Deficits in EMTALA Knowledge Among Pediatric Physicians.

OBJECTIVE: All US hospitals that participate in Medicare and Medicaid are regulated by the Emergency Medical Treatment and Active Labor Act (EMTALA). The law was enacted to prevent hospitals from turning away patients with emergency medical conditions. The law imposes specific obligations on hospitals and their physicians, and provides severe penalties for violations. The objective of this study was to evaluate hospital-based pediatric physicians' knowledge of these obligations and potential liabilities. METHODS: A questionnaire was submitted to the active medical staff and pediatric subspecialty residents at a tertiary care pediatric hospital. The questionnaire collected demographic information and posed 12 questions, based on well-established EMTALA principles, which addressed specific EMTALA obligations and liabilities. RESULTS: The questionnaire was returned by 123 of 332 (37%) potential participants. Twenty-four percent (n = 30) had never heard of EMTALA, 24% (n = 30) had only "heard of" the law, and 51% (n = 63) considered themselves "generally familiar" with EMTALA. No respondent correctly answered all 12 questions, and 13% (n = 16) answered all 12 questions incorrectly. The median score was 42%, with a range of 0% to 83% correct. Only 20% (n = 25) reported that they had ever received any EMTALA education. Prior EMTALA education was associated with a higher score (P = 0.001). Eighty percent (n = 98) expressed interest in attending a formal EMTALA education program. CONCLUSIONS: Physicians at this pediatric hospital were strikingly unaware of their EMTALA obligations and potential liabilities. A specific educational program regarding EMTALA should be provided to hospital-based pediatric physicians to improve compliance with the law and reduce potential liabilities.

Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs.

OBJECTIVES: To compare the frequency and severity of adverse events associated with parenteral drugs commonly used for procedural sedation and analgesia (PSA) in a pediatric emergency department. METHODS: A database of consecutive patients receiving parenteral PSA was prospectively generated with the intent of monitoring safety in the emergency department. Data were logged onto a dedicated sedation sheet. A retrospective analysis was performed; comparisons were made based on sedation drugs used. RESULTS: A total of 2,609 patients from June 1, 1996, to September 16, 2003, received PSA by emergency physicians. Patients who received PSA nonparenterally (n = 109) were excluded. A total of 2,500 patients (2,279, intravenous; 221, intramuscular) remained for analysis. Age range was 19 days to 32 years (median, 6.7 years). A total of 1,511 (60.4%) were male. Four major drug combinations were identified: ketamine alone (n = 1,492; 59.7%), ketamine/midazolam (n = 299; 12.0%), midazolam/fentanyl (n = 336; 13.4%), and midazolam alone (n = 260; 10.4%). A total of 113 patients (4.5%) received various other combinations of drugs. A total of 458 adverse events were observed in 426 patients (17%). Respiratory adverse events occurred as follows: ketamine alone, 91 patients (6.1%); ketamine/midazolam, 30 patients (10%); midazolam/fentanyl, 65 patients (19.3%); midazolam alone, 15 patients (5.8%). Vomiting occurred as follows: ketamine alone, 151 patients (10.1%); ketamine/midazolam, 16 patients (5.4%); midazolam/fentanyl, six patients (1.8%); midazolam alone, two patients (0.8%). CONCLUSIONS: Drug types used in pediatric PSA are associated with different adverse event profiles. Patients receiving ketamine with or without midazolam experienced fewer respiratory adverse events but more vomiting than the commonly used combination of midazolam and fentanyl. Adverse events may occur in any patient receiving parenteral PSA.

Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids.

BACKGROUND: The serum electrolyte panel (SEP) is a frequently ordered laboratory test, but it has unproven usefulness in the treatment of dehydrated pediatric patients. Our study purpose was to evaluate the usefulness of routinely ordering a SEP in the treatment of dehydrated pediatric patients receiving intravenous fluids (IVFs). METHODS: Children 2 months to 9 years of age who were receiving IVFs because of dehydration were prospectively studied in a pediatric emergency department (PED). Historical data, physical examination findings, degree of dehydration, and SEP results were recorded. After patient evaluation, attending physicians documented whether they would have ordered a SEP. Outcome measurements included changes in clinical management on the basis of SEP results, as well as correlations of dispositions and unscheduled return visits (URVs) with SEP results. RESULTS: A total of 182 patients were enrolled in the study. One hundred eleven patients had mild dehydration, 55 moderate dehydration, and 16 severe dehydration. Eighty-eight patients (48%; 95% confidence interval: 41-56%) had > or =1 abnormal SEP value. Clinically relevant findings included bicarbonate levels of <16 mmol/L for 28% of patients, hypoglycemia for 9.9%, hypokalemia for 6.0%, and hypernatremia for 3.0%. The attending physicians predicted that a SEP would be clinically important for 34% of all patients. There was a 58% sensitivity in detecting which children would have clinically significant SEP results. Overall, SEP results changed clinical management in 10.4% of cases. One hundred sixty-five (91%) of the patients were discharged from the PED (including 48 who were initially observed), of whom 7 (3.8%) had URVs to the PED within 72 hours and were given additional IVFs. Seventeen patients were admitted (median: 2.6 days), 2 of whom had URVs after hospital discharge for additional IVFs. CONCLUSIONS: On the basis of initial presentation, attending physicians were poor at predicting which children would have clinically significant SEP results. Low bicarbonate values were correlated with observation unit use but not with hospitalization or URVs. The observation unit provided effective care for a subset of dehydrated patients, avoiding the need for hospitalization. Obtaining a SEP can provide useful information for the treatment of some children receiving IVFs because of dehydration.