Practitioners of pediatric emergency medicine: a 5-year longitudinal study.

STUDY OBJECTIVE: To describe the evolution of the responsibilities, goals and expectations of sub-Board-certified practitioners of pediatric emergency medicine (PEM) over a 5-year period. METHODS: This was a prospective, cohort study. A questionnaire was mailed in January 1994 to all physicians sub-Board-certified in PEM by either the American Board of Pediatrics or the American Board of Emergency Medicine. It included questions about the type of work the physicians did and expectations for the future. This group of physicians was surveyed again in January 1999. The primary outcome measures were changes in the physicians' goals and expectations for the future. Table. RESULTS: Questionnaires were mailed to 232 PEM sub-Board-certified physicians in January 1994. By June 1994, 183 of the 232 responded to the survey. Follow-up questionnaires were mailed to the cohort of 183 physicians in January 1999. By June 1999, 170 of the 183 (93%) had replied. The table summarizes results. In 1994, the most commonly listed career goals were to increase research productivity (52%) and develop excellent teaching skills (35%). In 1999, the most commonly listed goals were to improve hours/lifestyle (61%) and increase administrative work (33%). CONCLUSION: The priorities of this cohort of PEM sub-Board-certified physicians have changed as the physicians grow older. Lifestyle issues must be taken into consideration to ensure longevity in the subspecialty.

A health promotion intervention for families in a Medicaid managed care plan.

OBJECTIVE: To determine whether implementation of an intervention based on a model of health promotion will encourage patients to seek care from their primary care provider (PCP) and reduce visits to the pediatric ED (PED) for minor illness. METHODS: Prospective, randomized, controlled study in the PED of an urban children's hospital (CH). Children <13 months old, enrolled in a Medicaid managed care plan, who identified the CH as their site for primary care and presented to the PED for evaluation of minor illness were enrolled after being seen by the triage nurse, before being seen by a physician. Subjects were randomly assigned to the intervention (I) group or control (C) group. Parents of all enrollees completed a survey about health care utilization habits. Each family in the I group received health promotion teaching from a single investigator. The intervention consisted of a review of the child's medical record with the parents, an explanation of what to expect at future well-child visits, and a discussion of the role of the PCP. A follow-up appointment was also provided prior to discharge from the PED. The C group received usual care. Use of health care by all subjects was tracked for one year by medical record review and phone interviews at six and 12 months. RESULTS: 102 subjects in the I group and 93 in the C group (mean +/- SD ages 6.4 months +/- 3.8 and 7.2 months +/- 3.9, respectively, p = 0.15) were enrolled from March 1996 to November 1996. The two groups were similar with respect to demographics and overall health status at enrollment. At study entry: 94 of 102 (92%) subjects in I and 87 of 93 (94%) in C had made at least one visit to the PED in the previous 12 months (p = 0.11); 95 of 102 (93%) in I and 75 of 93 (81%) in C had seen their PCP at least once for well-child care (p = 0.24). Twelve-month follow-up by medical record review was completed for all subjects; phone interviews were completed in 90 of 102 (88%) in I and 80 of 93 (86%) in C. At 12-month follow-up: 84 of 102 (82%) in I and 73 of 93 (78%) in C had made at least one visit to the PED (p = 0.59); 81 of 102 (79%) in I and 77 of 93 (83%) in C had made at least one visit to their CH PCP (p = 0.54). CONCLUSIONS: There was no difference in health care utilization between the intervention and control groups at 12-month follow-up. The health promotion intervention did not alter utilization habits.

Role of the primary care provider in expediting care of children with acute appendicitis.

