Pediatric Return Visits to the Emergency Department: The Time to Return Curve.

OBJECTIVE: Although 72-hour return visits are a frequently reported metric for pediatric patients discharged from the emergency department (ED), the basis for this metric is not established. Our objective was to statistically derive a cutoff time point for the characterization of pediatric return visits. METHODS: We performed a retrospective cohort study using data of patients discharged from any of 44 pediatric EDs. We selected the first encounter per patient from January 1 to December 31, 2019, as the index encounter and included the first return visit within 30 days. We constructed a cumulative hazard curve to characterize the timing of return visits and constructed a multivariable adaptive regression spline model to identify a hinge point in return visit presentations. We identified the association between admission for early return visits and admission for late return visits using generalized linear mixed modeling. RESULTS: Of 1,986,778 index ED discharges, 193,605 (9.7%) ED return visits were included. A double-exponential decay model demonstrated superior fit compared with a single exponential model ( P < 0.0001). Multivariable adaptive regression spline modeling identified a hinge at 7 days. When comparing proportions of return visits leading to hospitalization between early (23.8%) and late (15.1%) return visits, early visits (≤7 days) had higher adjusted odds of hospital admission (adjusted odds ratio, 1.73; 95% confidence interval, 1.69-1.77) relative to late return visits (>7 days). Findings were similar in sensitivity analyses within age subgroups, Census region, and in which the diagnosis (using the Diagnosis and Grouping System) was the same between the index and return visit. Among return visits that occurred within 7 days of the index visit, 46.3% had the same diagnosis grouping in both visits. CONCLUSIONS: An empirically derived 7-day cutoff may be more appropriate for characterization of pediatric return visits to the ED. Encounters after this period had lower adjusted odds of admission.

Longitudinal Trends in Pediatric Return Visits to US Emergency Departments.

OBJECTIVES: This study aimed to evaluate trends in pediatric emergency department (ED) 72-hour return visits and factors associated with return visits. METHODS: We performed a cross-sectional study from 2002 to 2018 using the National Hospital Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters. Patients 18 years or older were excluded. Our outcome of interest was 72-hour return ED encounter. We assessed changes in proportions of return visits over time using the Spearman rank-correlation test. We performed survey-weighted univariable and multivariable logistic regressions to identify factors associated with 72-hour return visit status. RESULTS: A total of 501 million (95% confidence interval [CI], 452-551 million) pediatric survey-weighted ED encounters occurred during the 17-year study period, of which 14,353,697 (3.2%; 95% CI, 2.7%-3.7%) represented 72-hour return visits. The proportion of pediatric ED return visits increased from 22.9 to 36.5 per 1000 pediatric encounters over the study period (ρ = 0.68, P < 0.01). Most return visits were of lower acuity (73.0%; 95% CI, 68.6%-11.5%), and 8.1% (95% CI, 6.3%-9.9%) of return visits were admitted to the hospital or transferred to a different facility. In multivariable analyses, older age, abnormal heart rate, and abnormal temperature had lower adjusted odds ratio (aOR) of 72-hour return visits compared with encounters not classified as return visit. Complaints of returning for test results, treatment, and diagnostic screening/administrative purposes were associated with a higher aOR of return visit. Admission/transfer (in comparison with discharge) had a higher odds of return visit status in univariable (odds ratio, 1.59; 95% CI, 1.24-2.04) and multivariable (aOR, 1.31; 95% CI, 1.03-1.68) analyses. CONCLUSIONS: The proportion of 72-hour US pediatric ED return visits is increasing over time. Return visit status was associated with admission/transfer, but otherwise with markers of lower patient acuity. These findings inform quality improvement efforts aimed at improving pediatric transition to outpatient care after an ED encounter.

Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States.

OBJECTIVE: This study aimed to compare statewide emergency medical services protocols for the management of pediatric respiratory distress. METHODS: We performed a descriptive study of emergency medical services protocols for the management of pediatric respiratory distress in the United States, excluding those without model or mandatory protocols. We compared medication recommendations for specific disease processes, including asthma, croup, epiglottitis, anaphylaxis, generalized respiratory distress, intubation, and drug assisted intubation. RESULTS: Thirty-four state protocols were included. All had protocols to address the management of pediatric respiratory distress. There was high agreement in albuterol use for bronchospasm and epinephrine use in anaphylaxis. Epinephrine was recommended in all anaphylaxis protocols, 27 croup protocols (79%), and 3 epiglottitis protocols (9%). Six states (18%) called for albuterol in patients with generalized respiratory distress. Steroid recommendations and indications had variance among states; 26 states (76%) allowed steroid use in patients with asthma, 19 states (56%) recommended steroid use in anaphylaxis, and 11 (32%) recommended steroid use in croup protocols. The route for steroid administration also varied among protocols. Five states (15%) allowed continuous positive airway pressure application in pediatric patients, whereas endotracheal intubation and rapid sequence intubations had varying requirements as well as recommendations for use. Twelve (35%) listed impending or current respiratory failure as an indication, whereas other states had specific markers, such as Glasgow Coma Scale or oxygen saturation, as indications. CONCLUSIONS: All included states had specific recommendations for the management of pediatric respiratory distress. There was consistency in recommendations for albuterol use for wheezing and epinephrine use for anaphylaxis. However, there was wide variability in other uses for epinephrine, steroid administration, continuous positive airway pressure use, and specific treatments for croup and epiglottitis. The findings of this study provide a base for important future evidence-based protocol developments and changes in prehospital pediatric respiratory distress treatment.

