Pediatric Malpractice Claims in the Emergency Department and Urgent Care Settings From 2001 to 2015.

OBJECTIVES: This study aimed to provide an assessment of medical malpractice claims involving pediatric patients cared for in emergency department and urgent care settings. METHODS: We performed a retrospective review of all closed malpractice claims involving children (0-17 years old) originating from emergency department or urgent care centers from the Physician Insurers Association of America's Data Sharing Project database for a 15-year period (2001-2015). Reported data collected include medical specialty involved, medical diagnoses, chief medical factors, severity of resulting injury, claim disposition, average indemnity, and average defense costs. RESULTS: A total of 728 closed claims in pediatric emergency care settings were reviewed. Money was paid to the claimant in 30% of cases (220/728), with a total of US $70.3 million (average $319,513) paid to patients or families during the 15-year period. The most common resulting medical conditions were cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs. Error in diagnosis was the most common chief medical factor (41%), whereas those that involved failure or delay in admission to the hospital, which was the eighth most common chief medical factor, resulted in the highest average indemnity. Of the 728 closed claims, 220 involved a patient death (30%), but claims involving major permanent injury more often resulted in a payment. Of the 57 cases that went to trial, verdicts favored the physician in 47 cases (82%). CONCLUSIONS: Cardiac conditions, appendicitis, and disorder of the male genital organs are the most common medical conditions, and error in diagnosis is the most common chief medical factor in pediatric emergency care malpractice suits. It is important for providers practicing in these settings to be familiar with the common diagnoses and chief medical factors involved in these claims.

Systematic review of child restraint system interventions (2007-2018).

Objective: To systematically review and summarize articles evaluating the effectiveness of child restraint system (CRS) interventions targeting parents/caregivers' knowledge of, overall rates of and/or proper use of CRSs published in a recent time period.Methods: Using multiple databases, we identified peer-reviewed journal articles published between January 1, 2007 and December 31, 2018 using selected key search terms. Inclusion criteria were: (1) evaluation of an intervention/program for child passenger safety targeting a parent or caregiver of a child (2) quantitative data-based results (i.e., change in knowledge, behavior, or observed outcomes), (3) English-language, and (4) peer-reviewed journal publication. Through a systematic review process and peer consensus, n = 23 articles met inclusion criteria. References of these articles were reviewed for inclusion using the same process and n = 12 additional articles were identified.Results: A total of n = 35 articles met inclusion criteria. Of the n = 35 articles, n = 9 were randomized controlled trials (RCTs), n = 4 were cluster RCTs, n = 11 were nonrandomized trials, and n = 11 were pretest post-test studies. Types of interventions included face-to-face education (n = 26), web/video-based education (n = 8) or written educational materials (n = 1). Of the articles reviewed, n = 20 involved distribution of free or subsidized CRSs to some or all subjects. N = 20 articles involved trained CRS technicians and/or CRS installation check-points. In terms of outcomes measured, n = 3 articles assessed changes in knowledge of CRS use, n = 22 assessed changes in CRS behaviors (which includes self-report or observed behavior change), and n = 10 assessed changes in both CRS knowledge and behaviors. All articles (n = 3) that measured changes in knowledge as their only outcome demonstrated positive effects while articles measuring behavioral outcomes (self-report or observed) (n = 32) had mixed results.Conclusions: This review included a wide range of articles of heterogeneous methodologies, sample sizes, and outcomes measured. Although different approaches to CRS interventions were effective in increasing awareness and knowledge, the effects on CRS use behaviors - whether self-reported or observed - were mixed. Future research is needed to increase appropriate CRS use and reduce the burden of motor vehicle crash-related injuries among children.

Validation of an ICD-9-CM and ICD-10-CM map to AIS 2005 Update 2008.

Although the Abbreviated Injury Scale (AIS) is the most widely used severity scoring system for traumatic injuries, hospitals are required to document and bill based on the International Classification of Diseases (ICD). An expert panel recently developed a map between ICD-9-CM and ICD-10-CM to AIS 2005 Update 2008. This study aimed to validate the recently developed map using a large trauma registry. The map demonstrated moderate to substantial agreement for maximum AIS (MAIS) scores per body region based on expert chart review versus map-derived values (range: 44%-86%). Injury Severity Scores (ISSs) calculated from expert coders versus map-derived values were also compared and demonstrated moderate agreement (ICD-9-CM: 48%, ICD-10-CM: 54%). Although not a perfect conversion tool, the new ICD-AIS map provides a systematic method to assign injury severity for datasets with only ICD-9-CM and ICD-10-CM codes available and can be used for future injury-related research and data analysis.

Hip Synovial Fluid Cell Counts in Children From a Lyme Disease Endemic Area.

BACKGROUND: Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated. METHODS: We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type. RESULTS: Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303-209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789-73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis. CONCLUSIONS: In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis.

Safety and Costs of Stroke Unit Admission for Select Acute Intracerebral Hemorrhage Patients.