OBJECTIVE: To assess the role of the primary care provider (PCP) in the diagnosis and treatment of acute appendicitis in children by determining whether there were differences in the treatment and outcome of children whose parents contacted the PCP before taking the child to the hospital compared with those who did not. DESIGN: Retrospective review of medical records of pediatric patients discharged from the hospital with the diagnosis of acute appendicitis. SETTING: An urban children's hospital. METHODS: The medical records of children treated for acute appendicitis from July 1, 1990, through June 30, 1994, were identified through review of hospital discharge data and divided into 2 groups based on whether the children's parents had contacted the PCP before their arrival at the hospital. Contact with the PCP was determined by record review or telephone interview with the parent. The 2 groups were then studied for differences in treatment and outcome. Statistical analysis was by the X2 test and the Student t test, as appropriate, with the level of significance determined at P < .05. RESULTS: During the 4-year period, 343 children underwent appendectomy. Medical records were available for review for 321 children (94%). After review, records of 38 children were excluded because the primary problem was not acute appendicitis. Of the 283 children whose records were included in the study, the parents of 160 had contacted the PCP before arrival at the hospital (group 1, those who called) and the parents of 99 had not called (group 2, those who did not call). It could not be determined whether a call had been made for 24 children. The mean age of the children in group 1 was 124 months and in group 2 was 126 months (P = .74). Of group 1, 24% arrived at the hospital on a Saturday or Sunday, compared with 40% of group 2 (P = .007). Children in group 1 who arrived at the hospital during the weekend were operated on a mean (SD) of 4.7 hours (3.7 hours) after arrival at the hospital, compared with 10.6 hours (17.1 hours) for children in group 2 (P = .04). The mean (SD) interval between arrival at the hospital and operation on weekdays (Monday through Friday) was similar in both groups: 12 hours (20.6 hours) in group 1 and 13.7 hours (25.6 hours) in group 2 (P = .63). Appendiceal perforation was less likely in children in group 1 (62/160 [39%]) than in those in group 2 (53/99 [54%]; P = .03). Parents of 50 (89%) of 56 children who belonged to a health maintenance organization called the PCP compared with 96 (62%) of the 156 with fee-for-service insurance and 10 (26%) of the 38 with Medicaid (P < .001). No difference was noted in the interval between arrival at the hospital and operation or incidence of appendiceal perforation according to type of insurance. CONCLUSIONS: Children with appendicitis whose parents contacted the PCP before arrival at the hospital were less likely to have appendiceal perforation than those whose parents did not call the PCP, irrespective of insurance status. Children whose parents called the PCP before arrival at the hospital during the weekend were operated on more promptly than were children whose parents did not call the PCP. Contact with the PCP was associated with more expeditious care of children with acute appendicitis.

Educational interventions to alter pediatric emergency department utilization patterns.

OBJECTIVE: To test the hypothesis that educating parents about use of their primary care provider and providing information about common pediatric illnesses will reduce visits to the pediatric emergency department (PED). DESIGN: Prospective, randomized, controlled trial conducted from September 1, 1993, to October 31, 1994. SETTING: Pediatric emergency department of an urban university hospital. PARTICIPANTS: Parents of 130 patients seen in the PED for minor illness. INTERVENTIONS: Subjects were randomized to intervention or control groups. Parents in both groups were interviewed about their child's health and use of health care services. The intervention group received education on pediatric health care issues; the control group received usual PED discharge instructions. Use of the PED by all subjects was tracked for 6 months by telephone follow-up and medical record review. MAIN OUTCOME MEASURES: Differences between the two groups in total number of return visits to the PED and return visits to the PED for minor illness. RESULTS: Sixty-seven (97%) of the 69 patients in the intervention group and 56 (92%) of the 61 patients in the control group identified a primary care provider. At 6-month follow-up, 21 patients (30%) from the intervention group and 16 (26%) from the control group had returned to the PED (P = .68, chi 2). Seventeen (81%) of intervention group returnees to the PED had minor illness, as did 11 (69%) of control group returnees. CONCLUSIONS: A one-time educational intervention in the PED does not alter long-term emergency department utilization habits. More extensive education and greater availability of primary care providers may be needed to decrease use of the PED for minor illness.

Pediatric emergency department utilization habits: a consumer survey.

The objective of this study was to identify pediatric emergency department (PED) utilization patterns to develop areas for future educational interventions. To this end a verbally administered questionnaire by a single interviewer was given over 17 days between February 8, 1993, through April 7, 1993, at a PED of an urban university hospital. Participating were 300 families (convenience sample) who were interviewed at varying times of the day and night. They represented about 20% of PED visits during the survey days. Each parent was surveyed about his/her child's health. Parents were also asked to indicate on a linear scale how sick they believed their child was. The mean patient age was 3.8 +/- 4.3 years; 81% were African-American, 15% were Caucasian, and 2% were Hispanic; 65% had medical assistance (MED), 21% had commercial insurance (COM), and 4% had both. Ten percent either had no insurance or their insurance status was unknown. Thirty-four percent of patients utilized a community clinic for primary health care, 32% identified a private physician, and 28% used the hospital's pediatric clinic. The most commonly stated reasons for coming to the PED differed between the MED and COM groups; 14% of the MED group was referred compared to 59% of the COM group (P = 0.002, chi 2), 24% of the MED group came because their primary care provider's office was closed compared to 3% of the COM group (P < 0.01, chi 2). Seventy-one percent of COM group called their primary care provider before coming to the PED compared to 27% of MED group (P < 0.001, chi 2). Analysis of parental rating of their child's illness severity on a linear (10-point) scale showed a mean of 5.7 +/- 2.5. The COM group had lower triage scores (indicating greater severity of illness) than the MED group: 50% COM patients were scored < or = 2.5 compared to 30% of MED patients (P < 0.01, chi 2). We found a significant difference in the PED utilization habits of patients on medical assistance compared to those with commercial insurance, and we plan to develop educational materials to meet the needs of our patients, many of whom utilize the PED for nonurgent illnesses.

Hyponatremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors.

STUDY OBJECTIVES: (1) To determine the incidence of hyponatremic seizures in infants, (2) to compare the severity and outcome of seizures in hyponatremic and normonatremic patients, and (3) to evaluate the utility of clinical predictors of hyponatremia. DESIGN: Retrospective chart review of infants who presented to an urban pediatric emergency department from 1988 through 1993. PARTICIPANTS: Patients who experienced seizures while in the ED. These patients were divided into hyponatremic and normonatremic groups. RESULTS: Hyponatremia was the cause of seizures in 70% of 47 infants younger than 6 months who lacked other findings suggesting a cause. Median seizure duration was longer in hyponatremic patients (30 versus 17 minutes; P = .007), with a greater incidence of status epilepticus (73% versus 36%; P = .02) and fewer patients with seizures lasting less than 10 minutes (9% versus 36%; P = .04). Emergency intubation was performed more often in hyponatremic patients (12% versus 0%; P = .009). The median temperature was lower in hyponatremic infants than in normonatremic patients (35.5 degrees C versus 37.2 degrees C; P = .0001). Exact logistic-regression methods identified temperature of 36.5 degrees C or less as the best predictor of hyponatremic seizures, with an OR of 64 (95% CI, 8 to 1,026). CONCLUSION: Hyponatremia should be strongly suspected in an infant less than 6 months old with seizures and a temperature of 36.5 degrees C or less.

Closed head injuries in children: is hospital admission always necessary?

The objective of this study was to identify a group of patients with mild closed head injury, lack of other significant trauma, and normal head computerized tomograph (CT), who could be safely observed at home by a reliable caretaker. Data were from a retrospective chart review of pediatric emergency department (PED) and hospital course of an urban university children's hospital. The pediatric trauma registry was used to identify patients one to 17 years old seen in the PED with closed-head injury and normal head CT between June 1991 and August 1992. A total of 746 patients with heads injury were seen in the PED, and 161 patients with closed-head injury were admitted during the study period. Sixty-two patients (mean age = 8.5 +/- 5 years) met inclusion criteria with hospital admission, mild head injury, Glasgow Coma Scale > or = 13, and normal head CT. Of the patients 63% (34) were male and 37% (23) were female, with 74% (46) African-American and 26% (16) Caucasian. The most frequent mechanisms of injury were 27% (17) fall from height (mean height = 6.7 +/- 4.6 feet) and 18% (11) passenger in a motor vehicle accident. Patients had a median Glasgow Coma Scale of 15 (mean 14.8) and median abbreviated injury score of 2 (mean = 1.8). Thirty-seven percent of patients (23) had a history of loss of consciousness (range one to five minutes) and 6% (4) had generalized tonic-clonic seizure after the injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision rules for roentgenography of children with acute ankle injuries.

