Primary care and emergency department decision making.

OBJECTIVE: To determine the effect of primary care status on decision making in the pediatric emergency department (ED). SETTING: Urban tertiary care children's hospital. DESIGN: Examining physicians prospectively completed questionnaires describing the presence of and their familiarity with patients' primary care providers (PCPs), as well as several relevant clinical factors. PATIENTS: We prospectively surveyed care for patients with triage temperature of 38.5 degrees C or higher or symptoms of gastroenteritis between August 1, 1999, and February 15, 2000. OUTCOME MEASURES: Intravenous fluid use, hospital admission status, rates of diagnostic testing and interventions, mean total costs, and length of ED stay. RESULTS: Among 1166 nonreferred patients, no PCP was identified for 164 patients and PCPs for 1002. The groups did not differ on ethnicity, mean age-adjusted vital signs, triage category, initial appearance, patient care setting (main ED or urgent care clinic), time of day, day of week, certainty of diagnosis, or perceived importance of follow-up. Mean unadjusted direct hospital costs for diagnostic testing were significantly higher for the group without PCPs, $23 vs $16. In regression models controlling for age, ethnicity, insurance status, patient care setting, ED attending physician, temperature, and initial appearance, the absence of a PCP was associated with an increased likelihood of diagnostic testing. Compared with a subset of the cohort with PCPs who were familiar to the treating physicians, the group without PCPs also had a significantly higher rate of intravenous fluid administration. CONCLUSION: In this patient population, ED physicians may vary their assessment and management decisions based on primary care status.

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.

Children with first-time simple febrile seizures are at low risk of serious bacterial illness.

OBJECTIVE: To describe the rates of serious bacterial illness (SBI) in children presenting to emergency departments (EDs) with first-time uncomplicated febrile seizures. METHODS: The ED visits from seven Chicago metropolitan area hospitals (two tertiary pediatric EDs, five community general EDs) for all pediatric patients seen between July 1995 and December 1997 with a discharge diagnosis including the term "seizure" were retrospectively identified. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure <20 minutes; absence of known central nervous system disease). Rates of bacteremia, urinary tract infection, bacterial meningitis, and pneumonia were determined. RESULTS: Four hundred fifty-five children were identified who had first-time simple febrile seizures. The study participants had a mean age of 21 months and a mean temperature of 39.6 degrees C, and 64% were male. Seventy-three percent were seen in a community hospital setting. Blood cultures were obtained for 315 children (69%). Four children (1.3% [95% CI = 0.1% to 2.5%]) were bacteremic, all with Streptococcus pneumoniae; the rate of bacteremia did not differ in the subset at highest risk for bacteremia (6-36 months, temperature >39 degrees C). No demographic or laboratory data distinguished the bacteremic children from those with negative blood cultures. One hundred seventy-one children (38%) had urine cultures obtained; 5.9% [95% CI = 2.4% to 9.4%] of the cultures grew >100,000 colony-forming units/mL of a single pathogenic organism. One hundred thirty-five children (30%) had cerebrospinal fluid cultures performed. None of these cultures grew a bacterial pathogen [95% CI = 0% to 2.2%]. Two hundred eight children (45.7%) had chest x-rays performed; 12.5% [95% CI = 10.2% to 14.8%] (n = 26) of the x-rays were read as consistent with pneumonia by the radiologist at the treating institution. None of the blood cultures performed on children with abnormal radiographs were positive (cultures drawn on 23 of 26 patients, 88%). Stool cultures were performed on 14 children (3.1%); two cultures (14.3% [95% CI = 0% to 32.6%]) grew a bacterial pathogen, both Shigella. CONCLUSIONS: Rates of SBI in this multi-institution population of children with first-time simple febrile seizures were low and are consistent with those published in the literature for febrile children without seizures.

The training of pediatric residents in the care of acutely ill and injured children.

OBJECTIVES: To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. DESIGN: A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. SETTING AND PARTICIPANTS: Pediatric residency programs and their directors. MAIN OUTCOME MEASURES: Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). RESULTS: One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. CONCLUSIONS: Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.

Setting-based practice variation in the management of simple febrile seizure.

