Pediatric emergency care最新文献

Objectives: Length of stay (LOS) and left without being seen (LWBS) rates are key measures of emergency department (ED) throughput. Few studies in the pediatric ED setting exist looking at the effect of rapid assessment team models on department operations/throughput. At our institution, a rapid assessment team was implemented to respond to patients who indicated a desire to leave before being evaluated, expedite assessment/treatment of lower-acuity cases that could be discharged directly, and initiate workups for patients experiencing excessive door-to-doctor times. We hypothesized that implementation of this team would be associated with decreased LOS, LWBS rates, and door-to-provider times in a pediatric ED.

Methods: We conducted a single-institution retrospective chart study to determine whether implementation of a rapid assessment team improved standard efficiency metrics (LWBS, LOS, door-to-provider time) within our pediatric ED. Data from a 4-year period (prerapid and postrapid assessment team implementation) were analyzed. Bivariate analyses (independent t test, Mann-Whitney U test, and χ2 test) were used to assess the association between baseline characteristics and primary outcomes. Multivariable logistic regression for the LWBS rate and linear regression for LOS examined the association between different time periods and outcomes while controlling for confounders.

Results: In total, 348,483 valid cases were analyzed. After implementation, the LWBS rate decreased from 0.7% to 0.5% (OR: 0.79, 95% CI: 0.72-0.87; P<0.001). Mean LOS decreased by 15.7 minutes (95% CI: 14.8-16.7; P<0.001), and door-to-provider time decreased by 19.2 minutes (95% CI: 18.8-19.6; P<0.001).

Conclusions: In our pediatric ED, implementation of a rapid assessment team was associated with reduced LOS, LWBS rates, and door-to-provider times.

Background: Incision and drainage (I&D) is the standard treatment for pediatric abscesses. However, discrepancies between estimated abscess volume, determined clinically or by point-of-care ultrasound (POCUS), and the actual volume expressed may result from poor ultrasound or I&D technique. These discrepancies may lead to inappropriate management decisions and unnecessary procedures.

Objective: To determine the prevalence of discrepancies between estimated and expressed abscess volumes during pediatric I&D.

Methods: We conducted a cross-sectional chart review at a tertiary care pediatric emergency department (ED) between 2017 and 2023. Patients younger than or qual to 21 years with an attempted I&D were identified using a natural language processing tool. We focused on 2 groups based off of documented abscess diameter: predicted volumes of ≤1 mL and ≥10 mL. Per author discretion, these values correspond with decision-making of 'not worth pursuing I&D' and 'definitely worth pursuing I&D', respectively. We considered a positive discrepancy if for an expected abscess volume of ≤1 mL, the documented volume expressed was ≥10 mL (underestimated), and if for an expected volume of ≥10 mL, the documented volume was ≤3 mL (overestimated). Prevalence and confidence intervals were calculated using descriptive statistics.

Results: Among 653 patients, 13.2% of sonographic and 7.6% of clinical estimates underestimated abscess volume, whereas 2.3% of sonographic and 19.6% of clinical estimates overestimated abscess volume. Combined assessment reduced discrepancies to 5.2% underestimated and 1.2% overestimated.

Conclusions: Combining clinical with POCUS assessment of pediatric abscesses provides better prediction of volume than reliance on a single method potentially reducing unnecessary procedures and missed I&D opportunities.

Objectives: Abdominal pain is a common presenting symptom in the pediatric emergency department (ED), with appendicitis being the most common surgical emergency. Administration of analgesia, including opioids, has not been shown to delay the diagnosis of appendicitis, yet oligoanalgesia remains a common occurrence. We aimed to determine the proportion of any analgesia and opioid analgesia administration, the median time to first analgesia administration, and to identify factors associated with the administration of any analgesia and opioid analgesia in patients with suspected appendicitis.

Methods: We conducted a single-center cross-sectional study of children less than 18 years of age evaluated in the pediatric ED from June 2014 to June 2021 for suspected appendicitis. Deidentified data were extracted from the electronic record through a data repository. Our primary outcomes were the administration of analgesia and the median time to first analgesia administration. We used descriptive statistics and multivariate regression analysis to compare independent influences on analgesia administration.

Results: During the 8-year study period, 7065 children were evaluated for appendicitis. Overall, 4821 (68.2%) received some form of analgesia, 3157 (44.7%) received nonopioid analgesia only, and 1664 (23.6%) received opioid analgesia during their ED visit. Overall median time to first analgesia was 104 minutes. Median time to first nonopioid analgesia and first opioid analgesia was 94.5 minutes and 136 minutes, respectively. Moderate and severe pain scores, fever, tachycardia, and higher ESI level of acuity were significantly associated with analgesia administration.

Conclusions: Analgesia administration in children with suspected appendicitis varies considerably. Efforts to target more consistent and timely pediatric pain management practices are needed.

