[On-drift spectrometer with double successive separation with ionization in the corona discharge].

An experimental high-resolution ion-drift spectrometer is described. Operating characteristics were improved by installation of a second grid gate in the center of the drift space. The ion-drift analyzer setups and the ranges of amplitude, length and temporary delay of control impulses were identified in the course of testing. The article gives illustration of mobility spectrum in case of a single or paired gate analysis.

Compliance with national recommendations for tuberculosis screening and immunization of healthcare workers in a children's hospital.

Physicians and clinical employees at a children's hospital were surveyed to compare their tuberculosis (TB) screening and immunization statuses. Failure to offer screening and immunization services to non-employee physicians was associated with lower rates of reported immunity to several vaccine-preventable diseases and with markedly lower rates of TB screening.

Payment of emergency department bills by Medicaid patients.

OBJECTIVE: To analyze ED services used by and payment received from patients who request to stay and assume responsibility for their bills after being denied emergency care payment by their Medicaid providers. METHODS: A retrospective chart review over an 18-month period was conducted. Charges for these visits were obtained from the physician billing service and hospital finance records. RESULTS: Of 193 patient visits identified, 192 charts were located and reviewed for chief complaint, diagnostic tests, and interventions performed. In total, the visits resulted in $18,120 in physician charges and $28,126 in hospital charges. Three payments amounting to $134 were collected, leaving $46,246 in nonreimbursed charges. CONCLUSIONS: Nearly all patients who elect to be seen in this pediatric ED after being denied by their Medicaid managed care providers do not pay their bills. ED resources, including laboratory studies, radiographs, and consultations, are used to evaluate and treat these patients without compensation. The cost of this nonreimbursed care must be recovered from other patient care charges.

Pediatric emergency physicians and communicable diseases: can we be trusted to take care of ourselves?

OBJECTIVE: To determine if pediatric emergency physicians (PEP) are following Centers for Disease Control and Prevention (CDC) recommendations that all health care workers receive routine vaccines and annual tuberculosis screens. DESIGN: A two-page mail survey with one follow-up mailing. PARTICIPANTS: All active members of the American Academy of Pediatrics (AAP), Section on Emergency Medicine. Additional inclusion criteria were completion of training and employment in an emergency setting. RESULTS: Of 407 surveys, 286 (60%) were returned; 209 met inclusion criteria. Proof of immunization was not required of 43% of PEP; 42% were not required to have an annual tuberculosis (TB) screen. PEP reported immunity to the following: polio (95%), measles (94%), hepatitis B (91%), rubella (90%), mumps (90%), varicella (90%), and diphtheria-tetanus (86%). However, only 72% received a TB screen, and 60% received an influenza vaccine within the past year. Proof of vaccination for employment was required by 57/85 hospitals, 47/79 universities, and 6/32 self-employed/group practices (chi 2, P < 0.001). Proof of an annual TB screen was required by 64/87 hospitals, 44/82 universities, and 8/32 self-employed/group practices (chi 2, P < 0.001). PEP were more likely to have had a recent annual TB screen if required by their employer (104/117) than if left to their own initiative (42/87) (chi 2, P < 0.001). CONCLUSIONS: Although PEP are well protected against most vaccine-preventable diseases, many are not receiving annual TB screens nor influenza vaccines. The CDC guidelines are not being routinely followed by PEP.

Utility of toxicology screening in a pediatric emergency department.

OBJECTIVE: To determine the types of patients who undergo toxicology screen testing (TS) and the clinical utility of the test in a pediatric emergency department. DESIGN: Retrospective chart review. SETTING: Urban pediatric emergency department. PATIENTS OR PARTICIPANTS: All patients, n = 338, less than 18 years of age who had a TS sent from the Kosair Children's Hospital Emergency Department between 1/1/91 and 12/31/91. RESULTS: Three hundred and thirty-eight charts were available for review from 344 patients who had TS testing. Seventy-eight patients (23%) were less than 12 years old; 164 patients (49%) were female. Forty-four patients were tested by serum TS only; 195 patients by serum plus urine TS; 94 patients by urine TS; four patients by serum, urine, and gastric aspirate TS, and one patient by urine and gastric aspirate TS. Chief complaints of patients who had TS sent were as follows: ingestion (211), abnormal behavior (56), seizures (30), trauma (18), syncope/tingling (7), depression/suicide (6), chest pain/palpitations (3), headaches (3), and other (4). While 195 patients (57%) had positive TS for at least one item, only 22 patients (7%) had a positive TS for an unexpected item, including seven patients with ingestions, eight with abnormal behavior, four with seizures, two with syncope, and one with trauma. Only three patients with unexpected positive TS had a change in medical management as a result of the TS findings. All three of these patients had abnormal physical examinations. CONCLUSION: A minority of patients have unexpected TS results. TS results rarely necessitate a change in medical management. Emergency physicians should reevaluate indications for TS testing in pediatric patients.