OBJECTIVE: To identify provider-based differences in the ED assessment and management of children presenting with uncomplicated, first-time febrile seizures. METHODS: Multicenter, retrospective cohort study of seven EDs in-the Chicago area: two tertiary academic pediatric EDs (PEDs) and five community-based general EDs (GEDs). The visits of all patients with a discharge diagnosis including the term "seizure" were identified from a 30-month period. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure <20 minutes; "alert" or "arousable" on presentation; absence of known neurologic disease). RESULTS: Four hundred fifty-five records were included: 330 and 125 patients presenting to GEDs and PEDs, respectively. The two groups did not differ in mean age, vital signs, reported duration of seizure, or prior antibiotic use. Lumbar puncture (LP) was performed more often in the GED group (33% vs 22%). No patients were found to have bacterial meningitis. The patients in the GED group were more likely to receive parenteral antibiotics in the ED (56% vs 22%) and to be admitted or transferred (18% vs 4%). In a logistic regression model incorporating age, temperature, seizure duration, seizure in the ED, prior antibiotic use, primary care, and insurance status, the GED patients remained more likely to have an LP (OR 1.5), receive parenteral antibiotics (OR 2.5), and be admitted or transferred (OR 2.5). CONCLUSIONS: There were significant setting-based differences in the evaluation and management of children with simple febrile seizures presenting to GEDs and PEDs.

Undiluted albuterol aerosols in the pediatric emergency department.

OBJECTIVE: To evaluate the efficacy and efficiency of a short treatment method of administering albuterol aerosols. METHODS: Fifty children 6 to 18 years of age with severe acute asthma (peak flow rates <60% of predicted) were enrolled in a single-blind, controlled trial in an urban pediatric emergency department. Patients were randomized to receive either the study short treatment (3.5 mL of undiluted albuterol nebulized for 20 inhalations) or the control treatment (albuterol diluted [.5 mL] and nebulized in normal saline [3 mL]) every 20 minutes for a total of 3 treatments. Peak flow and spirometric measurements were performed before and after each treatment. RESULTS: There were 25 patients in the study group and 25 in the control group. There were no demographic differences between groups; both had comparable pulmonary function at presentation. The mean forced expiratory volume in 1 second percent predicted improvement between 0 and 60 minutes was 18.8% in the study group and 14.5% in the control group. The total time of treatment delivery for the study group was 6.4 minutes versus 32.7 minutes for the control group. CONCLUSION: Undiluted albuterol short treatments seem to be as effective as standard diluted albuterol in severe asthmatics, while offering the ease and efficiency of shorter treatment administration time.

Fast track and the pediatric emergency department: resource utilization and patients outcomes.

OBJECTIVE: To examine differences in the evaluation, management, and outcomes for patients seen in an on-site "fast track" (FT) vs the main ED. METHODS: Over a three-month period, patients presenting to an urban pediatric ED were prospectively assessed. Patients included were: triaged as "nonurgent"; aged 2 months to 10 years; not chronically ill; and had fever, or complaint of vomiting, diarrhea, or decreased oral intake. Evening and weekend care was provided in the FT; at all other times these low-acuity patients were seen in the ED. Seven days after the visit, families were interviewed by telephone. RESULTS: Four hundred seventy-nine and 557 patients were seen in the FT and ED, respectively. The patients in the two settings did not differ in age, clinical condition, race, or commercial insurance status. Patient mean test charges were $27 and $52 for the FT and ED, respectively (p < 0.01). Twenty-four percent of the FT patients vs 41% of the ED patients had tests performed (p < 0.01). Average length of stay was 28 minutes shorter in the FT (95% CI = 19 to 36, p < 0.01). Follow-up was completed for 480 of 755 families with telephones (64%). The FT and ED patients did not differ at follow-up: 90% vs 88% had improved conditions (p = 0.53), 18% vs 15% had received unscheduled follow-up care (p = 0.44), and 94% of the families in both groups were satisfied with the visit (p = 0.98). CONCLUSIONS: Compared with those in the main ED, the study patients seen in the FT had fewer tests ordered and had briefer lengths of stay. These findings were not explained by differences in patient ages, vital signs, or demographic characteristics. No difference in final outcomes or satisfaction was detected among the families contacted for follow-up.

Language barriers and resource utilization in a pediatric emergency department.