Objective: Children with medical complexity are a growing population with multiple conditions, medical device dependency and frequent need for emergency department (ED) visits; their care and management in an emergency setting may be challenging. The pediatric palliative care (PPC) network aims to address the needs of these children and their families to improve their quality of life.The purpose of this retrospective single-center study was to determine the prevalence and reasons for visiting the ED, the management, outcome, and quality of care received in a Tertiary Care Pediatric Hospital, where the PPC facility is strongly integrated and cooperating with the ED.

Methods: We collected data on the 775 pediatric ED visits performed in Padua Pediatric ED between 2006 and 2023 by 85 children under the care of the regional center for PPC in Veneto, Italy.

Results: Median number of visits per patient was 2.0 per year, 33.4% resulting in hospital admissions. Most frequent reasons for ED visits were respiratory conditions (28.9%), followed by medical device malfunctions (18.3%). Other data included PPC specialist involvement, ED referral, time of arrival, color code, and type of assistance required. Over the years, there has been an increased number of ED visits, admissions, medical device malfunctions, hours spent in the ED, and involvement of PPC specialists. No significant influences were noted during the COVID-19 pandemic period.

Conclusion: These data highlight potential areas of intervention to enhance emergency care management for CMC, such as early PPC specialist involvement with the home care network activation, a specific training of ED providers, and a dedicated service for the management of device malfunctions.

Objectives: Our primary objectives were to describe pathogen-specific symptom severity and duration in a prospective cohort study of children with acute gastroenteritis (AGE). Our secondary objective was to quantify health care resource utilization.

Methods: This secondary analysis of 2 trials included children aged 3 to 48 months with AGE. Children were eligible if they had ≥3 watery stools in the preceding 24 hours and were brought to the Emergency Department. Disease severity was quantified by frequency and duration of vomiting and diarrhea, and the Modified Vesikari Scale score. We used descriptive statistics to summarize severity and regression models to identify associations between pathogen type and outcomes.

Results: In total, 1565 trial participants had pathogen testing performed and completed follow-up. Viral pathogens were identified in 47.9% (749/1565) and bacterial pathogens in 5.9% (92/1565). Norovirus (322/1565; 20.6%) was the most frequently identified pathogen. Diarrhea duration was greatest (median 160h, IQR: 98, 216) for children with Salmonella . Vomiting (aOR: 11.02; 95% CI: 7.47, 16.26) occurred more commonly in children with viruses compared with bacteria. The mean duration of diarrhea was shorter for viruses compared with bacteria (aIRR: 0.81, 95% CI: 0.68, 0.96). Mean MVS scores were higher in children with viruses compared with those with bacteria (coefficient: 1.64, 95% CI: 0.46, 2.82).

Conclusions: We describe the clinical course of viral and bacterial pathogens. Although statistically significant, differences in symptom severity across pathogens were not clinically meaningful for distinguishing between them based on symptoms alone.

Objectives: Pediatric emergency department (ED) visits for mental and behavioral health concerns are rising. Understanding psychosocial predictors of ED mental health visits among youth with elevated suicide risk may inform tailored interventions and/or targeted resource allocation, decreasing ED utilization. We examined the association between self-reported psychosocial risk factors among youth screened "at-risk" for suicide during a nonmental health index ED visit and subsequent ED mental health visits.

Methods: This single-center retrospective cohort study had an exploratory, hypothesis-generating design. We included youth aged 10 to 18 years who presented to the ED between July 2020 and June 2023 for a nonmental health concern, were identified as "at-risk" for suicide during universal screening, and completed a psychosocial risk questionnaire. Subsequent ED mental health visits were tracked for 6 months after the index encounter, through December 2023. Psychosocial factors were compared between youth with and without a subsequent mental health visit using χ 2 and Fisher exact tests. Multivariable logistic regression models assessed associations between risk factors and subsequent ED mental health visits.

Results: Of 740 youth, 88 (11.9%) had a subsequent ED mental health visit, most (69.3%) for suicidal ideation. Youth were female (70.9%), non-White (63.6%), Hispanic (50.7%), publicly insured (71.8%), and the median age was 15.2 years; many (48.9%) had no known mental health conditions. For the subgroup with prior ED mental health visit(s), the odds of a subsequent ED mental health visit were higher in youth who identified as sexual and gender minority (aOR: 3.05; 95% CI: 1.15, 8.09) and individuals who reported prior nonsuicidal self-injury (aOR 3.01; 95% CI: 1.05, 8.66).

Conclusions: Our results suggest a potential subpopulation, youth screened at-risk for suicide who identify as sexual and gender minority or report prior nonsuicidal self-injury, who may benefit from tailored interventions and/or resources to decrease subsequent ED utilization.

Objectives: Despite the ongoing mental health crisis among US youth and the critical role that pediatricians caring for children and adolescents in emergency departments (EDs) play, there are limited studies capturing these pediatricians' concerns, experiences, and needs.

Methods: National weighted survey data on mental health care were collected in 2022 from the American Academy of Pediatrics Pediatrician Life and Career Experience Study (PLACES) participants (response=67%). We analyzed responses from 115 pediatricians caring for children and adolescents in the ED. Participants reported perspectives on: (a) overall pediatric mental health concerns; (b) frequency of mental health presentations; (c) experience prescribing psychotropic medication; and (d) referral difficulty. We systematically examined open-ended responses on the most pressing mental health needs.

