Inpatient care for uncomplicated bronchiolitis: comparison with Milliman and Robertson guidelines.

CONTEXT: Bronchiolitis is the most common lower respiratory tract infection in infancy. A recent Centers for Disease Control and Prevention report confirmed that hospitalization rates for bronchiolitis have increased 2.4-fold from 1980 to 1996. Controversies exist about optimal treatment plans. Milliman and Robertson recommend ambulatory care management; in case of hospitalization, the recommended length of stay is 1 day. OBJECTIVES: To relate actual practice variation for infants admitted with uncomplicated bronchiolitis to Milliman and Robertson's recommendations. DESIGN: Prospective observational study. SETTING: General care wards of 8 pediatric hospitals of the Child Health Accountability Initiative during the winter of 1998-1999. PATIENTS: First-time admissions for uncomplicated bronchiolitis in patients not previously diagnosed as having asthma and who were younger than 1 year. MAIN OUTCOME MEASURES: Respiratory rate, monitored interventions, attainment of discharge criteria goals, and length of stay. RESULTS: Eight hundred forty-six patients were included in the final analysis: 85.7% were younger than 6 months, 48.5% were nonwhite, and 64.1% were Medicaid recipients or self-pay. On admission to the hospital, 18.3% of the infants had respiratory rates higher than higher than 80 breaths per minute, 53.8% received supplemental oxygen therapy, and 52.6% received intravenous fluids. These proportions decreased to 1.9%, 33.8%, and 20.3%, respectively, 1 day after admission, and to 0.7%, 20.1%, and 8.6%, respectively, 2 days after admission. The average length of stay was 2.8 days (SD, 2.3 days). CONCLUSIONS: Milliman and Robertson's recommendations do not correspond to practice patterns observed at the hospitals participating in this study; no hospital met the Milliman and Robertson recommended 1-day goal length of stay. Administration of monitored intervention persisted past the second day of hospitalization.

Urban Wisconsin pediatric patients using an after-hours telephone triage service: outcomes and compliance.

OBJECTIVE: Evaluate the ability of a telephone triage service (TTS) to assess illness acuity of and patient compliance with advice given. DESIGN: Retrospective, observational study. PATIENTS: Patients of an urban, academic, pediatric clinic whose parents or caregivers called the TTS between July 23, 1997 and August 23, 1997. OUTCOME MEASURES: Patient outcomes and visit information at related medical encounters subsequent to a TTS call. RESULTS: Patients were primarily African-American, under age 5, enrolled in a Medicaid HMO, and most often called for fever, HMO authorization, or asthma. Homecare and PED referrals were the two most frequent dispositions; overall compliance rate was 60%. No patient referred for non-emergent care required care on an urgent or emergent basis. CONCLUSIONS: Initial results suggest that the TTS can effectively evaluate illness acuity in an urban population and compliance with advice is reasonable. A TTS may offer significant benefits to ensure care quality and contain costs in this population.

A randomized clinical trial of dermal anesthesia by iontophoresis for peripheral intravenous catheter placement in children.

STUDY OBJECTIVE: To assess the efficacy of dermal anesthesia by lidocaine iontophoresis in children undergoing peripheral intravenous (PIV) catheter placement in the emergency department. METHODS: A double-blind, randomized, clinical trial was conducted at a tertiary children's hospital ED. Alert children 7 years or older requiring nonemergency PIV were eligible. Patients in the lidocaine group received 1 mL of 2% lidocaine with 1:100,000 epinephrine over a potential PIV site by iontophoresis. The control group received 1 mL of.9% saline solution with 1:100,000 epinephrine. After PIV placement, patients ranked the procedural pain using a visual analog scale. Complications were noted by visual inspection or telephone follow-up. RESULTS: During a 6-month period, 22 patients were assigned to the lidocaine group and 25 to the control group. There was no significant difference in age, sex, or ethnic background between the 2 study groups, and mean application time was 12.0 minutes. The median pain score was.5 in the lidocaine group compared with 4 in the control group (P =.0002; 95% confidence interval [CI] 1 to 5). No significant immediate or delayed complications were observed. CONCLUSION: Lidocaine iontophoresis provides effective dermal anesthesia for children older than 7 years of undergoing nonemergency PIV placement in the ED.

Nonurgent use of the pediatric emergency department during the day.

OBJECTIVE: To evaluate the pattern and reasons for nonurgent use of the pediatric emergency department (PED) during regular office hours and why primary care physicians (PCP) approve such visits. DESIGN: Prospective, cross-sectional, observational study. SETTING: Free-standing, university-affiliated children's hospital emergency department. PATIENTS: Patients presenting to the PED and triaged as nonurgent between June and November 1994, Monday through Friday from 6:30 am to 6:30 pm, and Saturday 6:30 am to 12:00 noon. MEASUREMENTS: Registration and triage information and all communication with the PCP. RESULTS: Of 1020 eligible patients, 364 patients and their PCP completed the study. Fifty-two percent of the study patients were enrolled in a health maintenance organization (HMO). This is consistent with the penetration of managed care in this community. Most HMO (118 of 191, 62%) and non-HMO enrollees (147 of 173, 86%) did not call their PCP prior to arrival in the PED. Comparing the reasons given by these patients (HMO enrollees versus non-HMO) for not calling, we found: convenience (HMO 17% vs non-HMO 4%, P < 0.01), "no identified PCP" (HMO 17% vs non-HMO 42%, P < 0.01), and "felt problem was an emergency" (HMO 19% vs non-HMO 10%, P = 0.03) to be important differences. HMO enrollees received approval for the visit 79% of the time. These approvals were mostly after noon, whereas most denials occurred before noon. We found a pattern in the reason for approvals. Before 3:30 pm, the most common reason was that the PCP "considered the problem medically urgent" (48 out of 106). After 3:30 pm, without significant difference in the pattern of patient's chief complaints, there was a dramatic change to "a full office schedule" (25 out of 45) as the most common reason. CONCLUSION: Communication between the patient and PCP prior to the PED visit is poor in the study population. Convenience and physician workload appear to be important factors in the choice to use the PED for nonurgent problems.