BACKGROUND AND PURPOSE: There are limited data to guide intensive care unit (ICU) versus dedicated stroke unit (SU) admission for intracerebral hemorrhage (ICH) patients. We hypothesized select patients can be safely cared for in SU versus ICU at lower costs. METHODS: We conducted a retrospective cohort study of consecutive patients with predefined minor ICH (≤20 cm3, supratentorial, no coagulopathy) receiving care in either an ICU or an SU. Multiple linear regression and inverse probability weighting were used to adjust for differences in patient characteristics and nonrandom ICU versus SU assignment. The primary outcome was poor functional status at discharge (modified Rankin score [mRS] ≥3). Secondary outcomes included complications, discharge disposition, hospital length of stay, and direct inpatient costs. RESULTS: The study population included 104 patients (41 admitted to the ICU and 63 admitted to the SU). After controlling for differences in baseline characteristics, there were no differences in poor functional outcome at discharge (93% vs 85%, P = .26) or in mean mRS (2.9 vs 3.0, P = .73). Similarly, there were no differences in the rates of complications (6% vs 10%, P = .44), discharged dead or to a skilled nursing facility (8% vs 13%, P = .59), or direct patient costs (US$7100 vs US$6200, P = .33). Median length of stay was significantly longer in the ICU group (5 vs 4 days, P = .01). CONCLUSIONS: This study revealed a shorter length of stay but no large differences in functional outcome, safety, or cost among patients with minor ICH admitted to a dedicated SU compared to an ICU.

Implementing Patient-Reported Outcome Measures in Your Practice: Pearls and Pitfalls.

Patient-reported outcome measures (PROMs) are an important component of health outcomes assessment. Preoperative and postoperative measurement of patient-reported pain, functionality, and quality of life offers many benefits to orthopedic surgeons in all practice settings. PROM data are used in research and have many other applications. Providers can use PROM data to measure the individual or institutional recovery trajectory for any surgical procedure, and patients can actively engage in their recovery after a procedure by learning about its expected outcomes. Although PROMs have many benefits and applications, implementation has its challenges. There are issues regarding PROM selection, longitudinal data collection with high compliance, and integration of PROMs into clinical care. In this article, we discuss the challenges associated with implementing PROMs in an orthopedic surgery practice and review the literature for best practices in PROM selection, patient follow-up, and novel ways to use PROM data.

The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis.

BACKGROUND: Increasing methicillin resistance and recognition of Propionibacterium acnes as a cause of infection in shoulder arthroplasty has led to the adoption of local vancomycin powder application as a more effective method to prevent expensive periprosthetic infections. However, no study has analyzed the cost effectiveness of vancomycin powder for preventing infection after shoulder replacement. METHODS: Cost data for infection-related care of 16 patients treated for deep periprosthetic shoulder infection was collected from our institution for the break-even analysis. An equation was developed and applied to the data to determine how effective vancomycin powder would need to be at reducing a baseline infection rate to make prophylactic use cost effective. RESULTS: The efficacy of vancomycin (absolute risk reduction [ARR]) was evaluated at different unit costs, baseline infection rates, and average costs of treating infection. We determined vancomycin to be cost effective if the initial infection rate decreased by 0.04% (ARR). Using the current costs of vancomycin reported in the literature (range: $2.50/1000 mg to $44/1000 mg), we determined vancomycin to be cost effective with an ARR range of 0.01% at a cost of $2.50/1000 mg to 0.19% at $44/1000 mg. Baseline infection rate does not influence the ARR obtained at any specific cost of vancomycin or the cost of treating infection. CONCLUSIONS: We have derived and used a break-even equation to assess efficacy of prophylactic antibiotics during shoulder surgery. We further demonstrated the prophylactic administration of local vancomycin powder during shoulder arthroplasty to be a highly cost-effective practice.

"That's Where the Arguments Come in": A Qualitative Analysis of Booster Sessions Following a Brief Intervention for Drug Use and Intimate Partner Violence in the Emergency Department.

Although booster phone calls have been used to enhance the impact of brief interventions in the emergency department, there has been less number of studies describing the content of these boosters. We conducted a qualitative analysis of booster calls occurring two weeks after an initial Web-based intervention for drug use and intimate partner violence (IPV) among women presenting for emergency care, with the objective of identifying the following: progress toward goals set during the initial emergency department visit, barriers to positive change, and additional resources and services needed in order to inform improvements in future booster sessions. The initial thematic framework was developed by summarizing codes by major themes and subthemes; the study team collaboratively decided on a final thematic framework. Eighteen participants completed the booster call. Most of them described a therapeutic purpose for their drug use. Altering the social milieu was the primary means of drug use change; this seemed to increase isolation of women already in abusive relationships. Women described IPV as interwoven with drug use. Participants identified challenges in attending substance use treatment service and domestic violence agencies. Women with substance use disorders and in abusive relationships face specific barriers to reducing drug use and to seeking help after a brief intervention.