up to 250-325% of basal levels over a 3-h period following intraperitoneal injection. The alpha 2-adrenoceptor agonists UK-14304 (2.5 mg/kg) and guanabenz (2.5 mg/kg) reduced ACh outflow by 80 and 60%, respectively. Clonidine (0.00063-0.16 mg/kg) had no significant depressant effect and at 2.5 mg/kg increased ACh outflow to 233% of basal levels. These results indicate a modulatory role for alpha 2-adrenoceptors on the release of ACh in the rat prefrontal cortex in vivo. Based on the facilitatory effects produced by the antagonists alone, this alpha 2-adrenoceptor modulation appears to be tonic and inhibitory. The ability of alpha 2-adrenoceptor antagonists to enhance ACh outflow suggests a therapeutic usefulness in disorders where cortical ACh release deficits have been implicated.

The alpha 2-adrenoceptor antagonist, (+)-efaroxan, enhances acetylcholine release in the rat cortex in vivo

Noradrenergic modulation of the cortical cholinergic system in vivo was studied by examining the effect of the selective alpha 2-adrenoceptor antagonist (+)-efaroxan on cortical acetylcholine outflow in the conscious rat, using the microdialysis technique. (+)-Efaroxan produced a dose-dependent increase in acetylcholine outflow (up to 300% at 0.63 mg/kg) which persisted for up to 3 h and which was stereospecific. The results demonstrate that rat cortical acetylcholine release can be augmented by (+)-efaroxan and that alpha 2-adrenoceptors may be involved. (+)-Efaroxan may have therapeutic potential in disorders in which cortical acetylcholine release is deficient.

Quantitative autoradiographic mapping of delta-opioid receptors in the rat central nervous system using [125I][D.Ala2]deltorphin-I

The distribution of delta-opioid binding sites was studied by quantitative autoradiography in rat brain and spinal cord using the highly selective ligand [125I][D.Ala2]deltorphin-I. The binding properties of [125I][D.Ala2]deltorphin-I were investigated by microdensitometry of autoradiographic films with the aid of a computer-assisted image-analysis system. [125I][D.Ala2]deltorphin-I appeared to interact with a single class of sites in all brain areas (KD = 0.9 nM). In 23 regions tested, whatever the delta site concentration, DTLET, a delta agonist, appears to be 2 orders of magnitude more effective than DAGO, a mu agonist, in inhibiting specific [125I][D.Ala2]deltorphin-I binding. The distribution of [125I][D.Ala2]deltorphin-I sites is globally consistent with that of other delta ligands and does not support the existence of a delta-receptor subtype recognized by [D.Ala2]deltorphin-I. [125I][D.Ala2]deltorphin-I binding sites were highly confined, exhibiting selective localization in the neocortex and a diffuse pattern in the striatum, accumbens nucleus, claustrum, layer of bulb, amygdaloid nucleus, pontine nuclei, and inferior colliculus. In several areas a rostro-caudal gradient of site concentration was indicated. [D.Ala2]deltorphin-I binding sites were also present in the substantia gelatinosa at all levels of the spinal cord and, unexpectedly, in deeper laminae and the ventral horn. These results demonstrate the ability of [125I][D.Ala2]deltorphin-I to characterize low concentrations of binding sites and to reveal new localizations of delta receptors.

Coupling of microdialysis with capillary electrophoresis: a new approach to the study of drug transfer between two compartments of the body in freely moving rats

The feasibility of in vivo microdialysis and capillary electrophoresis for pharmacokinetic studies was tested. Microdialysis probes were inserted in the jugular vein and brain of rats. After an intraperitoneal injection of phenobarbital, microdialysis was performed in the brain and the blood simultaneously in each rat under freely moving conditions. Capillary electrophoresis with ultraviolet absorption was used to measure phenobarbital in blood and brain dialysates. The time course of phenobarbital in the blood and in the extracellular space of the brain was followed. The results demonstrated that microdialysis can be used for pharmacokinetic studies in freely moving animals. Capillary electrophoresis has the potential to improve the time resolution of microdialysis. Other advantages of microdialysis and capillary electrophoresis for pharmacokinetic studies are discussed.