A survey of policies at children's hospitals regarding immunity of healthcare workers: are physicians protected?

OBJECTIVE: To determine policies at children's hospitals regarding immunizations, annual tuberculosis (TB) screening, and blood or body fluid exposure follow-up, particularly as they apply to physicians. DESIGN AND PARTICIPANTS: A three-page survey was sent to infection control practitioners (ICPs) in April 1994 at hospitals affiliated with the National Association of Children's Hospitals and Related Institutions. One follow-up mailing was sent to nonresponding ICPs. RESULTS: Responses were received from 62 (67%) of 93 ICPs. Thirty-five (66%) of 53 children's hospitals had an immunity policy that applied to medical students, 42 (79%) of 53 to resident physicians, 32 (52%) of 62 to hospital-based physicians, and 18 (29%) of 62 to private or community physicians (who admit patients to one hospital). Physicians were required to show evidence of an annual TB screen at 36 hospitals (58%). Immunity policies or TB screening were provided for the following physician groups: medical students, 13 (21%); resident physicians, 43 (69%); hospital-based physicians, 50 (81%); and private or community physicians, 23 (37%). Infection control practitioners reported that the following diseases had been identified within the past 5 years at their hospitals: measles, 82%; mumps, 40%; rubella, 31%; TB, 94%; hepatitis B, 94%; pertussis, 90%; varicella, 98%; and influenza, 94%. Physicians in these institutions were reported to have contracted the following diseases from patient exposure: measles, hepatitis B, TB, pertussis, varicella, and influenza. CONCLUSION: Children's hospitals vary widely in their policies regarding healthcare-worker immunity, and, in many cases, physicians may not be protected from nosocomial transmission of community infections.

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.

Educating residents: the effects of a mock code program.

Housestaff residents are often the primary participants in codes that occur in a hospital setting, yet it is unknown how much confidence and knowledge they possess in the management of these medical emergencies. A study to learn the effect of a mock code program on residents' level of confidence and knowledge regarding code situations was initiated in a children's tertiary care hospital. Thirty-three residents completed a questionnaire before initiation of the study. The questionnaire revealed that codes scare them (79%), and that they felt a need for more knowledge (76%) and more experience (82%) before supervising a code. They did not feel confident in performing certain procedures such as treating dysrhythmias (79%), obtaining i.v. access (64%), and doing intubations (30%). Sixteen residents then participated in mock codes, and the other seventeen residents served as controls. Compared to the pre-study questionnaire, residents who had participated in mock codes had more confidence in their ability to supervise and felt less of a need for more knowledge before supervising a code. The participants also felt more confident in obtaining i.v. access and performing intubations during a code situation. There was no difference in the pre- and post-questionnaires of the control group. Residency programs are not meeting the educational and confidence needs of pediatric residents. A mock code program improves residents' perceived need for more knowledge before supervising a code and improves their confidence in doing many lifesaving procedures.

Technical skills experiences in pediatric emergency medicine fellowship programs.

Guidelines for Pediatric Emergency Medicine (PEM) fellowship programs were published by the Curriculum Subcommittee, Section of Emergency Medicine, American Academy of Pediatrics in February 1993. The guideline listed 120 technical skills that the subcommittee felt all fellows should be able to perform at the completion of their training. The purpose of this study was to measure the experience of PEM fellows in performing skills recommended by the subcommittee and to determine if documentation lists were being maintained. A written survey was mailed to 63 graduating fellows in May 1993, requesting information on the number of times procedure skills were performed. Limited experience was defined as having performed a procedure five or less times. Thirty-two surveys (51%) were returned. Eleven fellows (34%) stated they maintained a procedure documentation list. Of 117 skills analyzed, the majority of fellows had limited experience in 49 procedures and zero experience in 22 procedures. The majority of fellows had limited experience in 12 of 20 life- or limb-saving procedures and zero experience in five. Large emergency department volumes did not influence number of procedure completions. Our data indicate that graduating PEM fellows have limited experience in performing many common as well as several life- and limb-saving skills. Documentation lists of technical skills are not being maintained by most fellows.