OBJECTIVE: The Ottawa Ankle Rules (OAR) assist emergency physicians in the appropriate use of roentgenography in adults with acute ankle injuries. The OAR state that ankle roentgenograms are needed only if there is pain near the malleoli and one or more of the following exists: (1) age 55 years or older; (2) inability to bear weight; or (3) bone tenderness at the posterior edge or tip of either malleolus. This study assessed the utility of the OAR on pediatric patients with acute ankle injuries. DESIGN: Prospective, consecutive survey of pediatric patients with acute ankle injuries. SETTING: Pediatric emergency department of an urban university hospital. PARTICIPANTS: Seventy-one children with acute ankle injuries were enrolled from July 22, 1993, to December 1, 1993. INTERVENTIONS: Twenty-four standardized clinical variables were assessed and recorded by physicians in the pediatric emergency department. The OAR were applied to each patient by the investigator to determine which ones would qualify for roentgenography. MAIN OUTCOME MEASURES: Sensitivity and specificity of the OAR were calculated, as was percent reduction in roentgenograms ordered. RESULTS: Seventy-one of 73 eligible patients were enrolled. The two missed patients had open fractures of the tibia. Sixty-eight of 71 patients had ankle roentgenography during the visit. Fourteen patients (21%) (mean age, 11.8 +/- 4.0 years) had fractures noted on the roentgenograms. Fifty-four patients (79%) (mean age, 12.0 +/- 3.6 years) had no fracture. Application of the OAR would have reduced the number of roentgenograms ordered by 25% without missing any fractures. Sensitivity of OAR was 100% (95% confidence interval, 77% to 100%), specificity was 32% (95% confidence interval, 21% to 43%), negative predictive value was 100% (95% confidence interval, 80% to 100%), and positive predictive value was 28% (95% confidence interval, 17% to 39%). CONCLUSIONS: Initial testing suggests that the OAR may help determine which children with acute ankle injuries could safely forgo roentgenograms without risk of missing fractures.

A trial of nebulized magnesium sulfate to reverse bronchospasm in asthmatic patients.

STUDY OBJECTIVE: To test the hypothesis that nebulized magnesium sulfate reverses methacholine-induced bronchospasm in asthmatic patients. DESIGN: Randomized, double-blind, crossover clinical trial. SETTING: Center for Asthma and Allergic Diseases, Children's Hospital of Pittsburgh. TYPE OF PARTICIPANTS: Ten patients who were 21 to 37 years old and had stable asthma. INTERVENTIONS: Patients withheld asthma medications for 24 hours before each study day. Patients with baseline forced expiratory volume in one second (FEV1) of less than 80% were excluded. All subjects underwent bronchial methacholine challenge to produce bronchospasm. They then received one of three different nebulized treatments: 2.5 mg albuterol in 3 mL saline, 3 mL magnesium sulfate (268 mmol/L, pH 6.4), or 3 mL normal saline. Patients repeated spirometry 15 minutes after completing the study drug and then received albuterol by metered-dose inhaler. Spirometry was repeated after the metered-dose inhaler. Each patient made three separate visits to receive each of the three medications. MEASUREMENTS AND RESULTS: Methacholine reduced each patient's FEV1 by at least 20% at each testing session. Post-methacholine treatment with nebulized albuterol improved FEV1 by a mean of 56% (SD, 19.6%). Nebulized normal saline led to a mean increase in FEV1 of 29% (SD, 26.5%). Nebulized magnesium sulfate improved FEV1 by a mean of 12% (SD, 12.0%) (P = .054 by paired t-test compared with normal saline). CONCLUSION: Nebulized magnesium sulfate has a minimal bronchodilatory effect in asthmatic patients with methacholine-induced bronchoconstriction. Responsiveness to magnesium sulfate may be dependent on the mechanism of induction of bronchospasm, and there probably is no role for nebulized magnesium sulfate in the treatment of acute bronchospasm due to cholinergic stimulation.

Pediatric emergency department complaints: a three-year analysis of sources and trends.

STUDY OBJECTIVE: To identify the incidence and major causes of patient and parental complaints in a pediatric emergency department. DESIGN: Retrospective analysis of complaints received regarding patients seen between January 1987 and December 1989. SETTING: ED of Children's Hospital of Pittsburgh. PARTICIPANTS: All complaints received during the three-year period. INTERVENTIONS: Complaints were reviewed for reason, validity, and location at which patient was seen. MEASUREMENTS AND RESULTS: One hundred seventy-six complaints from a total of 154,648 ED visits yielded a frequency of 1.1 complaints per 1,000 patient visits. Main reasons for dissatisfaction were misdiagnosis, billing, and inadequate treatment; 49% of complaints were judged valid. There were 0.69 complaints per 1,000 patient visits in the nonurgent medical portion of the ED. Patients seen emergently (critical care and trauma) had a significantly lower complaint frequency of 0.08 per 1,000 patient visits (P less than .001 by chi 2 analysis). CONCLUSION: Assessment of ED complaints is useful to highlight areas of patient dissatisfaction and develop plans for improving patient care.