An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost.

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.

Cost-effectiveness decision analysis of intramuscular ceftriaxone versus oral cefixime in adolescents with gonococcal cervicitis.

STUDY OBJECTIVE: We compared the cost-effectiveness of two single-dose treatment strategies for adolescents with uncomplicated Neisseria gonorrhoeae cervicitis. METHODS: We used a cost-effectiveness decision- analysis model to compare the two methods: the standard, ceftriaxone 125 mg given by IM injection; and an alternative, cefixime 400 mg given orally. The effect of the costs associated with the risk of accidental needlestick during IM administration was also evaluated. Key baseline assumptions (with ranges, when tested) were from the literature or costs to our hospital. These included ceftriaxone, $8.60 per dose; cefixime, $4.67 per dose; ceftriaxone efficacy, 98% (range, 94.9% to 100%); cefixime efficacy, 97% (94.1% to 100%); and a 15% probability of pelvic inflammatory disease (PID) related to failed treatment. We included costs for PID necessitating hospitalization, disseminated gonococcal infection, infertility, and ectopic pregnancy. Assumptions related to accidental needlestick included the rate of needlesticks with the disposable syringe, 6.9 per 100,000 injections (range, 0 to 69); cost of accidental needlestick to hospital; risk of HIV seroconversion after needlestick exposure to HIV-infected blood, .36% (range, 0% to .86%); rate of HIV infection in 15- to 19-year-olds attending sexually transmitted diseases clinics, .4% (range, 0 to 5); and lifetime treatment costs for a person with HIV. RESULTS: At baseline values the model favored ceftriaxone ($45 per patient) or cefixime ($59 per patient). However, over the range of efficacy of both drugs, two-way sensitivity analysis revealed no consistent cost advantage for either drug. The model was also insensitive to the economic effects associated with the risk of accidental needlestick during IM injection. CONCLUSION: over the range of efficacy by the 95% confidence intervals of both drugs, our analysis demonstrated no clear cost advantage for either. The economic effects of accidental needlestick do not change this conclusion. Compared with the IM alternative, oral cefixime is painless to the patient and simpler for the practitioner to administer. Oral cefixime also eliminates the psychologic effects associated with needlesticks in health care workers. For these reasons, we favor the use of oral cefixime for uncomplicated gonococcal cervicitis in adolescents.

Penetrating abdominal air gun injuries: pitfalls in recognition and management.

Emergency health care providers often underestimate the potential for pellet and BB guns to inflict life-threatening penetrating injuries. We present four children with intraabdominal injuries caused by air guns and summarize the characteristics of 12 similar cases reported in the literature. In the context of injury potential, the epidemiology of air gun injuries and the mechanical characteristics of air guns are reviewed. In addition, we suggest a general approach to the triage and management of children with air gun-inflicted abdominal wounds. Finally, preventive strategies are discussed.

Recognition and management of pregnant adolescents in the pediatric emergency department.

The early initiation of comprehensive prenatal care is essential to avoid the complications associated with the more than one million adolescent pregnancies in the United States each year. Pediatric emergency physicians can play an important role in the initial diagnosis and appropriate referral of pregnant teenagers. However, previous studies have shown that the diagnosis of pregnancy can be difficult. The goals of this study were to characterize the spectrum of presenting complaints and to evaluate the assessment and disposition of pregnant teenagers presenting to a pediatric emergency department (PED). We retrospectively reviewed the medical records of 94 adolescents who presented with 95 pregnancies to our PED over an 18-month period. The mean age was 15.7 years (range 12 to 19 years). Only 8% mentioned pregnancy in their chief complaint at triage, and a concern about pregnancy was revealed by only 36% during the history of present illness. Ten percent denied they were sexually active. The most frequent complaints were gastrointestinal (77%); other complaints were gynecologic, urinary, or nonspecific. A concurrent sexually transmitted disease (32%) or urinary tract infection (31%) was frequently clinically suspected. At disposition, 26% were transported to an general emergency department for urgent obstetric evaluation; others were referred to a primary caregiver (23%) or obstetrician (39%). Pregnant teenagers present to the PED with a wide variety of complaints that may suggest other diagnoses. A high index of suspicion is required to diagnose pregnancy in adolescent girls so that appropriate care and referral can be initiated.

Emergency department analgesic use in pediatric trauma victims with fractures.

STUDY OBJECTIVE: To investigate the frequency of emergency department analgesic use in children with presumably painful fractures who are also at risk for associated multiple injuries and to determine whether there are specific factors that distinguish those who are prescribed analgesics from those who are not. DESIGN: Descriptive, retrospective review of a computerized trauma registry. SETTING: Regional pediatric ED and trauma center. PARTICIPANTS: Four hundred thirty-three injured children met trauma team activation criteria from January 1, 1991 through June 30, 1992. Of these 433, we selected the 121 children who had fractures of the pelvis, long bones, ankle, wrist, or clavicle. Of these 121, we excluded the 22 children who underwent endotracheal intubation. Trauma registry data from the prehospital and ED phases of care from the remaining 99 children were reviewed for this study. INTERVENTIONS: None. MAIN RESULTS: Of the study group, 53% (52 of 99) received analgesics, all narcotics. Excluding the 46 children with multi-system injuries, only 62% (33 of 53) received analgesics. Patients in both the analgesic (52) and no-analgesic groups (47) were mildly to moderately injured based on initial ED trauma scores and vital signs. No statistical or clinical significant differences were found between the analgesic group and the no-analgesic group when comparing age, sex, race, mechanism of injury, vehicle speed, height of fall, time elapsed from injury until arrival at the ED, transport method, prehospital analgesic use, mortality, Injury Severity Score, and initial ED vital signs, Glasgow Coma Scale, Trauma Score, and Pediatric Trauma Score. Fifty-nine percent (ten of 17) of the children with associated internal injuries limited to the chest or abdomen received analgesics compared with 62% (33 of 53) in those with isolated fracture (P = .8). Those with an associated head injury (31%, nine of 29) received analgesics less frequently than those with isolated fracture (62%, 33 of 53) (P = .01). CONCLUSION: Our results suggest that ED analgesic use was low in these mildly to moderately injured children with presumably painful fractures who are also at risk for associated multiple injuries. Head injury was associated with especially low analgesic use. We did not identify other specific factors that distinguished those who received analgesics from those who did not. Further investigation is required to determine if after the initial evaluation, a larger proportion of mildly to moderately injured trauma victims with fractures are appropriate candidates for ED analgesic use.

Thermal epiglottitis after swallowing hot beverages.

Two young children who sustained thermal injuries to the epiglottis (or "thermal epiglottitis") after swallowing hot beverages are reported. Findings, clinically and radiologically, in both children were similar to acute infectious epiglottitis. Children with these injuries are at risk for significant upper airway obstruction which may progress for several hours. Children in whom thermal epiglottitis is suspected should be approached with the same caution and preparedness for emergency airway management and pediatric intensive care afforded those with acute infectious epiglottitis.

Pulse oximetry.

The pulse oximeter provides a noninvasive, continuous, and generally valid measure of SaO2. Armed with a basic understanding of its operating principles and limitations, and the proper interpretation of SaO2, the emergency physician will find the pulse oximeter to be a useful instrument for the detection of hypoxia in infants and children.