Preferences of parents for pediatric emergency physicians' attire.

While several studies have evaluated patient/parent's preference for physicians' attire in pediatric clinics, pediatric wards, and in adult emergency settings, none has been done in a pediatric emergency department (PED). Furthermore, factors that may influence these preferences such as severity of illness, time of visit, and type of emergency department (ED) visit (surgical vs medical) have not been considered. This study was designed to evaluate parents' attitudes toward pediatric emergency department physicians' professional appearance. By way of a survey, the parents/guardians of 360 patients presenting to Children's Hospital Medical Center PED in Cincinnati, Ohio, were presented with eight photographs of physician pairs (male/female) dressed in different levels of attire ranging from a formal style (white laboratory coat, dress shoes, and tie) to surgical scrubs with tennis shoes. They were asked to choose the pair of practitioners they liked the most and the least, and to indicate whether their perception of competence was affected by physician attire. Preferences were analyzed by gender, age, responsible person, insurance group, type of visit, severity of illness, and time of visit. The results showed that, when asked which physicians they would prefer the most to evaluate their child in the PED, the majority of subjects chose photographs of physicians dressed most formally (158/360 [chi 2, P < 0.0001]). When asked which physician they preferred the least, 229 subjects chose the photograph of doctors wearing no white laboratory coat, no tie, and tennis shoes (chi 2, P < 0.0001). Neither severity of illness, time of visit, insurance group, age, race, or gender of the guardian or parent had a significant statistical effect on the most preferred or disliked attire. However, subjects visiting the ED between 7 AM and 11 PM clearly preferred the formal attire when compared with the 11 PM to 7 AM shift (chi 2, P = 0.016). A significant difference was noted between the preference of surgical scrubs by the parents of patients with surgical emergencies (42/90 [58%]) vs medical patients (30/270 [23%]) (chi 2, P < 0.0001). Combining parents' selections, 75% preferred photographs of physicians wearing white laboratory coats, while 84% chose photographs of doctors who wore tennis shoes as the least liked physicians. Seventy-two percent of parents felt the physicians they preferred the most were not necessarily more capable than the other choices. Sixty-nine percent of subjects felt that it did not matter what their pediatric emergency physician was wearing. Formal attire was associated with "professional appearance" in 64% of the responses. Our study demonstrated that: 1) pediatric emergency physician's attire does not matter to most parents. However, when asked to choose, clear preferences for likes and dislikes become evident. 2) Parents/guardians prefer pediatric emergency physicians who wear formal attire, including white laboratory coat, and do not like casual dress with tennis shoes. 3) Severity of illness, insurance type, and age, race, and gender of guardians do not affect preferences. 4) Parents of patients with surgical emergencies are more likely to prefer doctors wearing surgical scrubs. 5) Parents visiting the ED during night shift (11 PM to 7 AM) showed less interest in formal attire. Our findings may assist in parent/physician interaction in a PED setting.

Effect of urine latex agglutination tests on the treatment of children at risk for invasive bacterial infection.

BACKGROUND: Identifying febrile children with invasive bacterial infection is difficult in the absence of telltale physical findings. Urine latex agglutination (ULA) tests have been used for rapid, on-site identification of such children. OBJECTIVES: To study the performance of ULA tests in identifying children with Haemophilus influenzae, Streptococcus pneumoniae, and group B streptococcus infection and to examine how the results of ULA tests affect patient treatment. DESIGN: Retrospective review. SETTING: Urban children's hospital. PATIENTS: All emergency department and hospital patients tested by ULA in 1990, excluding patients in the neonatal units. RESULTS: Of 1629 patients, 36 had positive tests (20 H influenzae, 5 S pneumoniae, and 11 group B streptococcus). Thirteen of these were false positive based on culture results. Although ULA tests demonstrated excellent specificity, their sensitivity was poor. Positive predictive values for bacteremia ranged from 0.346 to 0.600, and negative predictive values ranged from 0.972 to 0.997. The decision to treat with antibiotics was made before ULA test results were available in 19 (53%) of the 36 patients with positive test results. Of 1593 patients with negative test results, 1211 (76%) were admitted to the hospital, and approximately 81% were empirically treated with parenteral antibiotics. CONCLUSIONS: In clinical practice, treatment and disposition decisions are frequently made without regard to ULA test results.