BACKGROUND: Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB). OBJECTIVE: To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED. DESIGN: Prospective cohort study. METHODS: This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically ill, and had a presenting temperature >/=38.5 degrees C or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was <3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay. RESULTS: Data were obtained about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher: $145 versus $104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a $38 increase in charges for testing and a 20 minute longer ED stay. CONCLUSION: Despite controlling for multiple factors, the presence of a physician-family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reasons for these differences and ways to provide care more efficiently to non-English-speaking patients.

Evaluation of the infant with fever without source: an evidence based approach.

The infant with fever without an obvious source upon physical examination offers a challenging clinical problem. A combination of detailed history, physical examination, and selected laboratory tests allows the clinician to discern which infants are at lower risk for bacterial illness. Implications for management and future research are discussed herein.

The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department.

OBJECTIVE: We sought to determine whether information on hospital charges (prices) would affect test-ordering and quality of patient care in a pediatric emergency department (ED). DESIGN: Prospective, nonblind, controlled trial of price information. SETTING: Urban, university-affiliated pediatric ED. METHODS: We prospectively assessed patients 2 months to 10 years of age with a presenting temperature >/=38.5 degrees C or complaint of vomiting, diarrhea, or decreased oral intake. The assessments were done during three periods: September 1997 through December 1997 (control), January 1998 through March 1998 (intervention), and April 1998 (washout). In the control and washout periods, physicians noted tests ordered on a list attached to each chart. In the intervention period, physicians noted tests ordered on a similar list that included standard hospital charges for each test. Records of each visit were reviewed to determine clinical and demographic information as well as patient disposition. In the control and intervention periods, families of nonadmitted patients were interviewed by telephone 7 days after the visit. RESULTS: When controlled for triage level, vital signs, and admission rates, in a multivariate model, charges for tests in the intervention period were 27% less than charges in the control period. The greatest decrease was seen among low-acuity, nonadmitted patients (43%). In telephone follow-up, patients in the intervention period were slightly more likely to have made an unscheduled follow-up visit to a health care provider (24.4% vs 17.8%), but did not differ on improved condition (86.7% vs 83.4%) or family satisfaction (93.8% vs 93.0%). Adjusted charges in the washout period were 15% lower than in the control period and 15% higher than in the intervention period. CONCLUSION: Providing price information was associated with a significant reduction in charges for tests ordered on pediatric ED patients with acute illness not requiring admission. This decrease was associated with a slightly higher rate of unscheduled follow-up, but no difference in subjective outcomes or family satisfaction.

Hospital admissions of children from the emergency department: are decisions regarding children on public assistance different?

OBJECTIVE: To better understand the variables that influence the physician's decision to admit children from the emergency department (ED) for nonmedical problems. METHODS: A multicenter prospective questionnaire survey over a three-month study period. For all admitted children, the emergency physician completed a survey which recorded demographic data, insurance status, primary care provider (PCP), admitting diagnoses, and reason for admission. The reason for admission was noted as strictly medical or nonmedical (either an illness that could have been managed on an ambulatory care basis or a "psychosocial" admission). Group differences were analyzed by t test, chi 2, or logistic regression analysis where appropriate. RESULTS: There were 4318 ED admissions at five institutions of which 185 (4%) were judged to be nonmedical. No age or gender differences were found between the medical and nonmedical admission populations. Using logistic regression, adjusted odds ratios for nonmedical admissions were as follows: Medicaid insurance (2.34, 95% CI = 1.61-3.41), clinic-based primary care provider (1.54, 95% CI = 1.06-2.23), no or unknown primary care provider (2.40, 95% CI = 1.52-3.78), and after hours [eg, 5 PM to 8 AM] admissions (1.86, 95% CI = 1.31-2.63). CONCLUSIONS: These data suggest that children with lower socioeconomic status and limited primary care resources are more likely to be admitted from the ED for nonmedical reasons than children with commercial insurance resources or a private physician.

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.

A neural network approach for the determination of interhospital transport mode.

We report on the construction of neural networks for determining whether pediatric patients requiring transport to a tertiary care center should be moved by air or by ground. The networks were based on the functional-link net architecture. In two experiments, feedforward supervised-learning neural nets were trained with examples of an expert's decisions and then were used in a consulting mode to provide advice on cases not previously encountered. Training and validation were performed by a combination of the k-fold cross-validation and leaving-one-out sampling methods. Use of the functional-link net rather than the customary backpropagation net enabled us to carry out the training with fairly large amounts of data in realistically short time periods. In the first experiment, capillary refill, skin color, and stridor were consistently the input variables that were most strongly associated with the decision output. In both experiments, the networks were validated by comparing their performance retrospectively against the determination of an expert pediatric transport physician. The network was trained based on the expert's opinion about the correct mode of transport for each case with error rates of less than 10(-5).