Pediatric Patients Brought by Emergency Medical Services to the Emergency Department: An Analysis From the National Hospital Ambulatory Medical Care Survey.

BACKGROUND/OBJECTIVE: To describe the epidemiology of emergency department (ED) visits by pediatric patients transported from the out-of-hospital setting (ie, scene) by emergency medical services (EMS), and identify factors associated with EMS transport. METHODS: We performed a cross-sectional study of ED visits from 2014 to 2017 utilizing a nationally representative probability sample survey of visits to US EDs. We included pediatric patients (<18 years old) and compared encounters transported from the scene by EMS to those who arrived to the ED by all other means. We performed multivariable logistic regression to identify factors associated with scene EMS transport. RESULTS: Of 130.2 million pediatric ED encounters, 4.7 million (3.8%) arrived by EMS. Most patients were White (61.1%), non-Hispanic (77.5%), and publicly insured (52.2%). Multivariable analysis demonstrated associations with EMS transport: Black (vs White) race (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.16-1.89), ages 1 to younger than 5 years (aOR, 0.52; 95% CI, 0.37-0.72) and 5 to younger than 12 years (aOR, 0.56; 95% CI, 0.40-0.80) (vs adolescents), pediatric (aOR, 0.60; 95% CI, 0.42-0.85) and nonmetropolitan hospital status (aOR, 0.52; 95% CI, 0.35-0.78), blood testing (aOR, 2.34; 95% CI, 1.71-3.19), time to evaluation (31-60 minutes [aOR, 0.56; 95% CI, 0.39-0.80] and >60 minutes [aOR, 0.51; 95% CI, 0.33-0.77] compared with 0-30 minutes), admission (aOR, 3.20; 95% CI, 2.33-4.38), and trauma (1.80; 95% CI, 1.43-2.28). CONCLUSIONS: Four percent of pediatric ED patients are transported to the ED by EMS from the scene. These patients receive a rapid and resource intense diagnostic evaluation, suggesting that higher acuity. Black patients, adolescents, and those with trauma were more likely to be transported by EMS.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

OBJECTIVE: To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. STUDY DESIGN: Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. RESULTS: Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. CONCLUSIONS: Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.

Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States.

The objective of the study is to describe distinguishing characteristics of commercial sexual exploitation of children/child sex trafficking victims (CSEC) who present for health care in the pediatric setting. This is a retrospective study of patients aged 12-18 years who presented to any of three pediatric emergency departments or one child protection clinic, and who were identified as suspected victims of CSEC. The sample was compared with gender and age-matched patients with allegations of child sexual abuse/sexual assault (CSA) without evidence of CSEC on variables related to demographics, medical and reproductive history, high-risk behavior, injury history and exam findings. There were 84 study participants, 27 in the CSEC group and 57 in the CSA group. Average age was 15.7 years for CSEC patients and 15.2 years for CSA patients; 100% of the CSEC and 94.6% of the CSA patients were female. The two groups significantly differed in 11 evaluated areas with the CSEC patients more likely to have had experiences with violence, substance use, running away from home, and involvement with child protective services and/or law enforcement. CSEC patients also had a longer history of sexual activity. Adolescent CSEC victims differ from sexual abuse victims without evidence of CSEC in their reproductive history, high risk behavior, involvement with authorities, and history of violence.

Noninfectious disease among the Bhutanese refugee population at a United States urban clinic.

A large number of Bhutanese are currently being resettled to the United States. A high prevalence of noninfectious diseases has been noted in some refugee groups, but data on the Bhutanese refugee population are lacking. A retrospective, chart review study was conducted to determine proportion of noninfectious disease among ethnically Nepali Bhutanese refugees (n = 66) seen at the Grady Refugee Clinic (GRC). GRC disease proportions included the following: 52 % of the patients were overweight/obese (n = 34), 23 % were hypertensive (n = 15), 12 % had vitamin B(12) deficiency (n = 8), 15 % had depression (n = 10), and 14 % had diabetes (n = 9). Nine (90 %) patients with depression had chronic disease compared to 30 (54 %) of the patients without depression. The study found a substantial burden of chronic disease, micronutrient deficiency, and depression in the GRC. Further research is needed to accurately describe the disease burden in refugee populations and to evaluate pre-resettlement disease prevention strategies to provide a framework for future public health interventions.

Pediatric condyloma acuminata.

BACKGROUND: Condyloma acuminata are caused by human papilloma virus (HPV) 6 and 11 and most commonly present in the anogenital region. Most transmission among adults is via sexual transmission, but HPV and resulting anogenital warts in pediatric populations may be a result of perinatal vertical transmission, indirect transmission through contaminated objects or surfaces, autoinoculation, or sexual transmission. CASE: A 9-year-old premenarchal female presented with multiple perianal warts. She had no significant medical history, and denied history of any sexual contact, including sexual abuse. The external examination revealed multiple warts in the perianal region, but no lesions, discharge, inflammation, or external signs of trauma were visible. Tests for sexually transmitted infections were all negative. The warts were diagnosed as condyloma acuminata, and were subsequently treated with trichloroacetic acid 80% (TCA) in the provider's office. TCA was applied on 3 separate occasions 2 weeks apart, showing marked improvement at each visit. SUMMARY/DISCUSSION: While both sexual and nonsexual means of transmission are possible, sexual abuse must always be considered in pediatric cases. It is recommended that investigators proceed delicately, because the investigation can be psychologically damaging for patients and their families. Treatment methods are a unique consideration for pediatric patients, as most options are painful and require multiple office visits. The benefits of self-administration at home must be weighed with the likelihood of patient compliance and need for ongoing evaluation by the provider.