Evaluation of QBC Autoread performance in an emergency department setting.

The objective of the study was to examine the accuracy and clinical utility of technology using a quantitative buffy coat analysis in determining complete blood cell count results in an emergency department. A prospective observational study was done at an urban pediatric emergency department. One hundred ninety-one patients who had a complete blood cell count (CBC) ordered by the managing emergency physician from 11 AM to 3 AM participated. A blood analysis was performed in the emergency department on the QBC Autoread System for hemoglobin (Hgb), hematocrit (Hct), white blood cell count (WBC), absolute and percent granulocytes (Gr), absolute and percent lymphocytes/monocytes (L/M), and platelets (PTLS). Results were compared with a CBC analysis on the hospital laboratory system (Coulter S-8-80). Time from specimen collection to results were compared for QBC and laboratory CBC. Emergency physicians completed a clinical utility survey after reviewing QBC results. Linear regression curves revealed a high correlation between the two methods for all parameters studied (Hgb: R = 0.911, Hct: R = 0.868, natural log WBC: R = 0.938, % Gr: R = 0.932, % L/M: R = 0.939, and natural log PTLS: R = 0.877). The mean time for collection to QBC result was 17.3 +/- 11.6 minutes compared with 42.2 +/- 17.9 minutes for collection to CBC result. One hundred thirty-five clinical utility forms were completed by the managing physicians after a review of their patient's QBC result. In 20% of cases, physicians felt the QBC result would have shortened the patient's length of stay in the emergency department, and in 85% they felt the result confirmed their clinical impression.(ABSTRACT TRUNCATED AT 250 WORDS)

Routine screening of Halloween candy: helpful or hazardous?

STUDY OBJECTIVES: To determine the frequency of radiopaque items found in radiologic screening of Halloween candy and to determine the possibility of missing a small item. DESIGN: Prospective observational study on Halloween night, 1992. Data were collected from area medical centers that were screening Halloween candy. The ability to detect small sharp items was tested at five centers. SETTING: Five hospitals and three immediate care centers. PARTICIPANTS: Four hundred fifty-four bags of candy were screened. RESULTS: No unknown radiopaque items were discovered. One of five centers tested for accuracy failed to detect a small radiopaque item. Only one hospital required parents to sign a waiver of liability. The immediate care centers recorded patients' names; the other hospitals kept no record of the names of children whose bags were screened. No physicians viewed the radiographs or fluoroscopy. CONCLUSION: The routine radiologic screening of Halloween candy has an extremely low yield in detecting radiopaque items.

Foreign body ingestions in children: risk of complication varies with site of initial health care contact. Pediatric Practice Research Group.

Current recommendations for the management of pediatric foreign body ingestions are based on studies of patients cared for at tertiary care hospitals; they call for aggressive evaluation because of a high incidence of complications. Two hundred forty-four children with suspected foreign body ingestions were prospectively followed to analyze adverse outcomes, ie, procedures, complications, and hospitalizations. Patient enrollment into the study was from three sources: (1) patients who referred themselves to a tertiary pediatric emergency department, (2) patients referred to the same tertiary pediatric emergency department after an initial evaluation by another hospital or physician, and (3) patients who reported their foreign body ingestions to a private pediatric practitioner participating in the study. Most children were well toddlers in normal circumstances, under parent supervision at the time of ingestion. Coins were the most common item ingested (46%). Procedures were done in 53 (24%) of 221 patients and complications occurred in 48 (22%) of 221. Complications were higher in patients referred to the emergency department (63%) than in emergency department self-referred patients (13%) or private practice patients (7%) (chi 2, P < .01). These findings demonstrate the risk of drawing conclusions regarding a universal standard of care from studies involving only hospital-based patients.

Sharp object ingestions in children: illustrative cases and literature review.

Sharp object ingestions may require different management from other foreign body ingestions because of possible gastrointestinal tract perforation. Three cases of sharp object ingestion are presented to describe the possible outcomes. A review of the relevant literature follows.

The case of the slandered hamburgers.

Carbon monoxide poisoning is a common occurrence, especially during cold months. It can be overlooked, because its history and symptoms are often vague. We report a case of two children with carbon monoxide poisoning who typify the need for obtaining a careful history. A review of the literature, including clinical manifestations, diagnosis, and treatment, follows.