New approaches to upper airway disease.

Although laryngotracheobronchitis is the most common upper respiratory tract disorder in pediatrics, several other diseases are potentially life-threatening. The emergency physician must recognize both the obvious and subtle distinctions among upper airway diseases. The status of the patient's airway remains the primary concern regardless of the suspected disorder, but further definitive care depends on the specific disease entity. The prompt recognition and action of both the prehospital care provider and the ED physician in maintaining a critical airway and supporting ventilation until definitive pediatric critical or surgical care can be delivered is essential in ensuring optimal outcome for children suffering from a life-threatening upper airway illness.

Contribution of routine pulse oximetry to evaluation and management of patients with respiratory illness in a pediatric emergency department.

STUDY OBJECTIVE: To determine whether routine pulse oximetry in a pediatric emergency department can be used to identify patients with a low oxygen saturation (SaO2) that is unexpected on the basis of clinical evaluation. DESIGN: Prospective comparison of blinded, clinical evaluation by physicians with subsequent pulse oximetry readings. SETTING: Pediatric ED in an urban, university medical center. PARTICIPANTS: A convenience sample of 368 patients presenting to the pediatric ED with respiratory illnesses. METHODS: The history, physical examination, pediatric ED management, and therapy were recorded. Based on clinical assessment, the physician was asked whether the patient had a low SaO2 (< or = 92%). Room-air pulse oximetry was then obtained, with subsequent treatment and management plans recorded. RESULTS: Clinical assessment had a sensitivity of 33%, specificity of 86%, negative predictive value of 85%, and positive predictive value of 35% for detecting children with low SaO2. Unexpected low SaO2 usually led to a change in patient management or disposition. CONCLUSION: Clinical evaluation in a pediatric ED does not screen adequately for the detection of hypoxemia and should be supplemented by routine pulse oximetry in all patients with respiratory findings.

Hospital treatment of asthma: lack of benefit from theophylline given in addition to nebulized albuterol and intravenously administered corticosteroid.

STUDY OBJECTIVE: To determine the efficacy of theophylline when given in addition to nebulized albuterol and intravenously administered corticosteroid to children hospitalized with mild to moderate asthma. DESIGN: Randomized, prospective, placebo-controlled, double-blind trial. SETTING: Tertiary-care children's hospital. PATIENTS: Twenty-nine patients with asthma between the ages of 2 and 16 years completed the study. The treatment and placebo groups were similar in age, gender, race, illness severity, and emergency department treatment. INTERVENTIONS: All patients received intravenously administered methylprednisolone and nebulized albuterol. The treatment group received intravenous theophylline therapy and the placebo group dextrose in water. When intravenously administered medications were discontinued, therapy continued with oral administration of theophylline (or placebo) and of prednisone. MEASUREMENTS AND MAIN RESULTS: Twice-daily assessments of clinical asthma symptoms were made by using a scoring system consisting of respiratory rate, inspiratory/expiratory ratio, wheeze, and accessory muscle use. Time required to reach study discharge criteria (asthma score < or = 2) (30.4 +/- 16.8 vs 27.0 +/- 10.3 hours; p = 0.51) and the rate of improvement of the clinical asthma score (-0.10 +/- 0.05 unit/hr vs -0.11 +/- 0.09 unit/hr; p = 0.88) were not significantly different between the theophylline and placebo groups. The number of albuterol aerosol treatments required and the adverse effects experienced were not significantly different between groups. CONCLUSION: When the combination of systemically administered corticosteroid and inhaled albuterol is used in the treatment of children hospitalized with mild to moderate asthma, addition of theophylline may not be justified.

Mass illness at an intermediate school: toxic fumes or epidemic hysteria?

The report of an acute illness involving a large number of clustered children will undoubtedly provoke an urgent emergency care response or, in some instances, a mass casualty or disaster response. While responding to the perceived needs of those involved, the professionals caring for these children must consider epidemic hysteria along with the other causes of mass illness. Since the early recognition of epidemic or mass anxiety hysteria can have tremendous impact on the ease of treating this problem, that awareness is quite important.