Results: Eighty-four percent of pediatricians caring for children and adolescents in the ED reported that mental health is a significant problem for youth in their community. Nearly all (98%) reported caring for children and adolescents with mental health conditions in the past month. Many reported daily encounters with pediatric patients experiencing mental health conditions, including anxiety, depression, and suicidal ideation. One in five reported prescribing psychotropic medication in the past year, none of whom reported being "very" comfortable doing so. One in five said resources to care for children and adolescents with mental health conditions were very or moderately available in their community. Open-ended responses (n=79) highlighted the urgent need for resources and solutions at the national level.

Conclusions: Pediatricians in the ED have significant concerns about child and adolescent mental health in their communities, and many see youth with anxiety, depression, and suicidal behavior daily. Findings underscore a need for more support for pediatricians in the ED and innovative solutions to improve child and adolescent mental health.

Background and objectives: Bladder catheterization (BC) is a routine procedure, but unsuccessful attempts due to inadequate bladder volume are common and stressful for children and caregivers. Physician-performed bladder point-of-care ultrasound (POCUS) improves BC success rates, but the effect of nurse-performed POCUS remains understudied.

Methods: We randomized children under 24 months of age to receive either nurse-performed POCUS before BC or standard blind BC in the pediatric emergency department to compare dry catheterization rates. A simplified POCUS technique using a single bladder measurement was employed to enhance efficiency and feasibility for nursing staff. We also compared caregiver satisfaction and procedural time between groups. Statistical comparisons used the Pearson χ 2 test for categorical variables and the Wilcoxon rank sum test for continuous variables. A P value of <0.05 was considered statistically significant. Univariate logistic regression estimated the odds of outcomes with POCUS versus standard care.

Results: In the POCUS group, the dry catheterization rate was 5% compared with 17% in the standard group (odds ratio=0.24, 95% CI=[0.09, 0.72]), indicating fewer dry BCs in the POCUS group. Caregivers of children in the POCUS group reported higher satisfaction ( P =0.02). There was no significant difference in the time from BC orders to initial BC attempt between groups.

Conclusions: Nurse-performed POCUS before BC reduces dry BCs and improves caregiver satisfaction without causing procedural delays. Incorporating nurse-performed POCUS into standard BC workflows may enhance patient care.

Objectives: Telemedicine use has surged since the COVID-19 pandemic, offering patients access to remote health care and the potential to reduce nonemergent emergency department (ED) visits. This study aims to describe postpandemic virtual urgent care (VUC) utilization, including VUC-to-ED referral rates and outcomes in children.

Methods: We performed a retrospective cohort study of patients under 21 years presenting to the ED within 72 hours following a VUC visit from March 1, 2021, through February 28, 2023, using the electronic medical record. We reviewed demographic data and examined ED care and disposition for patients VUC physician-referred compared with those who self-referred.

Results: We analyzed 4676 completed VUC patient visits. Patients who preferred English, were non-Hispanic, and had commercial insurance were more likely to complete their VUC visit, with a rate of 72%. Among all patients who completed a VUC visit, 5.9% were referred to the ED by a VUC physician with a 19% admission rate, whereas 5% of patients self-referred with a 6% admission rate. On logistic regression analysis, only insurance status was significant; patients with Medicaid had twice the odds of a self-referred visit.

Conclusions: This study demonstrated low referral rates from VUC to ED. Despite modifications to improve VUC access, disparities in VUC utilization persist. Patients with Medicaid are more likely to self-refer to the ED, although they have lower rates of admission when self-referred. Future qualitative studies are needed to optimize VUC as an equitable health care resource.

Objective: Children with medical complexity (CMC) may bypass emergency departments (EDs) close to home to seek care at hospitals with more specialized pediatric services. However, few studies have examined ED choice for CMC or how this differs by rurality. This work describes rural-urban differences in ED care and bypass patterns, examines associations between ED bypass and visit outcomes, and identifies factors associated with ED bypass.

Methods: We analyzed 2012 to 2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire. Bypass was defined as a driving time of ≥5 minutes than time to the closest ED. We used logistic regression to identify factors associated with ED bypass and examine associations between bypass and rates of inter-facility transfer, index hospital admission, and in-hospital mortality.

Results: In total, 82,747 CMC experienced 284,374 ED visits. Rural-residing CMC were more often insured by Medicaid, more likely to travel >30 minutes, and less likely to bypass their closest EDs (26.9% vs. 43.7% for urban-residing CMC). In adjusted regression models, ED bypass was associated with significantly increased odds of admission (OR=2.19, 95% CI: 1.51-3.16) but not with interfacility transfer or mortality. Chronic condition primary diagnosis was associated with increased odds of bypass, and Medicaid coverage was associated with decreased odds of bypass for both rural-residing and urban-residing CMC.

Conclusions: Rural-residing and urban-residing CMC differed in where they sought ED care and in their ED bypass patterns. These findings illustrate several factors that may be associated with ED choice for CMC and can inform clinical improvement efforts for this population.